Author + information
- Received June 27, 2016
- Accepted July 14, 2016
- Published online October 10, 2016.
- Tsunehisa Yamamoto, MDa,
- Hideaki Kanazawa, MD, PhDa,∗ (, )
- Sho Tanosaki, MDa,
- Shinichi Goto, MDa,
- Mai Kimura, MDa,
- Hikaru Tsuruta, MDa,
- Yuji Itabashi, MD, PhDa,
- Mitsushige Murata, MD, PhDa,
- Akira Kunitomi, MDa,
- Yoshiyasu Aizawa, MD, PhDa,
- Takahiko Nishiyama, MD, PhDa,
- Takashi Kohno, MD, PhDa,
- Yuichiro Maekawa, MD, PhDa,
- Seiji Takatsuki, MD, PhDa,
- Motoaki Sano, MD, PhDa,
- Osamu Igawa, MD, PhDb and
- Keiichi Fukuda, MD, PhDa
- aDepartment of Cardiology, Keio University School of Medicine, Tokyo, Japan
- bDepartment of Internal Medicine and Cardiology, Nippon Medical School Tama Nagayama Hospital, Tokyo, Japan
- ↵∗Reprint requests and correspondence:
Dr. Hideaki Kanazawa, Department of Cardiology, Keio University School of Medicine, Shinanomachi 35, Shinjuku-ku, Tokyo 160-8582, Japan.
A 58-year-old woman visited the emergency room for faintness on exertion 1 month after treatment of an atrial septal defect (ASD) by transcatheter closure (Amplatzer septal occluder [ASO], St. Jude Medical, St. Paul, Minnesota). An electrocardiogram showed advanced atrioventricular (AV) block (Figure 1A). Transesophageal echocardiography and 3-dimensional computed tomography revealed no compression of the Valsalva sinus by ASO, and there was a sufficient margin from the edge to the ASO to the AV node (Figures 1B and 1C, Online Video 1), which are major risk factors of AV block after device closure of ASD. The AV block with reproducible pre-syncope occurred during the treadmill exercise test. Based on these findings, we re-evaluated the impact of blood supply impairment to the conduction system. The coronary angiography of right coronary artery obtained before device deployment showed a small branch arising from the sinoatrial nodal artery (Figures 2A and 2B, Online Video 2). Three-dimensional computed tomography demonstrated that this branch, named the right superior descending artery, provided an alternative blood supply to the AV node from the proximal right coronary artery, extending toward the AV node (Figure 2C, Online Video 3), which was compressed by the ASO proximal to the bifurcation (Figure 2D, Online Video 4). We concluded that compression by ASO caused exercise-induced ischemia of the AV node.
This is the first reported case of an adult patient with symptomatic AV block caused by involvement of the right superior descending artery with an ASD closure device.
For supplemental videos and their legends, please see the online version of this article.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received June 27, 2016.
- Accepted July 14, 2016.
- American College of Cardiology Foundation