Clinical Case Portal

Aortic-left atrial fistula three weeks after percutaneous atrial septal defect repair using an Amplatzer Septal Occluder

Date of publication:

28 Nov 2006

Authors:

Dr. Margherita Cinello: margherita.cinello@libero.it

Dr. Luigi Paolo Badano: badano.luigi@aoud.sanita.fvg.it

Dr. Pasquale Gianfagna: gianfagna.pasquale@aoud.sanita.fvg.it

Cardiopulmonary Science Department, S.O.C. Cardiologia, Azienda Ospedaliero-Universitaria di Udine, P.le S.Maria della Misericordia, 15. 33100, Udine, Italy

Case Report

We report a 53-year-old patient with a type II atrial septal defect who underwent defect closure with an Amplatzer Septal Occluder. He presented 20 days after the procedure with acute onset of dyspnoea and hypoxiemia, at which time a transoesophageal echocardiography showed a partially expanded device on the right side of interatrial septum and a decubitus of the device on the right coronary sinus with an aortic-to-left atrial fistula. The patient underwent uneventful surgical device retrieval. Atrial septal defect was closed by Hemapatch and the aorta-to-left atrium fistula was interrupted by a pericardial patch on the aortic side and a suture on the dome of the left atrium.

Patient history prior to current observation :

We report the case of a 53-year-old patient with a type II atrial septal defect who underwent an uneventful interventional defect closure with an Amplatzer Septal Occluder. He was a smoker with recent right pneumonectomy for squamous pulmonary carcinoma.

Clinical findings on admission, evolution and outcome :

He presented 20 days after procedure with acute onset of dyspnoea and hypoxiemia (periferic oxygen saturation of 86%).

Urgent transoesophageal echocardiography showed a partially expanded device on the right side of the atrial septum (fig. 1) with persistent interatrial right-to-left shunt (confirmed by contrast). In addition, a decubitus on the right coronary Valsalva sinus with aortic-to-left atrial fistula was found (fig. 2, fig. 3). Continuous-wave Doppler on the fistula disclosed continuous flow with a maximum gradient of 110 mmHg (fig. 4) coronary sinus with an aortic-to-left atrium fistula.

The patient underwent uneventful surgical device retrieval. Atrial septal defect was closed by Hemapatch and the aorta-to-left atrium fistula was interrupted by a pericardial patch on the aortic side and a suture on the dome of the left atrium.

Conclusion

Transcatheter approach is now becoming an increasingly widespread technique for closing secundum-type atrial septal defects because of its effectiveness, safety (with a complication rate comparable to surgical results) and lower invasivity (with shorter hospital stay) (1-7). However, complications may occur and can derive from unfavourable anatomy of the defect (deficient superior aortic rim) or over-dimensioning of the device (8-13). Detecting risk factors for such event could help in restrict selection criteria for this procedure or set out close echocardiographic follow-up for early detection of fistula formation. Even after an uncomplicated defect closure, an ecocardiographic follow-up is currently recommended at 1 and 6 months postimplant, with yearly exams thereafter (11).

References

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10. Knirsch W, Dodge-Khatami A, Balmer C, Peuster M, Kadner A, Weiss M, Pretre R, Berger F. Aortic sinus-left atrial fistula after interventional closure of atrial septal defect. Catheter Cardiovasc Interv 66: 10-3, 2005.

11. Mello DM, Fahey J, Kopf GS. Repair of aortic-left atrial fistula following the transcatheter closure of an atrial septal defect. Ann Thorac Surg 80: 1495-8, 2005.

12. Aggoun Y, Gallet B, Acar P, Pulik M, Czitrom D, Lagier A, Laborde F. [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 95: 479-82, 2002.

13. Jang GY, Lee JY, Kim SJ, Shim WS, Lee CH. Aorta to right atrial fistula following transcatheter closure of an atrial septal defect. Am J Cardiol 96: 1605-6, 2005.

fig. 1 :

Aortic-left atrial fistula_Transoesophageal echocardiogram recorded in longitudinal long-axis view