Abstract
With the introduction of technological improvements, invasive cardiologic interventions have become increasingly used alternatives to surgery. Despite its numerous benefits, serious and potentially life-threatening complications of invasive cardiology interventions may occur. Herein, we report a case who developed two different complications due to an invasive cardiology intervention at different times.
One of them was device embolization after transcatheter closure of atrial septal defect and the other was right ventricle perforation due to late pericardial tamponade-related percutaneous pericardiocentesis. Both complications associated with percutaneous intervention were surgically treated.
Introduction
Atrial septal defect (ASD) is one of the most common congenital heart defects requiring procedural intervention. Transcatheter closure of ASD has gained wide popularity thanks to its high success rates, lack of scar, low morbidity, and shorter hospital stay.
However, several complications have been reported, although rare, such as arrhythmia, embolization, erosion, fracture, malfunction, malposition, stroke, thrombus on device.[1] The reported incidence of early device embolization after transcatheter ASD closure with Amplatzer septal occluder (AGA Medical Corp, Golden Valley, Minn) is approximately 0.5%.[
Case Presentation
A 41-year-old female patient was admitted to cardiology outpatient clinic with complaints of shortness of breath and tachycardia. Transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) demonstrated a 20 mm secundum ASD with adequate rims. The patient was scheduled for the deployment of percutaneous closure device, as ASD’s morphology was suitable for percutaneous closure. A 26 mm Amplatzer device was deployed successfully without any complications through catheterization. On the first day after implantation, repeated echocardiography and fluoroscopy detected device migration into the left ventricle (Figure 1). The patient was taken to operation room immediately. After institution of cardiopulmonary bypass, a longitudinal right atriotomy was performed. The edges of the ASD were retracted and the device was detected under anterior leaflet of the mitral valve. The device was gently detached from chordae and retrieved (Figure 2). Mitral valve leaflets and chordae were examined carefully for a possible traumatic injury, however, no pathology was noted. Atrial septal defect was repaired with the running suture technique. The postoperative course was uneventful. Warfarin was initiated due to atrial fibrillation. The patient was discharged on the fifth postoperative day. At two months postoperatively, the patient was admitted with shortness of breath and hypotension. International normalized ratio (INR) was high (>7) and TTE detected massive pericardial effusion. With fresh frozen plasma, INR was normalized. Echocardiography-guided percutaneous pericardiocentesis was performed with the subxiphoid approach. Catheter was seen in right ventricle during procedure. The patient was then taken to operation room immediately. Following median sternotomy, 1500 mL of bloody effusion was drained. Catheter from the right ventricle was removed and the puncture hole was sutured (Figure 3). The patient was discharged on the fourth postoperative day.
Discussion
Percutaneous closure of ASD in adults has emerged as an alternative to surgery. Acute failure of these devices may occur due to several reasons, the most critical condition being poor patient and/or device selection.[2] The other suggested mechanisms of acute failure are as follows: operator-related failure resulting from inadequate experience (learning curve), inaccurate placement, inadequate defect rim to hold the device, tearing of the interatrial septum, at the lower rim of the ASD during catheter, particularly, and device manipulation.[3] According to Boysan et al.[4] coughing may be an interesting reason for device embolization.
A part of the device or the whole device may embolize to the right or left atrium, to the main pulmonary artery, or even to the other parts of the vascular tree. Embolization into left ventricle is rarer compared the right ventricle and pulmonary artery. Percutaneous retrieval of the embolized device is possible in about 70% of cases, and several techniques have been described, including the use of large sheaths, snares, or bioptomes.[5] However, some authors suggest that embolization of device is always an indication for emergency surgical retrieval, which also permits a direct inspection of intra-cardiac structures that may have become injured.[6] In our patient, we also preferred surgical approach due to close relation of device with mitral valve in the left ventricle.
Late postoperative cardiac tamponade is an uncommon, but potentially lethal condition. Several authors have asserted that excessive anticoagulation in the postoperative period is responsible for late postoperative tamponade. Pericardiocentesis with catheter placement is highly effective and patients can be re-anticoagulated safely. In a Mayo Clinic series, echocardiography-guided pericardiocentesis was successful in withdrawing pericardial fluid or relieving tamponade in 97% of the procedures.[7] Major complications including chamber laceration, intercostal vessel injury, pneumothorax requiring a chest tube, sustained ventricular tachycardia (VT), bacteremia, and death occurred in 1.2% of patients.[8] Tsang et al.[9] from Mayo Clinic reviewed 245 patients necessitating pericardiocentesis after cardiac surgery and showed 0.8% incidence of ventricular perforation.
In our case, perforation of right ventricle was diagnosed during pericardiocentesis and the patient was then taken into operation urgently.
In conclusion, a careful echocardiographic assessment and procedure planning should be done for a percutaneous intervention. In addition, surgical back-up must be available in the hospital to cope with potentially lethal acute complications.
Declaration of conflicting interests
The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.
