ARTICLE IN PRESS doi:10.1510/icvts.2008.198952
Interactive CardioVascular and Thoracic Surgery 8 (2009) 494–495 www.icvts.org
Case report - Cardiac general
Successful combination of interventional and surgical treatment of left atrium perforation Muzaffer Bahcivan*, Onur Doyurgan, Melih Urkmez, 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
Abstract 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. 䊚 2009 Published by European Association for Cardio-Thoracic Surgery. All rights reserved. Keywords: Atrial perforation; Intervention
1. Introduction 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 w1x. 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. 2. Case presentation 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 Hemodynamics of the patient altered when the sheath was withdrawn.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 reinserted 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 *Corresponding author. Tel.: q90 362 3121919-3110; fax: q90 362 4576049. E-mail address:
[email protected] (M. Bahcivan). 䊚 2009 Published by European Association for Cardio-Thoracic Surgery
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 70y50 mmHg, and the pulse was 140ymin. 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 2=2 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 4y0 polypropylene pledge suture, and the hemorrhage was brought under control. The patient was discharged in good condition four days after the surgical intervention. 3. Discussion 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 w2x. The principle of endocardial catheter ablation is to determine the arrhythmia cycle and its electrophysiological and
ARTICLE IN PRESS M. Bahcivan et al. / Interactive CardioVascular and Thoracic Surgery 8 (2009) 494–495
Fig. 1. Catheter’s tip is in the left atrium roof to stop hemorragy temporarily.
anatomic origin, so it can be ablated w1x. Although this is a curative treatment method, it is ultimately an invasive procedure and may lead to some complications. These are pulmonary vein stenosis w3x, stroke and peripheral thromboembolic complications w4x, atrial-esophageal fistula formation w5x, and cardiac tamponade associated with cardiac perforation w6x. 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 w3, 7x. 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 w1x. 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
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was present in 52.38% of the patients w8x. 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 4y0 or 5y0 polypropylene suture materials with the continuous suture technique w9x. 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 4y0 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. References w1x Akpinar B, Sagbas E, Guden M, Sanisoglu I. Surgical treatment of atrial fibrillation. Anadolu Kardiyol Derg 2007;7:65–73. ¨ z BS, Kumar P, Noir S, Moat N. Surgical epicardial ablation on beating w2 x O heart for lone atrial fibrillation: early results. AJCI 2007;1:30–34. w3x Bunch TJ, Asirvatham SJ, Friedman PA, Monahan KH, Munger TM. Outcomes after cardiac perforation during radiofrequency ablation of the atrium. J Cardiovasc Electrophysiol 2005;16:1172–1179. w4x Robbins IM, Colvin EV, Doyle TP, Kemp WE, Loyd JE. Pulmonary vein stenosis after catheter ablation of atrial fibrillation. Circulation 1998; 98;1769–1775. w5x Pappone C, Oral H, Santinelli V, Vicedomini G, Lang CC. Atrio-esophageal fistula as a complication of percutaneous transcatheter ablation of atrial fibrillation. Circulation 2004;109:2724–2726. w6x Tsang TS, Freeman WK, Barnes ME, Reeder GS, Packer D. Rescue echocardiographically guided pericardiocentesis for cardiac perforation complicating catheter-based procedures. The Mayo Clinic experience. J Am Coll Cardiol 1998;32:1345–1350. w7x Hsu LF, Jais P, Hocini M, Sanders P, Scave ´e C. Incidence and prevention of cardiac tamponade complicating ablation for atrial fibrillation. Pace 2005;28:106–109. w8x Kaplan M, Demirtas¸ M, Alhan C, Aka SA, Dagsali S. Cardiac injuries: experience with 63 cases. Turk J Cardiovasac Surg 1999;7:287–290. w9x Kec ¸eligil HT, Demirag MK. Cardiac injuries. Surg Med Sci 2007;7:31–36.
