Author + information
- Received November 22, 2016
- Accepted November 30, 2016
- Published online February 20, 2017.
- aDepartment of Radiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- bDepartment of Pediatrics, Taichung Veterans General Hospital, Taichung, Taiwan
- ↵∗Address for correspondence:
Dr. Ge-Jun Zhang, Department of Radiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China.
Cardiac perforation or erosion is a rare but potentially lethal complication of transcatheter closure of an atrial septal defect (ASD). The usual solution would be surgical repair (1). We present a patient who underwent device closure of an ASD with an Amplatzer septal occluder (ASO) (AGA Medical, Golden Valley, Minnesota) and later developed an aorta–to–right atrium fistula. The fistula was successfully closed using a transcatheter technique.
A 7-year-old girl with a 12-mm secundum-type ASD and a deficient aortic rim underwent successful ASD closure using a 16-mm ASO. Follow-up echocardiography 1 month later showed a small aorta–to–right atrium fistula (Figure 1). The patient was asymptomatic initially but developed hematuria and fatigue 3 weeks later. Hemoglobin dropped to 9.8 g/dl from 13.4 g/dl. After informed consent was obtained from the patient’s parents, cardiac catheterization was performed under general anesthesia with fluoroscopic and transthoracic echocardiographic guidance. Aortography showed that the diameter of the fistula was 3 mm (Figure 2). The fistula was crossed in a retrograde fashion from the aorta using a 5-F Judkins right coronary catheter. A 0.035-inch glide wire was advanced into the superior vena cava and exteriorized out of the femoral vein. A 6-F patent ductus arteriosus delivery sheath (Lifetech Scientific, Shenzhen, China) was advanced in an antegrade manner into the ascending aorta. A 6/4-mm patent ductus arteriosus device (Lifetech Scientific) was deployed to close the fistula (Figure 3). The patient is doing well with good device position and no residual leak on echocardiography through 3-year follow-up (Figure 4).
Transcatheter closure of ASDs has been proved to be safe and effective. The complication of cardiac perforation or erosion is very rare (0.1%) but potentially lethal (1–3).
Suggested risk factors for erosion include: 1) an atrial rim size of <5 mm; 2) excessive mobility of the device; 3) excessive oversizing of the ASO (≥1.5 times the size of the ASD); 4) splaying of the atrial disks across the aortic root; and 5) extreme movement of the deployed device before release (1,4). In our patient, there was a deficient aortic rim. The edge of the right atrial disk likely moved with the cardiac cycle and eroded the atrial wall.
This is the first reported case, to the best of our knowledge, of device closure of an aorta–to–right atrium fistula caused by an ASO device. After 3 years of follow-up, the patient is doing well without additional problems.
In conclusion, our limited experience demonstrates that device closure of an ASO-related fistula is feasible, safe, and effective.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received November 22, 2016.
- Accepted November 30, 2016.
- American College of Cardiology Foundation
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