doi: 10.1161/CIRCEP.108.818450
Images and Case Reports in Arrhythmia and Electrophysiology |
Delayed Heart Block After Temporary Balloon Occlusion of a Secundum Atrial Septal Defect
From the Massachusetts General Hospital, Boston, Mass.
Correspondence to Saumya Das, MD, Massachusetts General Hospital, GRB 109, 55 Fruit Street, Boston, MA 02114. E-mail sdas{at}partners.org
Although the association between atrial arrhythmias and atrial septal defects (ASD) has been well described, abnormalities of AV nodal conduction, typically in the setting of ASD device closure, have been infrequently reported.1–4 We report a case of transient complete heart block several hours after temporary balloon occlusion of a secundum ASD. To our knowledge, this is the first report describing delayed complete heart block with temporary balloon occlusion of an ASD.
A 35-year-old woman with Eisenmenger’s syndrome secondary to a secundum ASD and anomalous pulmonary venous drainage was hospitalized with a Hickman line infection. The decision was made to remove the line, given the presence of vegetations and septic pulmonary emboli. To avoid systemic vegetation embolization, temporary occlusion of the ASD at the time of the line removal was planned. The patient had no prior history of heart block and a normal PR interval on a baseline ECG (Figure, panel A).
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A 34-mm Amplatzer balloon was placed across the ASD and inflated (waist diameter 16 mm) to occlude flow between the right and left atria (panel B). The balloon remained inflated for 25 minutes during manipulation and removal of the Hickman line. No intraprocedural hemodynamic or conduction abnormalities were noted. Eighteen hours after the procedure the patient experienced syncope with documented high-grade AV block (panel C). The episode persisted for
3 minutes with spontaneous resumption of normal AV conduction. She was monitored with in-hospital telemetry for an additional 7 days and with an outpatient event monitor for 21 days. There were no further episodes of AV block. Transient AV block has been described as a complication of ASD device closure.1,2 In the largest series to date, 3.1% and 0.6% of patients developed transient second and third degree AV block, respectively, associated with device closure.1 To our knowledge, only a single case report exists describing the need for permanent pacing for third degree AV block postdevice closure.2 The mechanism and timing of AV block after such procedures is unclear and may be related to transient AV node edema with continuous pressure or abrupt changes in right heart hemodynamics. This case report suggests that even temporary balloon occlusion of an ASD may be associated with AV block and demonstrates the delayed presentation and transient duration of AV block. Knowledge of this phenomenon may avert the need for permanent pacemaker implantation.
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Dr Das received funding from the NIH/National Heart, Lung, and Blood Institute and the Deane Foundation at the Massachusetts General Hospital.
Disclosures
None.
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Footnotes |
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Both authors contributed equally to this work.
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1. Suda K, Raboisson MJ, Piette E, Dahdah NS, Miro J. Reversible atrio-ventricular block associated with closure of atrial septal defects using the Amplatzer device. J Am Coll Cardiol. 2004; 43: 1677–1682.
2. Hill SL, Berul C, Patel HT, Rhodes J, Supran SE, Cao QL, Hijazi HM. Early ECG abnormalities associated with transcatheter closure of atrial septal defects using the Amplatzer septal occluder. J Interv Card Electrophysiol. 2000; 4: 469–474.[CrossRef][Medline]
3. Chau AKT, Chung BHY, Lun KS, Cheung YF, Yung TC. Midterm outcomes of transcatheter closure of atrial septal defect using the Amplatzer septal occluder in children. Hong Kong J Pediatrics. 2005; 10: 251–256.
4. Chan KC, Godman MJ, Walsh K, Wilson N, Redington A, Gibbs JL. Transcatheter closure of atrial septal defect and interatrial communications with a new self expanding nitinol double disc device (Amplatzer septal occluder): Multicentre UK experience. Heart. 1999; 82: 300–306.
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