CASE REPORT – ADULT CARDIAC
Interactive CardioVascular and Thoracic Surgery 19 (2014) 1074–1076 doi:10.1093/icvts/ivu271 Advance Access publication 1 September 2014
Late erosion of Amplatzer septal occluder device resulting in cardiac tamponade Vakhtang Tchantchaleishvilia,*, Amber L. Melvina, Frederick S. Lingb and Peter A. Knighta a b
Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, USA Division of Cardiology, University of Rochester Medical Center, Rochester, USA
* Corresponding author. University of Rochester Medical Center, Box Cardiac Surgery, 601 Elmwood Avenue, Rochester, NY 14608, USA. Tel: +1-585-2751508; fax: +1-585-2447171; e-mail: [email protected] (V. Tchantchaleishvili). Received 1 June 2014; received in revised form 16 July 2014; accepted 21 July 2014
Abstract Transcatheter device closure of atrial septal defects (ASDs) is a minimally invasive technique that offers an alternative to conventional surgical repair. There are risks imposed by this technique; however, they compare favourably with risks of surgical closure. Here, we present a case of a 59-year old male with late erosion of an Amplatzer septal occluder device resulting in cardiac tamponade 5 years after device placement. To the best of our knowledge, cardiac tamponade this late after device placement has not yet been reported. Septal occlusion device erosion remains a major issue among the risks imposed by device closure of an ASD. More data are needed to better understand its true causes and possible solutions. Keywords: Atrial septal defects • Cardiac catheterization • Cardiac tamponade
INTRODUCTION
CASE REPORT
Transcatheter device closure of atrial septal defects (ASDs) is a minimally invasive technique that offers an alternative to conventional surgical repair. There are risks imposed by this technique; however, they compare favourably with risks of surgical closure [1].
A 59-year old male was referred for repair of a moderate to large secundum-type ASD. The defect measured 22 mm and had acceptable rim characteristics. The patient underwent defect closure with a 24-mm Amplatzer device. The procedure was performed
Figure 1: (A) CT scan demonstrating pericardial effusion (arrowheads). Amplatzer septal occlusion device (double arrows) appears in a proper position. (B) Intraoperative transoesophageal echocardiogram. The Amplatzer septal occlusion device (double arrows) is resting against the anterior left atrial wall adjacent to the aortic root (arrrow); however, no obvious protrusion is visualized. Ao: aorta; RA: right atrium.
© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
V. Tchantchaleishvili et al. / Interactive CardioVascular and Thoracic Surgery
Video 1: Intraoperative transoesophageal echocardiogram loop showing Amplatzer septal occlusion device resting against the anterior left atrial wall adjacent to the aortic root.
( probably related to low cardiac output), an intramural haematoma of the aorta could not be reliably ruled out. Transthoracic echocardiogram demonstrated moderate circumferential pericardial effusion with evidence of tamponade physiology. The patient was brought to the operating theatre for emergent exploration. Intraoperative transoesophageal echocardiogram showed the Amplatzer septal occlusion device (SOD) resting against the anterior left atrial wall. Although no obvious protrusion was visualized, the erosion of the device could not be ruled out (Fig. 1B and Video 1). Given the profound haemodynamic instability in light of an unclear diagnosis, the decision was made to take the patient to the operating room emergently, and proceed with median sternotomy instead of pursuing percutaneous drainage or a pericardial window with less invasive approaches (such as subxiphoid or lateral thoracotomy access). Once the pericardium was opened, frank blood was encountered and the patient regained his blood pressure, but remained hypotensive at 60–70/ 40 mmHg. Thus, the patient was rapidly placed on cardiopulmonary bypass using bicaval cannulation. With the patient stabilized on bypass, examination of the right atrium and aorta revealed no injury to the aorta, but a perforation was found at the junction of the right atrium and the left atrial roof (Fig. 2A and Video 2). The aorta was then cross-clamped, and cardiac arrest was induced with antegrade followed by retrograde cardioplegia. A right atrial incision was carried out and the device exposed (Fig. 2B). To expose the device completely, it was necessary to extend the incision both over the left atrial roof and into the atrial septum. The device was removed gradually, and the site of perforation was seen just cephalad to the device at the junction of the left atrial roof and the right atrium. The original ASD was closed with a Hemashield graft, and the atriotomies were closed primarily. The patient had an uneventful recovery and was discharged home on the 5th postoperative day.
Figure 2: (A) Intraoperative photograph of the anterior left atrial wall with perforation (arrow). The pericardial haematoma has been drained and the heart is connected to cardiopulmonary bypass. (B) Intraoperative photograph demonstrating an open right atrium and the Amplatzer septal occlusion device (double arrows). The device is in proper position and completely endothelialized.
CASE REPORT
uneventfully. An echocardiogram the next day, upon discharge from hospital, showed a well-positioned device with a negative saline study. Five years later, the patient presented with sudden-onset chest pain radiating back to front. In the emergency room, he became hypotensive and had an episode of syncope. Besides 325 mg aspirin daily, he was not on any antiplatelet or anticoagulant agents and, on presentation, had normal coagulation blood tests ( prothrombin time 10.9 s, international normalized ratio 1.1). A CT angiogram of the chest showed no evidence of aortic dilatation or dissection; however, it demonstrated moderate heterogeneous pericardial effusion (Fig. 1A). Given very slow progression of the intravenous contrast dye from the right heart to the left side
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V. Tchantchaleishvili et al. / Interactive CardioVascular and Thoracic Surgery
Although consensus and evidence is lacking regarding the causing factor(s) of erosion, device over-sizing and deficient retroaortic rims have been implicated as possible factors [3]. Still, the root cause of erosion has not been determined and the true incidence of this complication is unknown. These factors were among the reasons that ultimately led to creation of the IMPACT (IMproving Pediatric and Adult Congenital Treatments) registry [5], which was launched recently. Its accumulating body of data will hopefully shed more light on the true causes and possible solutions for this problem. Conflict of interest: none declared. Video 2: Intraoperative video perforation of the anterior left atrial wall.
REFERENCES DISCUSSION The technique of transcatheter device closure of an ASD is now well established, with technical success rates at 98.4% [2]. Among the risks imposed by device closure of an ASD, cardiac erosion is a single major safety issue that has come to light [1]. The estimated incidence rate of Amplatzer SOD erosion ranges from 0.1 to 0.3%, with clinical presentation ranging from haemopericardium resulting in cardiac tamponade to fistula formation [3]. Most commonly occurring early after implantation of the device, late device erosion has been reported as late as 8 years after placement [4]. However, to the best of our knowledge, this is one of the latest occurrences of cardiac tamponade.
[1] Moore J, Hegde S, El-Said H, Beekman R, Benson L, Bergersen L et al. Transcatheter device closure of atrial septal defects: a safety review. JACC Cardiovasc Interv 2013;6:433–42. [2] Forbes T. Interim Results of the Amplatzer Septal Occluder Post Approval Study. Pediatric & Adult Interventional Cardiac Symposium (PICS-AICS), July 24–27 2011; Boston, Massachusetts, USA, 2011. [3] Crawford GB, Brindis RG, Krucoff MW, Mansalis BP, Carroll JD. Percutaneous atrial septal occluder devices and cardiac erosion: a review of the literature. Catheter Cardiovasc Interv 2012;80:157–67. [4] Roberts WT, Parmar J, Rajathurai T. Very late erosion of Amplatzer septal occluder device presenting as pericardial pain and effusion 8 years after placement. Catheter Cardiovasc Interv 2013;82:E592–4. [5] Martin GR, Beekman RH, Ing FF, Jenkins KJ, McKay CR, Moore JW et al. The IMPACT registry: IMproving Pediatric and Adult Congenital Treatments. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2010;13:20–5.
Interactive CardioVascular and Thoracic Surgery 19 (2014) 1074–1076 doi:10.1093/icvts/ivu271 Advance Access publication 1 September 2014
Late erosion of Amplatzer septal occluder device resulting in cardiac tamponade Vakhtang Tchantchaleishvilia,*, Amber L. Melvina, Frederick S. Lingb and Peter A. Knighta a b
Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, USA Division of Cardiology, University of Rochester Medical Center, Rochester, USA
* Corresponding author. University of Rochester Medical Center, Box Cardiac Surgery, 601 Elmwood Avenue, Rochester, NY 14608, USA. Tel: +1-585-2751508; fax: +1-585-2447171; e-mail: [email protected] (V. Tchantchaleishvili). Received 1 June 2014; received in revised form 16 July 2014; accepted 21 July 2014
Abstract Transcatheter device closure of atrial septal defects (ASDs) is a minimally invasive technique that offers an alternative to conventional surgical repair. There are risks imposed by this technique; however, they compare favourably with risks of surgical closure. Here, we present a case of a 59-year old male with late erosion of an Amplatzer septal occluder device resulting in cardiac tamponade 5 years after device placement. To the best of our knowledge, cardiac tamponade this late after device placement has not yet been reported. Septal occlusion device erosion remains a major issue among the risks imposed by device closure of an ASD. More data are needed to better understand its true causes and possible solutions. Keywords: Atrial septal defects • Cardiac catheterization • Cardiac tamponade
INTRODUCTION
CASE REPORT
Transcatheter device closure of atrial septal defects (ASDs) is a minimally invasive technique that offers an alternative to conventional surgical repair. There are risks imposed by this technique; however, they compare favourably with risks of surgical closure [1].
A 59-year old male was referred for repair of a moderate to large secundum-type ASD. The defect measured 22 mm and had acceptable rim characteristics. The patient underwent defect closure with a 24-mm Amplatzer device. The procedure was performed
Figure 1: (A) CT scan demonstrating pericardial effusion (arrowheads). Amplatzer septal occlusion device (double arrows) appears in a proper position. (B) Intraoperative transoesophageal echocardiogram. The Amplatzer septal occlusion device (double arrows) is resting against the anterior left atrial wall adjacent to the aortic root (arrrow); however, no obvious protrusion is visualized. Ao: aorta; RA: right atrium.
© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
V. Tchantchaleishvili et al. / Interactive CardioVascular and Thoracic Surgery
Video 1: Intraoperative transoesophageal echocardiogram loop showing Amplatzer septal occlusion device resting against the anterior left atrial wall adjacent to the aortic root.
( probably related to low cardiac output), an intramural haematoma of the aorta could not be reliably ruled out. Transthoracic echocardiogram demonstrated moderate circumferential pericardial effusion with evidence of tamponade physiology. The patient was brought to the operating theatre for emergent exploration. Intraoperative transoesophageal echocardiogram showed the Amplatzer septal occlusion device (SOD) resting against the anterior left atrial wall. Although no obvious protrusion was visualized, the erosion of the device could not be ruled out (Fig. 1B and Video 1). Given the profound haemodynamic instability in light of an unclear diagnosis, the decision was made to take the patient to the operating room emergently, and proceed with median sternotomy instead of pursuing percutaneous drainage or a pericardial window with less invasive approaches (such as subxiphoid or lateral thoracotomy access). Once the pericardium was opened, frank blood was encountered and the patient regained his blood pressure, but remained hypotensive at 60–70/ 40 mmHg. Thus, the patient was rapidly placed on cardiopulmonary bypass using bicaval cannulation. With the patient stabilized on bypass, examination of the right atrium and aorta revealed no injury to the aorta, but a perforation was found at the junction of the right atrium and the left atrial roof (Fig. 2A and Video 2). The aorta was then cross-clamped, and cardiac arrest was induced with antegrade followed by retrograde cardioplegia. A right atrial incision was carried out and the device exposed (Fig. 2B). To expose the device completely, it was necessary to extend the incision both over the left atrial roof and into the atrial septum. The device was removed gradually, and the site of perforation was seen just cephalad to the device at the junction of the left atrial roof and the right atrium. The original ASD was closed with a Hemashield graft, and the atriotomies were closed primarily. The patient had an uneventful recovery and was discharged home on the 5th postoperative day.
Figure 2: (A) Intraoperative photograph of the anterior left atrial wall with perforation (arrow). The pericardial haematoma has been drained and the heart is connected to cardiopulmonary bypass. (B) Intraoperative photograph demonstrating an open right atrium and the Amplatzer septal occlusion device (double arrows). The device is in proper position and completely endothelialized.
CASE REPORT
uneventfully. An echocardiogram the next day, upon discharge from hospital, showed a well-positioned device with a negative saline study. Five years later, the patient presented with sudden-onset chest pain radiating back to front. In the emergency room, he became hypotensive and had an episode of syncope. Besides 325 mg aspirin daily, he was not on any antiplatelet or anticoagulant agents and, on presentation, had normal coagulation blood tests ( prothrombin time 10.9 s, international normalized ratio 1.1). A CT angiogram of the chest showed no evidence of aortic dilatation or dissection; however, it demonstrated moderate heterogeneous pericardial effusion (Fig. 1A). Given very slow progression of the intravenous contrast dye from the right heart to the left side
1075
1076
V. Tchantchaleishvili et al. / Interactive CardioVascular and Thoracic Surgery
Although consensus and evidence is lacking regarding the causing factor(s) of erosion, device over-sizing and deficient retroaortic rims have been implicated as possible factors [3]. Still, the root cause of erosion has not been determined and the true incidence of this complication is unknown. These factors were among the reasons that ultimately led to creation of the IMPACT (IMproving Pediatric and Adult Congenital Treatments) registry [5], which was launched recently. Its accumulating body of data will hopefully shed more light on the true causes and possible solutions for this problem. Conflict of interest: none declared. Video 2: Intraoperative video perforation of the anterior left atrial wall.
REFERENCES DISCUSSION The technique of transcatheter device closure of an ASD is now well established, with technical success rates at 98.4% [2]. Among the risks imposed by device closure of an ASD, cardiac erosion is a single major safety issue that has come to light [1]. The estimated incidence rate of Amplatzer SOD erosion ranges from 0.1 to 0.3%, with clinical presentation ranging from haemopericardium resulting in cardiac tamponade to fistula formation [3]. Most commonly occurring early after implantation of the device, late device erosion has been reported as late as 8 years after placement [4]. However, to the best of our knowledge, this is one of the latest occurrences of cardiac tamponade.
[1] Moore J, Hegde S, El-Said H, Beekman R, Benson L, Bergersen L et al. Transcatheter device closure of atrial septal defects: a safety review. JACC Cardiovasc Interv 2013;6:433–42. [2] Forbes T. Interim Results of the Amplatzer Septal Occluder Post Approval Study. Pediatric & Adult Interventional Cardiac Symposium (PICS-AICS), July 24–27 2011; Boston, Massachusetts, USA, 2011. [3] Crawford GB, Brindis RG, Krucoff MW, Mansalis BP, Carroll JD. Percutaneous atrial septal occluder devices and cardiac erosion: a review of the literature. Catheter Cardiovasc Interv 2012;80:157–67. [4] Roberts WT, Parmar J, Rajathurai T. Very late erosion of Amplatzer septal occluder device presenting as pericardial pain and effusion 8 years after placement. Catheter Cardiovasc Interv 2013;82:E592–4. [5] Martin GR, Beekman RH, Ing FF, Jenkins KJ, McKay CR, Moore JW et al. The IMPACT registry: IMproving Pediatric and Adult Congenital Treatments. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2010;13:20–5.
