CASE REPORT

Complete Heart Block Following Transcatheter Closure of AtrialSeptal Defect Due to Growth of Inflammatory Tissue

Hamid Amoozgar • Maryam Ahmadipoor •

Ahmad Ali Amirghofran

Received: 5 May 2014 / Accepted: 22 July 2014

� Springer Science+Business Media New York 2014

Abstract Transcatheter closure of atrial septal defect

(ASD) is the most common approach to close the defects

worldwide. In this approach, persistent conduction distur-

bance is extremely rare, but an acute increase in supra-

ventricular ectopy and minimal risk of atrioventricular

conduction disturbance, as complete heart block, has been

seen. Here, we report a patient who underwent ASD clo-

sure with device and presented with persistent complete

heart block 10 days after device occlusion due to inflam-

matory tissue formation just near the atrioventricular node

area at the floor of the right atrium without any direct

compression on the triangle of Koch.

Keywords Atrial septal defect � Heart block � Device �Transcatheter closure

Case report

A 7 year-old boy (30 kg) with atrial septal defect (ASD)

(15 mm in size by transthoracic echocardiography)

underwent percutaneous ASD closure in catheterization

laboratory of Kowsar hospital, Shiraz, Iran. In primary

electrocardiography, he had normal sinus rhythm, mildly

right-sided deviation of frontal axis, and evidence of

incomplete right bundle branch block (RSR pattern in V1).

Thus, device occlusion was performed under general

anesthesia with guidance of transesophageal echocardiog-

raphy. Vascular access was obtained in the right femoral

vein and standard right-heart catheterization was per-

formed to assess hemodynamics, such as pulmonary arte-

rial pressure, which showed the mean pulmonary artery

pressure to be 15 mmHg. Then, a right Judkins catheter

(Cordis, a Johnson and Johnson Co, Miami, Florida) was

introduced to the left upper pulmonary vein and an extra

stiff exchange wire (Balton, Bolton Medical Inc) was

advanced through it. Evaluation of the ASD size was done

by a 24 mm AGA sizing balloon (AGA Medical Corpo-

ration) under transesophageal echocardiography guidance

and a 16 mm dimension was recorded.

Once the device size was determined, the delivery

sheath was put over the guide wire into the left upper

pulmonary vein, the dilator and wire were pulled back, and

the device was advanced forward under fluoroscopy. Then,

the ASD was occluded by an 18 mm Figulla� Flex, Oc-

clutech’s septal occluder.

Post-occlusion transesophageal echocardiography

showed no residual flow through the defect. During the

procedure, the patient was under heart monitoring and no

abnormality of heart rhythm and rate was detected. After-

ward, the patient was transferred to the recovery room and

hemodynamically remained stable with no cardiac rhythm

abnormalities. Post-ASD closure electrocardiography taken

24 h after ASD closure revealed no abnormalities, either.

Therefore, the patient was discharged with salicylic acid,

80 mg daily. However, in the follow-up visit, 10 days after

the ASD closure, the electrocardiogram showed complete

heart block with ventricular rate of 55–70/min. Hence, the

H. Amoozgar � M. Ahmadipoor

Cardiac Research Center, Shiraz University of Medical Sciences,

Shiraz, Iran

H. Amoozgar (&)

Department of Pediatrics, Namazi Hospital, 7193711351 Shiraz,

Iran

e-mail: amozgah@sums.ac.ir; hamidamoozgar@gmail.com

A. A. Amirghofran

Cardiac Surgery Department, Shiraz University of Medical

Sciences, Shiraz, Iran

123

Pediatr Cardiol

DOI 10.1007/s00246-014-0986-3

patient was admitted to the hospital and started on anti-

inflammatory treatment (intravenous dexamethasone) and

high-dose aspirin (100 mg/KG). There was no response to

medical therapy after 7 days, and surgical removal of

device was done for him according to parental request.

Unfortunately, complete heart block was not relieved after

the surgery, and permanent endocardial pacemaker was

inserted for him.

Intraoperative findings demonstrated inflammatory tis-

sue formation just near the atrioventricular node area at the

floor of the right atrium, without any direct compression on

the triangle of Koch (Figs. 1, 2). A small biopsy was also

taken for pathologic evaluation which revealed chronic

inflammation.

Discussion

Procedure-related complications after device ASD closure

are relatively rare. However, early electrophysiologic

abnormalities, such as atrial and ventricular ectopy and AV

conduction disturbance, are common in the first days after

closure; of course, persistence of these abnormalities is

extremely rare [2, 5]. Nowadays, transcatheter closure of

ASD is commonly performed in many centers as an

alternative approach to surgical repair. There are several

studies reporting electrophysiologic abnormalities after

ASD repair, including sinus node dysfunction and atrio-

ventricular node dysfunction including supraventricular

and ventricular ectopy and atrioventricular block [3, 6].

The exact mechanism of heart block following ASD

closure is not clear. Continuous pressure or friction of atrial

disks on the atrioventricular node result in edema and could

lead to atrioventricular block secondary to the ASD device

closure [6]. Chen et al. [4] hypothesized that the possible

mechanism of heart block is an inflammatory response as a

result of mechanical rubbing of the occluder against the

proximal conduction system. Bachmann’s bundle, which is

the primary path for electrical conduction from the sinus

node to the atrioventricular node, and the atrioventricular

conduction bundle are very close to the margin of ASD

defect.

Insufficient rim to the atrioventricular valves and a small

distance between the right atrial disk and the tricuspid

valve can lead to this problem [6]. Al-Anani et al. [2]

emphasized that the risk of heart block is more pronounced

in patients with deficient posterior-inferior rims.The size of

the device is also a predisposing factor for heart block after

ASD closure. The device size of equal to or more than

18 mm has been reported as a risk factor for heart block

after ASD closure [2, 7].

In some studies, atrioventricular block improved spon-

taneously following ASD device closure, with no recur-

rence at mid-term follow-up [1]. In a study conducted by

Kenji et al. [7], two patients developed atrioventricular

block 48 h after uncomplicated Amplatzer closure of ASD,

which was completely resolved following surgical removal

of their devices.

Overall, the device removal is recommended in the

patients with heart block after ASD device closure in order

to avoid ischemia and fibrosis resulting in permanent injury

of the atrioventricular node. In the present case, however,

heart block did not improve despite the device removal

and, consequently, we inserted a permanent pacemaker. In

follow-up, the heart block was not reversed after 1 year.

Acknowledgments The authors would like to thank Ms. A. Ke-

ivanshekouh at the Research Improvement Center of Shiraz

Fig. 1 Opened right atrium shows the device in place with inflam-

matory tissue formation around the device

Fig. 2 The atrial septal occluder was removed which shows suitable

size device in comparison to atrial septal defect size and inflammatory

issue formation (Arrows)

Pediatr Cardiol

123

University of Medical Sciences for improving the use of English in

the manuscript.

References

1. Al Akhfash AA, Al-Mesned A, Fayadh MA (2013) Amplatzer

septal occluder and atrioventricular block: a case report and

literature review. J Saudi Heart Assoc 25(2):91–94

2. Al-Anani SJ, Weber H, Hijazi ZM (2010) Atrioventricular block

after transcatheter ASD closure using the Amplatzer septal

occluder: risk factors and recommendations. Catheter Cardiovasc

Interv 75(5):767–772

3. Bink-Boelkens MT, Meuzelaar KJ, Eygelaar A (1988) Arrhyth-

mias after repair of secundum atrial septal defect: the influence of

surgical modification. Am Heart J 115:629–633

4. Chen Q, Cao H, Zhang G-C, Chen L-W, Chen D-Z et al (2012)

Atrioventricular block subsequent to intraoperative device closure

atrial septal defect with transthoracic minimal invasion: a rare and

serious complication. PLoS One 7(12):e52726. doi:10.1371/

journal.pone.0052726

5. Du ZD, Hijazi ZM, Kleinman CS, Silverman NH, Larntz K (2002)

Comparison between transcatheter and surgical closure of secun-

dum atrial septal defect in children and adults: results of a

multicenter nonrandomized trial. J Am Coll Cardiol 39:1836–1844

6. Hill SL, Berul CI, Patel HT, Rhodes J, Supran SE, Cao QL, Hijazi

ZM (2000) Early ECG abnormalities associated with transcatheter

closure of atrial septal defects using the Amplatzer septal occluder.

J Int Card Electrophysiol 4:469–474

7. Kenji S, Marie-Jose R, Eric P (2004) Reversible atrioventricular

block associated with closure of atrial septal defects using the

Amplatzer device. J Am Coll Cardiol 43:1677–1682

Pediatr Cardiol

123