INTRODUCTION: We describe a very interesting iatrogenic complication of atrial septal defect closure device which divided the right atrium into two chambers. We name this complication as Cor Triatriatum Dextro Iatrogenica.
CASE PRESENTATION: A 29-year-old female was brought to the emergency room with complaints of sudden onset of ataxia and dysarthria. Magnetic resonance imaging of the brain revealed basilar infarct and subacute infarcts on both the medial thalami. A transesophageal echocardiogram (TEE) showed a large atrial septal defect (ASD) with shunt of 1.7:1 and a normal left ventricular function. Her neurological deficits gradually improved and she was transferred for transcatheter closure of ASD. An intracardiac echocardiogram during the procedure showed a septum secundum oval defect of 0.9-1.3cm with good septal margins that was closed using a helex device (30mm). There was no residual shunting through the defect by color flow mapping. Repeat TEE done after two months showed a very interesting finding that we have called Cor Triatriatum Dextro Iatrogenica, which means formation of iatrogenic triple atria. It was noticed that the inferior limb of the right atrial side of closure device was bent coming close to Eustachian valve, and partitioning the atrium into two parts - one part between atrial septum and Eustachian valve receiving blood from the inferior vena cava and the second part on the other side of Eustachian valve receiving blood from the superior vena cava with turbulent flow from the first to the second part through small opening between edges of Eustachian valve and the bent part of device. This functionally created third atria. No further intervention was done, as the patient was completely asymptomatic. Patient remained asymptomatic after a 9 month follow up.
DISCUSSION: Transcatheter closure of secundum ASD was first reported in 1976 (1), and now is more popular than surgery because of short learning curve, cosmetic benefits, reduced pain and reduced hospital stay. The development of transesophageal and intracardiac echocardiography has facilitated the use of transcatheter ASD closure device. These studies help in better evaluation of the defect size, shape and margins, device selection, placement and evaluation of complications post procedure.(2) The complications reported with these devices are device malposition, embolization, cardiac perforations, residual shunts, vascular trauma, thrombus formation, and sudden death. Device malposition or embolisation is the most common complication as seen in multiple studies ranging from 4% to 20% and mostly require surgery. Our patient also presented with an asymptomatic malposition diaganosed echocardiographically leading to a unique iatrogenic triatria. There have been few case reports of patients with a chamber in between the right and the left atria secondary to a rare congenital atrial septal malformations diagnosed echocardiographically. The possible hemodynamic effects of this are still not known. Although our patient was asymptomatic, it remains uncertain whether the increased turbulence due to iatrogenic triatria translates into increased chances of infective endocarditis and thrombus formation. Currently there are no guidelines regarding anticoagulation and follow up in these patients.
CONCLUSIONS: This case demonstrates an interesting iatrogenic complication of atrial septal device leading to creation of unique triatria which has not been reported so far.
Reference #1 King TD, Thompson SL, Steiner C, Mills NL. Secundum atrial septal defect. Nonoperative closure during cardiac catheterization. JAMA. Jun 7 1976;235(23):2506-2509.
Reference #2 Ewert P, Berger F, Daehnert I, et al. Transcatheter closure of atrial septal defects without fluoroscopy: feasibility of a new method. Circulation. Feb 29 2000;101(8):847-849.
DISCLOSURE: The following authors have nothing to disclose: Ankur Lodha, Mehandi Haran, Adnan Sadiq, Jacob Shani
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