- Email: [email protected]
Repair of Aortic–Left Atrial Fistula Following the Transcatheter Closure of an Atrial Septal Defect
Ann Thorac Surg 2005;80:1495– 8
© 2005 by The Society of Thoracic Surgeons Published by Elsevier Inc
1495
References 1. Rose EA, Moskowitz, AJ, Packer M, et al. Long-term use of a left ventricular assist device for end-stage heart failure. NEJM 2001;345:1435– 43. 2. Holman WL, Rayburn BK, McGiffin DC, et al. Infection in ventricular assist devices: prevention and treatment. Ann Thorac Surg 2003;75:S48 –57. 3. Fisher SA, Trenholme GM, Costanzo, MR, et al. Infectious complications in left ventricular assist device recipients. Clin Infect Dis 1997;24:18 –23. 4. Grossi P, Dalla GD, Pagani, F, et al. Infectious complications in patients with the Novacor left ventricular assist system. Transplant Proc 2001;33:1969 –71. 5. Pasque MK, Hanselman T, Shelton K, et al. Surgical management of Novacor drive-line exit site infections. Ann Thorac Surg 2002;74(4):1267– 8. 6. Morykwas MJ, Argenta LC, Shelton-Brown EI, et al. Vacuum assisted closure: a new method for wound control and treatment. Animal studies and basic foundation. Ann Plast Surg 1997;38:553– 62. 7. Argenta LC, Morykwas MJ. Vacuum assisted closure: a new method for wound control and treatment. Clinical experience. Ann Plast Surg 1997;38:563–77. 8. Obdeijn MC, de Lange MY, Lichtendahl DHE, et al. Vacuumassisted closure in the treatment of poststernotomy mediastinitis. Ann Thorac Surg 1999;68:2358 – 60.
Repair of Aortic–Left Atrial Fistula Following the Transcatheter Closure of an Atrial Septal Defect Dennis M. Mello, MD, John Fahey, MD, and Gary S. Kopf, MD Divisions of Cardiothoracic Surgery and Pediatric Cardiology, Yale University School of Medicine, New Haven, Connecticut
We describe the surgical treatment of an aortic–left atrial fistula that appeared 6 months after the placement of an Amplatzer septal occluder for closure of a large secundum atrial septal defect. Successful repair of the fistula was accomplished by a combined transatrial–transaortic approach similar to that used to repair the rupture of a sinus of Valsalva aneurysm. (Ann Thorac Surg 2005;80:1495– 8) © 2005 by The Society of Thoracic Surgeons
T
ranscatheter closure of secundum atrial septal defects (ASDs) with the Amplatzer septal occluder (ASO) has been reported for a large number of patients, with low complication rates [1]. Even relatively large ASDs have been closed with this device with good results and no reports of long-term complications [2– 4]. The presence of a thin or deficient aortic “rim” superiorly has been reported not to be a contraindication to successful closure [5], and in these cases the ASO device is positioned at the base of the aorta. Figure 1 shows the relationship between the occluder device near the supeAccepted for publication March 30, 2004. Address reprint requests to Dr Kopf, Yale-New Haven Hospital, Department of Surgery, Yale University School of Medicine, 333 Cedar St, Room 121 FMB, New Haven, CT 06510; e-mail: [email protected].
0003-4975/05/$30.00 doi:10.1016/j.athoracsur.2004.03.098
FEATURE ARTICLES
point where surrounding tissues are circumferentially adherent. This strategy is well-suited for localized exit site infections but has limited utility for more extensive, deeper driveline infections. Wide debridement leading to a shortened tract can result in an attenuated barrier to the pump pocket. Furthermore, displacement of the driveline to a more medial abdominal exit site after extensive tract debridement can present a significant hindrance to the patient’s mobility. Other groups have advocated replacing the distal portion of the driveline in a new subcutaneous tunnel. This approach may place the deeper segments of the driveline at risk for infection. In addition, the patient’s body habitus or pump orientation, or both, may limit options for alternative tract routes and exit sites. We describe the use of a vacuum-assisted wound closure system to manage extensive driveline tract infections, which unlike other methods, this system reestablishes the original tract and exit site, accelerates healing, and simplifies wound management for the patient. The VAC system was first introduced by Morykwas and Argenta [6, 7] for the treatment of pressure ulcers and other chronic wounds. Based on the application of negative pressure by controlled suction to the wound surface, granulation tissue proliferation is promoted by arteriolar dilatation [8]. The continuous suction reduces excess fluid collection and tissue edema, reducing bacterial colonization. Finally, the VAC system effectively seals the wound from the environment, reducing gross contamination and mixed flora colonization. These characteristics appear to accelerate wound healing. With respect to cardiac surgery, the VAC system has been successfully applied to deep sternal wound infections incurred with median sternotomies, either as a bridge to reconstruction with a pectoralis muscle flap or in preparation for primary wound closure [8]. Our excellent experience with the VAC system in this context prompted our group to apply it to deep LVAD driveline tract infections. We believe that our technique offers several advantages compared with other strategies in the management of extensive driveline tract infections. First, the VAC system permits definitive wide excision, drainage, and reestablishment of the original tract and exit site, obviating the need for replacement or repositioning of the driveline. Second, as with sternotomy wounds, the VAC system provides substantial wound stability, effectively immobilizing the driveline within the tract and optimizing conditions for circumferential tissue adherence to it. Third, the accelerated wound healing and closed-system configuration associated with the VAC approach would appear to be conducive to shorter hospital stays and outpatient wound care. Finally, by maintaining a hermetically sealed and well-drained environment over the redeveloping tract until circumferential tissue adherence around the driveline is reestablished, the tract and, by extension, the entire VAD system is protected from contamination. We plan on continuing this promising approach to validate its purported advantages.
CASE REPORT MELLO ET AL REPAIR OF AORTIC-LEFT ATRIAL FISTULA
1496
CASE REPORT MELLO ET AL REPAIR OF AORTIC-LEFT ATRIAL FISTULA
FEATURE ARTICLES
Fig 1. Schematic drawing of the base of the heart showing how a rigid atrial septal defect device placed in the superior-anterior atrial septum could impinge on the aortic root. (ANT ⫽ anterior; Circ. ⫽ circumflex; LA ⫽ left atrium; LAD ⫽ left anterior descending artery; LV ⫽ left ventricle; LCC ⫽ left coronary cusp; LMCA ⫽ left main coronary artery; MV ⫽ mitral valve; NCC ⫽ noncoronary cusp; POST ⫽ posterior; RA ⫽ right atrium; TV ⫽ tricuspid valve; RCA ⫽ right carotid artery; RCC ⫽ right coronary cusp; RV ⫽ right ventricle).
Ann Thorac Surg 2005;80:1495– 8
TEE demonstrated a fistula between the noncoronary sinus of Valsalva and the left atrium. No significant heart murmur was heard at this time. The device was well positioned, with no residual atrial septal defect and no atrial enlargement. Angiography with aortic root injection confirmed an aortic–left atrial fistula (Fig 2). The patient was referred for urgent surgical repair. The procedure was performed using standard cardiopulmonary bypass techniques with bicaval cannulation. Cardioplegia was administered retrograde with left ventricular venting through the right superior pulmonary vein. The fistula was approached both through the aortic root and right atrium. A 3-mm fistula was found extending from the base of the noncoronary sinus of Valsalva into the roof of the left atrium at the edge of the ASO device (Fig 3A). The fistula tract was surrounded by thick, chronic inflammatory tissue. Upon entering the right atrium, the ASO device was firmly adhering to the atrial septum, and it was well endothelialized with no residual ASD. The right atrial arm of the device was removed with sharp dissection, followed by entry into the left atrium and removal of the left atrial disk. The fistula appeared much larger viewed from the aortic root after the ASO device was removed (Fig 3B). The left superior aspect of the device had eroded into the base of the aorta.
rior-anterior aspect of the interatrial septum and the aortic root. However, the long-term complications of the presence of a large rigid foreign body in the heart close to the aortic root are unknown. Recently, there have been two reports of erosion of the Amplatzer septal occluder (ASO) into the aorta, creating a fistulous communication to either the right [6] or left atrium [7]. We describe the surgical repair of an aorta-to-left-atrial fistula that developed 6 months after the placement of an ASO device for the closure of a large ASD. A 16-year-old girl underwent placement of a 30-mm ASO device for the closure of a large secundum ASD. A transthoracic echocardiogram demonstrated a 22-mm secundum atrial septal defect with significant right ventricular dilatation. A transesophageal echocardiogram (TEE) at the time of the catheterization showed a deficient aortic rim. The “stretched” diameter, using a sizing balloon, was 27 mm. A 28-mm ASO device was initially placed, but it was removed before its release and replaced with a 30-mm ASO device. The device was oversized slightly in order to straddle the septum. A postprocedure echocardiogram showed good positioning of the device with no evidence of atrial shunting. The initial postimplant echocardiogram showed an intact atrial septum with no fistula. However, 6 months later, despite the absence of a significant heart murmur,
Fig 2. Left ventricular angiogram in the left anterior oblique view showing the fistula (arrow) between the aortic root and the left atrium (LA). (AO ⫽ aorta; LV ⫽ left ventricle.)
Ann Thorac Surg 2005;80:1495– 8
CASE REPORT MELLO ET AL REPAIR OF AORTIC-LEFT ATRIAL FISTULA
1497
tures and reendothelialized. The ASD was then closed with fresh autologous pericardium (Fig 5C). A postbypass echocardiogram showed no residual ASD or fistula and no aortic insufficiency. Because of the disrupted endothelium in the left atrium, the patient was maintained on warfarin for 6 weeks. At 6-month followup, the patient is doing well without evidence of recurrent fistula or atrial level shunting.
Transcatheter closure of large ASDs is becoming a common procedure. The development of an aorto–atrial fistula that involved the right and the left atrium has been reported previously [6, 7]. The placement of large or oversized devices in secundum ASDs that have little superior rim may be a risk factor for this potentially life-threatening complication. In addition, the fact a 28-mm device had initially been positioned and then removed may have abraded the aortic rim of the ASD and predisposed it to subsequent fistula formation after the 30-mm device was deployed. Close follow-up, especially for patients with large superiorly placed ASDs, is important to detect this complication. The natural history of such a fistula is unknown. The possibility of rupture into the pericardial space is a life-threatening complication. The patient was referred for surgical repair on an urgent basis because of the potential risks of this complication as well as the probability of progressive enlargement of the fistula with consequent left-to-right shunt. The fistula jet can cause thrombus formation on the device, which we observed. Once detected, surgical repair should be carried out without delay. The surgical approach is best accomplished with a combined aortic/atrial approach. This allows for closure of both ends of the fistula. Visualization and avoidance of injury to the aortic valve is accomplished from the aortic end. Thrombogenic surfaces caused by the removal of the ASO can be reendothelialized from the left atrial side. Fig 3. (A) A probe placed from the aortic root through the fistula into the left atrium (LA). The atrial septal defect device has been retracted anteriorly to show the left atrium. (RA ⫽ right atrium.) (B) View from the anesthesia screen showing the fistula (arrow) in the noncoronary sinus of Valsalva with the probe through it. The aortic cross-clamp is at the bottom of the picture. (LCC ⫽ left coronary cusp; NCC ⫽ noncoronary cusp.)
A thrombus, measuring 5 ⫻ 5 mm, was found attached to the left side of the ASO device (Fig 4). This may have represented an area near the point of contact of the regurgitant fistula jet. After the left atrial side of the device was removed, a significant amount of deendothelialized left atrial surface was left. The fistula tract was repaired with a series of simple, nonabsorbable monofilament sutures placed from the aortic sinus of Valsalva through the thickened, surrounding tissue and into the left atrium (Fig 5A). Care was taken to avoid injury to the aortic leaflet. Sutures were tied on the left atrial side (Fig 5B). The fistula tract on the left atrial side was closed with horizontal mattress su-
Fig 4. The Amplatzer septal occluder (ASO) used to repair the atrial septal defect has been retracted into the right atrium showing its left atrial (LA) side with thrombus formation (arrow)on the device near the site of the fistula.
FEATURE ARTICLES
Comment
1498
CASE REPORT SAXENA ET AL ORGANIZED TRICUSPID VALVE THROMBUS
Ann Thorac Surg 2005;80:1498 –500
Fig 5. (A) Monofilament sutures are placed from the aortic root into the left atrium and tied in the left atrium to obliterate the fistula. Care is taken to avoid injury to aortic leaflet. (AO ⫽ aortic opening; LA ⫽ left atrium; LCC ⫽ left coronary cusp; NCC ⫽ noncoronary cusp; RA ⫽ right atrium; RCC ⫽ right coronary cusp; SVC ⫽ superior vena cava.) (B) Additional sutures are placed from the left atrial side to reinforce closure and reendothelialize the denuded portion of the left atrium. (C) Patch closure of atrial septal defect (ASD).
FEATURE ARTICLES
Temporary anticoagulation treatment for 6 to 8 weeks should be initiated to prevent potential thrombus formation. Patients with large ASDs with deficient aortic rims that are closed with large occluder devices near the aortic base need to be followed closely for this potentially life-threatening complication. We currently recommend follow-up echocardiography at 1 and 6 months postimplant, with yearly exams thereafter.
A Rare Presentation of Tricuspid Valve Thrombus in a Normal Heart
References
Pankaj Saxena, MCh, Ross Mejia, MBBS, and Robert K. W. Tam, FRACS
1. Omeish A, Hijazi ZM. Transcatheter closure of atrial septal defects in children & adults using the Amplatzer Septal Occluder. J Interv Cardiol 2001;14(1):37– 44. 2. Demkow M, Ruzyllo W, Konka M, et al. Transvenous closure of moderate and large secundum atrial septal defects in adults using the Amplatzer septal occluder. Cathet Cardiovasc Interv 2001;52:188 –93. 3. Berger F, Ewert P, Abdul-Khaliq H, Nurnberg JH, Lange PE. Percutaneous closure of large atrial septal defects with the Amplatzer Septal Occluder: technical overkill or recommendable alternative treatment? J Interv Cardiol 2001;14(1):63–7. 4. Losay J, Petit J, Lambert V, Esna G, Berthaux X, Brenmot P, Angel C. Percutaneous closure with Amplatzer device is a safe and efficient alternative to surgery in adults with large atrial septal defects. Am Heart J 2001;142(3):544 – 8. 5. Du ZD, Koenig P, Cao QL, Waight D, Heitschmidt M, Hijazi ZM. Comparison of Transcatheter closure of secundum atrial septal defect using the Amplatzer Septal Occluder associated with deficient versus sufficient rims. Am J Cardiol 2002;90(8): 865–9. 6. Chun DS, Turrentine MW, Moustapha A, et al. Development of aorta-to-right atrial fistula following closure of secundum atrial septal defect using the Amplatzer septal occluder. Cathet Cardiovasc Interv 2003;58:246 –51. © 2005 by The Society of Thoracic Surgeons Published by Elsevier Inc
7. Aggoun Y, Gallet B, Acar P, et al. Perforation of the aorta after percutaneous closure of an atrial septal defect with Amplatzer prosthesis, presenting with severe hemolysis. Arch Mal Coeur Vaiss 2002;95:479 – 82.
Department of Cardiac Surgery, The Prince Charles Hospital, Chermside, Brisbane, Australia
A young woman presented with a presumptive diagnosis of tricuspid valve tumor in a structurally normal heart. She was recently started on oral progesterone for menorrhagia related to uterine fibroids. She underwent an excision of the mass attached to the tricuspid valve, which was found to be an organized thrombus. We suggest a clinical approach to this problem. (Ann Thorac Surg 2005;80:1498 –500) © 2005 by The Society of Thoracic Surgeons
Accepted for publication April 5, 2004. Address reprint requests to Dr Saxena, Department of Cardiac Surgery, The Prince Charles Hospital, Rode Rd, Chermside, Brisbane QLD 4032, Australia; e-mail: [email protected].
0003-4975/05/$30.00 doi:10.1016/j.athoracsur.2004.04.018
© 2005 by The Society of Thoracic Surgeons Published by Elsevier Inc
1495
References 1. Rose EA, Moskowitz, AJ, Packer M, et al. Long-term use of a left ventricular assist device for end-stage heart failure. NEJM 2001;345:1435– 43. 2. Holman WL, Rayburn BK, McGiffin DC, et al. Infection in ventricular assist devices: prevention and treatment. Ann Thorac Surg 2003;75:S48 –57. 3. Fisher SA, Trenholme GM, Costanzo, MR, et al. Infectious complications in left ventricular assist device recipients. Clin Infect Dis 1997;24:18 –23. 4. Grossi P, Dalla GD, Pagani, F, et al. Infectious complications in patients with the Novacor left ventricular assist system. Transplant Proc 2001;33:1969 –71. 5. Pasque MK, Hanselman T, Shelton K, et al. Surgical management of Novacor drive-line exit site infections. Ann Thorac Surg 2002;74(4):1267– 8. 6. Morykwas MJ, Argenta LC, Shelton-Brown EI, et al. Vacuum assisted closure: a new method for wound control and treatment. Animal studies and basic foundation. Ann Plast Surg 1997;38:553– 62. 7. Argenta LC, Morykwas MJ. Vacuum assisted closure: a new method for wound control and treatment. Clinical experience. Ann Plast Surg 1997;38:563–77. 8. Obdeijn MC, de Lange MY, Lichtendahl DHE, et al. Vacuumassisted closure in the treatment of poststernotomy mediastinitis. Ann Thorac Surg 1999;68:2358 – 60.
Repair of Aortic–Left Atrial Fistula Following the Transcatheter Closure of an Atrial Septal Defect Dennis M. Mello, MD, John Fahey, MD, and Gary S. Kopf, MD Divisions of Cardiothoracic Surgery and Pediatric Cardiology, Yale University School of Medicine, New Haven, Connecticut
We describe the surgical treatment of an aortic–left atrial fistula that appeared 6 months after the placement of an Amplatzer septal occluder for closure of a large secundum atrial septal defect. Successful repair of the fistula was accomplished by a combined transatrial–transaortic approach similar to that used to repair the rupture of a sinus of Valsalva aneurysm. (Ann Thorac Surg 2005;80:1495– 8) © 2005 by The Society of Thoracic Surgeons
T
ranscatheter closure of secundum atrial septal defects (ASDs) with the Amplatzer septal occluder (ASO) has been reported for a large number of patients, with low complication rates [1]. Even relatively large ASDs have been closed with this device with good results and no reports of long-term complications [2– 4]. The presence of a thin or deficient aortic “rim” superiorly has been reported not to be a contraindication to successful closure [5], and in these cases the ASO device is positioned at the base of the aorta. Figure 1 shows the relationship between the occluder device near the supeAccepted for publication March 30, 2004. Address reprint requests to Dr Kopf, Yale-New Haven Hospital, Department of Surgery, Yale University School of Medicine, 333 Cedar St, Room 121 FMB, New Haven, CT 06510; e-mail: [email protected].
0003-4975/05/$30.00 doi:10.1016/j.athoracsur.2004.03.098
FEATURE ARTICLES
point where surrounding tissues are circumferentially adherent. This strategy is well-suited for localized exit site infections but has limited utility for more extensive, deeper driveline infections. Wide debridement leading to a shortened tract can result in an attenuated barrier to the pump pocket. Furthermore, displacement of the driveline to a more medial abdominal exit site after extensive tract debridement can present a significant hindrance to the patient’s mobility. Other groups have advocated replacing the distal portion of the driveline in a new subcutaneous tunnel. This approach may place the deeper segments of the driveline at risk for infection. In addition, the patient’s body habitus or pump orientation, or both, may limit options for alternative tract routes and exit sites. We describe the use of a vacuum-assisted wound closure system to manage extensive driveline tract infections, which unlike other methods, this system reestablishes the original tract and exit site, accelerates healing, and simplifies wound management for the patient. The VAC system was first introduced by Morykwas and Argenta [6, 7] for the treatment of pressure ulcers and other chronic wounds. Based on the application of negative pressure by controlled suction to the wound surface, granulation tissue proliferation is promoted by arteriolar dilatation [8]. The continuous suction reduces excess fluid collection and tissue edema, reducing bacterial colonization. Finally, the VAC system effectively seals the wound from the environment, reducing gross contamination and mixed flora colonization. These characteristics appear to accelerate wound healing. With respect to cardiac surgery, the VAC system has been successfully applied to deep sternal wound infections incurred with median sternotomies, either as a bridge to reconstruction with a pectoralis muscle flap or in preparation for primary wound closure [8]. Our excellent experience with the VAC system in this context prompted our group to apply it to deep LVAD driveline tract infections. We believe that our technique offers several advantages compared with other strategies in the management of extensive driveline tract infections. First, the VAC system permits definitive wide excision, drainage, and reestablishment of the original tract and exit site, obviating the need for replacement or repositioning of the driveline. Second, as with sternotomy wounds, the VAC system provides substantial wound stability, effectively immobilizing the driveline within the tract and optimizing conditions for circumferential tissue adherence to it. Third, the accelerated wound healing and closed-system configuration associated with the VAC approach would appear to be conducive to shorter hospital stays and outpatient wound care. Finally, by maintaining a hermetically sealed and well-drained environment over the redeveloping tract until circumferential tissue adherence around the driveline is reestablished, the tract and, by extension, the entire VAD system is protected from contamination. We plan on continuing this promising approach to validate its purported advantages.
CASE REPORT MELLO ET AL REPAIR OF AORTIC-LEFT ATRIAL FISTULA
1496
CASE REPORT MELLO ET AL REPAIR OF AORTIC-LEFT ATRIAL FISTULA
FEATURE ARTICLES
Fig 1. Schematic drawing of the base of the heart showing how a rigid atrial septal defect device placed in the superior-anterior atrial septum could impinge on the aortic root. (ANT ⫽ anterior; Circ. ⫽ circumflex; LA ⫽ left atrium; LAD ⫽ left anterior descending artery; LV ⫽ left ventricle; LCC ⫽ left coronary cusp; LMCA ⫽ left main coronary artery; MV ⫽ mitral valve; NCC ⫽ noncoronary cusp; POST ⫽ posterior; RA ⫽ right atrium; TV ⫽ tricuspid valve; RCA ⫽ right carotid artery; RCC ⫽ right coronary cusp; RV ⫽ right ventricle).
Ann Thorac Surg 2005;80:1495– 8
TEE demonstrated a fistula between the noncoronary sinus of Valsalva and the left atrium. No significant heart murmur was heard at this time. The device was well positioned, with no residual atrial septal defect and no atrial enlargement. Angiography with aortic root injection confirmed an aortic–left atrial fistula (Fig 2). The patient was referred for urgent surgical repair. The procedure was performed using standard cardiopulmonary bypass techniques with bicaval cannulation. Cardioplegia was administered retrograde with left ventricular venting through the right superior pulmonary vein. The fistula was approached both through the aortic root and right atrium. A 3-mm fistula was found extending from the base of the noncoronary sinus of Valsalva into the roof of the left atrium at the edge of the ASO device (Fig 3A). The fistula tract was surrounded by thick, chronic inflammatory tissue. Upon entering the right atrium, the ASO device was firmly adhering to the atrial septum, and it was well endothelialized with no residual ASD. The right atrial arm of the device was removed with sharp dissection, followed by entry into the left atrium and removal of the left atrial disk. The fistula appeared much larger viewed from the aortic root after the ASO device was removed (Fig 3B). The left superior aspect of the device had eroded into the base of the aorta.
rior-anterior aspect of the interatrial septum and the aortic root. However, the long-term complications of the presence of a large rigid foreign body in the heart close to the aortic root are unknown. Recently, there have been two reports of erosion of the Amplatzer septal occluder (ASO) into the aorta, creating a fistulous communication to either the right [6] or left atrium [7]. We describe the surgical repair of an aorta-to-left-atrial fistula that developed 6 months after the placement of an ASO device for the closure of a large ASD. A 16-year-old girl underwent placement of a 30-mm ASO device for the closure of a large secundum ASD. A transthoracic echocardiogram demonstrated a 22-mm secundum atrial septal defect with significant right ventricular dilatation. A transesophageal echocardiogram (TEE) at the time of the catheterization showed a deficient aortic rim. The “stretched” diameter, using a sizing balloon, was 27 mm. A 28-mm ASO device was initially placed, but it was removed before its release and replaced with a 30-mm ASO device. The device was oversized slightly in order to straddle the septum. A postprocedure echocardiogram showed good positioning of the device with no evidence of atrial shunting. The initial postimplant echocardiogram showed an intact atrial septum with no fistula. However, 6 months later, despite the absence of a significant heart murmur,
Fig 2. Left ventricular angiogram in the left anterior oblique view showing the fistula (arrow) between the aortic root and the left atrium (LA). (AO ⫽ aorta; LV ⫽ left ventricle.)
Ann Thorac Surg 2005;80:1495– 8
CASE REPORT MELLO ET AL REPAIR OF AORTIC-LEFT ATRIAL FISTULA
1497
tures and reendothelialized. The ASD was then closed with fresh autologous pericardium (Fig 5C). A postbypass echocardiogram showed no residual ASD or fistula and no aortic insufficiency. Because of the disrupted endothelium in the left atrium, the patient was maintained on warfarin for 6 weeks. At 6-month followup, the patient is doing well without evidence of recurrent fistula or atrial level shunting.
Transcatheter closure of large ASDs is becoming a common procedure. The development of an aorto–atrial fistula that involved the right and the left atrium has been reported previously [6, 7]. The placement of large or oversized devices in secundum ASDs that have little superior rim may be a risk factor for this potentially life-threatening complication. In addition, the fact a 28-mm device had initially been positioned and then removed may have abraded the aortic rim of the ASD and predisposed it to subsequent fistula formation after the 30-mm device was deployed. Close follow-up, especially for patients with large superiorly placed ASDs, is important to detect this complication. The natural history of such a fistula is unknown. The possibility of rupture into the pericardial space is a life-threatening complication. The patient was referred for surgical repair on an urgent basis because of the potential risks of this complication as well as the probability of progressive enlargement of the fistula with consequent left-to-right shunt. The fistula jet can cause thrombus formation on the device, which we observed. Once detected, surgical repair should be carried out without delay. The surgical approach is best accomplished with a combined aortic/atrial approach. This allows for closure of both ends of the fistula. Visualization and avoidance of injury to the aortic valve is accomplished from the aortic end. Thrombogenic surfaces caused by the removal of the ASO can be reendothelialized from the left atrial side. Fig 3. (A) A probe placed from the aortic root through the fistula into the left atrium (LA). The atrial septal defect device has been retracted anteriorly to show the left atrium. (RA ⫽ right atrium.) (B) View from the anesthesia screen showing the fistula (arrow) in the noncoronary sinus of Valsalva with the probe through it. The aortic cross-clamp is at the bottom of the picture. (LCC ⫽ left coronary cusp; NCC ⫽ noncoronary cusp.)
A thrombus, measuring 5 ⫻ 5 mm, was found attached to the left side of the ASO device (Fig 4). This may have represented an area near the point of contact of the regurgitant fistula jet. After the left atrial side of the device was removed, a significant amount of deendothelialized left atrial surface was left. The fistula tract was repaired with a series of simple, nonabsorbable monofilament sutures placed from the aortic sinus of Valsalva through the thickened, surrounding tissue and into the left atrium (Fig 5A). Care was taken to avoid injury to the aortic leaflet. Sutures were tied on the left atrial side (Fig 5B). The fistula tract on the left atrial side was closed with horizontal mattress su-
Fig 4. The Amplatzer septal occluder (ASO) used to repair the atrial septal defect has been retracted into the right atrium showing its left atrial (LA) side with thrombus formation (arrow)on the device near the site of the fistula.
FEATURE ARTICLES
Comment
1498
CASE REPORT SAXENA ET AL ORGANIZED TRICUSPID VALVE THROMBUS
Ann Thorac Surg 2005;80:1498 –500
Fig 5. (A) Monofilament sutures are placed from the aortic root into the left atrium and tied in the left atrium to obliterate the fistula. Care is taken to avoid injury to aortic leaflet. (AO ⫽ aortic opening; LA ⫽ left atrium; LCC ⫽ left coronary cusp; NCC ⫽ noncoronary cusp; RA ⫽ right atrium; RCC ⫽ right coronary cusp; SVC ⫽ superior vena cava.) (B) Additional sutures are placed from the left atrial side to reinforce closure and reendothelialize the denuded portion of the left atrium. (C) Patch closure of atrial septal defect (ASD).
FEATURE ARTICLES
Temporary anticoagulation treatment for 6 to 8 weeks should be initiated to prevent potential thrombus formation. Patients with large ASDs with deficient aortic rims that are closed with large occluder devices near the aortic base need to be followed closely for this potentially life-threatening complication. We currently recommend follow-up echocardiography at 1 and 6 months postimplant, with yearly exams thereafter.
A Rare Presentation of Tricuspid Valve Thrombus in a Normal Heart
References
Pankaj Saxena, MCh, Ross Mejia, MBBS, and Robert K. W. Tam, FRACS
1. Omeish A, Hijazi ZM. Transcatheter closure of atrial septal defects in children & adults using the Amplatzer Septal Occluder. J Interv Cardiol 2001;14(1):37– 44. 2. Demkow M, Ruzyllo W, Konka M, et al. Transvenous closure of moderate and large secundum atrial septal defects in adults using the Amplatzer septal occluder. Cathet Cardiovasc Interv 2001;52:188 –93. 3. Berger F, Ewert P, Abdul-Khaliq H, Nurnberg JH, Lange PE. Percutaneous closure of large atrial septal defects with the Amplatzer Septal Occluder: technical overkill or recommendable alternative treatment? J Interv Cardiol 2001;14(1):63–7. 4. Losay J, Petit J, Lambert V, Esna G, Berthaux X, Brenmot P, Angel C. Percutaneous closure with Amplatzer device is a safe and efficient alternative to surgery in adults with large atrial septal defects. Am Heart J 2001;142(3):544 – 8. 5. Du ZD, Koenig P, Cao QL, Waight D, Heitschmidt M, Hijazi ZM. Comparison of Transcatheter closure of secundum atrial septal defect using the Amplatzer Septal Occluder associated with deficient versus sufficient rims. Am J Cardiol 2002;90(8): 865–9. 6. Chun DS, Turrentine MW, Moustapha A, et al. Development of aorta-to-right atrial fistula following closure of secundum atrial septal defect using the Amplatzer septal occluder. Cathet Cardiovasc Interv 2003;58:246 –51. © 2005 by The Society of Thoracic Surgeons Published by Elsevier Inc
7. Aggoun Y, Gallet B, Acar P, et al. Perforation of the aorta after percutaneous closure of an atrial septal defect with Amplatzer prosthesis, presenting with severe hemolysis. Arch Mal Coeur Vaiss 2002;95:479 – 82.
Department of Cardiac Surgery, The Prince Charles Hospital, Chermside, Brisbane, Australia
A young woman presented with a presumptive diagnosis of tricuspid valve tumor in a structurally normal heart. She was recently started on oral progesterone for menorrhagia related to uterine fibroids. She underwent an excision of the mass attached to the tricuspid valve, which was found to be an organized thrombus. We suggest a clinical approach to this problem. (Ann Thorac Surg 2005;80:1498 –500) © 2005 by The Society of Thoracic Surgeons
Accepted for publication April 5, 2004. Address reprint requests to Dr Saxena, Department of Cardiac Surgery, The Prince Charles Hospital, Rode Rd, Chermside, Brisbane QLD 4032, Australia; e-mail: [email protected].
0003-4975/05/$30.00 doi:10.1016/j.athoracsur.2004.04.018