Early and Late Cardiac Perforation by Amplatzer ASD and PFO Devices

Cardiac perforation and device erosion is an infrequent but potentially lethal complication of percutaneous occluder device insertion. Transthoracic and transesophageal echocardiography (TEE) and gated cardiac CT are useful in detecting this complication.Wepresent characteristic clinical and imaging findings of early and late cardiac perforation diagnosed at our institution, prior to surgical correction. Results: Echocardiograms from 230 device insertions were retrospectively reviewed. 2 cases of confirmeddevice erosion were identified, occurring from 2 weeks to 18 months after device insertion. Clinical and imaging features of device erosion were: (a) new cardiac symptoms of pericardial pain, dyspnoea or tamponade, (b) device size and geometry in relation to atrial size, particularly device extending >90% across the atrial septum, (c) relationship of device to aorta and posterior atrial wall, (d) deficient superior-anterior rim, (e) presence of pericardial fluid adjacent to device, (f) TEE or CT evidence of disc protrusion into or through the atrial/aortic wall. Discussion: Device erosion can be gradual and present with progressive symptoms of pericardial chest pain and/or dyspnoea in the early or late stages post percutaneous ASD or PFO closure. Cardiac perforation by the closure device can cause intermittent symptoms and pericardial fluid accumulation, due to intermittent occlusion of the puncture site by the device itself. Conclusion: Deficient superior-anterior rim and encroachment of the occluder device on the posterior atrial wall are important and under-recognised risk factors for device erosion. TEE should be performed prior to device insertion with heightened awareness of atrial geometry andmanufacturer’s guidelines for device sizing. This may reduce occurrence of this serious complication. TEE and cardiac CT are useful in confirming device erosion when present.