Percutaneous closure of atrial septal defect after surgical patch degradation

Sweta Mohanty; D Pradeep Kumar

doi:10.4103/JICC.JICC_2_18

CASE REPORT

Year : 2019 | Volume : 9 | Issue : 1 | Page : 45-46

Percutaneous closure of atrial septal defect after surgical patch degradation

Sweta Mohanty, D Pradeep Kumar
Department of Cardiac Sciences, Aster CMI Hospital, Bengaluru, Karnataka, India

Date of Web Publication

10-May-2019

Correspondence Address:
Dr. Sweta Mohanty
Apartment 602, Valmark Apas, Hulimavu, Bengaluru - 560 076, Karnataka
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JICC.JICC_2_18

Abstract

Patch degradation after surgical repair of atrial septal defect (ASD) is an uncommon complication. We report a case of surgically repaired ostium secundum ASD that presented with degradation of the patch and a hemodynamically significant shunt, which was subsequently closed by the transcatheter approach.

Keywords: Atrial septal defect, device closure, patch degradation

How to cite this article:
Mohanty S, Kumar D P. Percutaneous closure of atrial septal defect after surgical patch degradation. J Indian coll cardiol 2019;9:45-6

How to cite this URL:
Mohanty S, Kumar D P. Percutaneous closure of atrial septal defect after surgical patch degradation. J Indian coll cardiol [serial online] 2019 [cited 2021 Apr 12];9:45-6. Available from: https://www.joicc.org/text.asp?2019/9/1/45/257955

Introduction

Surgical repair of atrial septal defect is a well-established and highly durable treatment and patch degeneration is rare. We report a case of surgically repaired ostium secundum atrial septal defect that presented with degradation of the patch and a hemodynamically significant shunt, which was subsequently closed by transcatheter approach.

Case Report

A 4-year-old child with a large (22 mm) ostium secundum atrial septal defect (ASD) with deficient posterior and inferior rims [Figure 1]a, right heart dilation, and mild pulmonary hypertension underwent uneventful surgical closure of the defect with a pericardial patch. Postoperative echocardiogram confirmed closure of the defect with no residual shunt [Figure 1]b. On follow-up, 3 months later, she was found to have parasternal heave, wide fixed split S2, and a loud ejection systolic murmur. There was no history of fever in the interim period, no complaint of breathlessness, or other cardiac symptom. The echocardiogram is shown in [Figure 1]c.

Figure 1: (a) Transthoracic echocardiogram showing large ostium secundum atrial septal defect, measuring 22 mm in subcostal view. (b) Postoperative echocardiogram showing pericardial patch in situ. (c) Echocardiogram 3 months postoperatively showing a large defect in the patch

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Diagnosis

Surgical patch degradation.

Discussion

Surgical repair of ASD is a well-established and highly durable treatment. The pericardium is a suitable material for ASD closure and glutaraldehyde-treated pericardial patches are used to alleviate curling of the edges.^[1] However, the postoperative complications may include residual shunt, and uncommonly, patch shrinkage or retraction and degeneration.^[2] What differentiated this case from patch dehiscence was that the patch had not given way at the suture line, there was no flap visible and a part of the patch, roughly half the size of the original defect, was missing. Echocardiogram showed a significant left-to-right shunt (10-mm defect), mild right heart dilation, and mild pulmonary hypertension. For a hemodynamically insignificant residual defect, the medical follow-up would suffice.^[3] In our case, transcatheter closure of the defect was performed with an 18-mm device [Figure 2]. Postprocedure echocardiogram confirmed good device position [Figure 2]a. The child remained asymptomatic on follow-up.

Figure 2: (a) Echocardiogram after percutaneous device closure showing good device position. (b) Fluoroscopic image after transcatheter device deployment

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With the advent of interventional approaches since the 1990s, transcatheter closure with a nitinol occluder device is being increasingly preferred as a minimally invasive approach^[3],[4] for ASD closure. As a result, fewer ASD patients are referred for surgical closure and these mainly include patients with large or complex defects. Transcatheter closure of residual postsurgical ASD has been described previously^[5] as the preferred approach for residual defects. Residual defects after surgical closure have mainly been attributed to suture dehiscence. Suture dehiscence, may be due to excessive tension, trauma, and kinking stresses at knots,^[6] has been associated with primary closure of ASD as opposed to use of a patch,^[7] or has been seen in minimally invasive techniques where a limited surgical field may restrict the ability to identify a fractured suture line.^[8] In contrast to suture dehiscence, degradation of the pericardial patch after surgery is extremely uncommon, though previously described.^[3],[4] Degradation of autologous pericardial valves is more commonly described than ASD patch degradation and may be linked abnormal mechanical shear stresses on the nonpliable leaflets.^[9] Risk factors of atherosclerosis such as elevated lipid levels, smoking, or diabetes may play a substantial role in degeneration.^[10] Glutaraldehyde treatment of the autologous pericardium also favors degenerative processes and calcification.

In our case, the degradation of the pericardial ASD patch was noted 3 months after surgery. Transcatheter approach was preferred to avoid increased morbidity of reoperation. Although major complications have also been described after transcatheter ASD closure, namely, perforation of the atrial wall, atrial arrhythmias, and device embolization, the rate of such complications is <2%^[3] and may be avoided by careful selection of patients.

To summarize, this case illustrates the rare complication of surgical patch degradation and successful percutaneous closure of the resulting defect.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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