Catheterization and Cardiovascular Interventions 00:00–00 (2014)
Letter to the Editor Use of Contrast During Echocardiography to Diagnose Cardiac Perforation After Device Closure of Atrial Septal Defect SIR,
Transcatheter closure of select ostium secundum atrial septal defects (ASD) is now considered a safe and effective alternative to surgical closure [1]. Cardiac perforation (CP) or erosion after transcatheter ASD and patent foramen ovale (PFO) closure has been described with the incidence ranging between 0.1% and 4% [2–4]. Although CP is known to occur with most of the devices, it has been reported more commonly with the Amplatzer septal occluder (ASO, St Jude, Plymouth, MA). In a review of registry of complications associated with the ASO, Amin et al. noted that most of the CPs or erosions occurred near the dome of the atria near the aortic root [2]. A majority of these patients had deficient aortic margin and their device to unstretched ASD ratio was significantly larger. This led them to conclude that those with a deficient aortic/superior margin and those with an oversized ASO were at higher risk of erosion. In a data review provided by the US and Canadian drug agencies, 66% of the 29 CPs reported were late (postdischarge), 24% occurred 1–6 months later, and only 1 occurred more than a year later (3 years) [5]. Patients with CP may present with pericardial effusion, chest pain, dyspnea, syncope, hemodynamic collapse, or even sudden death [6]. Pericardial effusion in a patient with ASD device closure may be secondary to erosion or due to multiple other causes such as viral infection, inflammation associated with collagen vascular disease, secondary to renal dysfunction, hypothyroidism, idiopathic, and many other less common etiologies. Sometimes, after device closure one sees a small echo-free space posteriorly which was not very evident pre-procedure. This is more often associated with the use of large devices measuring more than 30 mm and is probably due to stenting of the interatrial septum tending to lift up the heart anteriorly. C 2014 Wiley Periodicals, Inc. V
A 30-year-old lady underwent transcatheter closure of a 28 mm ASD with a 34 mm ASO. The procedure was uneventful and she was discharged after 24 hr with no evidence of pericardial effusion on the predischarge echo. At a routine 1-month follow-up, she was asymptomatic with stable vital parameters. Her blood pressure was 110/70 mm Hg with no evidence of pulsus paradoxus and her jugular venous pressure was not elevated. There was no hepatomegaly or pedal edema. Her respiratory examination was unremarkable. On 2D echocardiography, the device was noted to be in position with no residual flow across the defect. The mitral and tricuspid valves were functioning normally. There was pericardial effusion noted predominantly posterior to the left ventricle. An intravenous line was secured and ultrasound contrast agent (SonoVue; Bracco Imaging, Gene`ve, Switzerland) was injected intravenously to opacify the right (Fig. 1) and subsequently the left sided cardiac chambers (Fig. 2). There was no contrast visualized in the pericardial space thus ruling out any erosion of the cardiac walls. The patient was managed conservatively and kept on a close follow-up with regular echocardiographic screening to rule out any increase in the amount of effusion. The patient remained hemodynamically stable with gradual reduction in the amount of pericardial effusion and subsequent disappearance. Use of contrast echocardiography to diagnose myocardial rupture was first reported by Waggoner et al. [7] in a patient after myocardial infarction. Since then there have been numerous reports of the use of contrast echocardiography for the purpose of identifying cardiac rupture after myocardial infarction [8,9]. We report for the first time, the use of contrast echocardiography
Conflict of interest: Dr. Bharat Dalvi is a consultant for St. Jude Medicals (Plymouth, MA, USA). None of the other authors have any conflict of interest. *Correspondence to: Dr. Bharat Dalvi, Cardiologist, Glenmark Cardiac Centre, 10, Nandadeep, 209-D Dr. Ambedkar Road, Matunga (E), Mumbai, Maharashtra, India 400 019. E-mail: [email protected] Received 19 August 2013; Revision accepted 21 December 2013 DOI: 10.1002/ccd.25373 Published online 00 Month 2014 in Wiley Online Library (wileyonlinelibrary.com)
2
Letter to the Editor
Fig. 1. A 2-dimensional echocardiographic (2D-Echo) image taken in the left parasternal short axis view showing opacification of the right ventricular cavity by the ultrasound contrast agent injected intravenously. There was no opacification visualized in the pericardial space. (RV: right ventricle; LV: left ventricle; PE: pericardial effusion). [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
Fig. 2. 2D-Echo image in the left parasternal short axis view showing subsequent appearance of the contrast agent in the left ventricle. Note that there is still no appearance of contrast within the pericardial space. (RV: right ventricle; LV: left ventricle; PE: pericardial effusion). [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.] Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
Letter to the Editor
for ruling out cardiac erosion following transcatheter closure of ASD using ASO. In order to distinguish erosion from other etiologies of pericardial effusion, we utilized this strategy of injecting a contrast intravenously and trying to see whether it leaks into the pericardial cavity. The presence of such a leak would be a pointer toward CP. Agitated saline contrast can also be used to opacify the right heart structures to identify erosion on the right side but its use is limited by the fact that the contrast bubbles do not cross over to the left side thereby preventing detection of CP in the left sided structures. CT angiography can also be used to identify protrusion of the ASO into the pericardial space but cannot be performed bed side and is much more expensive and less easily available in developing countries. In order to assess the sensitivity and specificity of these techniques, one will need to study a large cohort of patients subjected to both the techniques of evaluation. We suggest that contrast echocardiography should be done in all patients who develop pericardial effusion following device closure of ASD using ASO to confirm or rule out CP. Shreepal Jain, MD, FNB Robin Pinto, MD, DM Bharat Dalvi, MD, DM*
3
REFERENCES 1. Masura J, Gavora P, Podnar T. Long-term outcome of transcatheter secundum-type septal defect closure using Amplatzer septal occluders. J Am Coll Cardiol 2005;45:505–507. 2. Amin Z, Hijazi ZM, Bass JL, Cheatham JP, Hellenbrand WE, Kleinman CS. Erosion of Amplatzer septal occluder device after closure of secundum atrial septal defects: Review of registry of complications and recommendations to minimize future risk. Catheter Cardiovasc Interv 2004;63:496–502. 3. Ewert P, Kretschmar O, Peters B, et al. Preliminary experience with a new 18 mm Amplatzer PFO occluder for small persistent foramen ovale. Catheter Cardiovasc Interv 2003;59:518–521. 4. Schrader R. Catheter closure of secundum ASD using “other” devices. J Interv Cardiol 2003;16:409–412. 5. Divekar A, Gaamangwe T, Shaikh N, Raabe M, Ducas J. Cardiac perforation after device closure of atrial septal defects with the Amplatzer septel occluder. J Am Coll Cardiol 2005;45: 1213–1218. 6. Spence MS, Qureshi SA. Complications of transcatheter closure of atrial septal defects. Heart 2005;91:1512–1514. 7. Waggoner AD, Williams GA, Gaffron D, Schwarze M. Potential utility of left heart contrast agents in diagnosis of myocardial rupture by 2-dimensional echocardiography. J Am Soc Echocardiogr 1999;12:272–274. 8. Garcıa-Fernandez MA, Odreman Macchioli RO, Moreno PM, Yang€uela MM, Thomas JB, Sendon JLL, Lopez de Sa E, Abdou YH. Use of contrast echocardiography in the diagnosis of subacute myocardial rupture after myocardial infarction. J Am Soc Echocardiogr 2001;14:945–947. 9. Mittle S, Makaryus AN, Mangion J. Role of contrast echocardiography in the assessment of myocardial rupture. Echocardiography 2003;20:77–81.
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
Letter to the Editor Use of Contrast During Echocardiography to Diagnose Cardiac Perforation After Device Closure of Atrial Septal Defect SIR,
Transcatheter closure of select ostium secundum atrial septal defects (ASD) is now considered a safe and effective alternative to surgical closure [1]. Cardiac perforation (CP) or erosion after transcatheter ASD and patent foramen ovale (PFO) closure has been described with the incidence ranging between 0.1% and 4% [2–4]. Although CP is known to occur with most of the devices, it has been reported more commonly with the Amplatzer septal occluder (ASO, St Jude, Plymouth, MA). In a review of registry of complications associated with the ASO, Amin et al. noted that most of the CPs or erosions occurred near the dome of the atria near the aortic root [2]. A majority of these patients had deficient aortic margin and their device to unstretched ASD ratio was significantly larger. This led them to conclude that those with a deficient aortic/superior margin and those with an oversized ASO were at higher risk of erosion. In a data review provided by the US and Canadian drug agencies, 66% of the 29 CPs reported were late (postdischarge), 24% occurred 1–6 months later, and only 1 occurred more than a year later (3 years) [5]. Patients with CP may present with pericardial effusion, chest pain, dyspnea, syncope, hemodynamic collapse, or even sudden death [6]. Pericardial effusion in a patient with ASD device closure may be secondary to erosion or due to multiple other causes such as viral infection, inflammation associated with collagen vascular disease, secondary to renal dysfunction, hypothyroidism, idiopathic, and many other less common etiologies. Sometimes, after device closure one sees a small echo-free space posteriorly which was not very evident pre-procedure. This is more often associated with the use of large devices measuring more than 30 mm and is probably due to stenting of the interatrial septum tending to lift up the heart anteriorly. C 2014 Wiley Periodicals, Inc. V
A 30-year-old lady underwent transcatheter closure of a 28 mm ASD with a 34 mm ASO. The procedure was uneventful and she was discharged after 24 hr with no evidence of pericardial effusion on the predischarge echo. At a routine 1-month follow-up, she was asymptomatic with stable vital parameters. Her blood pressure was 110/70 mm Hg with no evidence of pulsus paradoxus and her jugular venous pressure was not elevated. There was no hepatomegaly or pedal edema. Her respiratory examination was unremarkable. On 2D echocardiography, the device was noted to be in position with no residual flow across the defect. The mitral and tricuspid valves were functioning normally. There was pericardial effusion noted predominantly posterior to the left ventricle. An intravenous line was secured and ultrasound contrast agent (SonoVue; Bracco Imaging, Gene`ve, Switzerland) was injected intravenously to opacify the right (Fig. 1) and subsequently the left sided cardiac chambers (Fig. 2). There was no contrast visualized in the pericardial space thus ruling out any erosion of the cardiac walls. The patient was managed conservatively and kept on a close follow-up with regular echocardiographic screening to rule out any increase in the amount of effusion. The patient remained hemodynamically stable with gradual reduction in the amount of pericardial effusion and subsequent disappearance. Use of contrast echocardiography to diagnose myocardial rupture was first reported by Waggoner et al. [7] in a patient after myocardial infarction. Since then there have been numerous reports of the use of contrast echocardiography for the purpose of identifying cardiac rupture after myocardial infarction [8,9]. We report for the first time, the use of contrast echocardiography
Conflict of interest: Dr. Bharat Dalvi is a consultant for St. Jude Medicals (Plymouth, MA, USA). None of the other authors have any conflict of interest. *Correspondence to: Dr. Bharat Dalvi, Cardiologist, Glenmark Cardiac Centre, 10, Nandadeep, 209-D Dr. Ambedkar Road, Matunga (E), Mumbai, Maharashtra, India 400 019. E-mail: [email protected] Received 19 August 2013; Revision accepted 21 December 2013 DOI: 10.1002/ccd.25373 Published online 00 Month 2014 in Wiley Online Library (wileyonlinelibrary.com)
2
Letter to the Editor
Fig. 1. A 2-dimensional echocardiographic (2D-Echo) image taken in the left parasternal short axis view showing opacification of the right ventricular cavity by the ultrasound contrast agent injected intravenously. There was no opacification visualized in the pericardial space. (RV: right ventricle; LV: left ventricle; PE: pericardial effusion). [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
Fig. 2. 2D-Echo image in the left parasternal short axis view showing subsequent appearance of the contrast agent in the left ventricle. Note that there is still no appearance of contrast within the pericardial space. (RV: right ventricle; LV: left ventricle; PE: pericardial effusion). [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.] Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
Letter to the Editor
for ruling out cardiac erosion following transcatheter closure of ASD using ASO. In order to distinguish erosion from other etiologies of pericardial effusion, we utilized this strategy of injecting a contrast intravenously and trying to see whether it leaks into the pericardial cavity. The presence of such a leak would be a pointer toward CP. Agitated saline contrast can also be used to opacify the right heart structures to identify erosion on the right side but its use is limited by the fact that the contrast bubbles do not cross over to the left side thereby preventing detection of CP in the left sided structures. CT angiography can also be used to identify protrusion of the ASO into the pericardial space but cannot be performed bed side and is much more expensive and less easily available in developing countries. In order to assess the sensitivity and specificity of these techniques, one will need to study a large cohort of patients subjected to both the techniques of evaluation. We suggest that contrast echocardiography should be done in all patients who develop pericardial effusion following device closure of ASD using ASO to confirm or rule out CP. Shreepal Jain, MD, FNB Robin Pinto, MD, DM Bharat Dalvi, MD, DM*
3
REFERENCES 1. Masura J, Gavora P, Podnar T. Long-term outcome of transcatheter secundum-type septal defect closure using Amplatzer septal occluders. J Am Coll Cardiol 2005;45:505–507. 2. Amin Z, Hijazi ZM, Bass JL, Cheatham JP, Hellenbrand WE, Kleinman CS. Erosion of Amplatzer septal occluder device after closure of secundum atrial septal defects: Review of registry of complications and recommendations to minimize future risk. Catheter Cardiovasc Interv 2004;63:496–502. 3. Ewert P, Kretschmar O, Peters B, et al. Preliminary experience with a new 18 mm Amplatzer PFO occluder for small persistent foramen ovale. Catheter Cardiovasc Interv 2003;59:518–521. 4. Schrader R. Catheter closure of secundum ASD using “other” devices. J Interv Cardiol 2003;16:409–412. 5. Divekar A, Gaamangwe T, Shaikh N, Raabe M, Ducas J. Cardiac perforation after device closure of atrial septal defects with the Amplatzer septel occluder. J Am Coll Cardiol 2005;45: 1213–1218. 6. Spence MS, Qureshi SA. Complications of transcatheter closure of atrial septal defects. Heart 2005;91:1512–1514. 7. Waggoner AD, Williams GA, Gaffron D, Schwarze M. Potential utility of left heart contrast agents in diagnosis of myocardial rupture by 2-dimensional echocardiography. J Am Soc Echocardiogr 1999;12:272–274. 8. Garcıa-Fernandez MA, Odreman Macchioli RO, Moreno PM, Yang€uela MM, Thomas JB, Sendon JLL, Lopez de Sa E, Abdou YH. Use of contrast echocardiography in the diagnosis of subacute myocardial rupture after myocardial infarction. J Am Soc Echocardiogr 2001;14:945–947. 9. Mittle S, Makaryus AN, Mangion J. Role of contrast echocardiography in the assessment of myocardial rupture. Echocardiography 2003;20:77–81.
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
