Circulation. 2008;117:e181-e183
doi: 10.1161/CIRCULATIONAHA.107.724039
(Circulation. 2008;117:e181-e183.)
© 2008 American Heart Association, Inc.
Images in Cardiovascular Medicine |
Unusual Complication With Transcatheter Closure of an Atrial Septal Defect Prevented by Adequate Imaging
Werner Scholtz, MD;
Smita Jategaonkar, MD;
Lothar Faber, MD, FESC;
Dieter Horstkotte, MD, PhD, FESC
From the Department of Cardiology, Heart and Diabetes Center North Rhine-Westphalia, Ruhr University Bochum, Bad Oeynhausen, Germany.
Correspondence to Dieter Horstkotte, MD, PhD, FESC, Heart and Diabetes Center North Rhine-Westphalia, Department of Cardiology, Georgstr. 11, D-32545 Bad Oeynhausen, Germany. E-mail akohlstaedt{at}hdz-nrw.de
A 44-year-old woman with progressive dyspnea was referred for transcatheter closure of a recently diagnosed secundum atrial septal defect (ASD). Chest x-ray showed prominent pulmonary arteries, a mild pulmonary volume overload, and a moderate right ventricular enlargement (Figure 1). ECG demonstrated normal sinus rhythm with mild repolarization disturbances in leads III and avL, an incomplete right bundle-branch block, and an indifferent axis with normal time intervals (Figure 2). Cardiac catheterization revealed a significant left-to-right shunt (Qp:Qs=2.9) and coronary angiography a type RII P coronary anomaly with one single coronary artery originating from the right aortic sinus1 (Figure 3). While the patient was sedated, a periprocedural transesophageal echocardiogram by balloon sizing demonstrated a 22-mm stretched diameter of the defect ("stop-flow-technique") and a close anatomic neighborhood of the ASD to the left coronary artery (LCA) (Figure 4).
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Figure 4. The close proximity of the LCA and ASD in a modified long-axis view with transesophageal echocardiography is shown.
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A 24-mm Amplatzer septal occluder was securely positioned in the defect and expanded. Because of the anatomic vicinity of LCA and occluder, coronary angiography was repeated before releasing the device. We thereby demonstrated a systolic compression of the LCA by the left atrial disc (Figure 5). No acute ECG or hemodynamic changes were observed in this situation. After removing the device and placing it on the delivery sheet, the compression disappeared (Figure 6). To prevent potential chronic vascular injuries by the interfering device, the procedure was discontinued and the patient recommended a surgical ASD patch closure.
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Figure 5. Inference between the ASD and LCA originating from the right sinus of Valsalva (right anterior oblique cranial view).
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Figure 6. After retrieval of the Amplatzer septal occluder back into the sheath, the compression of the LCA disappears.
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Despite low peri- and postprocedural complication rates, there are a few reports of sudden deaths during device closure of ASDs.2 In most cases, erosion with a consecutive cardiac tamponade was proven or suspected.3 Despite the low incidence,4 interference of a septal occluder with anatomic variant coronaries may also be a reason for postinterventional fatalities, as ASD patients usually have no coronary angiography on a routine basis. This case emphasizes the importance of adequate periinterventional cardiac imaging to prevent procedure-related complications.
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Disclosures
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None.
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Footnotes
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The online-only Data Supplement, which contains Movies I through X, is available with this article at http://circ.ahajournals.org/cgi/content/full/ 117/10/e181/DC1.
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References
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- Lipton MJ, Barry WH, Obrez I, Silverman JF, Wexler L. Isolated single coronary artery: diagnosis, angiographic, classification and clinical significance. Radiology. 1979; 130: 39–47.[Abstract]
- 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.[Abstract/Free Full Text]
- 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.[CrossRef][Medline]
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- Yamanaka O, Hobbs RE. Coronary artery anomalies in 126,595 patients undergoing coronary arteriography. Cathet Cardiovasc Diagn. 1990; 21: 28–40.[Medline]
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