European Journal of Echocardiography 2008 9(2):294-295; doi:10.1016/j.euje.2006.09.006
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2006. For permissions please email: journals.permissions@oxfordjournals.org
Percutaneous closure of an iatrogenic atrial septal defect
Alex Pitcher1,
Ryan G. Schrale2,*,
Andrew R.J. Mitchell3 and
Oliver Ormerod2
1 Royal Berkshire Hospital, Reading, UK
2 Department of Cardiology, John Radcliffe Hospital, Oxford, UK
3 Jersey General Hospital, Jersey, UK
Received 4 September 2006; accepted after revision 30 September 2006; online publish-ahead-of-print 10 November 2006.
* Corresponding author. Tel: +44 1865 220648; fax: +44 1865 221194. E-mail address: rschrale{at}hotmail.com (R.G. Schrale).
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Abstract
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We report the successful percutaneous closure of an iatrogenic
atrial septal defect in a 71-year-old woman. The patient had
undergone mitral valve replacement and coronary artery bypass
grafting, followed by redo surgery to repair a para-valvular
mitral leak. Post-operatively she remained significantly limited
by dyspnoea. Repeat transoesophageal echocardiography documented
a large iatrogenic atrial septal defect. The patient underwent
percutaneous, trans-femoral closure of the defect using the
Helex septal occluder (W.L. Gore, Newark, Delaware, USA) with
dramatic clinical improvement.
Keywords: Atrial septal defect; Mitral valve surgery; Iatrogenic; Percutaneous closure
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Introduction
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Access to the left atrium via a transeptal approach allows excellent
visualisation of the mitral valve and offers potential advantage
for mitral valve surgery.
1 A residual perforation of the atrial
septum is a rare but recognised complication.
2 When the iatrogenic
defect is large or produces symptoms, closure is indicated.
While this has been conventionally managed with redo surgery,
we report a case of successful percutaneous device closure of
an iatrogenic atrial septal defect using a Helex septal occluder
(Gore Medical, Delaware, USA).
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Case report
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A 70-year-old female presented with NYHA Class 3 heart failure
symptoms. Transthoracic and subsequent transoesophageal echocardiography
confirmed the presence of severe mitral regurgitation secondary
to marked bileaflet prolapse. The inter-atrial septum was seen
to be intact and left ventricular systolic function was preserved.
Coronary angiography demonstrated a 60% stenosis of the right
coronary artery. The patient proceeded to mitral valve replacement
(31 mm mechanical ATS valve, ATS Medical, Minneapolis, USA)
and vein grafting to the right coronary artery. Post-operative
recovery was slow. At four weeks she was readmitted with dyspnoea
and repeat transoesophageal echocardiography demonstrated severe
para-valvular mitral regurgitation (
Figure 1). She underwent
re-operation and successful closure of a 10 mm dehiscence of
the sewing ring of the mitral valve prosthesis.
Over the following 21 months she continued to suffer NYHA Class
3 dyspnoea. A further transoesophageal echocardiogram now demonstrated
a new 10–15 mm atrial septal defect (ASD) at the fossa
ovalis (
Figure 2), with significant left to right shunting
on colour flow Doppler imaging. The mitral valve prosthesis
was functioning satisfactorily.
It was felt that the defect would be suitable for percutaneous
device closure, avoiding the morbidity and mortality of a third
heart surgery. This was performed under general anaesthesia
with transoesophageal echocardiographic guidance. Via an 11
French sheath in the right femoral vein the ASD was crossed
with a 5 French multipurpose catheter. Over a 0.035 Amplatz
Super Stiff wire (Boston Scientific Corp., Natick, Massachusetts,
USA) the defect was balloon sized at 14 mm (
Figure 3).
A 30-mm Helex septal occluder was successfully deployed with
excellent positioning and trivial residual leak (
Figure 4).
Total procedure time was 38 min. The patient had an uncomplicated
recovery and was discharged on the first post-operative day.
On review at three months post-ASD closure the patient was free
of symptoms and now able to walk over an hour without breathlessness.
Follow-up echocardiography confirmed no residual shunt.
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Figure 4 (A) Transoesophageal echocardiography demonstrating successful placement of the Helex septal occluder. (B) Colour flow Doppler imaging documents a trivial residual shunt. LA = left atrium; RA = right atrium; Ao = aorta.
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Discussion
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ASDs have been described as a complication of numerous cardiac
surgical and percutaneous procedures including mitral and pulmonary
valve surgery, and mitral balloon valvuloplasty.
3,4 Deliberate
surgical perforation of the atrial septum is typically in the
area of the fossa ovalis, and so mimics the anatomical location
of congenital secundum type ASDs.
Traditionally repair has been undertaken on cardiac bypass using open surgical techniques. This case is unusual in that we were able to repair the surgical complication using a percutaneous procedure. Clinicians should be aware of the possibility of iatrogenic ASD in patients who become (or remain) breathless following cardiac surgery, particularly if an atrial septal incision was required. When diagnosed in a symptomatic patient, percutaneous device closure may be considered a safe and effective alternate strategy to close iatrogenic ASDs.
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References
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- Cohn LH, Edmunds LH Jr. Cardiac surgery in the adult (2003) 2nd ed. McGraw-Hill.
- Khanna A, Barberena J, Skolnick D. An unusual case of shunting across the atrial septum after mitral valve repair. J Am Soc Echocardiogr (2005) 18:78–9.[CrossRef][Web of Science][Medline]
- Earing MG, Connolly HM, Dearani JA, Ammash NM, Grogan M, Warnes CA. Long-term follow-up of patients after surgical treatment for isolated pulmonary valve stenosis. Mayo Clin Proc (2005) 80:871–6.[Abstract/Free Full Text]
- Zanchetta M, Onorato E, Rigatelli G, Dimopoulos K, Pedon L, Zennaro M, et al. Use of Amplatzer septal occluder in a case of residual atrial septal defect causing bidirectional shunting after percutaneous Inoue mitral balloon valvuloplasty. J Invasive Cardiol (2001) 13:223–6.[Medline]
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Abstract
Introduction
