A 26-year-old woman presented with acute hemolysis 1 month after percutaneous closure of an atrial septal defect. Three-dimensional transesophageal echocardiography was used to establish the diagnosis of a fistula from the aorta, toward the device and both atria. The patient required urgent surgical correction. Transcatheter closure of atrial septal defects has proven to be a highly successful alternative to surgery in the appropriate patient. Cardiac perforation and device erosion of the aortic wall are infrequent but potentially lethal complications of percutaneous occluder device insertion. Supportive features of device erosion include a wrong preimplantation assessment of the rims, the device extends across the atrial septum, and the device encroaches on the surrounding structures. In this case, the presumed mechanism of aortic fistula was aortic erosion by the left atrial disk of the occluder device.
Percutaneous closure of atrial septal defects (ASDs) has proven to be a highly successful alternative to surgery in the appropriate patient. Cardiac perforation and device erosion of the aortic wall are infrequent but potentially lethal complications of transcatheter occluder device insertion.
Case Report
A 26-year-old woman was admitted to the emergency department with asthenia and jaundice. As a medical history of interest, a percutaneous closure of a secundum ASD was performed 1 month previously with a 30-mm Amplatzer ASD device occluder (AGA Medical Corp., Plymouth, MN). On physical examination, the patient was afebrile. A continuous murmur was noted at the left sternal border. Her hemoglobin level was 6.7 g/dL, and laboratory studies confirmed a hemolytic anemia. The remaining physical examination results were unremarkable.
An emergency transthoracic echocardiography showed an abnormal high-velocity flow through the Amplatzer device, without pericardial effusion ( Video 1 ). A transesophageal study was recommended, and before the patient was transferred to the echocardiography laboratory, the medical recordings were reviewed.
The patient had a large ASD (maximum diameter 24.1 mm) with deficient rims (superior rim 4 mm; aortic rim 4 mm). The anatomy defined by echocardiography was considered unsuitable for percutaneous closure. However, after considerable debate with the patient and the hemodynamic team, the final decision was to attempt to close the ASD with a percutaneous device. The procedure was performed without complications. However, the device had to cover more than 90% of the atrial septum diameter, and it encroached on the aortic root, into the superior right pulmonary vein, and into the superior cava vein, with the left anchor pushing the noncoronary sinus ( Figure 1 ; Video 2 ).
The patient finally underwent transesophageal echocardiography (TEE), which confirmed a shunt between the atria and the aorta at the device level ( Figure 2 A). Real-time three-dimensional TEE images were obtained after two-dimensional TEE study. Confirmation of device positioning was easily obtained with three-dimensional zoom mode, and both sides of the device could be seen, as well as the tissue rim that was caught between them. Color full-volume data sets from seven R-wave–triggered subvolumes were analyzed, which allowed us to visualize a small fistula, with a continuous flow, from the noncoronary aortic sinus to the midportion of the device and toward both atria. A multiplanar reconstruction of the full-volume data set revealed an irregular and slim fistulous tract with a continuous flow streaming to both atria ( Figure 2 B; Videos 3 and 4 ).
