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Late Cardiac Perforation After Transcatheter Closure of Patent Foramen Ovale

2006; Elsevier BV; Volume: 81; Issue: 6 Linguagem: Inglês

10.1016/j.athoracsur.2006.02.057

1552-6259

Moreno Cecconi, Andrea Quarti, Fabio Bianchini, S Bucari, Carlo Costantini, Andrea Giovagnoni, Gian Piero Perna,

Atrial Fibrillation Management and Outcomes

Cardiac perforation after transcatheter closure of a patent foramen ovale is a very rare complication. We report a case of left atrial wall perforation and aortic root erosion occurring 16 months after implantation of an Amplatzer patent foramen ovale occluder that required emergent surgery. Cardiac perforation after transcatheter closure of a patent foramen ovale is a very rare complication. We report a case of left atrial wall perforation and aortic root erosion occurring 16 months after implantation of an Amplatzer patent foramen ovale occluder that required emergent surgery. Cardiac perforation is a rare, life-threatening complication of transcatheter atrial septal defect and patent foramen ovale (PFO) closure [1Amin Z. Hijazi Z.M. Bass J.L. Cheatham J.P. Hellenbrand W.E. Kleinman C.S. 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: 496-502Crossref PubMed Scopus (478) Google Scholar, 2Divekar A. Gaamangwe 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: 1213-1218Abstract Full Text Full Text PDF PubMed Scopus (223) Google Scholar, 3Trepels T. Zeplin H. Sievert H. et al.Cardiac perforation following transcatheter PFO closure.Catheter Cardiovasc Interv. 2003; 58: 111-113Crossref PubMed Scopus (63) Google Scholar, 4Preventza O. Sampath-Kumar S. Wasnick J. Gold J.P. Late cardiac perforation following transcatheter atrial septal defect closure.Ann Thorac Surg. 2004; 77: 1435-1437Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar]. This complication has been described after implantation of various devices, including the Amplatzer septal occluder and the Amplatzer PFO occluder [1Amin Z. Hijazi Z.M. Bass J.L. Cheatham J.P. Hellenbrand W.E. Kleinman C.S. 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: 496-502Crossref PubMed Scopus (478) Google Scholar, 2Divekar A. Gaamangwe 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: 1213-1218Abstract Full Text Full Text PDF PubMed Scopus (223) Google Scholar, 3Trepels T. Zeplin H. Sievert H. et al.Cardiac perforation following transcatheter PFO closure.Catheter Cardiovasc Interv. 2003; 58: 111-113Crossref PubMed Scopus (63) Google Scholar, 4Preventza O. Sampath-Kumar S. Wasnick J. Gold J.P. Late cardiac perforation following transcatheter atrial septal defect closure.Ann Thorac Surg. 2004; 77: 1435-1437Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar, 5Christen T. Mach F. Didier D. Kalangos A. Verin V. Trindade P.T. Late cardiac tamponade after percutaneous closure of a patent foramen ovale.Eur J Echocardiogr. 2005; 6: 465-469Crossref PubMed Scopus (16) Google Scholar]. The incidence of cardiac perforation after the placement of an Amplatzer septal occluder is approximately 0.1 % [1Amin Z. Hijazi Z.M. Bass J.L. Cheatham J.P. Hellenbrand W.E. Kleinman C.S. 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: 496-502Crossref PubMed Scopus (478) Google Scholar]. Cardiac perforation by an Amplatzer PFO occluder is even rarer, and we believe it has been reported in only 3 patients [1Amin Z. Hijazi Z.M. Bass J.L. Cheatham J.P. Hellenbrand W.E. Kleinman C.S. 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: 496-502Crossref PubMed Scopus (478) Google Scholar, 3Trepels T. Zeplin H. Sievert H. et al.Cardiac perforation following transcatheter PFO closure.Catheter Cardiovasc Interv. 2003; 58: 111-113Crossref PubMed Scopus (63) Google Scholar]. We describe a case of left atrial wall perforation associated with erosion of the aortic root, which occurred 16 months after placement of an Amplatzer PFO occluder. This is the longest latency between transcatheter closure of a PFO and cardiac perforation reported until now. A 65-year-old man presented with chest pain to the emergency department. Because of a history of multiple cerebral transitory ischemic events, he had undergone a transcatheter PFO closure with a 25-mm Amplatzer PFO occluder at another institution 16 months prior. However no specific details on the procedure were available; the device was reported to be correctly positioned, and no recurrent cerebral ischemic events occurred. On examination, the patient was clinically and hemodynamically stable. Electrocardiogram showed nonspecific ST-wave and T-wave changes. Transthoracic echocardiography demonstrated a mildly hypertrophied left ventricle with a normal systolic function, an enlarged aortic root and ascending aorta (maximum diameter, 4.2 cm), the Amplatzer PFO occluder within the atrial septum, and a mild to moderate pericardial effusion without evidence of cardiac tamponade. The patient was referred for a computed tomographic scan, which demonstrated a localized thickening of the posterior wall of the aortic root without diagnostic images of intramural hematoma or intimal flap. A transesophageal echocardiogram confirmed this finding and showed the “penetration” of the left atrial disk of the Amplatzer PFO occluder into the anterosuperior left atrial wall and the posterior wall of the aortic root (Fig 1). In addition, a left pleural effusion was found. A magnetic resonance angiographic scan showed an extravasation of the dye from the left atrial cavity into the pericardium and the pleura, bilaterally. This was consistent with a left atrial wall perforation by the Amplatzer PFO occluder. Thus an emergent surgery was planned. After removal of blood clots, a small perforation (3 mm in diameter) of the anterosuperior left atrial wall was detected (Fig 2). In addition, a concomitant erosion of the posterior wall of the aortic root involving the adventitia and the media was observed. Cardiopulmonary bypass was established as usual, and the device was removed. The septal defect was repaired by direct suture, while the anterosuperior left atrial wall was reinforced by means of pledgets. In addition, the aortic wall was secured with sutures reinforced with pledgets. Both pleural cavities were opened and blood was found and removed. The early postoperative course was characterized by reopening for bleeding. The patient was discharged on postoperative day 9 without further complications.Fig 2Intraoperative illustration showing the perforation of the anterosuperior left atrial wall (arrow). (Ao = aorta; SVC = superior vena cava.)View Large Image Figure ViewerDownload (PPT) The PFO has been increasingly recognized as a source of paradoxical embolism and is associated with cerebrovascular events, particularly in young patients [3Trepels T. Zeplin H. Sievert H. et al.Cardiac perforation following transcatheter PFO closure.Catheter Cardiovasc Interv. 2003; 58: 111-113Crossref PubMed Scopus (63) Google Scholar, 5Christen T. Mach F. Didier D. Kalangos A. Verin V. Trindade P.T. Late cardiac tamponade after percutaneous closure of a patent foramen ovale.Eur J Echocardiogr. 2005; 6: 465-469Crossref PubMed Scopus (16) Google Scholar, 6Windecker S. Wahl A. Nedeltchev K. et al.Comparison of medical treatment with percutaneous closure of patent foramen ovale in patients with cryptogenic stroke.J Am Coll Cardiol. 2004; 44: 750-758Abstract Full Text Full Text PDF PubMed Scopus (302) Google Scholar]. Transcatheter PFO closure has been proposed as an alternative to medical treatment or surgical closure for secondary prevention of cerebrovascular events in patients with presumed paradoxical embolism [3Trepels T. Zeplin H. Sievert H. et al.Cardiac perforation following transcatheter PFO closure.Catheter Cardiovasc Interv. 2003; 58: 111-113Crossref PubMed Scopus (63) Google Scholar, 5Christen T. Mach F. Didier D. Kalangos A. Verin V. Trindade P.T. Late cardiac tamponade after percutaneous closure of a patent foramen ovale.Eur J Echocardiogr. 2005; 6: 465-469Crossref PubMed Scopus (16) Google Scholar, 6Windecker S. Wahl A. Nedeltchev K. et al.Comparison of medical treatment with percutaneous closure of patent foramen ovale in patients with cryptogenic stroke.J Am Coll Cardiol. 2004; 44: 750-758Abstract Full Text Full Text PDF PubMed Scopus (302) Google Scholar]. This procedure is effective and safe [6Windecker S. Wahl A. Nedeltchev K. et al.Comparison of medical treatment with percutaneous closure of patent foramen ovale in patients with cryptogenic stroke.J Am Coll Cardiol. 2004; 44: 750-758Abstract Full Text Full Text PDF PubMed Scopus (302) Google Scholar]; however it is associated with a certain risk of complications, including embolization of the device, air embolism, vascular access site problems, and also, very rarely, cardiac perforation [1Amin Z. Hijazi Z.M. Bass J.L. Cheatham J.P. Hellenbrand W.E. Kleinman C.S. 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: 496-502Crossref PubMed Scopus (478) Google Scholar, 3Trepels T. Zeplin H. Sievert H. et al.Cardiac perforation following transcatheter PFO closure.Catheter Cardiovasc Interv. 2003; 58: 111-113Crossref PubMed Scopus (63) Google Scholar, 5Christen T. Mach F. Didier D. Kalangos A. Verin V. Trindade P.T. Late cardiac tamponade after percutaneous closure of a patent foramen ovale.Eur J Echocardiogr. 2005; 6: 465-469Crossref PubMed Scopus (16) Google Scholar, 6Windecker S. Wahl A. Nedeltchev K. et al.Comparison of medical treatment with percutaneous closure of patent foramen ovale in patients with cryptogenic stroke.J Am Coll Cardiol. 2004; 44: 750-758Abstract Full Text Full Text PDF PubMed Scopus (302) Google Scholar]. This last complication has been reported after closure of atrial septal defect and PFO using various devices [1Amin Z. Hijazi Z.M. Bass J.L. Cheatham J.P. Hellenbrand W.E. Kleinman C.S. 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: 496-502Crossref PubMed Scopus (478) Google Scholar, 2Divekar A. Gaamangwe 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: 1213-1218Abstract Full Text Full Text PDF PubMed Scopus (223) Google Scholar, 3Trepels T. Zeplin H. Sievert H. et al.Cardiac perforation following transcatheter PFO closure.Catheter Cardiovasc Interv. 2003; 58: 111-113Crossref PubMed Scopus (63) Google Scholar, 4Preventza O. Sampath-Kumar S. Wasnick J. Gold J.P. Late cardiac perforation following transcatheter atrial septal defect closure.Ann Thorac Surg. 2004; 77: 1435-1437Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar, 5Christen T. Mach F. Didier D. Kalangos A. Verin V. Trindade P.T. Late cardiac tamponade after percutaneous closure of a patent foramen ovale.Eur J Echocardiogr. 2005; 6: 465-469Crossref PubMed Scopus (16) Google Scholar]. Among patients with an Amplatzer device it was mainly described after closure of atrial septal defect using the Amplatzer septal occluder [1Amin Z. Hijazi Z.M. Bass J.L. Cheatham J.P. Hellenbrand W.E. Kleinman C.S. 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: 496-502Crossref PubMed Scopus (478) Google Scholar, 2Divekar A. Gaamangwe 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: 1213-1218Abstract Full Text Full Text PDF PubMed Scopus (223) Google Scholar, 4Preventza O. Sampath-Kumar S. Wasnick J. Gold J.P. Late cardiac perforation following transcatheter atrial septal defect closure.Ann Thorac Surg. 2004; 77: 1435-1437Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar]. It occurs at the anterosuperior wall of the atria and may also extend to the aortic root [1Amin Z. Hijazi Z.M. Bass J.L. Cheatham J.P. Hellenbrand W.E. Kleinman C.S. 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: 496-502Crossref PubMed Scopus (478) Google Scholar, 2Divekar A. Gaamangwe 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: 1213-1218Abstract Full Text Full Text PDF PubMed Scopus (223) Google Scholar, 4Preventza O. Sampath-Kumar S. Wasnick J. Gold J.P. Late cardiac perforation following transcatheter atrial septal defect closure.Ann Thorac Surg. 2004; 77: 1435-1437Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar]. It has been hypothesized that the Amplatzer septal occluder transmits deformative forces at the point of contact between the device, the anterosuperior atrial wall, and the aorta [2Divekar A. Gaamangwe 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: 1213-1218Abstract Full Text Full Text PDF PubMed Scopus (223) Google Scholar], which may result in cardiac perforation. Possible risk factors that may lead to cardiac perforation by the Amplatzer septal occluder (including a deficient aortic or superior rim of the ostium secundum atrial septal defect, or both, and an oversized device) have been identified [1Amin Z. Hijazi Z.M. Bass J.L. Cheatham J.P. Hellenbrand W.E. Kleinman C.S. 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: 496-502Crossref PubMed Scopus (478) Google Scholar, 2Divekar A. Gaamangwe 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: 1213-1218Abstract Full Text Full Text PDF PubMed Scopus (223) Google Scholar]. Cardiac perforation related to the Amplatzer PFO occluder is a very rare event that we believe was reported in only 3 previous cases [1Amin Z. Hijazi Z.M. Bass J.L. Cheatham J.P. Hellenbrand W.E. Kleinman C.S. 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: 496-502Crossref PubMed Scopus (478) Google Scholar, 3Trepels T. Zeplin H. Sievert H. et al.Cardiac perforation following transcatheter PFO closure.Catheter Cardiovasc Interv. 2003; 58: 111-113Crossref PubMed Scopus (63) Google Scholar]. The site and cause are similar to those found using the Amplatzer septal occluder [1Amin Z. Hijazi Z.M. Bass J.L. Cheatham J.P. Hellenbrand W.E. Kleinman C.S. 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: 496-502Crossref PubMed Scopus (478) Google Scholar]. Although it is desirable to implant smaller devices, the risk of cardiac perforation does not seem to be closely related to the size of the device itself, as it has also been reported for the Amplatzer septal occluder [2Divekar A. Gaamangwe 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: 1213-1218Abstract Full Text Full Text PDF PubMed Scopus (223) Google Scholar]. In our patient, a relatively small device (25 mm) was implanted; moreover, the erosion of the atrial wall was caused by the left occluder disk, which is smaller than the right one. We can hypothesize two factors that potentially concurred in the development of the cardiac perforation: (1) an upward location of the foramen ovale with a reduced distance between it and the anterosuperior atrial wall; (2) the concomitant dilatation of the proximal thoracic aorta, which might have promoted the contact between the device and the atrial wall and the aorta itself. Cardiac perforation is usually associated with cardiac tamponade [1Amin Z. Hijazi Z.M. Bass J.L. Cheatham J.P. Hellenbrand W.E. Kleinman C.S. 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: 496-502Crossref PubMed Scopus (478) Google Scholar, 2Divekar A. Gaamangwe 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: 1213-1218Abstract Full Text Full Text PDF PubMed Scopus (223) Google Scholar, 3Trepels T. Zeplin H. Sievert H. et al.Cardiac perforation following transcatheter PFO closure.Catheter Cardiovasc Interv. 2003; 58: 111-113Crossref PubMed Scopus (63) Google Scholar, 4Preventza O. Sampath-Kumar S. Wasnick J. Gold J.P. Late cardiac perforation following transcatheter atrial septal defect closure.Ann Thorac Surg. 2004; 77: 1435-1437Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar, 5Christen T. Mach F. Didier D. Kalangos A. Verin V. Trindade P.T. Late cardiac tamponade after percutaneous closure of a patent foramen ovale.Eur J Echocardiogr. 2005; 6: 465-469Crossref PubMed Scopus (16) Google Scholar]. In our case, the extravasation of blood both in the pericardium and in the pleura probably prevented overt tamponade. The long latency between the implant and the cardiac perforation (16 months) must be emphasized. Because timing for cardiac perforation development is unpredictable, a careful lifelong follow-up is needed, particularly in patients at higher risk, as those with dilatation of proximal thoracic aorta. We thank Prof Antonio Maria Calafiore for his critical review and suggestions.