Abstract 15146: A Flying Saucer- Asymptomatic Migration of an Atrial Septal Defect Occluder Device to the Aortic Arch - No Good Deed Goes Unpunished!

Abstract

Introduction: Though safe, the transcatheter closure with an atrial septal defect for secundum atrial septal defect (ASD) is associated with complications, such as device dislodgement. Case report: A 51-year-old female with a complex fenestrated secundum ASD (16mm superior defect and 14mm inferior defect with insufficient aortic rim) with hemodynamically significant shunt causing right heart dysfunction underwent placement of two atrial septal defect occluder devices (Amplatzer). While there was no shunting noted on immediate post-procedure transthoracic echocardiogram (TTE), a follow-up TTE after a year showed residual left to right shunting across the ASD. Transesophageal echocardiogram (TEE) showed a single occluder device (inferior) in place and a second device (superior) lodged in the distal aortic arch at the level of the left common carotid and left subclavian artery with mild local flow acceleration (aortic velocity 2.6 ms/s) and no superimposed device thrombus. Her only complaint was recurrent headaches, which pre-dated the procedure and were attributed to ocular migraine by her neurologist. The patient underwent a transcatheter procedure to attempt the retrieval of the dislodged device. The proximal end of the device was found adherent to the aortic wall. Aortogram revealed excellent flow around the device. The procedure was aborted due to the risk of dissection. Since the device did not cause any adverse effects and would likely continue to endothelialization. Conclusion: Atrial septal occluder device dislodgement can occur several months after implantation. Careful monitoring is required particularly when the ASD rim is insufficient. In cases of migration and adherence to the aortic wall without hemodynamic consequences, the device can likely be safely left in place to endothelialize. Despite a faster recovery with percutaneous procedures, a surgical approach should be considered in younger patients to avoid such complications.