Atrial septal defect (ASD) is the most common congenital heart defect detected in adults. Transcatheter closure is safe and has become the standard treatment for the majority of patients but may lead to severe procedural complications [1]. We report an unusual scenario where intraprocedural transesophageal echocardiographic monitoring prevented a potential stroke during atrial septal occluder implantation.
A 62-year-old female with hypertension, atrial fibrillation, and type 2 ASD (16 × 14 mm) was admitted to our hospital. Transthoracic echocardiography (TTE) confirmed significant right ventricular and right atrial volume overload with secondary severe tricuspid regurgitation. Transvascular implantation of 18 mm nitinol atrial septal occluder was initiated with standard premedication of 300 mg of acetylsalicylic acid, and 300 mg of clopidogrel, along with administration of unfractionated heparin during the procedure.
Immediately before occluder delivery, an unusual echogenicity within the catheter lumen was noted suggesting intraluminal thrombosis (Figure 1A–B; Supplementary material, Video S1). Immediate catheter withdrawal and intense aspiration resulted in the extraction of a long thrombus. The dose of heparin was increased due to subtherapeutic activated clotting time of 187 s (Figure 1C). The delivery system was retracted and carefully flushed, followed by reinitiation and successful completion of the procedure (Figure 1D). The patient did not suffer from any complications.
Following the procedure, coagulopathy was excluded. Dual antiplatelet therapy was recommended for 6 months with lifelong continuation of low-dose aspirin, which resulted in uncomplicated 24 months of follow-up. This corresponds with the results of the EACVI study, in which most participating centers recommended dual antiplatelet therapy for an initial 6 months and suggested lifetime single-antiplatelet therapy in only 42% of centers, while others limit it to 6 more months (36%) or for 5 years from the closure (12%) [2].
The rate of peri-procedural major complications in ASD closure is reported from 0% to 9.4%. The second most frequent major complication is device thrombosis (1.2%) [3]. In the pathogenesis of catheter-related thrombosis, several factors can be identified. The most common one is mechanical trauma. Others include concomitant infection, use of cytostatics, steroids, and antibiotics, enteral nutrition, and a positive family history of coagulopathies (thrombophilia) [4].
To conclude, this case demonstrates how crucial for patient safety and the optimal effect of the procedure is vigilant real-time monitoring of echocardiographic images during ASD closure. The thrombus formation may occur despite proper peri-procedural treatment, and without its early detection, the patient is at risk of life-threatening complications [5].
Supplementary material
Supplementary material is available at https://journals.viamedica.pl/polish_heart_journal.
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