Letter by Heidrich et al Regarding Article, “A Word of Caution: Risk of Device Erosion After Percutaneous Treatment of Atrial Septal Defect in Patients With Dilated Aortic Root”
To the Editor:
In this interesting report, Dardas et al1 describe another case of a rare yet potentially life-threatening complication of interventional atrial septal defect closure with a 20-mm Amplatzer septal occluder device. Transesophageal echocardiography revealed a 15-mm atrial septal defect complicated by a deficient aortic rim and a bicuspid aortic valve, along with aortic root dilation (42 mm). At the routine 6-month follow-up, transesophageal echocardiography showed device perforation into the aortic root. We previously described a series of 2 patients who underwent primarily uncomplicated interventional patent foramen ovale closure by a Cardia Star device (Cardia Inc). Routine transesophageal echocardiography follow-up revealed a small pericardial effusion, and a left-to-right shunt from the aortic root into the right atrium was detected. Here, device dislocation resulted in aortic root perforation.2
Although indications for atrial septal defect und patent foramen ovale closure are distinct and approved devices differ somewhat, these case reports exemplarily highlight the risk of potentially life-threatening complications. The point pressure of a Cardia Star device strut seemed to be the driving force for perforation in our report, whereas friction on the adjacent structures and subsequent erosion most likely were the driving forces in case of the Amplatzer septal occluder device.1,2 Therefore, being aware of potential risk factors for erosion and perforation to be ruled out before intervention is key for a safe procedure in the hands of experienced interventionalists. On the basis of a thoroughly conducted descriptive study on 12 patients who experienced erosion after Amplatzer septal occluder implantation, Amin3 recently proposed the following echocardiographic predictors of cardiac erosion: aortic rim absence in multiple views, poor posterior rim consistency, septal malalignment, and dynamic atrial septal defect. Unfortunately, in this case series, aortic root dilation and bicuspid aortic valve were not considered risk factors. In light of these case reports,1,2 focused re-evaluation of the echocardiography data in the Amin3 study for the presence of additional risk factors such as aortic root dilation would be particularly valuable. Nevertheless, to date, true independent predictors of device erosion/perforation can only be speculated on from the aforementioned case reports and series owing to the lack of randomized, controlled trials. In 2013, a safety review of transcatheter device closure concluded that there were insufficient solid data and a lack of expert consensus to demand a change in clinical practice.4 Therefore, interventionalists should aim to carefully rule out the presence of 1 or more of these risk factors before intervention. In summary, notes and words of caution could be put together into meaningful sentences in terms of the identification of true independent predictors of life-threatening complications.
Felix M. Heidrich, MD
Ruth H. Strasser, MD, PhD
Stephan Wiedemann, MD
Technische Universität Dresden
Heart Centre Dresden
- © 2015 American Heart Association, Inc.