Early Cardiac Perforation After Atrial Septal Defect Closure With the Amplatzer Septal Occluder

An asymptomatic child of pre-perforation erosion after transcatheter closure of atrial septal defect

BACKGROUND

Fatal pericardial tamponade caused by aortic or atrial perforation due to erosion of atrial septal occluders has been reported previously, but the timing of erosion is uncertain, and the process is also unclear.

CASE PRESENTATION

We present a case of a 5-year-old boy with erosion of the aorta and atrium by the occluder not leading to perforation or pericardial tamponade because of early detection and timely surgery. A small amount of pericardial effusion may be the only manifestation of early erosion. This case firstly revealed the early process of device erosion in children.

CONCLUSIONS

An absent aortic rim may be a higher risk factor for erosion than oversized device for a child, and it is wise to choose a relatively small occluder or change to surgery. This may be helpful for preventing and treating serious complications caused by erosion of the occluder.

Atrio-aortic erosion caused by Amplatzer Atrial Septal Occluder - a case report

Background

In specialized centers, percutaneous closure using specific occluders is the first-choice treatment in atrial septal defects (ASD). Late complications after this intervention, such as erosion of the aorta or the atria, are rare and have not been sufficiently approached and dealt with in literature. In our clinic we have been faced with the problematic situation of diagnosing and treating such cases. That is why, we have decided to share our experience with other colleagues.

Case presentation

We present two cases of severe late complications after percutaneous closure of atrial septal defects (ASD). In both cases, the atrial septal occluder (Amplatzer™ Atrial Septal Occluder Device, Abbott, Chicago USA) caused the erosion between the left atrium and the aortic root. The atrio-aortic erosion led to acute cardiac tamponade with upper venous congestion and shock. As the bleeding source remained undetectable for any imaging tools, a diagnostical sternotomy remained the only solution.

The cause of the acute bleeding was discovered to be the erosion between the left atrium and the aortic root. The treatment consisted in the removal of the occluder, direct suturing of the perforated areas and the surgical closure of the remaining ASD. The patients fully recovered within the nine to fourteen days’ hospital stay. Six months after surgery both patients were well and able to recover their daily routine.

Conclusions

The atrio-aortic erosion after percutaneous closure of atrial septal defects is a surgical emergency. The more so, since it can be complicated by the absence of specific symptoms. A key-element in the diagnosis of this rare pathology remains the medical history of the patient, which the surgeon has to consider thoroughly and launch the diagnostic sternotomy without delay.

Not just another large atrial septal defect: complex anatomy, challenging procedure, and an unusual complication

We report the case of a 59-year-old patient with a complex atrial septal defect in whom a 40-mm Amplatzer™ septal occluder was surgically extracted 50 days following implantation. Deployment manoeuvres were challenging leading to an immediate pericardial effusion that was closely monitored and uneventfully drained after 11 days. A dry pericardium was documented until 4 weeks of outpatient routine follow-up. However, the device was surgically explanted 2 weeks later, when an urgent chest computed tomography performed for worrisome symptoms showed pericardial effusion recurrence with peripheral contrast enhancement. Surprisingly, the surgical view showed a well-positioned device and an intact pericardium. We discuss the atypical sequence of clinical findings misleading our clinical judgement and precipitating surgery.

Surgical perspective of percutaneous device closure of atrial septal defect

Background Percutaneous device closure of an ostium secundum atrial septal defect is associated with excellent outcomes and cosmetic results but at the cost of occasional serious and sometimes fatal complications as well as lifelong follow-up. Surgical intervention is required in cases of device-related complications, which carries a slightly higher risk compared to primary closure of an atrial septal defect. We present a surgical perspective of device closure of atrial septal defect. Methods Our database was searched over 4 years for complications related to percutaneous device closure of atrial septal defect, which required surgical retrieval of the device and closure of the defect. We identified 14 cases that required surgical intervention. Results The median age of the 14 patients was 18 years (range 4-58 years). The size of the defect ranged from 15 to 40 mm (median 30 mm). Device embolization into any part of the cardiovascular system ( n = 8) was the most common complication, followed by malalignment of the device ( n = 5). One patient had left atrial appendage perforation causing pericardial effusion and cardiac tamponade, and underwent surgical repair. The other 13 patients underwent removal of the device and atrial septal defect closure. One patient developed severe mitral regurgitation requiring mitral valve replacement. There was no mortality. Conclusion Although the incidence of device-related complications may be small, they carry a high risk of death or long-term morbidity, even with a small atrial septal defect, unlike primary surgical closure of isolated atrial septal defect.

Budget impact analysis of the percutaneous septal occluder for treatment of ostium secundum atrial septal defects in the Brazilian Unified National Health System

The aim of this study was to perform a budget impact analysis on the adoption of percutaneous occlusion of ostium secundum atrial septal defects in the Brazilian Unified National Health System. Costs were collected using micro-costing technique from medical records for each treatment technique (conventional surgery versus percutaneous septal occluder) at a public federal hospital specialized in high-complexity cardiology. The analysis showed that expenditures associated with percutaneous occlusion were lower than with conventional surgery, and sensitivity analysis confirmed the cost reduction in several scenarios, showing a significant budget impact with a 30% adoption rate for the percutaneous occluder (savings of approximately 1.5 million dollars per year). The study indicates that the adoption of the percutaneous septal occluder would mean cost savings of approximately 3.5 million dollars for the Brazilian public health system.

Large Amplatzer atrial septal occluder in growing children: an echographic study

BACKGROUND

Lesions of adjacent structures have been reported after closure of large atrial septal defects with the Amplatzer septal occluder. In children, growth of the heart should modify the initial relationship between the device and surrounding structures.

AIM

To compare the relationship between large Amplatzer septal occluder and adjacent cardiac structures at short-, mid-, and long-term follow-up in at-risk paediatric population using echocardiography.

METHODS

A total of 25 children (4.6±2.9 years old, 18 girls) with the largest atrial septal defect devices implanted between 1997 and 2002 were enrolled prospectively for complete echocardiogram 17.8±10.5 months (mid-term follow-up) and 8.8±0.9 years (long-term follow-up) after the procedure. RESULTS were compared with the echocardiogram carried out 2.1±3.4 days after the procedure (short-term follow-up).

RESULTS

The minimal distance between the left disk and the mitral valve increased: 1.4±2.0 mm at short-term and 5.1±2.3 mm at long-term follow-up (p<0.05), leading to less contact between the disk and the anterior leaflet and less mitral regurgitation (10 at short-term, 4 at long-term follow-up, p<0.05). The number of devices straddling the aorta decreased from 17 to 12 at long-term follow-up (p<0.05). There was protrusion of disk in the venous structure in seven patients on the first echocardiogram, which disappeared at long-term follow-up.

CONCLUSION

Although frequently in close contact with the aortic root, mitral valve, or venous returns, large devices tend to centre and move away from the surrounding structures, with decreased risk for long-term distortion.

Transcatheter Closure of Large Atrial Septal Defects

Background—

Data are needed on the safety and efficacy of device closure of large atrial septal defects.

Methods and Results—

Between 1998 and 2013, 336 patients (161 children <15 years) with large, isolated, secundum atrial septal defects (balloon-stretched diameter ≥34 mm in adults or echocardiographic diameter >15 mm/m 2 in children) were managed using the Amplatzer device, at the Marie Lannelongue Hospital. Transthoracic echocardiographic guidance was used starting in 2005 (n=219; 65.2%). Balloon-stretched diameter was >40 mm in 36 adults; mean values were 37.6±3.3 mm in other adults and 26.3±6.3 mm/m 2 in children. Amplatzer closure was successful in 311 (92.6%; 95% confidence interval, 89%–95%) patients. Superior and posterior rim deficiencies were more common in failed than in successful procedures (superior, 24.0% versus 4.8%; P =0.002; and posterior, 32.0% versus 4.2%; P <0.001). Device migration occurred in 4 adults (2 cases each of surgical and transcatheter retrieval); in the 21 remaining failures, the device was unreleased and withdrawn. After a median follow-up of 10.0 years (2.5–17 years), all patients were alive with no history of late complications.

Conclusions—

Closure of large atrial septal defects using the Amplatzer device is safe and effective in both adults and children. Superior and posterior rim deficiencies are associated with procedural failure. Closure can be performed under transthoracic echocardiographic guidance in experienced centers. Early device migration is rare and can be safely managed by device extraction. Long-term follow-up showed no deaths or major late complications in our population of 311 patients.

Cost-effectiveness of procedures for treatment of ostium secundum atrial septal defects occlusion comparing conventional surgery and septal percutaneous implant

OBJECTIVES

The study performs a cost-effectiveness analysis of procedures for atrial septal defects occlusion, comparing conventional surgery to septal percutaneous implant.

METHODS

A model of analytical decision was structured with symmetric branches to estimate cost-effectiveness ratio between the procedures. The decision tree model was based on evidences gathered through meta-analysis of literature, and validated by a panel of specialists. The lower number of surgical procedures performed for atrial septal defects occlusion at each branch was considered as the effectiveness outcome. Direct medical costs and probabilities for each event were inserted in the model using data available from Brazilian public sector database system and information extracted from the literature review, using micro-costing technique. Sensitivity analysis included price variations of percutaneous implant.

RESULTS

The results obtained from the decision model demonstrated that the percutaneous implant was more cost effective in cost-effectiveness analysis at a cost of US$8,936.34 with a reduction in the probability of surgery occurrence in 93% of the cases. Probability of atrial septal communication occlusion and cost of the implant are the determinant factors of cost-effectiveness ratio.

CONCLUSIONS

The proposal of a decision model seeks to fill a void in the academic literature. The decision model proposed includes the outcomes that present major impact in relation to the overall costs of the procedure. The atrial septal defects occlusion using percutaneous implant reduces the physical and psychological distress to the patients in relation to the conventional surgery, which represent intangible costs in the context of economic evaluation.

Cardiac erosion after catheter closure of atrial septal defect: Septal malalignment may be a novel risk factor for erosion

Pericardial tamponade occurred 3 days after the catheter closure of an atrial septal defect (ASD) using Amplatzer Septal Occluder (St. Jude Medical, St. Paul, MN, USA). Before the closure, two-dimensional and real-time three-dimensional transesophageal echocardiography demonstrated a deficient aortic rim and atrial septal malalignment. Perforation of the right atrium toward the non-coronary sinus of the aortic root was confirmed at the emergent surgery. Cardiac erosion is one of the most catastrophic complications in ASD patients undergoing catheter closure with Amplatzer Septal Occluder. Hence, several risk factors for this complication are discussed and identified. Oversized device deployment and a deficient aortic rim are accepted factors potentially causing cardiac erosion. Besides, atrial septal malalignment, which is a morphological characteristic of ASD, may be a novel risk factor for cardiac erosion. <Learning objective: Cardiac erosion is a potentially lethal complication when catheter closure of atrial septal defects using Amplatzer Septal Occluder (St. Jude Medical, St. Paul, MN, USA) is provided to the patients. However, mechanisms of this complication remain to be completely elucidated. Atrial septal malalignment may be one of the novel risk factors for this catastrophic complication.>.

Atrial septum defect closure device in a beating heart, from the perspective of a researcher in artificial organs

Transcatheter closure of atrial septum defect (ASD) with a closure device is increasing, but the history of clinical use of this procedure is still short, and the efficacy and long-term safety remain unproved. The total number of closure devices implanted throughout the world has not been counted accurately. Therefore, the probability of complications occurring after implantation is uncertain. Device-related complications that occur suddenly late after implantation are life-threatening, and quite often necessitate emergency surgical intervention. In Japanese medical journals, authors reporting closure devices have mentioned no complications and problems in their facilities. Detailed studies of device-related complications and device removal have not been reported in Japan. In fact, this literature search found an unexpectedly large number of reports of various adverse events from many overseas countries. When follow-up duration is short and the number of patients is small, the incidence of complications cannot be determined. Rare complications may emerge in a large series with a long observation period. Consequently, the actual number of incidents related to ASD closure devices is possibly several times higher than the number reported. Guidelines for long-term patient management for patients with an implanted closure device are necessary and post-marketing surveillance is appropriate. Development of a national database, a worldwide registration system, and continuous information disclosure will improve the quality of treatment. The devices currently available are not ideal in view of reports of late complications requiring urgent surgery and the need for life-long follow-up. An ideal device should be free from complications during life, and reliability is indispensable.

Late free atrial wall rupture after percutaneous atrial septal defect closure and transvenous pacemaker implantation

We report a remarkable case of right atrial rupture, 3 years after transcatheter closure of a secundum atrial septal defect, and 7 months after permanent transvenous two-chamber pacemaker implantation. The etiology of the rupture remains unclear, but the presence of the two intracardiac devices is probably not coincidental.

Penetration of left and right atrial wall and aortic root by an Amplatzer atrial septal occluder in a nine year old boy with Marfan syndrome: Case report

Background

To describe complications associated with Amplatzer septal occluders in a patient with Marfan syndrome

Case presentation

A nine-year-old boy with Marfan syndrome and a 22 mm atrial septal defect (ASD) was treated successfully by interventional closure of his ASD by placing a 24 mm Amplatzer septal occluder. Follow up examinations showed a good result but an increasing enlargement of aortic root, so the patient was scheduled for operation. Intraoperative findings showed a perforation of the left atrial roof and the non-coronary sinus by penetration of the occluder device as well as penetration into the right atrial wall. The occluder was resected, the ASD was closed and the aortic sinus was reconstructed using a Dacron patch.

Conclusion

We describe the first case of a patient with Marfan syndrome and an interventional closure of an ASD. Due to alterations of the connective tissue, as it is typical for patients with Marfan syndrome, the Amplatzer occluder probably perforated adjacent structures more easily as in non-affected individuals. Amplatzer occluders should be used with caution and follow up examinations should be performed in short intervals.

Comparison of three patent foramen ovale closure devices in a randomized trial (Amplatzer versus CardioSEAL-STARflex versus Helex occluder)

This randomized trial compared procedural complications and 30-day clinical outcomes of 3 patent foramen ovale (PFO) closure devices (Amplatzer, Helex, and CardioSEAL-STARflex). It examined 660 patients (361 men, 299 women, mean age 49.3+/-1.9 years), with 220 patients per group. All patients had a history of paradoxical embolism. All PFO closures were successful technically. Exchange of devices for others was most frequently required for the Helex occluder (7 of 220) and 2 of 220 in either of the other groups. Three device embolizations in the Helex group were retrieved and replaced successfully. One patient with a Helex occluder developed a transient ischemic attack and recovered without treatment. A hemopericardium in that group was punctured without affecting the device. One tamponade in the Amplatzer group required surgical device explantation. In 8 of 660 patients in the CardioSEAL-STARflex group, thrombi resolved after anticoagulation. Sixteen patients (11 in the CardioSEAL-STARflex group, 3 in the Amplatzer group, and 2 in the Helex group) had episodes of atrial fibrillation. PFOs were closed completely in 143 of 220 patients (65%) in the Amplatzer group, 116 of 220 patients (52.7%) in the Helex group, and 137 of 220 patients (62.3%) in the CardioSEAL-STARflex group at 30 days with significant differences between the Helex and Amplatzer occluders (p=0.0005) and the Helex and CardioSEAL-STARflex occluders (p=0.0003). PFO closure can be performed safely with each device. In conclusion, the Helex occluder embolized more frequently. Device thrombus formation and paroxysmal atrial fibrillation were more common with the CardioSEAL-STARflex occluder.

Transcatheter closure of atrial septal defect with Amplatzer device in children aged less than 10 years old: immediate and late follow-up

AIMS

To analyze the efficacy and follow-up results of percutaneous closure of Atrial septal defect (ASD) with the Amplatzer septal occluder in children aged <10 years old.

METHODS

Between November 1998 and September 2005, 27 patients diagnosed with ASD were treated percutaneously with an Amplatzer septal occluder. The procedure was carried out in the cathlab, under general anesthesia and with both fluoroscopy and transesophageal echocardiography guidance. Basal physical examinations and echocardiograms were performed prior to the procedure and at 30 days, 6, and 12 months of follow-up. Survival free of symptom was estimated by Kaplan-Meier.

RESULTS

The mean age, weight, height, body mass index, and corporal surface was: 5.35 +/- 2.11 years, 23.07 +/- 9.43 kg, 110.55 +/- 17.6 cm, 16.77 +/- 2.42 kg/m(2), and 1.24 +/- 2.44 m(2). The prevalence of septal aneurysm was 3.7% and all patients presented single secundum ASD. The mean stretched diameter by fluoroscopy and transesophageal echocardiography were 17.18 +/- 6.75 mm and 16.77 +/- 5.99 mm, and the prostheses sizes were 18.83 +/- 6.98 mm, ranging from 10 to 30 mm. The systolic and diastolic pulmonary pressures were 25.26 +/- 5.97 mm Hg and 13.38 +/- 3.40 mm Hg, respectively. The procedure time was 82.92 +/- 29.14 min and the hospital stay was 2.20 +/- 0.26 days. Clinical and echocardiography follow-ups were performed within 11.59 +/- 4.42 months and all devices were in the correct position with no residual shunt. Right ventricular diameter decreased from 19.38 +/- 5.23mm to 11.38 +/- 11.92 (P 0.001). No major complications or deaths occurred; two patients had a hematoma at the vascular access.

CONCLUSION

Secundum atrial septal defect closure can be safely and successfully performed with the Amplatzer septal occluder in children younger than 10 years old.