This report describes the successful treatment of an out-of-hospital cardiac arrest case by immediate surgical repair for erosion after ASO without cardiopulmonary bypass. This case highlights that a bailout surgical strategy may be an important option for hemodynamically unstable patients, with a risk of multiple organ failure, such as in cardiac arrest patients.
This case has two important educational points. First, this case highlighted that ASD closure by the ASO carries a risk of life-threatening complications that cause cardiac tamponade and cardiac arrest. Cardiovascular surgeons should be aware of these rare complications and perform immediate emergency surgery. Catheterization for ASD was first reported by Mills et al. . In the late 1990s, the ASO was introduced and helped achieve good surgical outcomes and shorter hospitalization periods than did surgical treatment. However, erosion of the cardiac wall caused by the device has been attracting attention in recent years as a rare complication that can cause rapid cardiac tamponade and can be fatal if appropriate measures are not taken. The majority of perforations occur within 48 hours after surgery, but the incidence of remote erosion is rare at 0.1% [3, 4]. Erosions occurring several months or years after implantation have also been reported [5-8], indicating that careful follow-up is essential not only during the acute phase but also for a long time after surgery.
Second, we suggest that a bailout surgical strategy consisting of the immediate surgical control of bleeding without a cardiopulmonary bypass and planned reoperation for the permanent repair is an acceptable option to avoid multiple organ failure. Several strategies were previously reported for this complication. Amin et al. reported that out of 28 cases of erosion, 21 patients underwent surgery, 16 patients underwent device retrieval and closure of the perforation site, 5 underwent closure of the perforation site only, and 7 underwent conservative treatment and observation . Although some studies have reported of perforation repair performed without removing the device, some reports have advocated the prevention of recurrence by removal of the device and by careful follow-up . Other reports have indicated that emergency surgery for this complication had a high mortality rate. DiBardino et al. reported that of 223 adverse events reported to the FDA, emergency surgery was performed in 152 cases, and 17 patients died, including 4 surgical deaths, indicating that the mortality rate associated with emergency surgery for ASO-related complications is 20 times higher than that associated with conventional cardiac surgery . In the present case, we avoided definitive surgery to remove the device and perform repair procedures using a cardiopulmonary bypass. We assumed that cardiopulmonary bypass could cause severe complications or multiple organ failure in cardiac arrest patients. Generally, cardiopulmonary bypass carries a risk of coagulopathy and organ failure . Furthermore, cardiac arrest may cause organ injury such as rib fracture , hemothorax, and intra-abdominal bleeding caused by chest compression after resuscitation among these patients . These injuries may lead to life-threatening major bleeding with coagulopathy. Furthermore, following cardiac arrest, patients may develop a type of multiple organ failure called post-cardiac arrest syndrome caused by ischemic-reperfusion injury . In this case, the possibility of further secondary injuries was not ruled out, and the progression to multiple organ failure due to cardiac arrest was considered. Therefore, we decided to close the perforation and reinforce the perforation site with autologous pericardium without the use of extracorporeal hemodynamic support; we did not remove the ASO device. Therefore, it may be acceptable to perform temporary bleeding control for cardiac arrest patients while avoiding cardiopulmonary bypass. Although reports of complications such as erosion are rare, the sudden occurrence of chest pain or pericardial effusion after ASO treatment should raise suspicion of erosion and prompt consideration of bailout surgical treatment as a damage control strategy.
We successfully treated a case of cardiac arrest due to cardiac tamponade caused by erosion 6 years after the percutaneous closure of an atrial septal defect. We believe that the key point of this case was a bailout surgical strategy for patients who were hemodynamically unstable with risks of coagulopathy and multiple organ failure. This case suggests that cardiac surgeons need to be aware of the complications of percutaneous ASD closure and consider a bailout surgical strategy for patients at risk of multiple organ failure.