Emergency surgery after failed device closure of the atrial septal defect

Abstract

Clinical Summaries PATIENT 1. A 66-year-old woman with chronic atrial fibrillation (AF) and transient ischemic attacks (TIA) underwent closure of a 5-mm ASD with 14-mm Amplatzer device (AGA Medical Corp, Golden Valley, Minn). However, she remained symptomatic, with residual left-to-right shunt. A 25-mm Amplatzer device was placed 6 months later. The devices partially dehisced 2 years later, with large left-to-right shunt with pulmonary artery (PA) systolic pressure of 62 mm Hg. An attempt to place a 35-mm Amplatzer device resulted in further dehiscence of the interlocked devices, with threatening embolization. The patient underwent urgent surgery. Atrial septum was exposed through midline sternotomy. The devices were dehisced from the entire posterior rim of the septum and displaced into the left atrium (LA; Figure 1). The devices were retrieved from the LA, and the ASD was closed with direct suture. Aortic crossclamp (ACC) time was 30 minutes. Cardiopulmonary bypass (CPB) time was 57 minutes. The patient was discharged home on postoperative day 8. She died 30 months later from interstitial lung disease presumably related to amiodarone therapy for chronic AF. PATIENT 2. A 38-year old woman developed syncopal episodes. A sick sinus syndrome was diagnosed, and a permanent pacemaker was required. The echocardiogram demonstrated a 16-mm-diameter ASD. An attempt to place an 18-mm Amplatzer device resulted in the rupture of the inferior rim of the atrial septum. An attempt to place a 36-mm Amplatzer device resulted in further rupture and an insufficient inferior rim to secure the device. The ASD size increased to 2.5 cm 4 cm. A large flail segment of the inferior rim raised the concern of embolization. Emergency surgery was performed through midline sternotomy. The flail segment of the atrial septum was excised, and the ASD was closed with an autologous pericardial patch. ACC time was 21 minutes. CPB was 37 minutes. She was discharged on postoperative day 5 and underwent pacemaker insertion for the sick sinus syndrome. The patient remains asymptomatic at 1-year follow-up. PATIENT 3. A 61-year-old man with several episodes of TIA, hypertension, type 2 diabetes, and 10-mm ASD with left-to-right shunt underwent ASD closure with a 35-mm Helex occluder device (W.L. Gore and Associates, Inc, Flagstaff, Ariz). Upon deployment of the device, the patient developed cardiac tamponade. A pigtail catheter was placed in the pericardial cavity, and continuous autotransfusion of the aspirated blood was performed. Emergency surgery was performed through midline sternotomy. A tear of the atrial septum extending into the left atrial wall was found. The tear and the ASD were closed by direct running suture. ACC was 18 minutes. CPB was 29 minutes. The patient was discharged home on day 5. He remains asymptomatic at 3-year follow-up. PATIENT 4. A 16-year-old asymptomatic woman was considered for device closure of an 18-mm-diameter ASD with shunt of 2:1 and normal PA pressures. An attempt to place a 26-mm Amplatzer device resulted in the tear of the inferior rim of the atrial septum. The device was removed, and a 28-mm Amplatzer device was placed. The second device, however, embolized entirely into the LA, and the patient underwent urgent surgical removal of the device. The device was retrieved from the LA through midline sternotomy with standard CPB. A long tear was found in the inferior rim of the ASD, which measured 1.8 cm 4 cm. The ASD was closed with direct suture. ACC time was 18