Very late cardiac tamponade following successful transcatheter closure of an atrial septal defect with the Amplatzer septal occluder

To avoid late complications, ASDs should be closed even when detected in adults, an endeavor that may be performed surgically or via the transcatheter approach, as is done for secundum-type ASDs that possess suitable anatomy and no associated lesions. Surgical ASD closure carries a higher periprocedural risk compared with transcatheter closure, but has an excellent long-term prognosis. We report the occurrence of a rare but life-threatening long-term complication following transcatheter ASD closure, cardiac perforation with cardiac tamponade, and its successful surgical treatment. Secundum-type ASD was diagnosed in a 30-year-old woman by cardiac catheterization in 1982. Paroxysmal atrial fibrillation (AF) developed at an age of 56. Both transthoracic (TTE) and transesophageal echocardiography (TEE, see Online Resource ESM Fig. 1) demonstrated biatrial enlargement, the volume-overloaded right ventricle appeared dilated and had a reduced function. All pulmonary veins were connected to the LA. Coronary angiography was normal. Cardiac catheterization demonstrated mildly elevated pulmonary artery pressures. Oxymetric analysis confirmed the presence of a predominant left-to-right (67 %) shunt and a small right-to-left shunt (7 %). The balloon-stretched ASD diameter measured 25 mm by angiography, and 26 mm by intracardiac echocardiography (ICE). The ASD was closed with a 28 mm Amplatzer Septal Occluder (ASO, St. Jude Medical, Inc., St. Paul, MN) in 2008. Antiplatelet therapy was prescribed for 6 months, and then TEE documented correct positioning of the ASO with no residual shunts. The sizes of the atria decreased, and the RV function improved. Symptomatic paroxysmal atrial fibrillation necessitated treatment with flecainide and bisoprolol. The patient remained on aspirin. Acute chest pain and shortness of breath required urgent hospitalization three years after transcatheter ASD occlusion. On admission, the patient was in cardiogenic shock due to a large pericardial effusion with tamponade physiology (Fig. 1a). The removal of 350 ml of nonclotting blood (hematocrit = 42 %, identical to peripheral blood) via pericardiocentesis resulted in immediate hemodynamic improvement. The patient was transferred to a tertiary-care hospital. Correct positioning of the ASO, as well as a residual pericardial effusion was shown by TEE. An ECGtriggered cardiac CT scan indicated that the ASO impinged the left atrial dorsal wall (Fig. 1b), causing its erosion. The intact ASO (see Online Resource ESM Fig. 2) was removed, the ASD was closed with a patch, and the left atrial roof was surgically reconstructed 10 days later (Fig. 2). Additionally, a bipolar maze procedure was performed, and the left atrial appendage was ligated. Symptomatic bradycardia required the implantation of a DDDR pacemaker postoperatively. Follow-up exams confirmed excellent long-term operative results. Electronic supplementary material The online version of this article (doi:10.1007/s00392-015-0829-0) contains supplementary material, which is available to authorized users.