Cardiac Perforation during Patent Foramen Ovale Closure Sealed with an Amplatzer PFO Occluder

ABSTRACT: Percutaneous patent foramen ovale (PFO) closure is increasingly performed for a variety of different conditions and is usually relatively straightforward, with a low adverse event rate and virtually no mortality. In cases with a long PFO tunnel, the “puncture technique” — utilizing a transseptal puncture — is performed to achieve better apposition of the septum primum to the septum secundum, and to avoid device deformity. Even though transseptal puncture can be safely performed by experienced operators, there is still a 1–2% risk of cardiac perforation. We report a novel technique to percutaneously close a cardiac perforation that occurred while using the puncture technique for PFO closure using an Amplatzer PFO Occluder. The PFO occluder successfully sealed the perforation, prevented development of cardiac tamponade and avoided the need for surgical intervention in a frail patient. This technique can be applied to other cardiac chamber perforations, especially if iatrogenic. This case illustrates the need to be thoroughly familiar with the cardiac anatomy and to avoid “instinctively” withdrawing the equipment once perforation occurs. J INVASIVE CARDIOL 2008;20:665–668 Percutaneous patent foramen ovale (PFO) closure is increasingly performed for a variety of different conditions ranging from cryptogenic stroke, migraine with aura resistant to medical therapy, decompression illness in divers, platypnea-orthodeoxia syndrome, high-altitude pulmonary edema and obstructive sleep apnea.1–6 When indicated, the procedure is relatively straightforward, with a low adverse event rate and virtually no mortality.7–9 In certain cases, especially those with a long PFO tunnel, the “puncture technique”, which involves the use of transseptal puncture, is performed to achieve better apposition of the septum primum to the septum secundum and to avoid device deformity.10 Even though transseptal puncture can be safely performed by experienced operators, there is still a 1–2% risk of cardiac perforation.11,12 We report a case of cardiac perforation during transseptal puncture for PFO closure that was sealed successfully with an Amplatzer PFO Occluder (AGA Medical Corp., Plymouth, Minnesota). Case Presentation. A frail 79-year-old female was admitted for aphasia and confusion. Past medical history included hypertension, recent lumbar spine fracture and recent pneumonia. A complete stroke workup was negative for carotid disease, arrhythmias or thrombophilia, and significant only for computed tomography (CT) and magnetic resonance imaging of her brain that showed several old cerebral infarcts with a subacute left parietal lobe infarct. Based on the neurologist’s recommendation, a transesophageal echocardiogram was performed revealing an atrial septal aneurysm, a thick septum secundum lipomatosis, and a PFO that was positive for a right-to-left shunt during bubble study at rest. Percutaneous PFO closure was then recommended by the treating neurologist. The patient was brought to the catheterization laboratory where two 8 Fr sheaths were placed in the right femoral vein. An 8 Fr AccuNav intracardiac echocardiography catheter (Siemens AG, Malvern, Pennsylvania) was advanced to the right atrium (Figure 1). A bubble study demonstrated a right-to-left shunt at rest. Transseptal puncture was then performed in view of the long PFO tunnel (12–14 mm) and the septum secundum lipomatosis. The 8 Fr sheath was replaced with an 8 Fr Mullins sheath using a 0.032 inch wire. The Brockenbrough needle was advanced through the Mullins sheath, and this assembly was positioned on the septum primum at its superior aspect, close to the septum secundum. However, just at this point of puncture, the patient suddenly attempted to sit up and the needle and Mullins sheath were noticed to have advanced outside the cardiac silhouette. The patient was carefully laid down while the needle and sheath were kept in the extracardiac space by fluoroscopy. Perforation of the right atrial (RA) wall was confirmed by contrast injections showing that the needle and sheath were in the pericardial space. The sheath and dilator were advanced further to prevent rapid bleeding and cardiac tamponade. As the patient’s frail condition and recent acute stroke put her at high surgical risk, percutaneous closure of the perforation was considered. The needle was removed and the 0.032 inch wire advanced into the pericardial space. The dilator was then removed and a 4 Fr Glidecath (Terumo Interventional Systems, Somerset, New Jersey) advanced through the sheath into the pericardial space. Aspiration through the Glidecath yielded less than 10 ml of blood. Contrast was then slowly and continuously injected through the sheath while it was being withdrawn to outline the site of perforation, with access maintained by the 0.032 inch wire and the 4 Fr Glidecath. The sheath was then readvanced into the pericardial space and the 0.032 inch wire was replaced with a 0.018 inch RoadRunner wire (Cook, Inc., Bloomington, Indiana) through the Glidecath. The Glidecath was removed and the Mullins dilator was reintroduced to place the Mullins sheath well into the pericardial space. The dilator was then removed leaving the RoadRunner wire still across the perforation, and an 18 mm Amplatzer PFO Occluder was used to seal the perforation successfully. The RoadRunner wire was maintained across the perforation site and removed when the LA disc was firmly against the extracardiac surface of the right atrium (RA) (Figure 2). The RA disc was then deployed and the device released after injection of contrast confirmed no leak into the pericardial space. The procedure was terminated at this point, and the patient was stabilized and monitored in the coronary care unit. Serial transthoracic echocardiograms showed a small, non-enlarging pericardial effusion without tamponade physiology. The patient was returned 3 days later to the catheterization laboratory for PFO closure. Due to the thick septum secundum lipomatosis, a 20 mm Amplatzer Septal Occluder (ASO) was chosen to close the PFO successfully (Figure 3). A repeat bubble study showed no residual right-to-left shunt. Computed tomographic angiography (CTA) performed to delineate the relative positions of the devices showed that the perforation was on the medial RA wall (Figures 4 and 5). The patient made an uneventful recovery and was discharged from the hospital. Discussion. Several retrospective studies have documented the benefit of PFO closure in patients with cryptogenic stroke compared to medical therapy, although no randomized data are available.1 Percutaneous transcatheter PFO closure is increasingly performed with a very low procedural complication rate.7–9 Cardiac perforation complicating percutaneous PFO closure is rare, with most cases due to erosion of the device.7,13–16 The transseptal puncture technique can achieve better primum and secundum apposition, especially those with a long tunnel or atrial septal lipomatosis, without device deformity.10 Perforation complicating transseptal puncture can occur in approximately 1% of cases, even in the hands of experienced operators.11,12 Usually if only the needle has been advanced, even into the aorta, it can be withdrawn without any serious sequelae. However, if the perforation was unrecognized and the Mullins dilator or sheath has been advanced, then withdrawing this equipment would lead to rapid exsanguination. In our case, the perforation into the pericardial space occurred inadvertently as a result of sudden patient movement. Recognizing that both the needle and sheath were outside the cardiac silhouette, the equipment was not withdrawn. This prevented the development of massive blood loss into the pericardial space and was confirmed by the 10 ml of blood aspirated. Instead, a wire was advanced through the sheath well into the pericardial space to maintain access across the perforation. With the placement of this wire, the sheath could then be withdrawn whilst contrast was injected to outline the exact site of perforation, after which the sheath could easily and rapidly be readvanced. This maneuver was immensely helpful in subsequently sealing the perforation with a PFO occluder. A smaller-profile wire was then used to maintain access and was removed after confirming that the closure device was against the extracardiac RA wall. Alternatively, if there was concern about the device being “dragged back”, access could be maintained with the RoadRunner wire across the perforation until just before device release. This technique of using a small-profile wire to maintain access in a multi-fenestrated atrial septal defect (ASD) was recently reported by the authors.17 Although sealing cardiac perforations percutaneously with atrial septal occluders or PFO occluders has been reported,18–21 the technique described here is novel. Maintaining access across the perforation and injecting contrast while the sheath was slowly withdrawn allowed the exact perforation site to be identified. Percutaneous sealing with the PFO occluder was therefore made safer by reducing the risk of inadvertent “dragging” of the device’s LA disc through the perforation, with loss of access into the pericardial space and resultant pericardial effusion and life-threatening cardiac tamponade. This technique can also be applied to clinically-recognized perforation of any of the cardiac chambers as long as the initial catheter access is still present and is therefore most likely to be useful in situations of iatrogenic perforation. This case emphasizes the need for utmost care during transseptal puncture, the need for the operator to be thoroughly familiar with the cardiac anatomy/silhouette and last, but not least, to not “withdraw”, as a “knee-jerk” reaction, the transseptal needle and sheath, should perforation occur. Conclusion. A novel technique to percutaneously close a cardiac perforation that occurred while using the “puncture technique” for PFO closure is described. The PFO occluder successfully sealed the perforation, prevented the development of cardiac tamponade and avoided the need for surgical intervention in a frail patient. This technique can be applied to other cardiac chamber perforations, especially if iatrogenic. This case illustrates the need to be thoroughly familiar with the cardiac anatomy and to not “instinctively” withdraw the equipment once perforation occurs.

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