Pediatr Cardiol DOI 10.1007/s00246-014-0986-3
CASE REPORT
Complete Heart Block Following Transcatheter Closure of Atrial Septal Defect Due to Growth of Inflammatory Tissue Hamid Amoozgar • Maryam Ahmadipoor Ahmad Ali Amirghofran
•
Received: 5 May 2014 / Accepted: 22 July 2014 Ó Springer Science+Business Media New York 2014
Abstract Transcatheter closure of atrial septal defect (ASD) is the most common approach to close the defects worldwide. In this approach, persistent conduction disturbance is extremely rare, but an acute increase in supraventricular ectopy and minimal risk of atrioventricular conduction disturbance, as complete heart block, has been seen. Here, we report a patient who underwent ASD closure with device and presented with persistent complete heart block 10 days after device occlusion due to inflammatory tissue formation just near the atrioventricular node area at the floor of the right atrium without any direct compression on the triangle of Koch. Keywords Atrial septal defect Heart block Device Transcatheter closure
Case report A 7 year-old boy (30 kg) with atrial septal defect (ASD) (15 mm in size by transthoracic echocardiography) underwent percutaneous ASD closure in catheterization laboratory of Kowsar hospital, Shiraz, Iran. In primary
H. Amoozgar M. Ahmadipoor Cardiac Research Center, Shiraz University of Medical Sciences, Shiraz, Iran H. Amoozgar (&) Department of Pediatrics, Namazi Hospital, 7193711351 Shiraz, Iran e-mail: [email protected]; [email protected] A. A. Amirghofran Cardiac Surgery Department, Shiraz University of Medical Sciences, Shiraz, Iran
electrocardiography, he had normal sinus rhythm, mildly right-sided deviation of frontal axis, and evidence of incomplete right bundle branch block (RSR´ pattern in V1). Thus, device occlusion was performed under general anesthesia with guidance of transesophageal echocardiography. Vascular access was obtained in the right femoral vein and standard right-heart catheterization was performed to assess hemodynamics, such as pulmonary arterial pressure, which showed the mean pulmonary artery pressure to be 15 mmHg. Then, a right Judkins catheter (Cordis, a Johnson and Johnson Co, Miami, Florida) was introduced to the left upper pulmonary vein and an extra stiff exchange wire (Balton, Bolton Medical Inc) was advanced through it. Evaluation of the ASD size was done by a 24 mm AGA sizing balloon (AGA Medical Corporation) under transesophageal echocardiography guidance and a 16 mm dimension was recorded. Once the device size was determined, the delivery sheath was put over the guide wire into the left upper pulmonary vein, the dilator and wire were pulled back, and the device was advanced forward under fluoroscopy. Then, the ASD was occluded by an 18 mm FigullaÒ Flex, Occlutech’s septal occluder. Post-occlusion transesophageal echocardiography showed no residual flow through the defect. During the procedure, the patient was under heart monitoring and no abnormality of heart rhythm and rate was detected. Afterward, the patient was transferred to the recovery room and hemodynamically remained stable with no cardiac rhythm abnormalities. Post-ASD closure electrocardiography taken 24 h after ASD closure revealed no abnormalities, either. Therefore, the patient was discharged with salicylic acid, 80 mg daily. However, in the follow-up visit, 10 days after the ASD closure, the electrocardiogram showed complete heart block with ventricular rate of 55–70/min. Hence, the
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Pediatr Cardiol
Discussion
Fig. 1 Opened right atrium shows the device in place with inflammatory tissue formation around the device
Fig. 2 The atrial septal occluder was removed which shows suitable size device in comparison to atrial septal defect size and inflammatory issue formation (Arrows)
patient was admitted to the hospital and started on antiinflammatory treatment (intravenous dexamethasone) and high-dose aspirin (100 mg/KG). There was no response to medical therapy after 7 days, and surgical removal of device was done for him according to parental request. Unfortunately, complete heart block was not relieved after the surgery, and permanent endocardial pacemaker was inserted for him. Intraoperative findings demonstrated inflammatory tissue formation just near the atrioventricular node area at the floor of the right atrium, without any direct compression on the triangle of Koch (Figs. 1, 2). A small biopsy was also taken for pathologic evaluation which revealed chronic inflammation.
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Procedure-related complications after device ASD closure are relatively rare. However, early electrophysiologic abnormalities, such as atrial and ventricular ectopy and AV conduction disturbance, are common in the first days after closure; of course, persistence of these abnormalities is extremely rare [2, 5]. Nowadays, transcatheter closure of ASD is commonly performed in many centers as an alternative approach to surgical repair. There are several studies reporting electrophysiologic abnormalities after ASD repair, including sinus node dysfunction and atrioventricular node dysfunction including supraventricular and ventricular ectopy and atrioventricular block [3, 6]. The exact mechanism of heart block following ASD closure is not clear. Continuous pressure or friction of atrial disks on the atrioventricular node result in edema and could lead to atrioventricular block secondary to the ASD device closure [6]. Chen et al. [4] hypothesized that the possible mechanism of heart block is an inflammatory response as a result of mechanical rubbing of the occluder against the proximal conduction system. Bachmann’s bundle, which is the primary path for electrical conduction from the sinus node to the atrioventricular node, and the atrioventricular conduction bundle are very close to the margin of ASD defect. Insufficient rim to the atrioventricular valves and a small distance between the right atrial disk and the tricuspid valve can lead to this problem [6]. Al-Anani et al. [2] emphasized that the risk of heart block is more pronounced in patients with deficient posterior-inferior rims.The size of the device is also a predisposing factor for heart block after ASD closure. The device size of equal to or more than 18 mm has been reported as a risk factor for heart block after ASD closure [2, 7]. In some studies, atrioventricular block improved spontaneously following ASD device closure, with no recurrence at mid-term follow-up [1]. In a study conducted by Kenji et al. [7], two patients developed atrioventricular block 48 h after uncomplicated Amplatzer closure of ASD, which was completely resolved following surgical removal of their devices. Overall, the device removal is recommended in the patients with heart block after ASD device closure in order to avoid ischemia and fibrosis resulting in permanent injury of the atrioventricular node. In the present case, however, heart block did not improve despite the device removal and, consequently, we inserted a permanent pacemaker. In follow-up, the heart block was not reversed after 1 year. Acknowledgments The authors would like to thank Ms. A. Keivanshekouh at the Research Improvement Center of Shiraz
Pediatr Cardiol University of Medical Sciences for improving the use of English in the manuscript.
References 1. Al Akhfash AA, Al-Mesned A, Fayadh MA (2013) Amplatzer septal occluder and atrioventricular block: a case report and literature review. J Saudi Heart Assoc 25(2):91–94 2. Al-Anani SJ, Weber H, Hijazi ZM (2010) Atrioventricular block after transcatheter ASD closure using the Amplatzer septal occluder: risk factors and recommendations. Catheter Cardiovasc Interv 75(5):767–772 3. Bink-Boelkens MT, Meuzelaar KJ, Eygelaar A (1988) Arrhythmias after repair of secundum atrial septal defect: the influence of surgical modification. Am Heart J 115:629–633
4. Chen Q, Cao H, Zhang G-C, Chen L-W, Chen D-Z et al (2012) Atrioventricular block subsequent to intraoperative device closure atrial septal defect with transthoracic minimal invasion: a rare and serious complication. PLoS One 7(12):e52726. doi:10.1371/ journal.pone.0052726 5. Du ZD, Hijazi ZM, Kleinman CS, Silverman NH, Larntz K (2002) Comparison between transcatheter and surgical closure of secundum atrial septal defect in children and adults: results of a multicenter nonrandomized trial. J Am Coll Cardiol 39:1836–1844 6. Hill SL, Berul CI, Patel HT, Rhodes J, Supran SE, Cao QL, Hijazi ZM (2000) Early ECG abnormalities associated with transcatheter closure of atrial septal defects using the Amplatzer septal occluder. J Int Card Electrophysiol 4:469–474 7. Kenji S, Marie-Jose´ R, Eric P (2004) Reversible atrioventricular block associated with closure of atrial septal defects using the Amplatzer device. J Am Coll Cardiol 43:1677–1682
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CASE REPORT
Complete Heart Block Following Transcatheter Closure of Atrial Septal Defect Due to Growth of Inflammatory Tissue Hamid Amoozgar • Maryam Ahmadipoor Ahmad Ali Amirghofran
•
Received: 5 May 2014 / Accepted: 22 July 2014 Ó Springer Science+Business Media New York 2014
Abstract Transcatheter closure of atrial septal defect (ASD) is the most common approach to close the defects worldwide. In this approach, persistent conduction disturbance is extremely rare, but an acute increase in supraventricular ectopy and minimal risk of atrioventricular conduction disturbance, as complete heart block, has been seen. Here, we report a patient who underwent ASD closure with device and presented with persistent complete heart block 10 days after device occlusion due to inflammatory tissue formation just near the atrioventricular node area at the floor of the right atrium without any direct compression on the triangle of Koch. Keywords Atrial septal defect Heart block Device Transcatheter closure
Case report A 7 year-old boy (30 kg) with atrial septal defect (ASD) (15 mm in size by transthoracic echocardiography) underwent percutaneous ASD closure in catheterization laboratory of Kowsar hospital, Shiraz, Iran. In primary
H. Amoozgar M. Ahmadipoor Cardiac Research Center, Shiraz University of Medical Sciences, Shiraz, Iran H. Amoozgar (&) Department of Pediatrics, Namazi Hospital, 7193711351 Shiraz, Iran e-mail: [email protected]; [email protected] A. A. Amirghofran Cardiac Surgery Department, Shiraz University of Medical Sciences, Shiraz, Iran
electrocardiography, he had normal sinus rhythm, mildly right-sided deviation of frontal axis, and evidence of incomplete right bundle branch block (RSR´ pattern in V1). Thus, device occlusion was performed under general anesthesia with guidance of transesophageal echocardiography. Vascular access was obtained in the right femoral vein and standard right-heart catheterization was performed to assess hemodynamics, such as pulmonary arterial pressure, which showed the mean pulmonary artery pressure to be 15 mmHg. Then, a right Judkins catheter (Cordis, a Johnson and Johnson Co, Miami, Florida) was introduced to the left upper pulmonary vein and an extra stiff exchange wire (Balton, Bolton Medical Inc) was advanced through it. Evaluation of the ASD size was done by a 24 mm AGA sizing balloon (AGA Medical Corporation) under transesophageal echocardiography guidance and a 16 mm dimension was recorded. Once the device size was determined, the delivery sheath was put over the guide wire into the left upper pulmonary vein, the dilator and wire were pulled back, and the device was advanced forward under fluoroscopy. Then, the ASD was occluded by an 18 mm FigullaÒ Flex, Occlutech’s septal occluder. Post-occlusion transesophageal echocardiography showed no residual flow through the defect. During the procedure, the patient was under heart monitoring and no abnormality of heart rhythm and rate was detected. Afterward, the patient was transferred to the recovery room and hemodynamically remained stable with no cardiac rhythm abnormalities. Post-ASD closure electrocardiography taken 24 h after ASD closure revealed no abnormalities, either. Therefore, the patient was discharged with salicylic acid, 80 mg daily. However, in the follow-up visit, 10 days after the ASD closure, the electrocardiogram showed complete heart block with ventricular rate of 55–70/min. Hence, the
123
Pediatr Cardiol
Discussion
Fig. 1 Opened right atrium shows the device in place with inflammatory tissue formation around the device
Fig. 2 The atrial septal occluder was removed which shows suitable size device in comparison to atrial septal defect size and inflammatory issue formation (Arrows)
patient was admitted to the hospital and started on antiinflammatory treatment (intravenous dexamethasone) and high-dose aspirin (100 mg/KG). There was no response to medical therapy after 7 days, and surgical removal of device was done for him according to parental request. Unfortunately, complete heart block was not relieved after the surgery, and permanent endocardial pacemaker was inserted for him. Intraoperative findings demonstrated inflammatory tissue formation just near the atrioventricular node area at the floor of the right atrium, without any direct compression on the triangle of Koch (Figs. 1, 2). A small biopsy was also taken for pathologic evaluation which revealed chronic inflammation.
123
Procedure-related complications after device ASD closure are relatively rare. However, early electrophysiologic abnormalities, such as atrial and ventricular ectopy and AV conduction disturbance, are common in the first days after closure; of course, persistence of these abnormalities is extremely rare [2, 5]. Nowadays, transcatheter closure of ASD is commonly performed in many centers as an alternative approach to surgical repair. There are several studies reporting electrophysiologic abnormalities after ASD repair, including sinus node dysfunction and atrioventricular node dysfunction including supraventricular and ventricular ectopy and atrioventricular block [3, 6]. The exact mechanism of heart block following ASD closure is not clear. Continuous pressure or friction of atrial disks on the atrioventricular node result in edema and could lead to atrioventricular block secondary to the ASD device closure [6]. Chen et al. [4] hypothesized that the possible mechanism of heart block is an inflammatory response as a result of mechanical rubbing of the occluder against the proximal conduction system. Bachmann’s bundle, which is the primary path for electrical conduction from the sinus node to the atrioventricular node, and the atrioventricular conduction bundle are very close to the margin of ASD defect. Insufficient rim to the atrioventricular valves and a small distance between the right atrial disk and the tricuspid valve can lead to this problem [6]. Al-Anani et al. [2] emphasized that the risk of heart block is more pronounced in patients with deficient posterior-inferior rims.The size of the device is also a predisposing factor for heart block after ASD closure. The device size of equal to or more than 18 mm has been reported as a risk factor for heart block after ASD closure [2, 7]. In some studies, atrioventricular block improved spontaneously following ASD device closure, with no recurrence at mid-term follow-up [1]. In a study conducted by Kenji et al. [7], two patients developed atrioventricular block 48 h after uncomplicated Amplatzer closure of ASD, which was completely resolved following surgical removal of their devices. Overall, the device removal is recommended in the patients with heart block after ASD device closure in order to avoid ischemia and fibrosis resulting in permanent injury of the atrioventricular node. In the present case, however, heart block did not improve despite the device removal and, consequently, we inserted a permanent pacemaker. In follow-up, the heart block was not reversed after 1 year. Acknowledgments The authors would like to thank Ms. A. Keivanshekouh at the Research Improvement Center of Shiraz
Pediatr Cardiol University of Medical Sciences for improving the use of English in the manuscript.
References 1. Al Akhfash AA, Al-Mesned A, Fayadh MA (2013) Amplatzer septal occluder and atrioventricular block: a case report and literature review. J Saudi Heart Assoc 25(2):91–94 2. Al-Anani SJ, Weber H, Hijazi ZM (2010) Atrioventricular block after transcatheter ASD closure using the Amplatzer septal occluder: risk factors and recommendations. Catheter Cardiovasc Interv 75(5):767–772 3. Bink-Boelkens MT, Meuzelaar KJ, Eygelaar A (1988) Arrhythmias after repair of secundum atrial septal defect: the influence of surgical modification. Am Heart J 115:629–633
4. Chen Q, Cao H, Zhang G-C, Chen L-W, Chen D-Z et al (2012) Atrioventricular block subsequent to intraoperative device closure atrial septal defect with transthoracic minimal invasion: a rare and serious complication. PLoS One 7(12):e52726. doi:10.1371/ journal.pone.0052726 5. Du ZD, Hijazi ZM, Kleinman CS, Silverman NH, Larntz K (2002) Comparison between transcatheter and surgical closure of secundum atrial septal defect in children and adults: results of a multicenter nonrandomized trial. J Am Coll Cardiol 39:1836–1844 6. Hill SL, Berul CI, Patel HT, Rhodes J, Supran SE, Cao QL, Hijazi ZM (2000) Early ECG abnormalities associated with transcatheter closure of atrial septal defects using the Amplatzer septal occluder. J Int Card Electrophysiol 4:469–474 7. Kenji S, Marie-Jose´ R, Eric P (2004) Reversible atrioventricular block associated with closure of atrial septal defects using the Amplatzer device. J Am Coll Cardiol 43:1677–1682
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