Aortic dilation might be a risk factor for early cardiac perforation after interventional closure of patent foramen ovale: a case report

Abstract

Background: Patent foramen ovale (PFO) is present in ∼20% of adults and is associated with cryptogenic stroke, recurrent transient neurological deficit, decompression illness, and migraines. In patients with high probability of a PFO-related ischaemic event, the preferred management strategy is the endovascular closure of the PFO, whenever feasible. Cardiac erosion or perforation is an unusual event after the interventional closure of a PFO, but its occurrence portends a life-threatening potential. Therefore, clinicians should be aware of this serious complication when faced with acute cardiac tamponade in a patient with a history of PFO closure.

Case summary: We report the case of a 57-year-old man, with a recent PFO-related ischaemic stroke, who presented for elective endovascular closure of the PFO. Patent foramen ovale and surrounding structures seemed amenable for closure, and recommended a 25-mm Amplatzer device. Isolated dilation of the aortic bulb was noted by transoesophageal echocardiography (TEE), but with normal valve morphology and no aortic regurgitation. The procedure was performed without complications, and 24 h echo follow-up showed no impingement of the device on the surrounding structures. However, 36 h after the procedure, the patient developed sudden chest pain and cardiac tamponade. Emergency cardiac surgery with intra-operative TEE guidance revealed right atrial and aortic bulb perforation caused by the larger right disc of the occluder. The device was removed, and the defects were sutured. The patient was discharged within 14 days after the event, with no further complications.

Discussion: Perforation of the aortic root is a very rare complication after interventional PFO closure. This complication usually occurs at a long distance after the procedure, and is associated with oversized devices, deficient or absent aortic rim, or misalignment of the defect with the aorta. Our patient presented none of the above, but a moderate dilation of the aortic bulb, which might have triggered the rapid erosion and perforation.

Keywords: Amplatzer device complication; Aortic dilation; Aortic perforation; Case report; PFO interventional closure.

Figure 1

Two-dimensional transoesophageal echocardiography of the aorta (long axis view). An aortic root diameter of 45 mm with normal annulus size is observed.

Figure 2

Two-dimensional transoesophageal echocardiography of the persistent foramen ovale (PFO), seen from the short axis view at the level of the aortic valve (A). Three-dimensional transoesophageal echocardiography of the PFO (B). LA, left atrium; RA, right atrium.

Figure 3

Intra-procedural three-dimensional echocardiography of the catheter through the PFO (A). Three-dimensional echocardiography of the occluder; ‘en face’ view from the left atrial side (B). LA, left atrium; RA, right atrium.

Figure 4

Intra-operative two-dimensional transoesophageal echocardiography. Red arrow, peri-aortic haematoma; Ao, aorta.

Figure 5

Intra-operative two-dimensional transoesophageal echocardiography. Red arrow, the right atrial disc of the device perforating the aortic wall; yellow arrow, the site of the perforation at the level of the aortic root; Ao, aorta.