Aortic erosion occurring in over 5 years after Amplatzer septal Occluder implantation for secundum atrial septal defect: a case report

BACKGROUND: Aortic erosion is a serious complication that usually occurs shortly after Amplazter Septal Occluder (ASO) implantation for atrial septal defect (ASD). CASE PRESENTATION: A seven-year-old girl was diagnosed with secundum ASD without symptoms. Transesophageal echocardiography (TEE) showed a defect of 20 mm in diameter in the fossa ovalis without aortic rim. An ASO device of 24 mm in diameter was selected and electively implanted. The “A-shape” of the device was confirmed by intraoperative TEE, a landmark finding indicating the proper implantation of ASO in patients without aortic rim. After an uneventful postoperative course of 5 years and 10 months, she was transferred to our unit due to cardiogenic shock. Her echocardiogram in emergency room showed pericardial effusion with collapsed right ventricle. Given her history of ASO and the observation of the sequentially increasing pericardial effusion, we diagnosed her with acute cardiac tamponade due to aortic erosion. Emergency pericardiotomy was then performed to improve the hemodynamic condition. Fresh clots were found, so we immediately prepared the cardiopulmonary bypass circuit and explored the damage to the aorta, in which the clots had accumulated. Bleeding suddenly started when the clots were removed. We then inserted the cannulae for perfusion and venous drainage. The clots were removed, and tears were found in both the lateral side of the ascending aorta and the right atrial wall. Intraoperative TEE showed that an edge of the ASO device was directly touching the aortic wall and the Doppler color-flow imaging showed blood flow through this lesion. The erosive lacerations of both the ascending aorta and right atrium were detected from the inside after achieving cardioplegic cardiac arrest. The ascending aorta was obliquely incised, and the laceration was closed from inside the aortic root. The postoperative course was uneventful. She has been doing well for 5 years since the surgery. CONCLUSIONS: We experienced and successfully treated a rare case of acute cardiac tamponade caused by aortic erosion 5 years and 10 months after ASO implantation.