Persistent Iatrogenic Catheter Induced Atrial Septal Defect Complicating Minimally Invasive Atrial Fibrillation Ablation
Royan L. Richards, Mohammed Mohammed, Andy Knowles, Amal K. Bose.
Lancashire Cardiac Centre, Blackpool, United Kingdom.
OBJECTIVE: Persistent iatrogenic atrial septal defect( iASD) is a recognised complication of interventional procedures involving the puncture of the interatrial septum. This technique has rapidly increased over the last few decades as a result of increasing catheter ablations which require left heart catherisation through the trans-septal approach. We report a case of persistent iASD complicating thoracoscopic minimal access af ablation surgery.
METHODS: A 46 year old gentleman with increased BMI and permanent atrial fibrillation was referred for elective surgical AF ablation. He had previous catheter based af ablation which failed. He had an uncomplicated bilateral video assisted thoracoscopic atrial fibrillation and left atrial appendage occlusion surgery. The procedure was performed with single lung ventilation on either side under general anaesthesia and was transferred to the intensive care unit after extubation. However, his post operative recovery was complicated by profound hypoxaemia with increasing oxygen requirements, even though he did not have any pre-existing respiratory conditions. Chest physiotherapy, mobilisation and increased diuresis did not make any improvement to his hypoxaemia. Meanwhile, his CVP remained elevated with dilated right ventricle and right heart dysfunction. A CTPA ruled out pulmonary embolism. Transoesophageal echocardiography showed a 12 mm persistent iASD with a right to left reversal of shunt and bidirectional flow across the ASD.
RESULTS: He subsequently had a successful percutaneous closure of the persistent iASD with a 12 mm amplatzer septal occluder device. Echocardiography confirmed no residual shunting across the ASD He went on to make a quick recovery and was discharged home.
CONCLUSIONS: Persistent iASDs have been described as a well known complication of numerous cardiac surgical and percutaneous procedures including catheter ablations via the transeptal approach. In this case, clinicians were aware of the persistent iASD preoperatively which was inconsequential under optimal conditions, but later caused profound hypoxaemia when there was right to left reversal of shunting and dramatically improved after the ASD was closed.Hence, in patients who have had previous catheter ablations clinicians should not overlook the possibility of persistent iASD in patients who become (or remain) hypoxic postoperatively.
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