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CLOSURE OF A VENTRICULAR SEPTAL DEFECT COMPLICATED BY HEMOLYSIS REQUIRING TRANSCATHETER RETRIEVAL OF AMPLATZER OCCLUDER
2233 JACC March 21, 2017 Volume 69, Issue 11
FIT Clinical Decision Making CLOSURE OF A VENTRICULAR SEPTAL DEFECT COMPLICATED BY HEMOLYSIS REQUIRING TRANSCATHETER RETRIEVAL OF AMPLATZER OCCLUDER Poster Contributions Poster Hall, Hall C Friday, March 17, 2017, 3:45 p.m.-4:30 p.m. Session Title: FIT Clinical Decision‐Making: Prevention, Adult Congenital and Congenital Heart Disease Abstract Category: Congenital Heart Disease Presentation Number: 1169-388 Authors: Akanksha Thakkar, Ponraj Chinnadurai, Maan Malahfji, Gary Monteiro, John Breinholt, C. Huie Lin, Houston Methodist DeBakey Heart and Vascular Center, Houston, TX, USA Background: Hemolysis due to transcatheter ventricular septal defect (VSD) closure is infrequently reported and ideal management is unclear.
Case: 78M with prior surgical VSD repair/RV infundibular resection presented with orthopnea. Exam revealed a systolic murmur at the left upper sternal border and bilateral LE edema. CTA showed a 16 mm membranous VSD with L-R shunt. Qp:Qs was 2 by CMR. Three defects in the ventricular septum (2 membranous at prior patch repair site, 1 high muscular) were seen on LV gram; the largest was closed with an 8 mm Amplatzer™ Septal Occluder (St. Jude Medical, Inc., MN) by TEE and 2D-3D CTA fusion guidance. Residual shunt was noted, but expected to resolve with endothelialization of device. Patient developed tea colored urine on post op day 0 with a drop in hemoglobin from 14.5 to 11 g/dL, platelets from 145 to 86 k/µL. LDH was 1218 U/L and haptoglobin was <10 mg/dL.
Decision‐Making: There is no consensus on management of hemolysis after device closure of VSDs. Watchful waiting may lead to hemoglobin associated nephropathy, coils may embolize and do not necessarily eliminate residual shunt, and there is a high risk of morbidity with emergency thoracic surgery. Our patient was minimally symptomatic due to the VSD and did not require urgent VSD closure. Instead of leaving the device in vivo and exposing him to the risk of renal failure, we chose to retrieve it as open surgical risk was unacceptable. The patient was urgently returned to the cath lab and the device was snared and re-sheathed. Post retrieval, his urine color was normal in 24 hours and CBC returned to baseline at 2 weeks. He will be evaluated in the future for VSD closure using an alternate device. Conclusions: This case highlights an infrequently reported complication of transcatheter VSD closure. Conservative or surgical management may be appropriate in some cases; however, until further data becomes available, it may be prudent to retrieve the device to prevent further complications. Further, optimal device selection to completely occlude all defects may reduce risk of post-op hemolysis. Choice of ideal device may require advanced 3D imaging and pre-op planning such as 3D printing.
FIT Clinical Decision Making CLOSURE OF A VENTRICULAR SEPTAL DEFECT COMPLICATED BY HEMOLYSIS REQUIRING TRANSCATHETER RETRIEVAL OF AMPLATZER OCCLUDER Poster Contributions Poster Hall, Hall C Friday, March 17, 2017, 3:45 p.m.-4:30 p.m. Session Title: FIT Clinical Decision‐Making: Prevention, Adult Congenital and Congenital Heart Disease Abstract Category: Congenital Heart Disease Presentation Number: 1169-388 Authors: Akanksha Thakkar, Ponraj Chinnadurai, Maan Malahfji, Gary Monteiro, John Breinholt, C. Huie Lin, Houston Methodist DeBakey Heart and Vascular Center, Houston, TX, USA Background: Hemolysis due to transcatheter ventricular septal defect (VSD) closure is infrequently reported and ideal management is unclear.
Case: 78M with prior surgical VSD repair/RV infundibular resection presented with orthopnea. Exam revealed a systolic murmur at the left upper sternal border and bilateral LE edema. CTA showed a 16 mm membranous VSD with L-R shunt. Qp:Qs was 2 by CMR. Three defects in the ventricular septum (2 membranous at prior patch repair site, 1 high muscular) were seen on LV gram; the largest was closed with an 8 mm Amplatzer™ Septal Occluder (St. Jude Medical, Inc., MN) by TEE and 2D-3D CTA fusion guidance. Residual shunt was noted, but expected to resolve with endothelialization of device. Patient developed tea colored urine on post op day 0 with a drop in hemoglobin from 14.5 to 11 g/dL, platelets from 145 to 86 k/µL. LDH was 1218 U/L and haptoglobin was <10 mg/dL.
Decision‐Making: There is no consensus on management of hemolysis after device closure of VSDs. Watchful waiting may lead to hemoglobin associated nephropathy, coils may embolize and do not necessarily eliminate residual shunt, and there is a high risk of morbidity with emergency thoracic surgery. Our patient was minimally symptomatic due to the VSD and did not require urgent VSD closure. Instead of leaving the device in vivo and exposing him to the risk of renal failure, we chose to retrieve it as open surgical risk was unacceptable. The patient was urgently returned to the cath lab and the device was snared and re-sheathed. Post retrieval, his urine color was normal in 24 hours and CBC returned to baseline at 2 weeks. He will be evaluated in the future for VSD closure using an alternate device. Conclusions: This case highlights an infrequently reported complication of transcatheter VSD closure. Conservative or surgical management may be appropriate in some cases; however, until further data becomes available, it may be prudent to retrieve the device to prevent further complications. Further, optimal device selection to completely occlude all defects may reduce risk of post-op hemolysis. Choice of ideal device may require advanced 3D imaging and pre-op planning such as 3D printing.