Percutaneous ASD closure has established itself as a routine intervention due to the effectiveness and safety of the procedure as well as the advantage of a short learning curve. Rupture of the free right atrial wall must be considered a severe complication of percutaneous CHD interventions. This may be a potentially life-threatening complication if it leads to cardiac tamponade. Atrial erosion has been reported in association with Amplatzer septal occluders[3, 4]. According to the data reviewed by Pediatric and Adult Interventional Cardiac Symposium (PICS) 2012, most of the erosion occurred near the aortic root and the top of the atrium: 47 cases involved perforation of the roof of the left atrium (28 cases involved the aorta), 26 cases involved perforation of the roof of the right atrium (22 cases involved the aorta), and 9 cases involved both atria; in 15 cases, the site was unknown. Similarly, in Pics 2012 data, approximately 87.6% of erosions occurred in the first year after implantation. The incidence of erosions in children was 57% within 72 hours after the operation, and it was 65% in adults after more than 72 hours after implantation.
Our case demonstrated perforation of the atrial wall and aortic sinus as a complication of the atrial septal defect closure device 3 months after implantation of a 12-mm ASO. Since erosion occurs several hours or even days after a successful transcatheter closure, it can be concluded that the damage mechanism is not related to a catheterization technique-related complication but rather to a complex interaction between the device and the atrial wall. According to previous experience with occlusion, the base of the aorta is adjacent to the anterosuperior rim or limbus of the defect. In some cases, it is the only structure of this boundary. Due to the position of the device against the interatrial septum, the anterosuperior aspect of the device is in constant contact with the aorta during the cardiac cycle. Moreover, due to defects in the aortic rings, especially with the deployment of a significantly oversized device, the edge of the device may elongate the free atrial wall adjacent to the atrial septum. With each cardiac cycle, the movement of the edge of the device near the superior edge leads to a "seesaw" mechanism, resulting in potential erosion of the atrial roof and the adjacent aorta. The result is the development of pericardial hemorrhage and hemodynamic damage. The vulnerability of the atrial wall becomes more exaggerated with oversizing of the device and reduction of the RA cavity after ASD closure. We also found that compared with other atrial septal occluders, AGA occluder material has greater hardness. If placed near the aortic wall, this structure will lead to more rigid contact with the atrial wall and aortic wall, resulting in a higher risk of atrial and aortic erosion.
However, the current analysis of and theory on how device erosion occurs have significant limitations. Therefore, we should pay attention to the following points in future transcatheter closure: first, we should rigorously identify the indications before the operation; second, we must improve transthoracic echocardiography and transesophageal echocardiography before the operation to preoperatively assess the morphology of the ASD with respect to its location, size, shape, and margins and select the appropriate occluder according to the examination results; third, since events are more frequent in the first year, there should be frequent follow-up in the first year (e.g., serial echocardiography at 1 week, 1 month, 3 months, and 6 months) and clinical follow-up annually with less frequent follow-up after the first year; fourth, clinicians must ensure that patients are well informed of the risks/benefits of transcatheter closure of ASD. Further, sufficient communication between clinicians and their patients who have undergone implantation should be occur to educate patients about symptoms without creating fear and anxiety.
To summarize, with this case report, we want to illustrate that although percutaneous closure of ASD is regarded as a routine procedure, we should not forget the potentially lethal complications, especially cardiac erosion. Therefore, we should carefully evaluate the risk of erosion before surgery, and careful lifelong follow-up is needed.