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EXPERIENCE & REASON |
a Divisions of Emergency Medicine
b Cardiology
c Pathology, Hospital for Sick Children, Toronto, Ontario, Canada
ABSTRACT
A 14-year-old boy presented to the emergency department unaccompanied by his parents with a decreased level of consciousness, bradycardia, and hypotension after a syncopal episode. The patient's electronic chart revealed a percutaneous closure of a secundum atrial septal defect using an Amplatzer septal occluder (AGA Medical, Golden Valley, MN) 6 weeks before this presentation. An urgent echocardiogram revealed a moderate pericardial effusion, and 320 mL of fresh blood was evacuated by subxiphoid pericardiocentesis. The child underwent surgical exploration and was found to have a perforation in the superior-posterior aspect of the right atrium, which was corrected. The septal occluder was extracted, and the atrial septal defect was closed with a pericardial patch. This case illustrates a rare but life-threatening complication of percutaneous closure of atrial septal defect using an Amplatzer septal occluder and the importance of timely access to patient records when available history and physical examination are limited.
Key Words: Amplatzer septal occluder • cardiac perforation • tamponade • complication • electronic charting
Abbreviations: ASD, atrial septal defect
Percutaneous transcatheter atrial septal defect (ASD) closure has become a widely practiced technique and has replaced surgical ASD closure in many centers.1 The implant used most often is the Amplatzer septal occluder (AGA Medical, Golden Valley, MN), which has a relatively low complication rate, with most of the reported complications occurring early and a few reported late complications.2–4 Here we report the first case of right atrium perforation presenting as cardiogenic shock 6 weeks post–ASD closure using an Amplatzer septal occluder in a child.
CASE REPORT
A 14-year-old boy was brought to the department of emergency medicine in a tertiary care pediatric hospital with a decreased level of consciousness. His parents did not accompany him. According to the emergency medical services crew, he complained of chest pain and collapsed at home, and his mother called emergency medical services. On arrival, the paramedics found the child unconscious, pale, and extremely diaphoretic. His initial vital signs were: heart rate, 51 beats per minute; systemic blood pressure, 80/54 mm Hg; respiratory rate, 18 breaths per minute; and normal blood glucose level. The child was given 20 mL/kg 0.9% saline en route from his home to the emergency department.
In the emergency department, the child was lethargic, with a Glasgow coma score of 14 (eyes: 3; verbal: 5; motor: 6), blood pressure of 80/40 mm Hg, heart rate of 60 beats per minute, and arterial oxygen saturation of 95% on room air. His extremities were cold and peripheral pulses weak. He had normal femoral pulses, normal jugular venous pulsations, and no pulsus paradoxus. On examination, his heart sounds were normal with no murmur. He had a decreased level of consciousness and no focal findings on neurologic examination. The rest of the physical examination was unremarkable.
The child was treated with an intravenous fluid bolus of 20 mL/Kg 0.9% saline via a rapid infuser with improvement of blood pressure to 88/56 mm Hg and to 90/40 mm Hg after the second bolus. His level of consciousness improved, and he became more alert and responded to questions. He mentioned that he was taking acetylsalicylic acid for his heart but did not know the exact nature of his cardiac problem.
A quick electronic chart review revealed a history of a secundum ASD, left atrial isomerism, and interrupted inferior caval vein diagnosed at the age of 6 months. Six weeks before his current presentation, a transcatheter ASD closure from the right internal jugular vein was performed using an 18-mm Amplatzer septal occluder for a balloon-stretched diameter of 16 mm. Note was made of the superior location of the defect, although sinus venosus septum was present. At follow-up, 10 days before presentation to the emergency department, echocardiography had shown a normal-sized right ventricle with no atrial shunt, and the occluder appeared to be in an appropriate position.
A complete blood count, serum urea nitrogen, creatinine, serum electrolytes, and venous blood gas measurements, and urine toxicology screen were within normal limits. A chest radiograph showed a globular cardiac silhouette, normal pulmonary vasculature, and the Amplatzer septal occluder in the superior part of the cardiac shadow. A 12-lead electrocardiogram showed low-voltage QRS complexes in sinus rhythm, RSr' pattern in lead V1, and diffuse T-wave flattening. Bedside echocardiography revealed a moderate pericardial effusion but no obvious tear at the location of the implant (Figs 1 and 2). An urgent subxiphoid pericardiocentesis was performed, and 320 mL of fresh blood was evacuated.
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DISCUSSION
Secundum ASDs represent 6% to 10% of all cardiac anomalies5 and occur in 1 child per 1500 live births.6 Surgical repair was the preferred correction method of these defects, with a reported mortality rate of 0.4%.7 King et al8 reported the first transcatheter ASD closure in 1976. Subsequently, a number of devices have been developed, with the Amplatzer septal occluder currently being the preferred implant for closure.9
Percutaneous transcatheter delivery of the Amplatzer septal occluder has a success rate that parallels surgery while maintaining a low complication rate.2,3,10–15 Immediate complications include arrhythmias,3,4,10–14 transient ST-T elevation,10–14 systemic and pulmonary embolization,16 and acute cardiac perforation.4,17,18
Late complications are rare. There are 2 published case reports of late atrial wall erosions in patients who underwent percutaneous ASD repair with Amplatzer septal occluders. An aorta to right atrial fistula 3 months after the procedure was reported in a 10-year-old.19 Preventza et al20 reported a case of right atrial perforation 6 months after an uncomplicated closure of a small ASD in a 42-year-old female who presented with cardiogenic shock. A total of 29 cases of erosion of Amplatzer septal occluders after closure of secundum ASDs have been reported in the literature,15,17 10 of which were in children younger than 18 years. Eight of the children presented in the first 72 hours postprocedure, and 2 children experienced late erosion and had a left atrium to aorta fistula with no hemodynamic compromise.18 Our case is, to our knowledge, the first pediatric report of late cardiac perforation presenting with pericardial tamponade after transcatheterization closure using an Amplatzer septal occluder.
Possible risk factors for erosion of the Amplatzer septal occluder are deficient aortic and superior rim or oversizing of the device, which may increase the chance of contact between the device and the atrial wall. Deformations of the device at the aortic root and small pericardial effusion at 24 hours are also potential risk factors.18 The risk factor in this case was the superior location of the defect. The balloon-stretched size of the ASD was 16 mm and the implanted device was 18 mm, as recommended.18
Our patient presented with bradycardia, which improved after evacuation of the hemopericardium. There are no published reports of bradycardia in patients with cardiac tamponade. A possible explanation is the higher incidence of bradyarrhythmias seen in patients with left atrial isomerism secondary to defective sinus node and atrioventricular conduction.21,22In our case, there was no other evidence for defective sinus node and atrioventricular conduction.
Nonsurgical interventional procedures are widely performed for pediatric patients of all ages by interventional cardiologists, interventional radiologists, pulmonologists, and gastroenterologists for a variety of indications. It offers several advantages such as the avoidance of a surgical wound and general anesthesia. One of the disadvantages is the lack of a scar, which provides an obvious mark on physical examination for pediatricians and emergency physicians, who may be the first responders when these children present to the hospital with acute illness.
Chest radiography is a rapid, noninvasive test performed at any hospital or clinic and may reveal the diagnosis in a patient who presents with cardiopulmonary symptoms. In this child, a chest radiograph showed the device, but the cardiomegaly was minimal, and migration of the device was not obvious.
This case is also a clear example of the benefits of timely access to a patient's hospital records even in the initial evaluation of critically ill patients. Access to the electronic chart facilitated the diagnosis and timely management of this patient when history was not readily available and there were no obvious surgical scars to indicate previous cardiac surgical interventions.
CONCLUSIONS
We report the first case of a child who had right atrium perforation and presented in cardiogenic shock 6 weeks after percutaneous transcatheter ASD repair using a Amplatzer septal occluder. Physicians should be aware of this rare complication and consider it in any patient who has undergone this procedure presenting with cardiac-related complaints such as chest pain, syncope, dyspnea, or shock.
ACKNOWLEDGMENTS
Dr Maimon is supported by the Sacta-Rashi Foundation (Kfar Hanoar Ben-Shemen, Israel).
FOOTNOTES
Accepted Jun 5, 2006.
Address correspondence to Savithiri Ratnapalan, MBBS, MEd, MRCP, FRCPC, FAAP, Division of Emergency Medicine, Hospital for Sick Children, 555 University Ave, Toronto, Ontario, Canada M5G 1X8. E-mail: savithiri.ratnapalan{at}sickkids.ca
The authors have indicated they have no financial relationships relevant to this article to disclose.
Dr Maimon's current address is Pediatric Emergency Medicine Department, Soroka University Medical Center, Ben-Gurion University, Beer-Sheva 84101, Israel.
REFERENCES
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