Ann Thorac Surg 2014;98:1821–3
CASE REPORT KRANTZ AND LAWTON ENDOCARDITIS OF ATRIAL SEPTAL CLOSURE DEVICE
1821
under cardiopulmonary bypass through a median sternotomy because the left atrial diverticulum was giant and thin.
subacute endocarditis of the completely endothelialized device 2 years after placement. (Ann Thorac Surg 2014;98:1821–3) Ó 2014 by The Society of Thoracic Surgeons
References
T
1. McGuinness J, Kindawi A, Tajri S, Walsh K, Nolke L, Wood AE. Surgical management of giant left atrial diverticulum. J Thorac Cardiovasc Surg 2007;133:820–2. 2. Nomura K, Matsumura Y, Shinohara G, Nakamura Y. A 4-year-old girl with giant left atrial diverticulum resulting in severe mitral regurgitation. Cardiovasc Pathol 2008;17: 254–5. 3. Peng LQ, Yu JQ, Yang ZG, et al. Left atrial diverticula in patients referred for radiofrequency ablation of atrial fibrillation: assessment of prevalence and morphologic characteristics by dual-source computed tomography. Circ Arrhythm Electrophysiol 2012;5:345–50. 4. Stanczyk J, Moll J, Wilczynski J. Prenatal diagnosis of a fetal left atrial diverticulum. Prenat Diagn 1999;19:1055–7. 5. Gao C, Wang R, Wang G, Wang Y. Giant left atrial diverticulum. J Card Surg 2011;26:70.
Subacute Endocarditis of an Atrial Septal Closure Device in a Patient With a Patent Foramen Ovale
he treatment of patent foramen ovale (PFO) in patient with cryptogenic stroke remains controversial. There have been three multicenter prospective, randomized, controlled trials comparing transcatheter closure with medical therapy, and none has shown a benefit for transcatheter closure. As many as half of PFOs are incidental findings. Determining which patients show the most benefit for closure remains a challenge. Balancing the risks against this uncertain benefit remains a major challenge for clinicians and patients alike. Further studies are needed to clarify which patients will derive the greatest benefit. A 37-year-old obese man with a history of poorly controlled type I diabetes mellitus, transient ischemic attacks, and transcatheter closure of a PFO in 2011 with an Amplatzer Septal Occluder (St. Jude Medical, St. Paul, MN), presented to the emergency department with diffuse chest pain, diaphoresis, and generalized malaise. After an emergent evaluation for an acute myocardial infarction, including coronary angiogram, was found to
Seth B. Krantz, MD, and Jennifer S. Lawton, MD Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
The role of transcatheter closure of a patent foramen ovale for cryptogenic stroke remains controversial. The most common complications include atrial arrhythmia and bleeding. Infectious complications are exceedingly rare. We describe a 37-year-old man with a history of transient ischemic attacks and a patent foramen ovale who underwent transcatheter closure, complicated by Accepted for publication Dec 30, 2013. Address correspondence to Dr Lawton, Washington University School of Medicine, Division of Cardiothoracic Surgery, Department of Surgery, 660 S Euclid Ave, Campus Box 8234, St. Louis, MO 63110; e-mail: lawtonj@ wustl.edu.
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier
Fig 1. Transesophageal echocardiogram demonstrating vegetations on the Amplatzer Septal Occluder device. 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.12.079
FEATURE ARTICLES
Fig 2. The macrostructure and pathologic morphology: (A) The diverticulum is seen as a giant, thin cavity that extends over the left ventricle. (B) Hematoxylin and eosin staining of the diverticulum tissue demonstrates endocardium and thin myocardium (original magnification 100).
1822
CASE REPORT KRANTZ AND LAWTON ENDOCARDITIS OF ATRIAL SEPTAL CLOSURE DEVICE
Ann Thorac Surg 2014;98:1821–3
hospitalization and had experienced a 20 kg weight loss. Given this recent history along with his transcatheter PFO closure, endocarditis was the presumptive diagnosis. The initial transthoracic echocardiogram was unrevealing; a transesophageal echocardiogram was performed and revealed a highly mobile, multilobulated vegetation on the left atrial aspect of his PFO closure device (Fig 1). He was taken to the operating room and was found to have an intense inflammatory reaction with a thickened pericardium and a dense inflammatory peel along the entire epicardial surface of the heart. A right atriotomy revealed the device to be endothelialized on the right atrial side without vegetations (Fig 2). The left atrium was friable and thickened, and the device on this side, while epithelialized, had considerable vegetations (Fig 3). It was sharply debrided and excised. Upon removal, the inferior aspect of his atrial septum was debrided back to healthy tissue and closed with an autologous pericardial patch. Transesophageal echocardiography showed no residual flow across the atrial septum. Tissue cultures from the device and the pericardium grew MRSA. The patient’s initial recovery was uncomplicated, and he was discharged with 6 additional weeks of intravenous antibiotics. He presented 6 weeks later with a loculated right pleural effusion and underwent thoracoscopic decortication. His postoperative course was uneventful, and he was discharged home in good condition. FEATURE ARTICLES
Comment Fig 2. Intraoperative view of the epithelialized device viewed from the right atrium.
be negative, he was admitted for presumed pericarditis. He subsequently became febrile with blood cultures positive for methicillin-resistant Staphylococcus aureus (MRSA). His course was further complicated by pneumonia and development of a thoracic spine epidural abscess. One month earlier he had been hospitalized after presenting with malaise and low grade fevers and was treated for both pneumonia and a MRSA urinary tract infection. He had been feeling generally unwell since that Fig 3. Vegetations on the epithelialized surface of the excised device.
The first transcatheter closure of a PFO was in 1992 [1]. Since that time, with the development of new atrial septal occluder devices, transcatheter closure of PFOs in adults has increased substantially. Although the overall serious complication rate is approximately 15% to 20%, with atrial fibrillation and bleeding being the most common [2–4], infectious complications are exceedingly rare [5–10], and most of the reported cases are in patients who had a true atrial septal defect as opposed to a PFO. In the two reported patients with a PFO who had endocarditis, both had an atrial septal aneurysm, although with such a small number of cases, it is unknown whether that was contributory [8, 10].
Contrary to other reported cases, the device in this patient was completely endothelialized. The risk of complications such as thrombosis and infection is thought be primarily related to the exposure of the prosthetic material and thus occurs either before endothelialization occurs or in poorly endothelialized devices [6–10]. This case highlights that infection is possible even with endothelialization, and thus represents a lifetime potential risk for these patients. Making the diagnosis of endocarditis in these patients can be challenging and frequently requires transesophageal echocardiography [8–10]. In this patient, endocarditis was suspected, but the initial transthoracic echocardiogram was negative. For patients with fevers and prosthetic devices in which endocarditis is suspected, transesophageal echocardiography is likely the test of choice and should be performed expeditiously. The role of transcatheter closure of a PFO in patients with cryptogenic stroke remains to be defined. There have been three multicenter prospective, randomized, controlled trials (CLOSURE I, PC, and RESPECT) comparing transcatheter closure with medical therapy; none of the trials demonstrated a benefit for transcatheter closure [2–4]. Better stratification and identification of patients in whom the PFO is the likely source of stroke is needed before the optimal means of treatment can be determined. The data suggest no benefit to closure over medical management; however, post hoc analysis from all three trials suggests that younger patients lacking other risk factors for stroke and patients with a large degree of shunt may derive a benefit. Although infection is an uncommon complication of septal closure devices, its presence mimics the clinical course of an intravascular foreign body infection similar to prosthetic valve endocarditis and should be treated accordingly. It can occur late after device placement, and even in cases where the device is endothelialized. Thus, the risk of endocarditis is lifelong, similar to that for a prosthetic valve, and should be considered when placing these devices. For the patient presented here, this diagnosis was delayed for several months and even after endocarditis was suspected, the initial transthoracic echocardiogram was negative, suggesting that transesophageal echocardiography should be the test of choice in patients who have had atrial septal defect closure devices and in whom endocarditis is suspected. At the time of surgery, despite endothelialization, several large, friable vegetations were present. A high index of suspicion must be maintained in such patients.
CASE REPORT MAURI ET AL POORLY TOLERATED VSD AFTER TAVI
1823
4. Meier B, Kalesan B, Mattle HP, et al. Percutaneous closure of patent foramen ovale in cryptogenic embolism. N Engl J Med 2013;368:1083–91. 5. Sarris GE, Kirvassilis G, Zavaropoulos P, et al. Surgery for complications of trans-catheter closure of atrial septal defects: a multi-institutional study from the European Congenital Heart Surgeons Association. Eur J Cardiothorac Surg 2010;37:1285–90. 6. Slesnick TC, Nugent AW, Fraser CDJ, Cannon BC. Images in cardiovascular medicine. Incomplete endothelialization and late development of acute bacterial endocarditis after implantation of an amplatzer septal occluder device. Circulation 2008;117:e326–7. 7. Bullock AM, Menahem S, Wilkinson JL. Infective endocarditis on an occluder closing an atrial septal defect. Cardiol Young 1999;9:65–7. 8. Divchev D, Podewski EK, Mengel M, Meyer GP, Drexler H, Schaefer A. Inflammatory, abscess-forming foreign body reaction mimics a thrombus formation on an atrial septal defect closure device: a commented case report. Eur J Echocardiogr 2007;8:298–302. 9. Zahr F, Katz WE, Toyoda Y, Anderson WD. Late bacterial endocarditis of an Amplatzer atrial septal defect occluder device. Am J Cardiol 2010;105:279–80. 10. Walpot J, Amsel B, Rodrigus I, Pasteuning WH, Koeman J, Hokken R. Late infective endocarditis of an atrial septal occluder device presenting as a cystic mass. Echocardiography 2011;28:E131–3.
Percutaneous Closure of a Poorly Tolerated Post–Transcatheter Aortic Valve Implantation Ventricular Septal Defect Lucia Mauri, MD, Philippe Aldebert, MD, Thomas Cuisset, MD, PhD, Jacques Quilici, MD, and Alain Fraisse, MD, PhD Service de Cardiologie P ediatrique et Cong enitale, CHU Timone Enfants, and Service de Cardiologie, CHU Timone Adultes, Marseille, France
We report the case of a 78-year-old woman with severe aortic valve stenosis that was successfully treated with transcatheter aortic valve implantation, with initial good hemodynamic results and clinical improvement of the patient. After 3 weeks, her clinical condition worsened, with progressive heart failure. Transthoracic echocardiography revealed an iatrogenic large subaortic ventricular septal defect with important left-to right shunt (Qp/Qs 3:1). The patient underwent successful transcatheter closure of the ventricular septal defect with a 14-mm Amplatzer mVSD Occluder (AGA Medical, Plymouth, MN), resulting in dramatic clinical improvement. (Ann Thorac Surg 2014;98:1823–6) Ó 2014 by The Society of Thoracic Surgeons
References 1. Bridges ND, Hellenbrand W, Latson L, Filiano J, Newburger JW, Lock JE. Transcatheter closure of patent foramen ovale after presumed paradoxical embolism. Circulation 1992;86:1902–8. 2. Carroll JD, Saver JL, Thaler DE, et al. Closure of patent foramen ovale versus medical therapy after cryptogenic stroke. N Engl J Med 2013;368:1092–100. 3. Furlan AJ, Reisman M, Massaro J, et al. Closure or medical therapy for cryptogenic stroke with patent foramen ovale. N Engl J Med 2012;366:991–9. Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier
Accepted for publication Dec 30, 2013. Address correspondence to Dr Fraisse, Cardiologie P ediatrique, CHU Timone Enfants, 264 Rue Saint Pierre, Marseille 13385, Cedex 05, France; e-mail: [email protected].
Dr Fraisse discloses a financial relationship with St. Jude Medical (AGA Medical Devices).
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.12.072
FEATURE ARTICLES
Ann Thorac Surg 2014;98:1823–6
CASE REPORT KRANTZ AND LAWTON ENDOCARDITIS OF ATRIAL SEPTAL CLOSURE DEVICE
1821
under cardiopulmonary bypass through a median sternotomy because the left atrial diverticulum was giant and thin.
subacute endocarditis of the completely endothelialized device 2 years after placement. (Ann Thorac Surg 2014;98:1821–3) Ó 2014 by The Society of Thoracic Surgeons
References
T
1. McGuinness J, Kindawi A, Tajri S, Walsh K, Nolke L, Wood AE. Surgical management of giant left atrial diverticulum. J Thorac Cardiovasc Surg 2007;133:820–2. 2. Nomura K, Matsumura Y, Shinohara G, Nakamura Y. A 4-year-old girl with giant left atrial diverticulum resulting in severe mitral regurgitation. Cardiovasc Pathol 2008;17: 254–5. 3. Peng LQ, Yu JQ, Yang ZG, et al. Left atrial diverticula in patients referred for radiofrequency ablation of atrial fibrillation: assessment of prevalence and morphologic characteristics by dual-source computed tomography. Circ Arrhythm Electrophysiol 2012;5:345–50. 4. Stanczyk J, Moll J, Wilczynski J. Prenatal diagnosis of a fetal left atrial diverticulum. Prenat Diagn 1999;19:1055–7. 5. Gao C, Wang R, Wang G, Wang Y. Giant left atrial diverticulum. J Card Surg 2011;26:70.
Subacute Endocarditis of an Atrial Septal Closure Device in a Patient With a Patent Foramen Ovale
he treatment of patent foramen ovale (PFO) in patient with cryptogenic stroke remains controversial. There have been three multicenter prospective, randomized, controlled trials comparing transcatheter closure with medical therapy, and none has shown a benefit for transcatheter closure. As many as half of PFOs are incidental findings. Determining which patients show the most benefit for closure remains a challenge. Balancing the risks against this uncertain benefit remains a major challenge for clinicians and patients alike. Further studies are needed to clarify which patients will derive the greatest benefit. A 37-year-old obese man with a history of poorly controlled type I diabetes mellitus, transient ischemic attacks, and transcatheter closure of a PFO in 2011 with an Amplatzer Septal Occluder (St. Jude Medical, St. Paul, MN), presented to the emergency department with diffuse chest pain, diaphoresis, and generalized malaise. After an emergent evaluation for an acute myocardial infarction, including coronary angiogram, was found to
Seth B. Krantz, MD, and Jennifer S. Lawton, MD Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
The role of transcatheter closure of a patent foramen ovale for cryptogenic stroke remains controversial. The most common complications include atrial arrhythmia and bleeding. Infectious complications are exceedingly rare. We describe a 37-year-old man with a history of transient ischemic attacks and a patent foramen ovale who underwent transcatheter closure, complicated by Accepted for publication Dec 30, 2013. Address correspondence to Dr Lawton, Washington University School of Medicine, Division of Cardiothoracic Surgery, Department of Surgery, 660 S Euclid Ave, Campus Box 8234, St. Louis, MO 63110; e-mail: lawtonj@ wustl.edu.
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier
Fig 1. Transesophageal echocardiogram demonstrating vegetations on the Amplatzer Septal Occluder device. 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.12.079
FEATURE ARTICLES
Fig 2. The macrostructure and pathologic morphology: (A) The diverticulum is seen as a giant, thin cavity that extends over the left ventricle. (B) Hematoxylin and eosin staining of the diverticulum tissue demonstrates endocardium and thin myocardium (original magnification 100).
1822
CASE REPORT KRANTZ AND LAWTON ENDOCARDITIS OF ATRIAL SEPTAL CLOSURE DEVICE
Ann Thorac Surg 2014;98:1821–3
hospitalization and had experienced a 20 kg weight loss. Given this recent history along with his transcatheter PFO closure, endocarditis was the presumptive diagnosis. The initial transthoracic echocardiogram was unrevealing; a transesophageal echocardiogram was performed and revealed a highly mobile, multilobulated vegetation on the left atrial aspect of his PFO closure device (Fig 1). He was taken to the operating room and was found to have an intense inflammatory reaction with a thickened pericardium and a dense inflammatory peel along the entire epicardial surface of the heart. A right atriotomy revealed the device to be endothelialized on the right atrial side without vegetations (Fig 2). The left atrium was friable and thickened, and the device on this side, while epithelialized, had considerable vegetations (Fig 3). It was sharply debrided and excised. Upon removal, the inferior aspect of his atrial septum was debrided back to healthy tissue and closed with an autologous pericardial patch. Transesophageal echocardiography showed no residual flow across the atrial septum. Tissue cultures from the device and the pericardium grew MRSA. The patient’s initial recovery was uncomplicated, and he was discharged with 6 additional weeks of intravenous antibiotics. He presented 6 weeks later with a loculated right pleural effusion and underwent thoracoscopic decortication. His postoperative course was uneventful, and he was discharged home in good condition. FEATURE ARTICLES
Comment Fig 2. Intraoperative view of the epithelialized device viewed from the right atrium.
be negative, he was admitted for presumed pericarditis. He subsequently became febrile with blood cultures positive for methicillin-resistant Staphylococcus aureus (MRSA). His course was further complicated by pneumonia and development of a thoracic spine epidural abscess. One month earlier he had been hospitalized after presenting with malaise and low grade fevers and was treated for both pneumonia and a MRSA urinary tract infection. He had been feeling generally unwell since that Fig 3. Vegetations on the epithelialized surface of the excised device.
The first transcatheter closure of a PFO was in 1992 [1]. Since that time, with the development of new atrial septal occluder devices, transcatheter closure of PFOs in adults has increased substantially. Although the overall serious complication rate is approximately 15% to 20%, with atrial fibrillation and bleeding being the most common [2–4], infectious complications are exceedingly rare [5–10], and most of the reported cases are in patients who had a true atrial septal defect as opposed to a PFO. In the two reported patients with a PFO who had endocarditis, both had an atrial septal aneurysm, although with such a small number of cases, it is unknown whether that was contributory [8, 10].
Contrary to other reported cases, the device in this patient was completely endothelialized. The risk of complications such as thrombosis and infection is thought be primarily related to the exposure of the prosthetic material and thus occurs either before endothelialization occurs or in poorly endothelialized devices [6–10]. This case highlights that infection is possible even with endothelialization, and thus represents a lifetime potential risk for these patients. Making the diagnosis of endocarditis in these patients can be challenging and frequently requires transesophageal echocardiography [8–10]. In this patient, endocarditis was suspected, but the initial transthoracic echocardiogram was negative. For patients with fevers and prosthetic devices in which endocarditis is suspected, transesophageal echocardiography is likely the test of choice and should be performed expeditiously. The role of transcatheter closure of a PFO in patients with cryptogenic stroke remains to be defined. There have been three multicenter prospective, randomized, controlled trials (CLOSURE I, PC, and RESPECT) comparing transcatheter closure with medical therapy; none of the trials demonstrated a benefit for transcatheter closure [2–4]. Better stratification and identification of patients in whom the PFO is the likely source of stroke is needed before the optimal means of treatment can be determined. The data suggest no benefit to closure over medical management; however, post hoc analysis from all three trials suggests that younger patients lacking other risk factors for stroke and patients with a large degree of shunt may derive a benefit. Although infection is an uncommon complication of septal closure devices, its presence mimics the clinical course of an intravascular foreign body infection similar to prosthetic valve endocarditis and should be treated accordingly. It can occur late after device placement, and even in cases where the device is endothelialized. Thus, the risk of endocarditis is lifelong, similar to that for a prosthetic valve, and should be considered when placing these devices. For the patient presented here, this diagnosis was delayed for several months and even after endocarditis was suspected, the initial transthoracic echocardiogram was negative, suggesting that transesophageal echocardiography should be the test of choice in patients who have had atrial septal defect closure devices and in whom endocarditis is suspected. At the time of surgery, despite endothelialization, several large, friable vegetations were present. A high index of suspicion must be maintained in such patients.
CASE REPORT MAURI ET AL POORLY TOLERATED VSD AFTER TAVI
1823
4. Meier B, Kalesan B, Mattle HP, et al. Percutaneous closure of patent foramen ovale in cryptogenic embolism. N Engl J Med 2013;368:1083–91. 5. Sarris GE, Kirvassilis G, Zavaropoulos P, et al. Surgery for complications of trans-catheter closure of atrial septal defects: a multi-institutional study from the European Congenital Heart Surgeons Association. Eur J Cardiothorac Surg 2010;37:1285–90. 6. Slesnick TC, Nugent AW, Fraser CDJ, Cannon BC. Images in cardiovascular medicine. Incomplete endothelialization and late development of acute bacterial endocarditis after implantation of an amplatzer septal occluder device. Circulation 2008;117:e326–7. 7. Bullock AM, Menahem S, Wilkinson JL. Infective endocarditis on an occluder closing an atrial septal defect. Cardiol Young 1999;9:65–7. 8. Divchev D, Podewski EK, Mengel M, Meyer GP, Drexler H, Schaefer A. Inflammatory, abscess-forming foreign body reaction mimics a thrombus formation on an atrial septal defect closure device: a commented case report. Eur J Echocardiogr 2007;8:298–302. 9. Zahr F, Katz WE, Toyoda Y, Anderson WD. Late bacterial endocarditis of an Amplatzer atrial septal defect occluder device. Am J Cardiol 2010;105:279–80. 10. Walpot J, Amsel B, Rodrigus I, Pasteuning WH, Koeman J, Hokken R. Late infective endocarditis of an atrial septal occluder device presenting as a cystic mass. Echocardiography 2011;28:E131–3.
Percutaneous Closure of a Poorly Tolerated Post–Transcatheter Aortic Valve Implantation Ventricular Septal Defect Lucia Mauri, MD, Philippe Aldebert, MD, Thomas Cuisset, MD, PhD, Jacques Quilici, MD, and Alain Fraisse, MD, PhD Service de Cardiologie P ediatrique et Cong enitale, CHU Timone Enfants, and Service de Cardiologie, CHU Timone Adultes, Marseille, France
We report the case of a 78-year-old woman with severe aortic valve stenosis that was successfully treated with transcatheter aortic valve implantation, with initial good hemodynamic results and clinical improvement of the patient. After 3 weeks, her clinical condition worsened, with progressive heart failure. Transthoracic echocardiography revealed an iatrogenic large subaortic ventricular septal defect with important left-to right shunt (Qp/Qs 3:1). The patient underwent successful transcatheter closure of the ventricular septal defect with a 14-mm Amplatzer mVSD Occluder (AGA Medical, Plymouth, MN), resulting in dramatic clinical improvement. (Ann Thorac Surg 2014;98:1823–6) Ó 2014 by The Society of Thoracic Surgeons
References 1. Bridges ND, Hellenbrand W, Latson L, Filiano J, Newburger JW, Lock JE. Transcatheter closure of patent foramen ovale after presumed paradoxical embolism. Circulation 1992;86:1902–8. 2. Carroll JD, Saver JL, Thaler DE, et al. Closure of patent foramen ovale versus medical therapy after cryptogenic stroke. N Engl J Med 2013;368:1092–100. 3. Furlan AJ, Reisman M, Massaro J, et al. Closure or medical therapy for cryptogenic stroke with patent foramen ovale. N Engl J Med 2012;366:991–9. Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier
Accepted for publication Dec 30, 2013. Address correspondence to Dr Fraisse, Cardiologie P ediatrique, CHU Timone Enfants, 264 Rue Saint Pierre, Marseille 13385, Cedex 05, France; e-mail: [email protected].
Dr Fraisse discloses a financial relationship with St. Jude Medical (AGA Medical Devices).
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.12.072
FEATURE ARTICLES
Ann Thorac Surg 2014;98:1823–6
