ARTICLE IN PRESS doi:10.1510/icvts.2007.165647
Interactive CardioVascular and Thoracic Surgery 7 (2008) 167–169 www.icvts.org
Case report - Congenital
Complications in atrial septal defect device closure Arani R. Raghuram*, Ramiah Krishnan, Subbiah Kumar, Kathamuthu Balamurugan Department of Cardiothoracic Surgery, Meenakshi Mission Hospital and Research Center, Melur Road, Madurai 625 107, India Received 26 August 2007; received in revised form 12 October 2007; accepted 15 October 2007
Abstract Atrial septal defect (ASD) is a common congenital cardiac anomaly. Even though surgery is the gold standard, percutaneous device closure is gaining popularity because of the short learning curve, cosmetic advantage and relative safety. The long-term implications are open to question. We report here two cases where surgical intervention was required during attempted percutaneous closure and briefly review the relevant literature. 䊚 2008 Published by European Association for Cardio-Thoracic Surgery. All rights reserved. Keywords: Congenital; Acyanotic; Device; Embolism
1. Introduction Atrial septal defect (ASD) is the commonest surgery performed by cardiac surgeon in training to learn the basics of cardiopulmonary bypass. Of late this entity is slowly slipping out of the surgeon’s hands because of the percutaneous devices. Their usage has gone up significantly because of the short learning curve, cosmetic benefits and safety. However, there is a definite role for the cardiac surgeon in this as exemplified in two of our patients described below. 2. Case report 2.1. Case 1 A 30-year-old lady underwent an uneventful device closure with 30 mm Blockaid ASD Occluder (Shangai Shape Memory Alloy Company, China) under transesophageal echocardiographic (TEE) guidance. She was fine at first month follow-up. Two months after the procedure she complained of vague chest pain and breathlessness. TEE done at that time (Fig. 1) revealed the device in a partially displaced state with significant left to right shunt. At surgery (Fig. 2), the device was found attached to a narrow area of the posterior margin with the rest of the device hanging loosely. The ASD had well defined margins and appeared to be a good case for device closure. It was removed by carefully incising the attached margin of ASD and a pericardial patch was sutured. She made an uneventful recovery. 2.2. Case 2 A 40-year-old gentleman with 36 mm ASD with left to right shunt with moderate pulmonary hypertension and *Corresponding author: Tel.: q91 452 258 8741; fax: q91 452 258 6353. E-mail address:
[email protected] (A.R. Raghuram). 䊚 2008 Published by European Association for Cardio-Thoracic Surgery
moderate right ventricular dysfunction was advised surgical closure. He elected to have device closure. A 40 mm Blockaid device was used to close the ASD. About 10 min after deployment, the device displaced from the site and left to right shunt increased. As it was being observed it gradually got detached and embolised into the right ventricle. A second attempt was made to reposition the device but failed. During the process he developed hemodynamic disturbance. So the procedure was abandoned and taken up for surgical closure. The device was removed percutaneously by holding with a bioptome introduced transfemorally and pulling out. Surgery was scheduled for the next day. At surgery the defect was large with laceration of the posterior rim. He underwent pericardial patch closure and was discharged on the seventh postoperative day. 3. Discussion King and Mills w1x reported in 1976 the feasibility of percutaneous closure of ASD. Latson et al. w2x in 1991 reported successful closure of ASDs in 500 patients with Bard clamshell device. It is gaining popularity because of the short learning curve, cosmetic benefits, reduced pain and reduced hospital stay. However, technical complications with occasional deaths have been reported. The complications reported include cardiac perforations, device malposition or embolisation, residual shunts, vascular trauma, thrombus formation, atrioventricular valve regurgitation, atrial arrhythmias, infectious endocarditis and sudden death w3x. Malposition or embolisation is the commonest reason for surgical intervention. Out of 124 patients who underwent percutaneous closure of ASD, ten patients needed surgical intervention w3x. Seven of these ten patients needed the intervention because of malposition or dislocation. Chessa et al. w4x reported on 417 patients of whom ten patients
ARTICLE IN PRESS 168
A.R. Raghuram et al. / Interactive CardioVascular and Thoracic Surgery 7 (2008) 167–169
Fig. 1. Transthoracic echocardiogram.
Device-related perforations occurred frequently after hospital discharge. The anterosuperior atrial wall andyor adjacent aorta are uniquely vulnerable. Perforations have occurred even after six months. Residual shunts are more frequent with percutaneous closures than with surgical closures. Rao et al. w7x found color Doppler evidence of residual shunts in 45% of patients. Worms et al. w8x found residual shunt in 37% patients with Sideris device. There are many reports of surgical closure of atrial septal defects with no residual shunt. The incidence of thrombus formation is 1.2% in ASD patients and 2.5% in patent foramen ovale (PFO) patients in a study of 1000 patients who underwent percutaneous device closure w9x. Post-procedure atrial fibrillation and persistant atrial septal aneurysm were significant predictors of thrombus formation. The Amplatzer device with nitinol wire covered with expanded polytetrafluoroethylene fabric is less thrombogenic than CardioSEAL and StarFLEX devices, which have a metallic framework with Dacron fabric. 4. Conclusion
Fig. 2. Peroperative photograph.
needed surgical intervention because of malposition or embolisation. The ASDOS and Sideris devices have a higher failure rate than Amplatz device. The Blockaid septal occluder that we have used is a morphological replica of the Amplatzer device available at a fraction of the cost in developing countries. Out of twelve patients who received this device, one patient suffered from dislocation after two months. The other patient in whom a 40 mm device was implanted suffered from intraoperative embolisation. It is emphasized w5x that five rims must be routinely evaluated to decide about suitability for device implantation. Aortic rim, related to aorta and abutting the anterior superior rim of the defect, superior rim, abutting the superior wall of the atrium, SVC rim, bordered by the SVC near the right upper pulmonary vein, inferior rim, bounded by the atrioventricular valves and IVC rim, abutting the IVC. The reported sites of embolisation include right ventricle, pulmonary artery, left ventricle, arch of aorta and peripheral vessels. Perforation is the next common complication. Divekar et al. w6x in a retrospective review found 24 events with Amplatzer device. The technique-related cardiac perforations occur during catheterization or typically before hospital discharge and are amenable to intervention.
Transcatheter closure of ASD is gaining popularity. The procedure related complications are small but not negligible. Absence of residual shunts and late thromboembolic events is in favor of surgical closure of ASD. Minimally invasive techniques address cosmetic angle without compromising results. The need for lifelong antiplatelet agents and SBE prophylaxis has to be weighed against the disadvantage of a small incision. A promising early result does not guarantee a favorable late outcome. Austin w10x in his editorial has rightly reminded us of our experience with Ionescu–Shiley and Bjork–Shiley valves to emphasize the need for continued follow-up and critical evaluation of this method against the gold standard of surgical closure of ASD. References w1x King TD, Mills NL. Secundum atrial septal defects: nonoperative closure during cardiac catheterization. J Am Med Assoc 1976;235:2506–2509. w2x Latson LA, Benson LN, Hellenbrand WE, Mulins CE, Lock JE. Transcatheter closure of ASD – early results of multicenter trial of the Bard clamshell septal occluder. Circulation 1991;84(Suppl II):44. w3x Berdat PA, Chatterjee T, Pfammatter JP, Windecker S, Meier B, Carrel T. Surgical management of complication after transcatheter closure of an atrial septal defect or patent foramen ovale. J Thorac Cardiovasc Surg 2000;120:1034–1039. w4x Chessa M, Carminati M, Butera G, Bini RM, Drago M, Rosti L, Giamberti A, Pome G, Bossone E, Frigiola A. Early and late complications associated with transcatheter occlusion of secundum atrial septal defect. J Am Coll Cardiol 2002;39:1061–1065. w5x Amin Z, Hijazi ZM, Bass JL, Cheatham JP, Hellenbran WE, Kleinman CS. Erosion of Amplatzer septal occluderdevice 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. w6x Divekar A, Gaamangwee T, Shaikh N, Raabe M, Ducas J. Cardiac perforation after device closure of atrial septal defects with the Amplatzer septal occluder. J Am Coll Cardiol 2005;45:1213–1218. w7x Rao PS, Sideris EB, Hausdorf G, Rey C, Lloyd TR, Beekman RH, Worms AM, Boulron F, Onorato E, Khalilullah M. International experience with
ARTICLE IN PRESS A.R. Raghuram et al. / Interactive CardioVascular and Thoracic Surgery 7 (2008) 167–169 secundum atrial septal defect occlusion by the buttoned device. Am Heart J 1994;128:1022–1035. w8x Worms AM, Rey C, Bourlon F, Losay J, Marcon F, Godart F, Coullet JM. Experience francaise de la fermeture des communications interauruculaires de type ostium secundum par la prothese boutonnee de Sideris. Arch Mal Coeur Vaiss 1996;89:509–515.
169
w9x Krumsdorf U, Ostermeyer S, Billinger K, Trepels T, Zadan E, Horvath K, Sievert H. Incidence and clinical course of thrombus formation on atrial septal defect and patent foramen ovale closure devices in 1000 consecutive patients. J Am Coll Cardiol 2004;43:302–309. w10x Austin EH. Editorial. Transcathetr closure of atrial septal defects. J Thorac Cardiovasc Surg 2000;120:1032–1033.
