Angio-Seal closure of an iatrogenic right ventricular perforation

Abstract

Vascular closure devices are commonly used following arteriotomy as they improve patient comfort, provide rapid hemostasis, and shorten discharge time following coronary angiography [3]. The off-label use of these devices is relatively uncommon and limited to other arterial injuries [1, 4]. Pericardiocentesis is frequently performed for diagnosis and therapeutic management of hemodynamically significant pericardial effusions. Although relatively safe, complication rates between 1.0 and 4.8 % have been reported—including pneumothorax, ventricular puncture and liver laceration [5]. Ventricular perforation, while infrequent (incidence rate between 0.4 and 1.4 %) is the most serious complication, which is typically managed surgically. Herein, we report a case of an iatrogenic placement of a pigtail catheter in the right ventricle (RV), which was successfully closed via Angio-Seal collagenbased arterial closure device. A 75-year-old male with past medical history of recurrent large B cell lymphoma was referred for dyspnea and a large pericardial effusion. On assessment, the patient was tachycardic with an elevated jugular venous pressure. Chest X-ray demonstrated a loculated right-sided pleural effusion and an enlarged cardiac silhouette. An echocardiogram demonstrated a large circumferential pericardial effusion (Fig. 1a). Pericardiocentesis from a parasternal approach with placement of an eight French pigtail catheter was performed for palliative symptom relief. A large volume (greater than 1 L) of frank blood raised suspicion of right ventricular perforation. A repeat echocardiogram using Definity contrast confirmed the position of the pigtail catheter within the RV (Fig. 1b, Supplemental Video 1). A computed tomography study of the chest confirmed RV catheter placement and raised suspicion of tumor encasing the myocardium rather than pericardial effusion (Fig. 1c, d). Cardiac surgery was consulted but given the patients prognosis surgical intervention was declined. Accordingly, in conjunction with the patient a decision was made to attempt percutaneous closure. Contrast injection through the venous catheter reconfirmed the RV placement (Supplemental Video 2). A guide wire was introduced into the RV and the pigtail catheter was withdrawn. Pulsatile bleeding was observed from the catheter tract. An 8Fr Angio-Seal closure device was then introduced into the RV and deployed and anchored in the usual fashion. The collagen plug was depressed and tension maintained for several minutes (Supplemental Video 3). Successful closure was confirmed by lack of bleeding from the entry site and echocardiography demonstrating no fluid accumulation. A repeat CT scan the following day identified the collagen plug at the pigtail insertion site (Fig. 1e). The patient passed away several days later. Autopsy revealed no pericardial fluid and presence of tumor A. Pourdjabbar and B. Hibbert have contributed equally.