Unusual Complication With Transcatheter Closure of an Atrial Septal Defect Prevented by Adequate Imaging
A 44-year-old woman with progressive dyspnea was referred for transcatheter closure of a recently diagnosed secundum atrial septal defect (ASD). Chest x-ray showed prominent pulmonary arteries, a mild pulmonary volume overload, and a moderate right ventricular enlargement (Figure 1). ECG demonstrated normal sinus rhythm with mild repolarization disturbances in leads III and avL, an incomplete right bundle-branch block, and an indifferent axis with normal time intervals (Figure 2). Cardiac catheterization revealed a significant left-to-right shunt (Qp:Qs=2.9) and coronary angiography a type RII P coronary anomaly with one single coronary artery originating from the right aortic sinus1 (Figure 3). While the patient was sedated, a periprocedural transesophageal echocardiogram by balloon sizing demonstrated a 22-mm stretched diameter of the defect (“stop-flow-technique”) and a close anatomic neighborhood of the ASD to the left coronary artery (LCA) (Figure 4).
A 24-mm Amplatzer septal occluder was securely positioned in the defect and expanded. Because of the anatomic vicinity of LCA and occluder, coronary angiography was repeated before releasing the device. We thereby demonstrated a systolic compression of the LCA by the left atrial disc (Figure 5). No acute ECG or hemodynamic changes were observed in this situation. After removing the device and placing it on the delivery sheet, the compression disappeared (Figure 6). To prevent potential chronic vascular injuries by the interfering device, the procedure was discontinued and the patient recommended a surgical ASD patch closure.
Despite low peri- and postprocedural complication rates, there are a few reports of sudden deaths during device closure of ASDs.2 In most cases, erosion with a consecutive cardiac tamponade was proven or suspected.3 Despite the low incidence,4 interference of a septal occluder with anatomic variant coronaries may also be a reason for postinterventional fatalities, as ASD patients usually have no coronary angiography on a routine basis. This case emphasizes the importance of adequate periinterventional cardiac imaging to prevent procedure-related complications.
The online-only Data Supplement, which contains Movies I through X, is available with this article at http://circ.ahajournals.org/cgi/content/full/ 117/10/e181/DC1.