Atrial Perforation Research Articles

Echocardiographic Diagnosis of Right Atrial Perforation due to Primary Cardiac Angiosarcoma Using Hand-Agitated Saline Contrast

Introduction Primary cardiac tumors are rare, and approximately 25% of which are malignant. Primary cardiac angiosarcoma, which is a rapidly progressing tumor, is the most common malignant tumor of cardiac origin. It is associated with a poor prognosis and median survival time of 3 to 6 months. We report a case of 61-year-old woman who had a history of unknown cause of pericardial effusion 7 months ago. Cardiac angiosarcoma with right atrial perforation was demonstrated by two-dimensional and contrast echocardiography.

Cardiovascular Collapse After Femoral Venous Cannula Placement for Robotic-Assisted Mitral Valve Repair and Patent Foramen Ovale Closure

botica of t ary b diac a air a a per ula i nous c on in t case, t with s ave b as d perf rnal j p nula h left a has b re p lacem that s dden c t t p P c b CASE IS PRESENTED of sudden cardiac decompen tion in a patient undergoing femoral venous cann lacement for robotic-assisted mitral valve repair and pa oramen ovale (PFO) closure. Robotic-assisted and minima nvasive techniques for cardiac surgery create new and un hallenges for anesthesiologists and surgeons. A rare com ation of left atrial appendage perforation and ensuing car amponade secondary to transatrial septal guidewire passage he setting of robotic-assisted surgery is described.

Safety of Single Transseptal Puncture for Ablation of Atrial Fibrillation: Retrospective Study from a Large Cohort of Patients

Transseptal puncture (TSP) is the conventional approach to assess the left atrial chamber. This technique has been widely used in interventional cardiology and, in the last years, this approach is mostly applied to electrophysiologic procedures. For atrial fibrillation (AF) ablation, two or more transseptal sheaths are often positioned in the left atrium in the majority of centers, therefore requiring two or more transseptal punctures. Theoretically, double puncture could bear additional risks or could increase the risk of persistence of septal defects. We reported the results of a retrospective analysis of a single transseptal puncture as a simplified approach for positioning multiple catheters in the left atrium during AF ablation. Between November 2003 and November 2005, 1,150 consecutive patients (mean age 54 +/- 8 years, 75% men) were considered for AF ablation and underwent single transseptal puncture for positioning multiple catheters in the left atrium. In only 6 of 1,150 (0.5%) cases a second transseptal puncture was required to position the ablation catheter in the left atrium. Neither acute complications related to transseptal catheterization such as atrial or aortic perforations, pericardial tamponade, thrombotic formation, or air embolism, nor complications due to the attempts of crossing the septum with the ablation catheter were reported. In all cases, each mapping catheter was properly maneuvered at different sites in the left atrium and at the pulmonary veins. In no patient was a residual septal atrial defect after the transseptal maneuvers detected during a mean follow up of 14 +/- 2 months. This retrospective study on a large cohort of patients shows that single transseptal puncture for positioning two or more catheters in the left atrium for AF ablation is a highly successful and safe maneuver with a very low morbidity in the majority of patients. This may avoid potential complications related to a second transseptal puncture.

Port‐a‐Cath perforation of the right atrium closed with an amplatzer ASD occluder

Right atrial perforation can lead to tamponade and death. Closure devices are used for sealing of shunts in the heart. We describe an indwelling catheter that caused perforation of the right atrium and was treated with a percutaneous closure device.

Cardiac Tamponade as Complication of Active‐Fixation Atrial Lead Perforations: Proposed Mechanism and Management Algorithm

Cardiac tamponade is a rare complication after implantation of dual chamber pacemaker or defibrillator systems. Its pathophysiology and optimal management are not currently well established. Three cases of cardiac tamponade following successful implantation of transvenous dual chamber pacemakers with active-fixation atrial leads were identified. All three patients with post-implant cardiac tamponade were suspected to have the same etiology of bleeding into the pericardial space. This was due to protrusion of the helix of the active-fixation atrial pacing lead through the atrial wall with subsequent abrasion of visceral pericardial layer and bleeding from the atrium through the perforation. In two patients, the perforation sites were visualized and repaired during open thoracotomy in the operating room. The third patient underwent lead repositioning under fluoroscopic guidance in the electrophysiology laboratory. Based on the reviewed cases, we describe the pathophysiology of, and recommend a safe conservative algorithm for, the management of cardiac tamponade after successful transvenous lead implantation. Percutaneous pericardiocentesis with placement of the pericardial drain followed by lead repositioning under fluoroscopic guidance with surgical backup appears to be safe and effective.

Transseptal puncture: Use of an angioplasty guidewire for enhanced safety

During transseptal puncture, once the needle tip has successfully accessed the left atrium, advancement of the needle, dilator and sheath into the left atrium can risk left atrial free wall perforation, particularly if the interatrial septum is aneurysmal and tents far into the left atrial cavity during puncture. We have modified our transseptal technique such that once the left atrium is accessed with the needle tip, a 0.014'' angioplasty guidewire is advanced down the Brockenbrough needle. This is guided into the left upper pulmonary vein, and the needle, dilator and sheath advanced over this wire towards the left upper pulmonary vein. In this way, the risk of perforation of the left atrial free wall is negated. We have since used this technique in 30 cases without difficulties.

Late migration of a Sideris buttoned device for occlusion of atrial septal defect

We describe a 17-year-old patient with an atrial septal defect who underwent device closure with a second generation Sideris buttoned device at 4 years of age. She presented 13 years after the procedure with the acute onset of chest discomfort, at which time a chest radiograph showed migration of the wire of the right atrial counter-occluder to the lateral aspect of the right atrial wall, with an associated right atrial perforation. The patient underwent uneventful surgical device retrieval and atrial septal defect closure. Late migration of a portion of the Sideris buttoned device can occur, suggesting the need for continued follow up, and a high index of suspicion for device failure should a patient become symptomatic.

Late Cardiac Perforation After Transcatheter Closure of Patent Foramen Ovale

Cardiac perforation after transcatheter closure of a patent foramen ovale is a very rare complication. We report a case of left atrial wall perforation and aortic root erosion occurring 16 months after implantation of an Amplatzer patent foramen ovale occluder that required emergent surgery.

Catheter‐based decompression of the left atrium in patients with hypoplastic left heart syndrome and restrictive atrial septum is safe and effective

Infants with hypoplastic left heart syndrome (HLHS) and restrictive or intact atrial septum (rAS) present with cyanosis, pulmonary edema, and are critically ill. A previous report from our institution on emergent Norwood for HLHS with rAS showed 10% survival. We hypothesized that transcatheter left atrial (LA) decompression in HLHS with rAS would safely and effectively relieve LA hypertension, improve oxygenation, and improve Norwood survival. Between 1996 and 2004, 30 patients with HLHS and rAS underwent cardiac catheterization for pre-Norwood intervention. Twenty-eight atrial septostomies were performed: 23 static balloon dilations, 4 Rashkind septostomies, and 1 intra-atrial stent. Two procedures were aborted due to perforation (n = 1) or inability to enter the LA (n = 1). Eight total patients required surgical septectomy, for a failure rate of 27%. There were no catheter-related mortalities, although two patients died within 36 hr of the procedure after surgical septectomy. Major complications occurred in three patients (10%)--atrial perforations requiring intervention. Mean atrial septal defect gradient fell from 16.7 +/- 4.9 to 6.3 +/- 3.4 mm Hg (P < 0.001; n = 18). Mean LA pressure dropped from 21.8 +/- 5.5 to 13.1 +/- 6.5 mm Hg (P < 0.001; n = 16). Mean PaO(2) rose from 29.5 +/- 9.1 to 36.5 +/- 5.1 torr (P < 0.001; n = 23). Seventeen of 30 patients (57%) survived to discharge from Norwood. Thirteen have undergone hemi-Fontan and nine Fontan. Sixteen of 22 successful decompressions (73%) survived to discharge. Transcatheter decompression of the LA for patients with HLHS and rAS can be performed safely, reduces the transatrial gradient, and improves oxygenation. Catheter intervention improves survival compared to historical controls undergoing emergent Norwood.

Right Atrial Perforation Resulting From Pulmonary Artery Catheter Insertion During Coronary Artery Bypass Surgery

An 84-year-old man presenting with triple-vessel coronary artery disease and unstable angina pectoris associated with mitral valve stenosis was scheduled for coronary artery bypass graft surgery and mitral valve replacement. His medical history was significant for chronic pulmonary obstructive disease and moderate left ventricular dysfunction, thus warranting the use of a PAC for the accurate monitoring of hemodynamic parameters. Although transesophageal echocardiography has been widely used during cardiac surgery, the use of a PAC is still an alternative when TEE is not available in the operating room. The patient was premedicated with a combination of midazolam, 5 mg, and fentanyl, 50 g, intravenously, 30 minutes before surgery. PAC insertion was performed by using a modified Seldinger technique. The right internal jugular vein was punctured with a 22-G seeker needle at the angle formed by the bellies of the sternocleidomastoid muscle near the level of the cricoid cartilage. The vessel was cannulated with an 18-G straight introducer needle to a depth of 2 to 3 cm. Dark, nonpulsatile venous blood was obtained by aspiration during needle placement. A J-tip wire guide was inserted through the needle without difficulty, and an 8.5F introducer sheath of the PAC was placed over a dilator, which was introduced to its full length. Once again dark, nonpulsatile venous blood was easily aspirated from the sheath. A 7.5F PAC (model 831F75, Baxter Edwards, Irvine, CA) was inserted via the introducer into the right internal jugular vein. The balloon had been previously checked for proper inflation over the end of the catheter. After the insertion of 25 cm of the PAC with the balloon inflated, a significant resistance to pass the catheter into the RV was experienced. After several attempts that took about 5 minutes and without taking any additional measures, the catheter was successfully introduced into the right ventricle and then into the pulmonary artery, as assessed by the corresponding pressure waves. The final position of the catheter was at about 50 cm of insertion. There were no significant alterations in hemodynamic parameters or in electrocardiographic tracings during the wire guide or PAC insertion. General anesthesia was induced by using a combination of fentanyl, 300 g, and etomidate, 10 mg; pancuronium, 6 mg, was used for neuromuscular blockade. Anesthesia was maintained with isoflurane, 1.5% to 2% in oxygen. The chest was opened with a median sternotomy incision. After opening the pericardium, the presence of blood within the pericardial sac led to the identification of a perforation in the right atrium. It was an elliptically-shaped perforation with about 1 mm of diameter in the inferior portion of the atrial lateral wall, about 2 to 3 cm from the superior vena cava junction. The perforation was then sutured, and the patient underwent coronary artery bypass graft surgery without presenting further complications. Recovery was uneventful, and the patient was discharged 10 days after surgery with no residual complications.

Emergency surgery after percutaneous transmitral commissurotomy: Operative versus echocardiographic findings, mechanisms of complications, and outcomes

This study was undertaken to determine the clinical profile of patients undergoing emergency surgery after balloon mitral valvotomy, to note operative findings and compare them with those of transthoracic echocardiography, to describe the mechanisms of complications, and to describe outcomes. A retrospective study was undertaken of patients requiring emergency surgery after percutaneous mitral valvotomy with an Inoue balloon from January 1990 to December 2003. The data analyzed included demographic variables, causes and clinical presentations of complications, and outcome. In 14 consecutive cases of mitral regurgitation, an observational study comparing the operative findings with echocardiography was also undertaken. In 1388 cases of valvotomy, complications necessitating urgent surgery occurred in 31 cases (2.2%). Acute mitral regurgitation occurred in 23 cases (74.2%), and cardiac tamponade occurred in 8 cases (25.8%). Mitral regurgitation was due to leaflet tearing in all cases: anterior leaflet in 20 cases and posterior leaflet in 3 cases. Hypotension, orthopnea, and pulmonary edema were the clinical presentation for mitral regurgitation. Transthoracic echocardiography underestimated the severity of mitral valve pathology. Bilateral severe commissural fusion and pliable leaflet with paracommissural calcium was seen in anterior leaflet tearing. Cardiac tamponade with hemodynamic compromise occurred as a result of left atrial perforation in 6 cases, right atrial perforation in 1 case, and left ventricular perforation in 1 case. High septal puncture led to atrial perforation. Operative mortality was 9.6%, and low cardiac output developed in 29%. Acute mitral regurgitation and cardiac tamponade were the causes of emergency surgery after balloon valvotomy. Transthoracic echocardiography underestimated the severity of valve pathology.

Fatality Following Right Atrial Perforation by a Screw-in Pacemaker Electrode

This paper describes the first reported fatality from right atrial perforation complicating the insertion of a screw-in right atrial pacemaker electrode. The patient was an 84-year-old woman with the sick sinus syndrome who also had hepatic cirrhosis.

Transcatheter creation of atrial septal perforation using a radiofrequency transseptal system: Novel approach as an alternative to transseptal needle puncture

Indications for the transseptal approach to the left side of the heart have recently broadened, as it provides a therapeutic access for both left-sided catheter ablation and also percutaneous transvenous valvular intervention. Despite rising demand for transseptal procedures, the technique and device used for this purpose have remained essentially unchanged over the past 4 decades. The possibilities of failure of puncturing distorted and thickened atrial septal tissue or risks of complications related to cardiac perforation remain limitations of the technique. A new radiofrequency catheter provides an alternative approach to create a controlled transseptal perforation. We applied this technique to a series of patients and evaluated its feasibility as an alternative to conventional transseptal needle puncture.

Surgical treatment of atrial fibrillation with diathermy: an in vitro study

The utilization of diathermy (electrocautery) as an energy source in the treatment of chronic atrial fibrillation has generated positive early clinical results. Although this technology is available and affordable, it has not been well studied for this indication. The objectives of this study were: (1) to characterize atrial lesions created by diathermy, (2) to determine relationships between power setting, tissue contact time, and lesion depth and (3) to histologically compare diathermy and unipolar radiofrequency lesions. Fresh bovine atrial tissue samples were used to create endocardial lesions using a unipolar diathermy system with a blade tip. A total of 120 lesions were created at varying power settings and tissue contact times. Subendocardial temperatures were recorded. All lesions were examined grossly, then fixed, sectioned and evaluated histologically by a blinded pathologist. Comparisons were made with saline irrigated unipolar radiofrequency lesions. Gross examination revealed extensive tissue destruction of the endocardial surface at the point of contact. Histological examination showed minimal penetrance of the lesions beyond the destroyed tissue margin of the endocardium. This was corroborated by the finding of minimal thermal penetration beyond the endocardium and superficial myocardium. There was a linear relationship between the power setting (15-55 watts), depth of penetrance (2-15 mm) at varying contact times (1-5s/cm). In this in vitro model, lesions created by diathermy were not transmural, even with high power settings and prolonged contact times. At these settings, significant tissue destruction was observed that may predispose to atrial perforation without achieving penetration. Diathermy did not constitute an effective energy source in the creation of transmural lesions for atrial fibrillation ablation.

Transcatheter closure of large secundum atrial septal defects using the 40 mm Amplatzer septal occluder: Results of an international registry

Little is known about the efficacy and safety of the 40 mm Amplatzer septal occluder (ASO). Thirty-three patients (22 female, 11 male) with a large secundum atrial septal defect (ASD) underwent attempted device closure using the 40 mm ASO at a median age of 40 years (range, 14-81 years) and median weight of 65 kg (range, 48-98 kg). The median size of the ASD measured on 2D transesophageal echocardiography (27 patients) or intracardiac echocardiography (6 patients) was 30.5 mm (range, 24-39 mm) and the median balloon-stretched diameter was 37.7 mm (range, 32-43.7 mm). The median Qp:Qs ratio was 3.2:1 (range, 1.4-6.2). The attempt was unsuccessful in five patients; two had device embolization and one had left atrial wall perforation due to the sheath; all three required emergent surgery. The attempt was successful in the 28 remaining patients, resulting in complete immediate closure in 14 and a trivial residual shunt in 14. Fluoroscopy time ranged from 8.6 to 37.8 min (median, 12.2 min). At 24-hr follow-up, 2D transthoracic echocardiography with color flow Doppler revealed complete closure in 23 patients, and 5 had a trivial residual shunt. There were no complications encountered in patients who received the device. On follow-up, all patients are doing well. We conclude that the 40 mm ASO is safe and effective in most patients with a large ASD up to a diameter of 39 mm. However, the use of this device requires careful attention as the procedure may be unsuccessful or the device may embolize.

Atrial Septal Perforation From TIPS Stent Migration

Transjugular intrahepatic portosystemic shunts (TIPS) are safe and effective for the treatment of portal hypertension. Cardiac complications are unusual. This study reports a case of TIPS stent migration to the right atrium causing perforation of the atrial septum in a patient with end-stage liver disease. The shunt was removed transvenously but attempts at transvenous occlusion of the septal perforation were unsuccessful. The patient went on to undergo combined open-heart surgery with septum repair and liver transplantation. The case highlights a rare complication of TIPS and methods for treatment including transvenous removal, transvenous repair, and combined cardiotomy-liver transplantation surgery.

Right Pneumothorax Resulting From an Endocardial Screw-In Atrial Lead

Right pneumothorax complicated by an endocardial atrial lead has never been reported. Herein, we report on a small-build 79-year-old Taiwanese woman who suffered from complete AV block and underwent dual-chamber permanent pacemaker implantation. An active fixation screw-in atrial lead was chosen. The procedure was complicated by right pneumothorax associated with atrial perforation. Since simple measurements of the implantation parameters could not be used to predict the occurrence of perforation, great caution should be taken in to avoid overscrewing the atrial lead, and in scrutinizing the penetration depth of the helix of the lead under fluoroscopy.

TRANSESOPHAGEAL ECHOCARDIOGRAPHY AS A GUIDE TO CENTRAL VENOUS CATHETER PLACEMENT IN CONGENITAL CARDIAC SURGERY

Introduction: Transesophageal echocardiography (TEE) has become an essential monitor for the management of most patients undergoing surgery for congenital heart disease. Central venous access for monitoring and drug infusion is used in many centers, despite a recognized incidence of complications from malposition, most significantly cardiac perforation from right atrial positioning [1,2]. This study assesses the effect of TEE on correct catheter placement and complications. Methods: After informed consent, 143 patients age 1 day-29 years undergoing surgery for congenital heart disease were enrolled. Patients were randomized to the TEE group or the control group, and further randomized to receive an internal jugular or subclavian vein catheter. The TEE group had a TEE probe inserted, and a transverse plane four-chamber view obtained. Then the vein was entered and a guidewire advanced into the right atrium under direct TEE visualization. The catheter was advanced over the guidewire until its full length was inserted, and a longitudinal plane TEE view of the junction of the superior vena cava (SVC) and right atrium (RA) was obtained. Catheter position was adjusted until the tip was in the SVC at the superior edge of the crista terminalis. Control group patients had the central venous catheter (CVC) placed by standard methods, which included observing the electrocardiogram for premature atrial contractions to confirm atrial guidewire position. Catheter insertion length to the distal SVC was estimated to place the tip midway between the sternal notch and the nipples. The location of the CVC was assessed by TEE after placement. Both groups had catheter location assessed radiographically, with desired location in the SVC, parallel to the vessel wall. Results were compared using a paired T test or Chi square analysis. Results: 76 catheters were placed in the right subclavian vein, 2 in the left subclavian vein, 62 in the right internal jugular vein, and 1 each in the left internal jugular and right external jugular. There was no difference in rate of successful placement if the chest radiograph was used to determine correct placement. There was, however, a significant increase in success rate if the TEE was used to determine correct placement. The SVC/RA junction was an average of 15 mm lower by TEE than by CXR, explaining the difference in success rate. The complication rate, or number of attempts required between the two groups was not different. The time to placement was significantly shorter in the control group. (Table 1)Table 1All catheters inserted via the internal jugular vein were in the SVC or RA. 4 of 77 subclavian catheters were located in the contralateral innominate vein. There was one significant complication: an SVC perforation from a subclavian catheter in the control group necessitating surgical reexploration. Discussion: TEE can be reliably used to assist in the placement of CVC in pediatric cardiac surgical patients. Catheters located high in the RA by CXR are probably in the SVC and pose little risk of atrial perforation.

Transcatheter closure of atrial septal defect and patent foramen ovale with the ASDOS device (a multi-institutional European trial)

A clinical trial was conducted to assess the feasibility, safety, and efficacy of the atrial septal defect (ASD) occlusion system for transcatheter closure of secundum ASD and patent foramen ovale (PFO) after episodes of cerebral embolism. Occlusion was attempted in 200 patients aged 1 to 74 years (mean 32). The procedure failed in 26 patients (13%); the device was retrieved through a catheter in 20 and through surgery in 6 patients. Procedure-related complications necessitating surgical removal of the device included device embolization in 2, device entrapment within the Chiari network in 1, frame fracture in 1, and perforation of atrial wall in 2. All 6 patients experienced an uneventful postoperative course. An additional 11 patients (6%) underwent surgical removal of the device during follow-up. There were 163 patients (81%) with an implanted ASD occlusion system at follow-up of from 6 to 36 months (mean 17). Thrombus formation around the device was detected by transesophageal echocardiography in 9 patients 1 to 4 weeks after implantation. One of these patients (who had a coagulation factor XII deficiency) suffered a cerebral thromboembolism. Late atrial wall perforation (5, 6, and 8 months after implantation) occurred in 3 adult patients. Infectious endocarditis developed in 2 adult patients (1%). No late device embolization and no atrioventricular valve injury occurred. An asymptomatic device frame fracture was found in 14% and frame deformity in 4% of all patients during the follow-up period of >230 patient-years. Immediately after closure, a moderate/large residual shunt remained in 8% and a small shunt in 29% of patients. After 1 year, a moderate/large shunt was present in 2% and a small one in 26% of patients. During a total follow-up of 49 patient-years, only 1 of 46 patients with PFO had a transient neurologic event after the closure. The study indicates that patients with centrally situated secundum ASD and those with PFO after cerebral embolism can be treated with this system with a high success rate and an acceptable morbidity.

Migration and Right Atrial Perforation of an Accufix Atrial Lead Retention Wire Following Partial Lead Removal During Myomectomy

A 36-year-old man with a history of hypertrophic obstructive cardiomyopathy presented to the emergency room with "stabbing" chest pain. He had undergone dual-chamber pacemaker implantation in 1993 using an atrial lead (Accufix; Telectronics; Englewood, Colo) and a myomectomy in 1996 during which the distal portion of the atrial lead was removed. Digital fluoroscopy revealed that the retention wire had migrated out of the remaining atrial lead and perforated the right atrium. The retention wire was successfully removed percutaneously. The need for complete removal of the retention wire in the Accufix lead at the time of open-heart surgery is emphasized.