Accidental Closure of the Left Upper Pulmonary Vein With an Amplatzer Atrial Septal Defect Occluder

ABSTRACT: We report the clinical outcome of a 46-year-old man referred for percutaneous closure of an atrial septal defect under transthoracic echocardiographic and fluoroscopic guidance, whose upper left pulmonary vein was erroneously obliterated using an Amplatzer atrial septal defect occluder. Various medical conditions have been associated with pulmonary vein stenosis including dyspnea on exertion or at rest, cough, and hemoptysis. However, there were no short- or long-term symptoms in this patient.

J INVASIVE CARDIOL 2012;24(10):E219-E221

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Case Report. A 46-year-old male patient was referred for transcatheter closure of an atrial septal defect (ASD) under transthoracic echocardiographic and fluoroscopic guidance. His upper left pulmonary vein was erroneously obliterated using an Amplatzer ASD occluder. During the previous year the patient experienced recurrent seizure disorders and radiological investigations, including cerebral magnetic resonance imaging, showed multiple lesions of white matter and cortex supporting an embolic etiology. Transesophageal echocardiography (TEE) revealed the presence of an ASD leading to a significant left to right shunt (diameter about 12 mm; Qp:Qs 2) with concomitant dilatation of the right atrium and ventricle. During a sustained Valsalva maneuver, shunt inversion was documented. The patient had no cardiovascular risk factors, no dyspnea on exertion, and the physical examination was normal. Considering the presence of multiple cerebral embolic lesions, we decided to close the defect using an Amplatzer ASD occluder. The intervention was performed under local anesthesia using simultaneous fluoroscopic and transthoracic echocardiographic guidance. After fluoroscopic visualization (Figure 1a) and balloon measurement (Figure 1b) a 19 mm device was erroneously deployed and released into the upper left confluent pulmonary vein ostium (Figure 2). The mistake was immediately detected. In the absence of symptoms, the device was left in place and a second device (18 mm) correctly positioned in the ASD during the same intervention (Figure 3). The patient remained well. A TEE performed the next day confirmed accidental complete occlusion of the left upper pulmonary vein and correct position of the second device without residual shunt (Figure 4a). A treatment with clopidogrel for 2 months and acetylsalicylic acid for life was initiated before discharge. The patient has been regularly followed for more than 7 years (Figure 4b). Periodic echocardiographic and radiographic studies excluded pulmonary hypertension due to the improperly positioned device. Except for rare episodes of symptomatic paroxysmal tachycardia requiring treatment with a beta blocker, the patient presented no symptoms or physical restrictions.

Discussion. Percutaneous ASD closure using the Amplatzer ASD occluder is a safe and effective treatment to prevent pulmonary hypertension, right heart overload, and paradoxical embolism in adult patients with ASD.^1,2 It has become the procedure of choice in suitable patients with secundum ASD.

The hemodynamic consequences of pulmonary vein stenosis and occlusion have been best studied in patients undergoing catheter ablation of atrial fibrillation. According to current reports, the incidence of this common complication ranges from 1% to 10%.^3-5 In recent observational studies they have been linked to a variety of symptoms^3-6 usually appearing months after intervention and consisting of cough, dyspnea on exertion or even at rest, pleuritic pain, and hemoptysis.^3-6 In several reports, catheter-based treatments using percutaneous transluminal angioplasty only or pulmonary vein stenting have been discussed.^7-9 However, considering the majority of the patients with discrete or absent symptoms, the real hemodynamic and clinical significance of such complication and the need for preemptive radiological assessment and interventional treatment still remain controversial.¹⁰

This case of accidental occlusion of a pulmonary vein during percutaneous ASD closure is of note, as the patient remained asymptomatic suggesting that the hemodynamic consequences of pulmonary vein stenosis or partial occlusion are less severe than one would expect. Probable explanations for these observations are the multiple parallel pathways of the pulmonary vascular drainage.

References

1. Majunke N, Bialkowski J, Wilson N, et al. Closure of atrial septal defect with the Amplatzer septal occluder in adults. Am J Cardiol. 2009;103(4):550-554.
2. Knepp MD, Rocchini AP, Lloyd TR, Aiyagari RM. Long-term follow up of secundum atrial septal defect closure with the amplatzer septal occluder. Congenit Heart Dis. 2010;5(1):32-37.
3. Packer DL, Keelan P, Munger TM, et al. Clinical presentation, investigation, and management of pulmonary vein stenosis complicating ablation for atrial fibrillation. Circulation. 2005;111(5):546-554.
4. Di Biase L, Fahmy TS, Wazni OM, et al. Pulmonary vein total occlusion following catheter ablation for atrial fibrillation: clinical implications after long-term follow-up. J Am Coll Cardiol. 2006;48(12):2493-2499.
5. Dong J, Vasamreddy CR, Jayam V, et al. Incidence and predictors of pulmonary vein stenosis following catheter ablation of atrial fibrillation using the anatomic pulmonary vein ablation approach: results from paired magnetic resonance imaging. J Cardiovasc Electrophysiol. 2005;16(8):845-852.
6. Saad EB, Marrouche NF, Saad CP, et al. Pulmonary vein stenosis after catheter ablation of atrial fibrillation: emergence of a new clinical syndrome. Ann Intern Med. 2003;138(8):634-638.
7. Qureshi AM, Prieto LR, Latson LA, et al. Transcatheter angioplasty for acquired pulmonary vein stenosis after radiofrequency ablation. Circulation. 2003;108(11):1336-1342.
8. Neumann T, Sperzel J, Dill T, et al. Percutaneous pulmonary vein stenting for the treatment of severe stenosis after pulmonary vein isolation. J Cardiovasc Electrophysiol. 2005;16(11):1180-1188.
9. Prieto LR, Schoenhagen P, Arruda MJ, Natale A, Worley SE. Comparison of stent versus balloon angioplasty for pulmonary vein stenosis complicating pulmonary vein isolation. J Cardiovasc Electrophysiol. 2008;19(7):673-678.
10. Arentz T, Jander N, von Rosenthal J, et al. Incidence of pulmonary vein stenosis 2 years after radiofrequency catheter ablation of refractory atrial fibrillation. Eur Heart J. 2003;24(10):963-969.

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From the ¹Department of Cardiology, University Hospital Bern, Switzerland and ²Cardiology, Grand Hôpital de Charleroi, Belgium.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Bernhard Meier reports that he has received a research grant from and is on the speaker’s bureau for AGA Medical. No other author reports any disclosures regarding the content herein.
Manuscript submitted April 23, 2012, provisional acceptance given May 21, 2012, final version accepted June 20, 2012.
Address for correspondence: Bernhard Meier, MD, FACC, FESC, Professor and Chairman of Cardiology, Swiss Cardiovascular Center Bern, University Hospital, 3010 Bern, Switzerland. Email: bernhard.meier@insel.ch