European Journal of Echocardiography 2007 8(2):155-157; doi:10.1016/j.euje.2005.12.013
Copyright © 2005, The European Society of Cardiology
Echocardiographic visualization of laceration of atrial septum during balloon sizing of atrial septal defect*
Ahmed A. Alsaileek*,
Ahmad Omran,
Michael Godman and
Hani K. Najm
King Abdulaziz Cardiac Center, National Guard Health Affairs, Riyadh, Saudi Arabia
Received 13 September 2005; received in revised form 14 December 2005; accepted after revision 23 December 2005.
* Corresponding author. Division of Cardiovascular Diseases, Mayo Clinic, 200 First Street, SW, Rochester, MN 55905, USA. alsaileek.ahmed{at}mayo.edu
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Abstract
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Transcatheter closure of atrial septal defect (ASD) has become
an accepted alternative to surgery. A number of complications
associated with ASD device closure have been recognized but
most are rare or minor in severity. We report a rare complication
of atrial septal laceration during transcatheter closure of
secundum ASD. We discuss the diagnostic confusion, which resulted
in the decision for surgical correction.
Keywords: Atrial septal defect; Amplatzer device; Transesophageal echocardiography; Laceration; Complication; Congenital; Device closure; Echocardiography
* There is no grant support for this case report. 
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Case report
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A 35-year-old-female was referred to our hospital with the diagnosis
of secundum atrial septal defect (ASD) for device closure. She
had intermittent palpitation for 3months. Cardiac examination
revealed fixed split second heart sound and an ejection murmur
at the left upper sternal edge. The rest of the examination
was within normal limit. Electrocardiogram showed normal sinus
rhythm with incomplete right bundle branch block. Transthoracic
and transesophageal echocardiography confirmed the diagnosis
of a secundum ASD of 20-mm maximum diameter and adequate rim
suitable for device closure. There was mild right-sided heart
enlargement and elevated right ventricular systolic pressure
(RVSP=35 mmHg) with no additional associated cardiovascular
abnormality (
Fig. 1a). She was scheduled to undergo Amplatzer
device occlusion of the defect under general anesthesia. Right-sided
catheterization and angiography were performed according to
a standard protocol.
1 The assessment of the stretched diameter
of the ASD was made with a Meditec sizing balloon. The stretched
diameter was measured at 24–25mm. During this part of
the procedure the balloon passed from the left atrium to the
right atrium with slight but not marked resistance. Following
manipulation of the Meditec sizing balloon, two echo-dense linear
structures were observed on transesophageal echocardiography
extending from both edges of the ASD (
Fig. 1b). The structures
were highly mobile, extending toward the right atrial cavity
and measuring approximately 20mm in length (
Fig. 2). Because
of this observation, which was assumed to be a thrombus, the
procedure was terminated and the patient was started on intravenous
heparin infusion. A transthoracic echocardiography was repeated
12h later, and showed the highly mobile linear structures to
be longer and extending to the left atrium. Because of a perceived
risk of systemic embolization, surgical exploration was deemed
indicated.
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Figure 1 Transesophageal echocardiographic imaging of the atrial septal defect: (a) immediately prior to the procedure (black arrow) and (b) demonstrates the lacerated interatrial septum (white arrow) early during balloon sizing of transcatheter ASD device occlusion (ASD, atrial septal defect; LA, left atrium; RA, right atrium).
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Figure 2 Transesophageal echocardiographic imaging demonstrates the lacerated interatrial septum (arrows) approximately 10min after balloon sizing of transcatheter ASD device occlusion (LA=left atrium, RA=right atrium, Lac IAS=lacerated interatrial septum).
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At surgery, there was no detectable intracardiac thrombus. The
linear structures represented edges of the lacerated atrial
septum. The laceration involved the superior and posterior aspects
of the atrial septum. The secundum part of the atrial septum
was torn and created a crescent like flap. The atrial septum
was repaired and the ASD closed with autologous pericardium.
The postoperative period was uneventful and postoperative transesophageal
echocardiography showed no abnormal masses and no residual shunting.
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Discussion
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For many years, surgical closure was the only definite treatment
for secundum ASD. The first non-surgical approach at closing
an ASD was by King and colleagues in 1976
2 but was not widely
adopted into clinical practice. The last decade, however, has
witnessed the development of several devices for closure of
secundum ASD. This approach has become accepted alternative
to surgery, and the preferred method in selected patients. It
has been shown to be safe and effective in the vast majority
of patients.
3–5 With increasing use of this technique,
a number of complications have been recognized (
Table 1). Because
of continuous echocardiographic monitoring approximately 6–10%
of patients are documented to have some sort of complication.
These complications are either related to access site, the device
used, or cardiac catheterization complications.
5–10 Though
these complications are uncommon some are serious and warrant
urgent surgical intervention. To our knowledge atrial septal
laceration has not been previously reported as a cause of morbidity.
Sizing balloon manipulation or passing the guidewire through
a small atrial septum fenestration was likely to have caused
this injury. Other possible causes are over-stretching of the
sizing balloon with too much contrast or manipulating the sizing
balloon in ASD associated with aneurysmal atrial septum. The
echocardiographic features were unfamiliar and non-specific
and we could not exclude large intracardiac thrombosis. In retrospect
we were unable to identify features, which with confidence,
would have enabled us to differentiate between a septal flap
and thrombus. With this uncertainty we believe the appropriate
management was termination of the procedure and referral to
surgery for identification of the problem and closure of the
ASD. In the future three-dimensional echocardiography or intracardiac
echo may better assist in differentiating laceration from thrombus
formation on atrial septum.
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Notes
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* There is no grant support for this case report.
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References
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- Berger F., Vogel M., Alexi-Meskishvili V., Lange P.E. Comparision of results and complications of surgical and Amplatzer device closure of atrial septal defects. Journal of Thoracic & Cardiovascular Surgery (1999) 118:674–678. [discussion 678-80].[CrossRef]
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Abstract
Case report