Percutaneous repair of right ventricular perforation with Amplatzer septal defect occlusion device

A 65-year-old man with non-ischaemic cardiomyopathy and electrical storm was referred for catheter ablation of refractory ventricular tachycardia (VT). The patient had a remote history of prior endo- and epicardial VT ablation. Electrocardiogram characteristics of the presenting VT were consistent with an epicardial exit. Epicardial access was obtained without complication, although some resistance was noted during mapping due to pericardial adhesions. At an adhesion site, the ablation catheter and sheath perforated the right ventricular (RV) free wall (white arrows, Panels A and B). The catheter was removed and the sheath, which partially sealed the perforation, was left in place. With ongoing bleeding, a second epicardial access was utilized for pericardial drainage and continued mapping. Epicardial ablation was completed, rendering all VTs non-inducible. The patient was subsequently transported to a hybrid operating room for percutaneous repair of the perforation with cardiac surgical backup. Uncomplicated trans-catheter closure of the RV perforation with an Amplatzer septal defect occlusion device (St. Jude Medical, St. Paul, MN) was performed (black arrows, Panels C and D). The patient recovered without adverse events, was discharged 2 days later, and has not had recurrent VT during follow-up. In summary, cardiac perforation is a known risk of epicardial ablation and may require emergent intervention. This is the first report of safe and effective repair of a RV perforation with a transcatheter closure device in humans. With early recognition of this complication and multidisciplinary involvement, the need for emergent cardiac surgery with sternotomy can be averted. Supplementary material is available at European Heart Journal online.