Interact CardioVasc Thorac Surg 2009;8:494-495. doi:10.1510/icvts.2008.198952
© 2009 European Association of Cardio-Thoracic Surgery
Case report - Cardiac general |
Successful combination of interventional and surgical treatment of left atrium perforation
Muzaffer Bahcivan*,
Onur Doyurgan,
Melih Urkmez and
Hasan Tahsin Keceligil
Department of Cardiovascular Surgery, School of Medicine, Ondokuz Mayis University, 55139 Kurupelit, Samsun, Turkey
Received 19 November 2008;
received in revised form 29 December 2008;
accepted 30 December 2008
*Corresponding author. Tel.: +90 362 3121919-3110; fax: +90 362 4576049.
E-mail address: mbahcivan33{at}yahoo.com (M. Bahcivan).
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Abstract
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Percutaneous interventions are increasingly used in the treatment of cardiac diseases which are resistant to medical treatment. However, the complications caused by these interventions can lead to serious results. In this article, we present a case of a successful combination of interventional and surgical treatment methods, following the development of left atrial perforation during radiofrequency catheter ablation (RFA), in a patient with atrial fibrillation resistant to medical treatment.
Key Words: Atrial perforation; Intervention
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1. Introduction
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Iatrogenic injuries of the heart during catheterization may develop secondary to diagnostic and treatment interventions such as coronary angioplasty, stenting, pacemaker implantations, balloon valvuloplasty, and central catheter applications. Failure of early diagnosis and lack of the necessary intervention may lead to death in cardiac tamponade consequent to cardiac injury [1].
In this article, a successful treatment of left atrium perforation and sudden cardiac tamponade which developed during radiofrequency catheter ablation (RFA) is presented as a result of the combination of interventional and surgical treatment methods.
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2. Case presentation
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A 42-year-old female patient with supraventricular tachycardia was hospitalized in the Cardiology Clinic, diagnosed with atrial fibrillation (AF) following electrophysiology test results, and planned for RFA. A transseptal incision was performed using a Brockenbrough needle through the right femoral route. The 8F sheath was shifted. The injected contrast substance was observed to pass through the pericardial sac. Hemodynamics of the patient altered when the sheath was withdrawn. A guide-wire was immediately re-inserted further through the right femoral route of the patient, who developed a clinical picture of cardiac tamponade. When the wire found the lumen and penetrated the pericardial sac, the sheath was shifted over it, the lumen was closed and, by this, the hemorrhage was temporarily stopped. Emergency pericardiocentesis was performed and 150 ml of hemorrhagic-like fluid was evacuated. The patient, whose clinical picture had partially improved, was consulted by the Cardiovascular Surgery Department. The emergency evaluation performed on the patient demonstrated dyspnea and palpitations. The patient's general condition was moderate, she was conscious and co-operative. The patient had venous fullness in the neck, tachycardia and tachypnea, and was receiving oxygen. The blood pressure was 70/50 mmHg, and the pulse was 140/min. The catheter on the right femoral artery was still in position. Emergency surgery for primary repair of atrium injury and cardiac tamponade was conducted. Median sternotomy was performed under general anesthesia. The pericardium was seen to be very tense; it was opened carefully and hemorrhagic-like fluid was evacuated in a controlled manner. Following this procedure, the patient's hemodynamic state and tachycardia dramatically improved. During the subsequent exploration, it was possible to view the catheter's tip, which caused a 2x2 mm perforation and injury on the left atrium's roof between the superior vena cava and the ascending aorta (Fig. 1). The catheter was withdrawn and removed. The perforation in the atrium was primarily repaired using a 4/0 polypropylene pledge suture, and the hemorrhage was brought under control. The patient was discharged in good condition four days after the surgical intervention.
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3. Discussion
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AF is currently the most commonly encountered cardiac rhythmic abnormality in the clinic. There is a recent increased trend of non-pharmacologic treatment of AF in many clinics. Ablation is performed for both pulmonary veins and atria by catheter meditative methods [2].
The principle of endocardial catheter ablation is to determine the arrhythmia cycle and its electrophysiological and anatomic origin, so it can be ablated [1]. Although this is a curative treatment method, it is ultimately an invasive procedure and may lead to some complications. These are pulmonary vein stenosis [3], stroke and peripheral thromboembolic complications [4], atrial-esophageal fistula formation [5], and cardiac tamponade associated with cardiac perforation [6]. Failure to treat cardiac tamponade early enough may result in death. Cardiac tamponade developed in 22 of the 980 patients who underwent catheter ablation due to AF, and current reports describe that surgical intervention was necessary in three of these patients [3, 7]. In another clinical study conducted with the usage of radiofrequency energy, two out of the 225 patients were taken in for early stage re-examination as a result of hemorrhage from the atrial auricle [1].
According to a study by Kaplan et al., iatrogenic injuries to the heart may occur secondary to diagnostic and treatment interventions such as catheterization, coronary angioplasty, stenting, pacemaker implantations, balloon valvuloplasty, and central catheter applications. During cardiopulmonary resuscitation, iatrogenic injuries of the heart may also occur, consequent to sternum and rib fractures. In addition, this study reports that 1.59% of heart injuries were of iatrogenic causes, while cardiac tamponade was present in 52.38% of the patients [8]. In the case of cardiac tamponade development, the fluid which causes the tamponade should be evacuated with echocardiographically guided pericardiocentesis, and hemodynamic stability should be provided. However, surgical repair is recommended for patients who do not demonstrate any recovery. On the other hand, patients may further worsen and develop cardiac arrest due to hemorrhage during the time elapsed until arrival at the operating room. As a result, temporary stoppage of the hemorrhage is vital. As in this present study, stoppage of the hemorrhage at the site of catheter perforation is time-saving for the surgical intervention. The same procedure can also be carried out with a balloon catheter.
Most cardiac injuries can successfully be repaired without the need for cardiopulmonary bypass. Repair of atrial and caval defects is performed by using 4/0 or 5/0 polypropylene suture materials with the continuous suture technique [9]. In the present study, after removal of the catheter which led to cardiac injury, primary repair of the hole in the atrium was also performed by the continuous suture technique with the use of a 4/0 polypropylene suture material. Cardiopulmonary bypass was unnecessary.
It is very important to provide early intervention for the complications resultant from invasive techniques. In order to provide hemodynamic stability prior to surgery in patients who develop cardiac injury, temporary stoppage of the hemorrhage with balloon catheters may be life saving.
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References
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Abstract
1. Introduction