International Journal of Cardiology 201 (2015) 193–194
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Recovering sinus rhythm by fine adjustments of an Amplatzer duct occluder after ventricular septal defect closure Ming-Chih Lin, Yun-Ching Fu ⁎, Sheng-Ling Jan Department of Pediatrics and Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan Division of Pediatric Cardiology, Department of Pediatrics, Taichung Veterans General Hospital, Taichung, Taiwan
a r t i c l e
i n f o
Article history: Received 14 July 2015 Accepted 1 August 2015 Available online 4 August 2015 Keywords: Heart block Ventricular septal defect Amplatzer duct occluder
A 45-year-old man with a peri-membranous type ventricular septal defect (VSD) underwent trans-catheter closure of the VSD using a 12/10 mm Amplatzer duct occluder I. By left ventricular angiography,
the narrowest part of the VSD aneurysm was 7.3 mm (Fig. 1A). Initially, there was no residual VSD and the patient did well (Fig. 1B). However, six days after the procedure, the patient consulted at the emergency room for two episodes of syncope at home. Electrocardiography (ECG) revealed complete heart block with a ventricular rate of 40 beats per minute. A temporal pacing catheter was immediately placed in his right ventricle (VVI mode). Because of the persistence of the heart block despite corticosteroid therapy with dexamethasone 5 mg twice a day for 3 days, we decided to adjust the position of his device to relieve tension against the ventricular septum. After establishing vascular accesses, a 15 mm AndraSnare (Andramed GmbH, Germany) was used through a 6 Fr Juking right catheter to capture the waist of the occluder (Fig. 2A). After pulling the device 1–2 mm away from the septum (Fig. 2B and online video),
Fig. 1. (A) By left ventricular angiography, the narrowest part of the VSD aneurysm was 7.3 mm. (B) There was no residual shunt after releasing the device.
⁎ Corresponding author at: Department of Pediatrics, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sect. 4, Taichung 40705, Taiwan. Tel.: +886 4 23592525 ext 5900; fax: +886 4 23741359. E-mail address: [email protected] (Y.-C. Fu).
http://dx.doi.org/10.1016/j.ijcard.2015.08.031 0167-5273/© 2015 Published by Elsevier Ireland Ltd.
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M.-C. Lin et al. / International Journal of Cardiology 201 (2015) 193–194
Fig. 2. (A) The waist of the duct occluder was captured by a 15 mm AndraSnare catheter (online video). (B) The device was pulled 1–2 mm away from the septum (online video). (C) The heart rhythm suddenly changed from pacemaker rhythm to sinus rhythm with first degree AV block.
the heart rhythm suddenly changed from pacemaker rhythm to sinus rhythm with first degree AV block (Fig. 2C). Although left bundle branch block was initially noted, the ECG demonstrated sinus rhythm with narrow QRS pattern four days after adjustment of the device position. Trans-catheter closure of VSD by various amplatzer devices has become more and more popular [1–8]. However, heart block is a major concern from the outset and the incidence ranges from 3.8% to 22% when using an Amplatzer membranous VSD occluder (AGA Medical Corp, Plymouth, Minn) [3–6]. The heart block can be divided into early or acute-onset type and late-onset type. Mechanical trauma and/or compression of the conduction system by the delivery system or the device are the most common causes of the acute-onset type. For the late-onset type, inflammation and fibrosis may play a major role. If the heart block occurs during or within several days after the procedure, device removal is the best intervention to recover sinus rhythm [3,6,9]. In the present case, mechanical tension on the septum may play a role on the development of heart block after device placement. The tension may be relieved by fine adjustments of the device position. Several devices are currently applied for VSD closure, including Amplatzer duct occluder I [1], Amplatzer duct occluder II [7], and Amplatzer VSD occluder II [8]. Early reports show smaller heart block rates. It may contribute to less tension on the septum due to the lack of a right disc or softer materials. This case report provides scientific evidence on the mechanism of complications that develop post-VSD occlusion [10]. This case also highlights an interventional approach for sinus rhythm recovery in such a difficult situation. Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ijcard.2015.08.031.
Conflict of interest The authors report no relationships that could be construed as a conflict of interest. References [1] S.M. Lee, J.Y. Song, J.Y. Choi, S.Y. Lee, J.S. Paik, S.I. Chang, et al., Trans-catheter closure of peri-membranous ventricular septal defect using Amplatzer ductal occluder, Catheter. Cardiovasc. Interv. 82 (2013) 1141–1146. [2] H.G. El Said, A. Bratincsak, B.M. Gordon, J.W. Moore, Closure of peri-membranous ventricular septal defects with aneurysmal tissue using the Amplatzer duct occluder I: lessons learned and medium-term follow-up, Catheter. Cardiovasc. Interv. 80 (2012) 895–903. [3] G. Butera, M. Carminati, M. Chessa, L. Piazza, A. Micheletti, D.G. Negura, et al., Transcatheter closure of peri-membranous ventricular septal defects: early and long-term results, J. Am. Coll. Cardiol. 50 (2007) 1189–1195. [4] M. Carminati, G. Butera, M. Chessa, J. De Giovanni, G. Fisher, M. Gewillig, et al., Transcatheter closure of congenital ventricular septal defects: results of the European registry, Eur. Heart J. 28 (2007) 2361–2368. [5] Y.C. Fu, J. Bass, Z. Amin, W. Radtke, J.P. Cheatham, W.E. Hellenbrand, et al., Trans-catheter closure of peri-membranous ventricular septal defects using the new Amplatzer membranous VSD occluder: results of the U.S. phase I trial, J. Am. Coll. Cardiol. 47 (2006) 319–325. [6] D. Predescu, R.R. Chaturvedi, M.K. Friedberg, L.N. Benson, A. Ozawa, K.J. Lee, Complete heart block associated with device closure of peri-membranous ventricular septal defects, J. Thorac. Cardiovasc. Surg. 136 (2008) 1223–1228. [7] M. Kanaan, P. Ewert, F. Berger, S. Assa, S. Schubert, Follow-up of patients with interventional closure of ventricular septal defects with Amplatzer duct occluder II, Pediatr. Cardiol. 36 (2015) 379–385. [8] A. Tzikas, R. Ibrahim, D. Velasco-Sanchez, X. Freixa, M. Alburquenque, P. Khairy, et al., Trans-catheter closure of peri-membranous ventricular septal defect with the Amplatzer ((R)) membranous VSD occluder 2: initial world experience and one-year follow-up, Catheter. Cardiovasc. Interv. 83 (2014) 571–580. [9] G. Butera, C. Massimo, C. Mario, Late complete atriovenous block after percutaneous closure of a peri-membranous ventricular septal defect, Catheter. Cardiovasc. Interv. 67 (2006) 938–941. [10] K. Mallula, N. Patel, Z. Amin, New design of the Amplatzer membranous VSD occluder: a step forward? Pediatr. Cardiol. 34 (2013) 2068–2072.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Recovering sinus rhythm by fine adjustments of an Amplatzer duct occluder after ventricular septal defect closure Ming-Chih Lin, Yun-Ching Fu ⁎, Sheng-Ling Jan Department of Pediatrics and Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan Division of Pediatric Cardiology, Department of Pediatrics, Taichung Veterans General Hospital, Taichung, Taiwan
a r t i c l e
i n f o
Article history: Received 14 July 2015 Accepted 1 August 2015 Available online 4 August 2015 Keywords: Heart block Ventricular septal defect Amplatzer duct occluder
A 45-year-old man with a peri-membranous type ventricular septal defect (VSD) underwent trans-catheter closure of the VSD using a 12/10 mm Amplatzer duct occluder I. By left ventricular angiography,
the narrowest part of the VSD aneurysm was 7.3 mm (Fig. 1A). Initially, there was no residual VSD and the patient did well (Fig. 1B). However, six days after the procedure, the patient consulted at the emergency room for two episodes of syncope at home. Electrocardiography (ECG) revealed complete heart block with a ventricular rate of 40 beats per minute. A temporal pacing catheter was immediately placed in his right ventricle (VVI mode). Because of the persistence of the heart block despite corticosteroid therapy with dexamethasone 5 mg twice a day for 3 days, we decided to adjust the position of his device to relieve tension against the ventricular septum. After establishing vascular accesses, a 15 mm AndraSnare (Andramed GmbH, Germany) was used through a 6 Fr Juking right catheter to capture the waist of the occluder (Fig. 2A). After pulling the device 1–2 mm away from the septum (Fig. 2B and online video),
Fig. 1. (A) By left ventricular angiography, the narrowest part of the VSD aneurysm was 7.3 mm. (B) There was no residual shunt after releasing the device.
⁎ Corresponding author at: Department of Pediatrics, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sect. 4, Taichung 40705, Taiwan. Tel.: +886 4 23592525 ext 5900; fax: +886 4 23741359. E-mail address: [email protected] (Y.-C. Fu).
http://dx.doi.org/10.1016/j.ijcard.2015.08.031 0167-5273/© 2015 Published by Elsevier Ireland Ltd.
194
M.-C. Lin et al. / International Journal of Cardiology 201 (2015) 193–194
Fig. 2. (A) The waist of the duct occluder was captured by a 15 mm AndraSnare catheter (online video). (B) The device was pulled 1–2 mm away from the septum (online video). (C) The heart rhythm suddenly changed from pacemaker rhythm to sinus rhythm with first degree AV block.
the heart rhythm suddenly changed from pacemaker rhythm to sinus rhythm with first degree AV block (Fig. 2C). Although left bundle branch block was initially noted, the ECG demonstrated sinus rhythm with narrow QRS pattern four days after adjustment of the device position. Trans-catheter closure of VSD by various amplatzer devices has become more and more popular [1–8]. However, heart block is a major concern from the outset and the incidence ranges from 3.8% to 22% when using an Amplatzer membranous VSD occluder (AGA Medical Corp, Plymouth, Minn) [3–6]. The heart block can be divided into early or acute-onset type and late-onset type. Mechanical trauma and/or compression of the conduction system by the delivery system or the device are the most common causes of the acute-onset type. For the late-onset type, inflammation and fibrosis may play a major role. If the heart block occurs during or within several days after the procedure, device removal is the best intervention to recover sinus rhythm [3,6,9]. In the present case, mechanical tension on the septum may play a role on the development of heart block after device placement. The tension may be relieved by fine adjustments of the device position. Several devices are currently applied for VSD closure, including Amplatzer duct occluder I [1], Amplatzer duct occluder II [7], and Amplatzer VSD occluder II [8]. Early reports show smaller heart block rates. It may contribute to less tension on the septum due to the lack of a right disc or softer materials. This case report provides scientific evidence on the mechanism of complications that develop post-VSD occlusion [10]. This case also highlights an interventional approach for sinus rhythm recovery in such a difficult situation. Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ijcard.2015.08.031.
Conflict of interest The authors report no relationships that could be construed as a conflict of interest. References [1] S.M. Lee, J.Y. Song, J.Y. Choi, S.Y. Lee, J.S. Paik, S.I. Chang, et al., Trans-catheter closure of peri-membranous ventricular septal defect using Amplatzer ductal occluder, Catheter. Cardiovasc. Interv. 82 (2013) 1141–1146. [2] H.G. El Said, A. Bratincsak, B.M. Gordon, J.W. Moore, Closure of peri-membranous ventricular septal defects with aneurysmal tissue using the Amplatzer duct occluder I: lessons learned and medium-term follow-up, Catheter. Cardiovasc. Interv. 80 (2012) 895–903. [3] G. Butera, M. Carminati, M. Chessa, L. Piazza, A. Micheletti, D.G. Negura, et al., Transcatheter closure of peri-membranous ventricular septal defects: early and long-term results, J. Am. Coll. Cardiol. 50 (2007) 1189–1195. [4] M. Carminati, G. Butera, M. Chessa, J. De Giovanni, G. Fisher, M. Gewillig, et al., Transcatheter closure of congenital ventricular septal defects: results of the European registry, Eur. Heart J. 28 (2007) 2361–2368. [5] Y.C. Fu, J. Bass, Z. Amin, W. Radtke, J.P. Cheatham, W.E. Hellenbrand, et al., Trans-catheter closure of peri-membranous ventricular septal defects using the new Amplatzer membranous VSD occluder: results of the U.S. phase I trial, J. Am. Coll. Cardiol. 47 (2006) 319–325. [6] D. Predescu, R.R. Chaturvedi, M.K. Friedberg, L.N. Benson, A. Ozawa, K.J. Lee, Complete heart block associated with device closure of peri-membranous ventricular septal defects, J. Thorac. Cardiovasc. Surg. 136 (2008) 1223–1228. [7] M. Kanaan, P. Ewert, F. Berger, S. Assa, S. Schubert, Follow-up of patients with interventional closure of ventricular septal defects with Amplatzer duct occluder II, Pediatr. Cardiol. 36 (2015) 379–385. [8] A. Tzikas, R. Ibrahim, D. Velasco-Sanchez, X. Freixa, M. Alburquenque, P. Khairy, et al., Trans-catheter closure of peri-membranous ventricular septal defect with the Amplatzer ((R)) membranous VSD occluder 2: initial world experience and one-year follow-up, Catheter. Cardiovasc. Interv. 83 (2014) 571–580. [9] G. Butera, C. Massimo, C. Mario, Late complete atriovenous block after percutaneous closure of a peri-membranous ventricular septal defect, Catheter. Cardiovasc. Interv. 67 (2006) 938–941. [10] K. Mallula, N. Patel, Z. Amin, New design of the Amplatzer membranous VSD occluder: a step forward? Pediatr. Cardiol. 34 (2013) 2068–2072.
