Late Perforation of the Aortic Root by an Atrial Septal Defect Occlusion Device

Abstract

A 55-year-old woman was admitted to the emergency unit with severe dyspnea. Oral history revealed acute chest pain and collapse at home, which led to the tentative diagnosis of an acute aortic dissection. The electrocardiogram was normal. Transthoracic echocardiography showed a massive pericardial effusion (PE), no dissection flap, and a competent aortic valve. A computed tomographic scan was initiated. Meanwhile, evaluation revealed that the patient had undergone a percutaneous catheter occlusion of a persistent foramen ovale with an atrial septal defect occluder system device (D) 4 years before. The device could be located by computed tomographic scan through intensive roentgenogram reflection from its metal struts (Fig 1A; LA = left atrium; RA = right atrium). During scanning, the patient's hemodynamics deteriorated rapidly, necessitating mechanical resuscitation. An immediate paraxiphoidal pericardiocentesis was performed. The drainage showed fresh arterial blood. After hemodynamic recovery the patient was transferred immediately to the operating room. Intraoperative transesophageal echocardiography displayed an echogenic structure projecting on the cranial aspect of the interatrial septum in close proximity to the aorta (AO; Fig 1B). After pericardiotomy and removal of clots and fresh blood, arterial bleeding originating from a small perforation (2 mm) of the aortic root at the noncoronary sinus of Valsalva could be identified (Fig 2A). Moreover, the tip of a metal strut (S) penetrating the roof of the left atrium (LA)—without bleeding—directly opposite from the aortic perforation was visible. The aortic perforation was closed by a suture reinforced with autologous pericardium (P). By a second operation 1 week later, the device was removed (Fig 2B) electively by using cardiopulmonary bypass. For avoiding massive tissue damage, special tools provided by the manufacturer to disconnect the device were necessary. The atrial septal defect was closed with an equine pericardial patch. After an uneventful course, the patient was discharged home on the eighth postoperative day.