a 43-year - old man visited the emergency room with complaints of abrupt chest and back pain that began 20 minutes earlier . the patient was previously healthy and did not take any medication , although he had a history of transcatheter atrial septal defect ( asd ) device ( amplatzer septal occluder ; aga medical co. , golden valley , mn , usa ) closure performed 31 months ago . the return of spontaneous circulation was achieved within 1 minute with cardiopulmonary resuscitation and intubation . however , the moderate hemopericardium extended into the superior recess . the asd closure device had not migrated ( fig . 1 ) . after the patient s admission to the intensive care unit , tte revealed moderate hemopericardium with mild right atrial collapse , suggesting residual tamponade physiology . the asd closure device was found in situ in the interatrial septum , abutting to the aortic root due to the scant aortic rim ( fig . 2 ) . however , there was no evidence of any residual interatrial shunt , valvular dysfunction , or device erosion . transesophageal echocardiography showed that the pericardial effusion had resolved , and there were no additional abnormal findings . his left pleural effusion was controlled by closed thoracostomy with a 10-fr mini - tube . although the patient s status stabilized after appropriate management , we were not able to identify the exact reason for the hemopericardium . clinically , we ruled out left atrium ( la ) perforation on the basis of the asd closure device abutting the aortic root and the la roof . however , it was difficult to decide to perform surgical exploration for resolved hemopericardium without a definite reason or new symptoms . although the patient exhibited no abnormal laboratory findings or fever and the culture results were negative , empirical antibiotics ( vancomycin , gentamicin , and rifampicin ) were started in accordance with infective endocarditis on the prosthetic valve . diagnostic and therapeutic surgical exploration was performed on the eighth day after admission . with full median sternotomy and pericardiotomy , mild adhesion around the la roof , aortic root , and the right pulmonary artery was found . however , there was no evidence of active bleeding , organized hematoma , abscess formation , or infective tissue . right atriotomy was then performed under aorto - bicaval cannulation with antegrade cold crystalloid cardioplegic arrest . the device was removed with electrocautery and dissection using metzenbaum scissors . after inspecting the la cavity via the asd the asd was closed with a glutaraldehyde - fixed autologous pericardial patch . the cardiopulmonary bypass time and the aortic cross clamp time the patient was extubated 2 hours after surgery and transferred to a general ward on postoperative day 1 . the patient was transferred to department of cardiology and maintained with 2 weeks of gentamicin and 6 weeks of vancomycin and rifampicin therapy . the closure of secundum asd without severe irreversible pulmonary artery hypertension either percutaneously or surgically is a preferable therapy for adult patients . the amplatzer septal occluder ( aga medical co. ) , which was approved by the us food and drug administration in december 2001 , is a safe and effective closure device for children and adult patients . although the device has been used widely , several early and late complications have been reported , including device malposition , device embolization , arrhythmia , pericardial effusion , thrombus formation , and iliac vein dissection . among the complications after transcatheter asd device closure , cardiac erosion with tamponade most of the complications from erosion occur within 1 year of device closure , but more than 10% of the cases of erosion occurred more than 1 year after device closure . with proper clinical follow - up , early erosion can be treated appropriately . however , as in this case , sudden cardiac tamponade caused by cardiac erosion several years after the procedure is difficult to distinguish from hemopericardium due to other causes . therefore , if a patient with a history of device closure of asd presents with chest pain , syncope , or other shock symptoms , device - related cardiac erosion should be suspected and urgent evaluation should be performed for confirmation . a deficient retroaortic rim has been considered to be a risk factor for erosion . however , o byrne et al . have argued that it is not associated with an increased risk of technical failure or early adverse events . on the other hand , mcelhinney et al . have evaluated the relative risk factors and revealed that deficiency of any rim , the ratio of the size of the device to the size of the rim , and oversized devices are associated with erosion . a recent study has shown that absence of the aortic rim , poor posterior rim consistency , septal malalignment , and dynamic morphology of the asd in echocardiographic findings can significantly increase the risk of erosion . in addition , a case report has described device embolization in the left ventricular outflow tract ( lvot ) in a left - to - right shunt asd patient with an aortic rim defect . with a low incidence of early and late complications , however , given the severity of complications such as lvot embolization or device erosion , decision - making regarding device closure for asd patients with some risk factors should be based on a multidisciplinary team approach .
a 43-year - old man who had had a history of atrial septal defect ( asd ) device closure 31 months previously presented with abrupt chest and back pain along with progressive cardiogenic shock and cardiac arrest . 
 after resuscitation , he was diagnosed with cardiac tamponade . 
 diagnostic and therapeutic surgical exploration revealed left atrium ( la ) perforation due to la roof erosion from a deficient aortic rim . 
 device removal , primary repair of the la perforation site , and asd patch closure were performed successfully . 
 the postoperative course was uneventful . 
 the patient was discharged after 6 weeks of empirical antibiotic therapy without any other significant complications .