European Journal of Echocardiography 2007 8(1):57-59; doi:10.1016/j.euje.2005.11.001
Copyright © 2005, The European Society of Cardiology
Late spontaneous resolution of iatrogenic fistula between right atrium and aorta secondary to percutaneous closure of patent foramen ovale
Jean-Marc Meier*,
Mohammed Nasratullah and
Eric Eeckhout
Service of Cardiology, Centre Hospitalier Universitaire Vaudois, Rue du Bugnon 46, 1011 Lausanne, Switzerland
Received 11 July 2005; received in revised form 10 November 2005; accepted after revision 17 November 2005.
* Corresponding author. Tel.: +41 21 314 05 16; fax: +41 21 314 00 22. jean-marc.meier{at}chuv.hospvd.ch
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Case report
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We recently investigated in our center a 53-year-old farmer
known for two consecutive strokes in 1999 and 2001, considered
as cryptogenic after extensive neurological work-up. Transthoracic
(TTE) and transoesophageal (TEE) echocardiographies revealed
a patent foramen ovale (PFO) with an interatrial septum aneurysm
of 13mm excursion and a large right-to-left shunt. Therefore,
in May 2002, we performed a percutaneous closure of the PFO
with implantation of a 35/5-mm PFO Star device in a 108 kg and
178-cm tall patient. There was no periprocedural or early complication.
One year later a small fistula between the right atrium and
aortic root was incidentally diagnosed during routine TTE follow-up,
and confirmed by TEE (
Figs. 1 and 2
), whereas clinical examination
revealed no audible cardiac murmur. Due to its location, this
fistula was considered as a decubitus lesion caused by one of
the mechanical arms of the device. Antiaggregant treatment (Aspirin
100mg/d) was discontinued and conservative attitude with regular
echocardiographic follow-up was initiated in this asymptomatic
patient. After 18 months of follow-up the status was unchanged.
At 2 years, no residual shunt was visualized during TTE and
TEE confirmed the resolution of the aorto-atrial fistula (
Fig. 3).
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Discussion
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This case illustrates a rare complication of percutaneous closure
of PFO with an uncommon evolution.
Baseline echocardiographic findings revealed a slightly enlarged left atrium (23mm/m2), a PFO with large right-to-left shunt during the Valsalva maneuver after antecubital vein injection of microbubbles and a 13-mm atrial septal aneurysm (ASA), and normal adjacent cardiac structures. During TEE, atrial septum diameter was 28mm at 0° and 36mm at 78°. CE approved 35-mm PFO Star occluder was chosen on the basis of atrial septum size and concomitant presence of ASA and optimal deployment of discs on both sides of atrial septum was visualized at the end of the procedure. We believe that the late complication we observed was unpredictable on the basis of periprocedural echocardiography but might be most probably related to the mechanical characteristics of this old generation of PFO Star device and the fact that one of the arm of the implant was directly protruding into the aorta.
To our knowledge, only three similar cases of aorto-atrial fistulas following transcatheter closure of PFO or atrial septal defect have been reported so far in the literature.1–3 Two case reports refer to fistula between aorta and right or left atrium, respectively, following percutaneous implantation of Amplatzer septal occluder for atrial septal defects. One case of fistula between aorta and right atrium after PFO closure with the PFO Star device has been briefly mentioned. Diagnosis was made 1 month after closure during routine echocardiography and the authors report a spontaneous closure after discontinuation of oral anticoagulation.
Our report of late spontaneous fistula closure after discontinuation of antiagregant therapy in an asymptomatic patient is of paramount interest in the management of such rare potential complication of percutaneous PFO closure as this procedure is emerging as the treatment of choice for selected patients who suffered cryptogenic stroke due to paradoxical embolism.
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References
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- Chun D.S., Turrentine M.W., Moustapha A., Hoyer M.H. Development of aorta-to-right atrial fistula following closure of secundum atrial septal defect using the Amplatzer septal occluder. Catheter Cardiovasc Interv (2003) 58(2):246–251.[CrossRef][Web of Science][Medline]
- Aggoun Y., Gallet B., Acar P., Pulik M., Czitrom D., Lagier A., et al. Perforation of the aorta after percutaneous closure of an atrial septal defect with an Amplatz prosthesis, presenting with acute severe hemolysis. Arch Mal Coeur Vaiss (2002) 95(5):479–482.[Web of Science][Medline]
- Stauffer J.C., Serra M., Juillard J.M., Seydoux C., Perret F., Owlya R., et al. Percutaneous closure of patent foramen ovale: preliminary experience with the PFO Star. Arch Mal Coeur Vaiss (2004) 97(1):37–41.[Web of Science][Medline]
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