Canadian Journal of Cardiology
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(2015) 1.e1e1.e3 www.onlinecjc.ca
Case Report
Late Infection of an Atrial Septal Defect Closure Device: A Possible Complication Nicolas Thibodeau-Jarry, MD, Reda Ibrahim, MD, FRCPC, Anique Ducharme, MD, and Ying Tung Sia, MD, MSc, FRCPC Department of Medicine, Montreal Heart Institute, Universite de Montre al, Montreal, Que bec, Canada
ABSTRACT
RESUM E
Atrial septal defect is a common congenital heart defect. In the late 1990s, percutaneous closure became available and eventually the treatment of choice. The procedure is considered safe because of its low incidence of complications. Infection rate is extremely low and occurs typically early after device implantation. Herein we present a case of late and dramatic infection of an Amplatzer Septal Occluder (St Jude Medical). This case illustrates that infection remains possible a long time after atrial septal defect occlusion despite theoretical device endothelialization.
nitale La communication interauriculaire est une anomalie conge quente du cœur. À la fin des anne es 1990, la fermeture par voie fre e est devenue disponible, puis finalement le traitement de percutane re e comme e tant sûre puisque ses choix. L’intervention est conside complications sont peu nombreuses. Le taux d’infection est extrêmement faible et apparaît habituellement peu de temps après l’imsentons un cas d’infection tardive plantation du dispositif. Ici, nous pre et importante d’un obturateur septal Amplatzer (St Jude Medical). Ce cas montre que l’infection demeure possible longtemps après l’ocpit de la the orie clusion de la communication interauriculaire en de lialisation du dispositif. entourant l’endothe
In the past 2 decades, new options have become available for atrial sepal defect (ASD) closure, one of the most common adult congenital heart defects. Nowadays, percutaneous ASD closure using different devices is the treatment of choice in most patients with secundum defects. So far, more than 300,000 devices have been implanted worldwide. Because of the large number of patients with implanted devices, even very rare complications might be seen more frequently. In this report, we present a case of late infection of an ASD closure device.
without complication. The procedure was performed using routine antibiotic coverage. The patient presented to a community hospital in May 2013 with fever and new onset confusion with a fluctuating level of consciousness. Cerebral computed tomograpy scan and magnetic resonance imaging revealed numerous bilateral ischemic lesions highly suggestive of thromboembolic phenomenon (Fig. 1A). Two blood cultures were drawn and subsequently revealed group C b-hemolytic streptococcus septicemia. These findings made the diagnosis of endocarditis with cerebral septic emboli very likely. A transthoracic echocardiogram was performed but did not reveal any valvular vegetation. A TEE was subsequently performed and showed a highly mobile mass, measuring 20 8 mm, attached to the left atrial aspect of the Amplatzer device ; view video online). No interatrial (Fig. 1B and Video 1 shunt was observed. Three smaller vegetations were seen on the left atrium side of the anterior and posterior leaflets of the mitral valve. An underlying abscess could not be excluded, but was difficult to visualize because of the shadows from the device. The patient had been treated with antibiotics for 1 week, but because of the dramatic presentation, the patient was transferred to our institution for urgent surgery, which was done 2 days after the TEE. A preoperative coronary angiogram was normal and the patient underwent surgical removal of the Amplatzer device and of the vegetations followed by
Case Summary The patient was a 71-year-old gentleman with a medical history of atrial flutter, diabetes, dyslipidemia, asbestosis, and sleep apnea. In 2009, a transesophageal echocardiogram (TEE) revealed a 17-mm secundum ASD with significant enlargement of the right atrium and right ventricle. The patient then underwent percutaneous closure of his defect with a 28-mm (the stretched estimate of the size of the device) Amplatzer Septal Occluder (St Jude Medical, St Paul, MN) Received for publication October 11, 2014. Accepted January 1, 2015. Corresponding author: Dr Ying Tung Sia, 5000 Belanger St, Montreal, Quebec H1T 1C8, Canada. Tel.: þ1-514-376-3330 3800. E-mail: [email protected] See page 1.e2 for disclosure information.
http://dx.doi.org/10.1016/j.cjca.2015.01.043 0828-282X/Ó 2015 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
1.e2
Canadian Journal of Cardiology Volume - 2015
Figure 1. (A) Magnetic resonance image showing extensive right occipital lesion; (B) transesophageal echocardiogram still-frame showing vegetation attached to the left atrial aspect of the Amplatzer Septal Occluder (St Jude Medical, St Paul, MN).
ASD closure using autologous pericardium. The procedure was complicated by important bleeding and the postoperative course was complicated by atrioventricular block requiring a pacemaker and by hemorrhagic transformation of the brain lesions. The patient remained with an important left hemianopsia, making it difficult for him to walk.
Discussion Percutaneous ASD closure is usually a safe and well tolerated procedure, but serious complications can occur. Those usually occur early after implantation and include device embolization or malposition, pericardial effusion, thrombus formation, iliac vein dissection, and groin hematoma. Longer-term complications include cardiac perforation, sudden death, and device erosion.1 Endocarditis is a rare event in patients with ASDs. In one large survey, only 3 of 882 patients with a secundum ASD had a history of endocarditis.2 The incidence of ASD occluder infection is also low, ranging from 0% to 1% in larges series,3
and most of them occur early (< 6 months) after implantation. Late infections of ASD devices are rare. Only 5 cases (3 adults and 2 infants) have been reported in the literature.3-5 Clinical presentations are variable, including fever, sepsis, general malaise, positive blood culture, and peripheral and cerebral emboli with confusion. Our patient presented with confusion and fever. Subsequent imaging showed multiple cerebral emboli along with highly mobile intracardiac vegetations. Interestingly, the dominant vegetation was attached to a region of the Amplatzer device that it was free of endothelium (Fig. 2), which is also shown in previous case reports. Endothelialization of prosthetic material is an important factor that diminishes the risk of endocarditis. Indeed, some bacteria are able to attach to medical devices that are free of endothelium by recognizing adhesive matrix molecules or by formation of biofilms. Endothelialization of prosthetic devices usually occurs within 3 months after the procedure in animal models.5 Risk factors have not yet been identified for incomplete and/or delayed endothelialization in humans. However, because of the increased use of these devices in the world and the consensual length of endocarditis prophylaxis after ASD device implantation is 6 months, it is important to maintain a high index of suspicion for late device infection if patients present with embolic or septic events.
Disclosures The authors have no conflicts of interest to disclose. References 1. Chessa M, Carminati M, Butera G, et al. Early and late complications associated with transcatheter occlusion of secundum atrial septal defect. J Am Coll Cardiol 2002;39:1061-5.
Figure 2. Photo showing incomplete endothelialization of the atrial septal defect occluder and the site of attachment of the vegetation.
2. Engelfriet P, Boersma E, Oechslin Tijssen J, et al. The spectrum of adult congenital heart disease in Europe: morbidity and mortality in a 5 year follow-up period. The Euro Heart Survey on adult congenital heart disease. Eur Heart J 2005;26:2325-33.
Thibodeau-Jarry et al. Late Infection of an Atrial Septal Occluder
1.e3
3. Walpot J, Amsel B, Rodrigus I, et al. Late infective endocarditis of an atrial septal occluder device presenting as a cystic mass. Echocardiography 2011;28:E131-3.
implantation of an Amplatzer septal occluder device. Circulation 2008;117:e326-7.
4. Aruni B, Sharifian A, Eryazici P, Herrera CJ. Late bacterial endocarditits of an Amplatzer atrial septal device. Indian Heart J 2013;65: 450-1.
Supplementary Material To access the supplementary material accompanying this article, visit the online version of the Canadian Journal of Cardiology at www.onlinecjc.ca and at http://dx.doi.org/10. 1016/j.cjca.2015.01.043.
5. Slesnick TC, Nugent AW, Fraser CD, Cannon BC. Incomplete endothelialization and late development of acute bacterial endocarditis after
-
(2015) 1.e1e1.e3 www.onlinecjc.ca
Case Report
Late Infection of an Atrial Septal Defect Closure Device: A Possible Complication Nicolas Thibodeau-Jarry, MD, Reda Ibrahim, MD, FRCPC, Anique Ducharme, MD, and Ying Tung Sia, MD, MSc, FRCPC Department of Medicine, Montreal Heart Institute, Universite de Montre al, Montreal, Que bec, Canada
ABSTRACT
RESUM E
Atrial septal defect is a common congenital heart defect. In the late 1990s, percutaneous closure became available and eventually the treatment of choice. The procedure is considered safe because of its low incidence of complications. Infection rate is extremely low and occurs typically early after device implantation. Herein we present a case of late and dramatic infection of an Amplatzer Septal Occluder (St Jude Medical). This case illustrates that infection remains possible a long time after atrial septal defect occlusion despite theoretical device endothelialization.
nitale La communication interauriculaire est une anomalie conge quente du cœur. À la fin des anne es 1990, la fermeture par voie fre e est devenue disponible, puis finalement le traitement de percutane re e comme e tant sûre puisque ses choix. L’intervention est conside complications sont peu nombreuses. Le taux d’infection est extrêmement faible et apparaît habituellement peu de temps après l’imsentons un cas d’infection tardive plantation du dispositif. Ici, nous pre et importante d’un obturateur septal Amplatzer (St Jude Medical). Ce cas montre que l’infection demeure possible longtemps après l’ocpit de la the orie clusion de la communication interauriculaire en de lialisation du dispositif. entourant l’endothe
In the past 2 decades, new options have become available for atrial sepal defect (ASD) closure, one of the most common adult congenital heart defects. Nowadays, percutaneous ASD closure using different devices is the treatment of choice in most patients with secundum defects. So far, more than 300,000 devices have been implanted worldwide. Because of the large number of patients with implanted devices, even very rare complications might be seen more frequently. In this report, we present a case of late infection of an ASD closure device.
without complication. The procedure was performed using routine antibiotic coverage. The patient presented to a community hospital in May 2013 with fever and new onset confusion with a fluctuating level of consciousness. Cerebral computed tomograpy scan and magnetic resonance imaging revealed numerous bilateral ischemic lesions highly suggestive of thromboembolic phenomenon (Fig. 1A). Two blood cultures were drawn and subsequently revealed group C b-hemolytic streptococcus septicemia. These findings made the diagnosis of endocarditis with cerebral septic emboli very likely. A transthoracic echocardiogram was performed but did not reveal any valvular vegetation. A TEE was subsequently performed and showed a highly mobile mass, measuring 20 8 mm, attached to the left atrial aspect of the Amplatzer device ; view video online). No interatrial (Fig. 1B and Video 1 shunt was observed. Three smaller vegetations were seen on the left atrium side of the anterior and posterior leaflets of the mitral valve. An underlying abscess could not be excluded, but was difficult to visualize because of the shadows from the device. The patient had been treated with antibiotics for 1 week, but because of the dramatic presentation, the patient was transferred to our institution for urgent surgery, which was done 2 days after the TEE. A preoperative coronary angiogram was normal and the patient underwent surgical removal of the Amplatzer device and of the vegetations followed by
Case Summary The patient was a 71-year-old gentleman with a medical history of atrial flutter, diabetes, dyslipidemia, asbestosis, and sleep apnea. In 2009, a transesophageal echocardiogram (TEE) revealed a 17-mm secundum ASD with significant enlargement of the right atrium and right ventricle. The patient then underwent percutaneous closure of his defect with a 28-mm (the stretched estimate of the size of the device) Amplatzer Septal Occluder (St Jude Medical, St Paul, MN) Received for publication October 11, 2014. Accepted January 1, 2015. Corresponding author: Dr Ying Tung Sia, 5000 Belanger St, Montreal, Quebec H1T 1C8, Canada. Tel.: þ1-514-376-3330 3800. E-mail: [email protected] See page 1.e2 for disclosure information.
http://dx.doi.org/10.1016/j.cjca.2015.01.043 0828-282X/Ó 2015 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
1.e2
Canadian Journal of Cardiology Volume - 2015
Figure 1. (A) Magnetic resonance image showing extensive right occipital lesion; (B) transesophageal echocardiogram still-frame showing vegetation attached to the left atrial aspect of the Amplatzer Septal Occluder (St Jude Medical, St Paul, MN).
ASD closure using autologous pericardium. The procedure was complicated by important bleeding and the postoperative course was complicated by atrioventricular block requiring a pacemaker and by hemorrhagic transformation of the brain lesions. The patient remained with an important left hemianopsia, making it difficult for him to walk.
Discussion Percutaneous ASD closure is usually a safe and well tolerated procedure, but serious complications can occur. Those usually occur early after implantation and include device embolization or malposition, pericardial effusion, thrombus formation, iliac vein dissection, and groin hematoma. Longer-term complications include cardiac perforation, sudden death, and device erosion.1 Endocarditis is a rare event in patients with ASDs. In one large survey, only 3 of 882 patients with a secundum ASD had a history of endocarditis.2 The incidence of ASD occluder infection is also low, ranging from 0% to 1% in larges series,3
and most of them occur early (< 6 months) after implantation. Late infections of ASD devices are rare. Only 5 cases (3 adults and 2 infants) have been reported in the literature.3-5 Clinical presentations are variable, including fever, sepsis, general malaise, positive blood culture, and peripheral and cerebral emboli with confusion. Our patient presented with confusion and fever. Subsequent imaging showed multiple cerebral emboli along with highly mobile intracardiac vegetations. Interestingly, the dominant vegetation was attached to a region of the Amplatzer device that it was free of endothelium (Fig. 2), which is also shown in previous case reports. Endothelialization of prosthetic material is an important factor that diminishes the risk of endocarditis. Indeed, some bacteria are able to attach to medical devices that are free of endothelium by recognizing adhesive matrix molecules or by formation of biofilms. Endothelialization of prosthetic devices usually occurs within 3 months after the procedure in animal models.5 Risk factors have not yet been identified for incomplete and/or delayed endothelialization in humans. However, because of the increased use of these devices in the world and the consensual length of endocarditis prophylaxis after ASD device implantation is 6 months, it is important to maintain a high index of suspicion for late device infection if patients present with embolic or septic events.
Disclosures The authors have no conflicts of interest to disclose. References 1. Chessa M, Carminati M, Butera G, et al. Early and late complications associated with transcatheter occlusion of secundum atrial septal defect. J Am Coll Cardiol 2002;39:1061-5.
Figure 2. Photo showing incomplete endothelialization of the atrial septal defect occluder and the site of attachment of the vegetation.
2. Engelfriet P, Boersma E, Oechslin Tijssen J, et al. The spectrum of adult congenital heart disease in Europe: morbidity and mortality in a 5 year follow-up period. The Euro Heart Survey on adult congenital heart disease. Eur Heart J 2005;26:2325-33.
Thibodeau-Jarry et al. Late Infection of an Atrial Septal Occluder
1.e3
3. Walpot J, Amsel B, Rodrigus I, et al. Late infective endocarditis of an atrial septal occluder device presenting as a cystic mass. Echocardiography 2011;28:E131-3.
implantation of an Amplatzer septal occluder device. Circulation 2008;117:e326-7.
4. Aruni B, Sharifian A, Eryazici P, Herrera CJ. Late bacterial endocarditits of an Amplatzer atrial septal device. Indian Heart J 2013;65: 450-1.
Supplementary Material To access the supplementary material accompanying this article, visit the online version of the Canadian Journal of Cardiology at www.onlinecjc.ca and at http://dx.doi.org/10. 1016/j.cjca.2015.01.043.
5. Slesnick TC, Nugent AW, Fraser CD, Cannon BC. Incomplete endothelialization and late development of acute bacterial endocarditis after
