When past becomes prologue: extremely late mechanical complication after implantation of an atrial septal occluder device

A 34-year-old woman, who had fainted playing with her children, presented to our emergency department with severe chest pain radiating to the shoulders and the back, aggravated during inspiration. With suspected acute coronary syndrome, physical examination and electrocardiogram were unremarkable, cardiac troponin remained negative. The past medical history comprised of interventional treatment of a secundum atrial septal defect (ASD), which had been performed 14 years ago by transcatheter implantation of a 24 mm Amplatzer Septal Occluder (St. Jude Medical, St. Paul, MN, USA). Further evaluation revealed moderate pericardial effusion mainly related to the right ventricle. Computed tomography confirmed the presence of partially organized pericardial effusion, while excluding aortic dissection and other thoracic pathologies (Panel A). The patient was planned for diagnostic pericardiocentesis the next day, however, 7 hours after presentation the patient developed clinical signs of cardiac tamponade necessitating urgent pericardiocentesis which confirmed the diagnosis of haemopericardium. Emergency cardiac magnetic resonance imaging was performed and ruled out myocardial contusion and contained left ventricular rupture (Panel B). Undergoing cardiac surgery, a small erosion at the roof of the right atrium, likely caused by the ASD occluder, was detected. Intraoperatively, the device was removed and replaced by a bovine patch (Panels C and D). To our knowledge, this is amongst the latest occurrences of severe mechanical complications after implantation of atrial septal occluders. This case should alert clinicians to consider very late device-related complications when encountering cardiac tamponade in patients with a history of interventional ASD closure. (Panel A) Cardiac computed tomography, (Panel B) cardiac magnetic resonance imaging SSFP cine four-chamber view, (Panel C) intraoperative situs, and (Panel D) explanted ASD occluder. PE, pericardial effusion.