Clin Res Cardiol (2016) 105:463–466 DOI 10.1007/s00392-015-0943-z
LETTER TO THE EDITORS
Percutaneous management of periprocedural cardiac perforation during left atrial appendage closure Nico Reinsch1 • Hagen Ka¨lsch2 • Philipp Kahlert2
Received: 27 September 2015 / Accepted: 13 November 2015 / Published online: 26 November 2015 Ó Springer-Verlag Berlin Heidelberg 2015
Sirs: Percutaneous closure of the left atrial appendage (LAA) has become a common procedure in patients not eligible to oral anticoagulation because of a high risk for bleeding or prior bleeds [1–3]. However, pericardial effusion due to free-wall perforation of the atrium or the LAA remains a severe complication. A 77-year-old woman with persistent atrial fibrillation and a high thromboembolic risk (CHADS2-VA2Sc score, 5) was referred to our institution for percutaneous occlusion of the LAA. The patient was at increased risk for bleeding (HAS-BLED score, 5) and had even experienced a subdural hematoma under oral anticoagulation with phenprocoumon, rendering her an ideal candidate for LAA occlusion. The procedure was performed in conscious sedation and under transoesophageal echocardiographic guidance. The INR was in a normal range and heparin was administered in boluses to aim for an ACT level of C300 s. In total, 10,000 IE heparin were administered. After successful transseptal puncture using a SL1-sheath (St. Jude Medical, USA) and a NRGÒ radiofrequency transseptal needle (Baylis Medical, Canada), a 6F-pigtail catheter was used to engage and inject the LAA. The maximal diameter of the ostium and the landing zone were measured using & Nico Reinsch [email protected] 1
Division of Electrophysiology, Department of Internal Medicine I and Cardiology, Alfried Krupp Hospital, Essen, Germany
2
Department of Cardiology, West German Heart and Vascular Center, Essen University Hospital, University DuisburgEssen, Essen, Germany
fluoroscopy and transoesophageal echocardiography, respectively. Based on these measurements, a 24 mm Amplatz Cardiac Plug (ACP, St. Jude Medical, USA) was selected. Using a 6F-multipurpose-catheter, an Amplatz superstiff wire was placed into the left superior pulmonary vein. Thereafter, the SL1-sheath was exchanged and the dedicated TorqVue 45° 13F delivery-sheath (St. Jude Medical, USA) inserted. During sheath insertion into the LAA, however, pericardial effusion was noted on transoesophageal echocardiography and on fluoroscopy (halo). Transoesophageal echocardiography and angiography over the sheath revealed perforation of the LAA in the proximity of the cranial pole of the LAA, most likely caused by the tip of the delivery sheath (Fig. 1). Within the next minutes hemodynamic instability occurred as a result of the pericardial effusion. Immediately, pericardiocentesis via the subxiphoidal approach was performed with autotransfusion of the drained blood into an additional venous sheath in the femoral vein. There were administered 5000 IE protamine sulfate to neutralize heparin, resulting in an ACT level \200 s. Since there was no cessation of the bleeding, emergent open-heart surgery with suture or patch plastic of the perforation seemed inevitable. However, as the perforation was close to the cranial pole of the LAA and, thus, potentially sealable by the ACP device, we decided to continue the procedure with ACP implantation as a first strategy. Indeed, the leak could be completely sealed by ACP implantation, and angiography did not show any further contrast medium getting in the pericardial space. After full device deployment (i.e. release), all criteria of correct implantation were checked. Notably, the device covered and successfully compressed the area of perforation (Fig. 2), and remained in a stable position during the wiggle maneuver. No recurrent effusion occurred in the further course. The patient was
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Clin Res Cardiol (2016) 105:463–466
Fig. 1 Preimplantation measurements; a right anterior oblique view; b transoesophageal echocardiography; c pericardial effusion caused by the device hook (dotted arrow); d area of left atrial appendage perforation (dotted arrow)
transferred to our intensive care unit for hemodynamic surveillance for 24 h. Drainage catheters were removed 12 h after echocardiography confirmed the absence of intrapericardial bleeding and double antiplatelet therapy with aspirin (100 mg/day) and clopidogrel (75 mg/day) was started after 48 h of stable haemodynamic conditions. The patient could be discharged after an uneventful course 8 days later showing the device in place. Percutaneous exclusion of LAA is a recently developed approach used for thromboembolic stroke prevention as an effective alternative in patients with atrial fibrillation and previous major bleeding or at high-bleeding risk [3– 6]. The feasibility and safety of LAA closure with the ACP have been recently evaluated and published. However, as with most invasive procedures, serious adverse events in the peri-procedural phase may occur even in highly skilled hands [7–10]. Particularly pericardial effusion and tamponade, peri-procedural strokes, air embolism and device embolization have been described. The rate of pericardial effusion requiring drainage was
123
3.5 % in a study of Park et al. [11]. In the PLAATO trial, cardiac tamponade is being reported to be the most frequent complication [12]. In the Embolic Protection in Patients With Atrial Fibrillation (PROTECT-AF) study, the rate of peri-procedural pericardial hemorrhage requiring intervention was 4.8 % [1]. As pericardial effusion may lead to pericardial tamponade resulting in a life-threatening condition, urgent open-heart surgery may be the only promising treatment option to close the atrial leakage. In the PROTECT-AF and PLAATO trial about one-third of the patients underwent surgical intervention [1, 12]. To the best of our knowledge, this is the first report of perforation of the LAA and life-threatening tamponade that was successfully sealed by the plug itself. The ACP was very effective in left appendage exclusion as pre-discharge echo and computed tomography showed complete occlusion of the left auricle. Finally, this case report highlights that these procedures should be carried out only in very experienced hands and probably best with surgical back-up as interventional
Clin Res Cardiol (2016) 105:463–466
465
Fig. 2 Postimplantation assessment. a ACP in loco typico showing no contrast agent in the pericardial space; b transoesophageal view in a long axis view; CT-heart scan; c visualisation of the LAA before
implantation of the device; d ACP in loco typico with complete occlusion of the LAA
management may not always be successful in serious complications that can occur during LAA closure.
occlusion in valvular atrial fibrillation following MitraClip implantation. Clin Res Cardiol. 101:393–396 Camm AJ, Lip GY, De Caterina R, Savelieva I, Atar D, Hohnloser SH, Hindricks G, Kirchhof P (2012) 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association. Eur Heart J 33:2719–2747 Gloekler S, Shakir S, Doblies J, Khattab AA, Praz F, Guerios E, Koermendy D, Stortecky S, Pilgrim T, Buellesfeld L, Wenaweser P, Windecker S, Moschovitis A, Jaguszewski M, Landmesser U, Nietlispach F, Meier B (2015) Early results of first versus second generation Amplatzer occluders for left atrial appendage closure in patients with atrial fibrillation. Clin Res Cardiol 104:656–665 Seeger J, Bothner C, Dahme T, Gonska B, Scharnbeck D, Markovic S, Rottbauer W, Wohrle J (2015) Efficacy and safety of percutaneous left atrial appendage closure to prevent thromboembolic events in atrial fibrillation patients with high stroke and bleeding risk. Clin Res Cardiol (Epub ahead of print) Elbey MA, Ertas G, Bacaksiz A, Goktekin O, Erdogan E (2013) Transcatheter closure of left ventricular free wall rupture with Amplatzer atrial septal defect occluder. Clin Res Cardiol 102:313–314
4.
Compliance with ethical standards Conflict of interest
There are no conflicts to disclosure. 5.
References 1. Holmes DR, Reddy VY, Turi ZG, Doshi SK, Sievert H, Buchbinder M, Mullin CM, Sick P (2009) Percutaneous closure of the left atrial appendage versus warfarin therapy for prevention of stroke in patients with atrial fibrillation: a randomised non-inferiority trial. Lancet 374:534–542 2. Meier B, Palacios I, Windecker S, Rotter M, Cao QL, Keane D, Ruiz CE, Hijazi ZM (2003) Transcatheter left atrial appendage occlusion with Amplatzer devices to obviate anticoagulation in patients with atrial fibrillation. Catheter Cardiovasc Interv 60:417–422 3. Jabs A, Hink U, Warnholtz A, Stephan von Bardeleben R, Nikolai P, Munzel T, Gori T (2012) Left atrial appendage
6.
7.
123
466 8. Hanazawa K, Brunelli M, Geller JC (2014) Thromboembolic stroke after cardioversion with incomplete left atrial appendage closure. Clin Res Cardiol 103:835–837 9. Tiyerili V, Nickenig G, Hammerstingl C (2015) Catch of the day: interventional device retrieval after late embolization of an Amplatzer cardiac plug left atrial appendage occluder. Clin Res Cardiol (Epub ahead of print) 10. Schroeter MR, Danner BC, Hunlich M, Schillinger W (2014) Uncommon delayed and late complications after percutaneous left atrial appendage closure with Amplatzer((R)) Cardiac Plug. Clin Res Cardiol 103:285–290 11. Park JW, Bethencourt A, Sievert H, Santoro G, Meier B, Walsh K, Lopez-Minquez JR, Meerkin D, Valdes M, Ormerod O,
123
Clin Res Cardiol (2016) 105:463–466 Leithauser B (2011) Left atrial appendage closure with Amplatzer cardiac plug in atrial fibrillation: initial European experience. Catheter Cardiovasc Interv 77:700–706 12. Bayard YL, Omran H, Neuzil P, Thuesen L, Pichler M, Rowland E, Ramondo A, Ruzyllo W, Budts W, Montalescot G, Brugada P, Serruys PW, Vahanian A, Piechaud JF, Bartorelli A, Marco J, Probst P, Kuck KH, Ostermayer SH, Buscheck F, Fischer E, Leetz M, Sievert H (2010) PLAATO (Percutaneous Left Atrial Appendage Transcatheter Occlusion) for prevention of cardioembolic stroke in non-anticoagulation eligible atrial fibrillation patients: results from the European PLAATO study. EuroIntervention 6:220–226
LETTER TO THE EDITORS
Percutaneous management of periprocedural cardiac perforation during left atrial appendage closure Nico Reinsch1 • Hagen Ka¨lsch2 • Philipp Kahlert2
Received: 27 September 2015 / Accepted: 13 November 2015 / Published online: 26 November 2015 Ó Springer-Verlag Berlin Heidelberg 2015
Sirs: Percutaneous closure of the left atrial appendage (LAA) has become a common procedure in patients not eligible to oral anticoagulation because of a high risk for bleeding or prior bleeds [1–3]. However, pericardial effusion due to free-wall perforation of the atrium or the LAA remains a severe complication. A 77-year-old woman with persistent atrial fibrillation and a high thromboembolic risk (CHADS2-VA2Sc score, 5) was referred to our institution for percutaneous occlusion of the LAA. The patient was at increased risk for bleeding (HAS-BLED score, 5) and had even experienced a subdural hematoma under oral anticoagulation with phenprocoumon, rendering her an ideal candidate for LAA occlusion. The procedure was performed in conscious sedation and under transoesophageal echocardiographic guidance. The INR was in a normal range and heparin was administered in boluses to aim for an ACT level of C300 s. In total, 10,000 IE heparin were administered. After successful transseptal puncture using a SL1-sheath (St. Jude Medical, USA) and a NRGÒ radiofrequency transseptal needle (Baylis Medical, Canada), a 6F-pigtail catheter was used to engage and inject the LAA. The maximal diameter of the ostium and the landing zone were measured using & Nico Reinsch [email protected] 1
Division of Electrophysiology, Department of Internal Medicine I and Cardiology, Alfried Krupp Hospital, Essen, Germany
2
Department of Cardiology, West German Heart and Vascular Center, Essen University Hospital, University DuisburgEssen, Essen, Germany
fluoroscopy and transoesophageal echocardiography, respectively. Based on these measurements, a 24 mm Amplatz Cardiac Plug (ACP, St. Jude Medical, USA) was selected. Using a 6F-multipurpose-catheter, an Amplatz superstiff wire was placed into the left superior pulmonary vein. Thereafter, the SL1-sheath was exchanged and the dedicated TorqVue 45° 13F delivery-sheath (St. Jude Medical, USA) inserted. During sheath insertion into the LAA, however, pericardial effusion was noted on transoesophageal echocardiography and on fluoroscopy (halo). Transoesophageal echocardiography and angiography over the sheath revealed perforation of the LAA in the proximity of the cranial pole of the LAA, most likely caused by the tip of the delivery sheath (Fig. 1). Within the next minutes hemodynamic instability occurred as a result of the pericardial effusion. Immediately, pericardiocentesis via the subxiphoidal approach was performed with autotransfusion of the drained blood into an additional venous sheath in the femoral vein. There were administered 5000 IE protamine sulfate to neutralize heparin, resulting in an ACT level \200 s. Since there was no cessation of the bleeding, emergent open-heart surgery with suture or patch plastic of the perforation seemed inevitable. However, as the perforation was close to the cranial pole of the LAA and, thus, potentially sealable by the ACP device, we decided to continue the procedure with ACP implantation as a first strategy. Indeed, the leak could be completely sealed by ACP implantation, and angiography did not show any further contrast medium getting in the pericardial space. After full device deployment (i.e. release), all criteria of correct implantation were checked. Notably, the device covered and successfully compressed the area of perforation (Fig. 2), and remained in a stable position during the wiggle maneuver. No recurrent effusion occurred in the further course. The patient was
123
464
Clin Res Cardiol (2016) 105:463–466
Fig. 1 Preimplantation measurements; a right anterior oblique view; b transoesophageal echocardiography; c pericardial effusion caused by the device hook (dotted arrow); d area of left atrial appendage perforation (dotted arrow)
transferred to our intensive care unit for hemodynamic surveillance for 24 h. Drainage catheters were removed 12 h after echocardiography confirmed the absence of intrapericardial bleeding and double antiplatelet therapy with aspirin (100 mg/day) and clopidogrel (75 mg/day) was started after 48 h of stable haemodynamic conditions. The patient could be discharged after an uneventful course 8 days later showing the device in place. Percutaneous exclusion of LAA is a recently developed approach used for thromboembolic stroke prevention as an effective alternative in patients with atrial fibrillation and previous major bleeding or at high-bleeding risk [3– 6]. The feasibility and safety of LAA closure with the ACP have been recently evaluated and published. However, as with most invasive procedures, serious adverse events in the peri-procedural phase may occur even in highly skilled hands [7–10]. Particularly pericardial effusion and tamponade, peri-procedural strokes, air embolism and device embolization have been described. The rate of pericardial effusion requiring drainage was
123
3.5 % in a study of Park et al. [11]. In the PLAATO trial, cardiac tamponade is being reported to be the most frequent complication [12]. In the Embolic Protection in Patients With Atrial Fibrillation (PROTECT-AF) study, the rate of peri-procedural pericardial hemorrhage requiring intervention was 4.8 % [1]. As pericardial effusion may lead to pericardial tamponade resulting in a life-threatening condition, urgent open-heart surgery may be the only promising treatment option to close the atrial leakage. In the PROTECT-AF and PLAATO trial about one-third of the patients underwent surgical intervention [1, 12]. To the best of our knowledge, this is the first report of perforation of the LAA and life-threatening tamponade that was successfully sealed by the plug itself. The ACP was very effective in left appendage exclusion as pre-discharge echo and computed tomography showed complete occlusion of the left auricle. Finally, this case report highlights that these procedures should be carried out only in very experienced hands and probably best with surgical back-up as interventional
Clin Res Cardiol (2016) 105:463–466
465
Fig. 2 Postimplantation assessment. a ACP in loco typico showing no contrast agent in the pericardial space; b transoesophageal view in a long axis view; CT-heart scan; c visualisation of the LAA before
implantation of the device; d ACP in loco typico with complete occlusion of the LAA
management may not always be successful in serious complications that can occur during LAA closure.
occlusion in valvular atrial fibrillation following MitraClip implantation. Clin Res Cardiol. 101:393–396 Camm AJ, Lip GY, De Caterina R, Savelieva I, Atar D, Hohnloser SH, Hindricks G, Kirchhof P (2012) 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association. Eur Heart J 33:2719–2747 Gloekler S, Shakir S, Doblies J, Khattab AA, Praz F, Guerios E, Koermendy D, Stortecky S, Pilgrim T, Buellesfeld L, Wenaweser P, Windecker S, Moschovitis A, Jaguszewski M, Landmesser U, Nietlispach F, Meier B (2015) Early results of first versus second generation Amplatzer occluders for left atrial appendage closure in patients with atrial fibrillation. Clin Res Cardiol 104:656–665 Seeger J, Bothner C, Dahme T, Gonska B, Scharnbeck D, Markovic S, Rottbauer W, Wohrle J (2015) Efficacy and safety of percutaneous left atrial appendage closure to prevent thromboembolic events in atrial fibrillation patients with high stroke and bleeding risk. Clin Res Cardiol (Epub ahead of print) Elbey MA, Ertas G, Bacaksiz A, Goktekin O, Erdogan E (2013) Transcatheter closure of left ventricular free wall rupture with Amplatzer atrial septal defect occluder. Clin Res Cardiol 102:313–314
4.
Compliance with ethical standards Conflict of interest
There are no conflicts to disclosure. 5.
References 1. Holmes DR, Reddy VY, Turi ZG, Doshi SK, Sievert H, Buchbinder M, Mullin CM, Sick P (2009) Percutaneous closure of the left atrial appendage versus warfarin therapy for prevention of stroke in patients with atrial fibrillation: a randomised non-inferiority trial. Lancet 374:534–542 2. Meier B, Palacios I, Windecker S, Rotter M, Cao QL, Keane D, Ruiz CE, Hijazi ZM (2003) Transcatheter left atrial appendage occlusion with Amplatzer devices to obviate anticoagulation in patients with atrial fibrillation. Catheter Cardiovasc Interv 60:417–422 3. Jabs A, Hink U, Warnholtz A, Stephan von Bardeleben R, Nikolai P, Munzel T, Gori T (2012) Left atrial appendage
6.
7.
123
466 8. Hanazawa K, Brunelli M, Geller JC (2014) Thromboembolic stroke after cardioversion with incomplete left atrial appendage closure. Clin Res Cardiol 103:835–837 9. Tiyerili V, Nickenig G, Hammerstingl C (2015) Catch of the day: interventional device retrieval after late embolization of an Amplatzer cardiac plug left atrial appendage occluder. Clin Res Cardiol (Epub ahead of print) 10. Schroeter MR, Danner BC, Hunlich M, Schillinger W (2014) Uncommon delayed and late complications after percutaneous left atrial appendage closure with Amplatzer((R)) Cardiac Plug. Clin Res Cardiol 103:285–290 11. Park JW, Bethencourt A, Sievert H, Santoro G, Meier B, Walsh K, Lopez-Minquez JR, Meerkin D, Valdes M, Ormerod O,
123
Clin Res Cardiol (2016) 105:463–466 Leithauser B (2011) Left atrial appendage closure with Amplatzer cardiac plug in atrial fibrillation: initial European experience. Catheter Cardiovasc Interv 77:700–706 12. Bayard YL, Omran H, Neuzil P, Thuesen L, Pichler M, Rowland E, Ramondo A, Ruzyllo W, Budts W, Montalescot G, Brugada P, Serruys PW, Vahanian A, Piechaud JF, Bartorelli A, Marco J, Probst P, Kuck KH, Ostermayer SH, Buscheck F, Fischer E, Leetz M, Sievert H (2010) PLAATO (Percutaneous Left Atrial Appendage Transcatheter Occlusion) for prevention of cardioembolic stroke in non-anticoagulation eligible atrial fibrillation patients: results from the European PLAATO study. EuroIntervention 6:220–226
