Retrograde aortic perfusion dislodges a dislodged Amplatzer device

Abstract

Transcatheter closure of secundum atrial septal defects (ASDs) with an Amplatzer septal occluder (ASO) (AGA Medical Corporation, Golden Valley, Minn) has become a standard procedure in most pediatric and adult populations.1Spies C. Timmermanns I. Schrader R. Transcatheter closure of secundum atrial septal defects in adults with the Amplatzer septal occluder: intermediate and long-term results.Clin Res Cardiol. 2007; 96: 340-346Crossref PubMed Scopus (59) Google Scholar Different series have reported successful closure of ASDs with good follow-up.1Spies C. Timmermanns I. Schrader R. Transcatheter closure of secundum atrial septal defects in adults with the Amplatzer septal occluder: intermediate and long-term results.Clin Res Cardiol. 2007; 96: 340-346Crossref PubMed Scopus (59) Google Scholar, 2Chessa M. Carminati M. Butera G. Bini R.M. Drago M. Rosti L. et al.Early and late complications associated with transcatheter occlusion of secundum atrial septal defect.J Am Coll Cardiol. 2002; 39: 1061-1065Abstract Full Text Full Text PDF PubMed Scopus (473) Google Scholar, 3Fischer G. Stieh J. Uebing A. Hoffmann U. Morf G. Kramer H.H. Experience with transcatheter closure of secundum atrial septal defects using the Amplatzer septal occluder: a single centre study in 236 consecutive patients.Heart. 2003; 89: 199-204Crossref PubMed Scopus (226) Google Scholar One of the most frequently reported complications is device embolization/malposition.1Spies C. Timmermanns I. Schrader R. Transcatheter closure of secundum atrial septal defects in adults with the Amplatzer septal occluder: intermediate and long-term results.Clin Res Cardiol. 2007; 96: 340-346Crossref PubMed Scopus (59) Google Scholar Devices usually embolize into the main pulmonary artery. We report a case of device embolization into the aorta and the strategy for surgical retrieval. A 53-year-old woman presented to the cardiology clinic with complaints of palpitations. Echocardiographic analysis revealed a 15-mm secundum ASD. She underwent elective closure of the ASD with ASO without any complications. Her predischarge echocardiogram revealed that the ASD was still present. Fluoroscopic study of the thorax showed that the device had embolized into the ascending aorta (Figure 1). She was taken to the operating room for retrieval of the device and closure of the ASD. A transesophageal echocardiogram (TEE) was performed after induction, which confirmed the presence of the device in the ascending aorta just proximal to the innominate artery. The initial plan was to start the patient on circulatory arrest and retrieve the device. Femoral bypass was initiated, and hypothermia was used. Adequate exposure of the ascending aorta was obtained, avoiding manipulation of the aorta, with plans of aortotomy and ASO retrieval during circulatory arrest. On initiation of femoral bypass, it was observed on TEE that the device could no longer be visualized in the ascending aorta. A fluoroscopic scan using a C-arm was performed, and it demonstrated that the device had embolized back into the left ventricle. An aortic crossclamp was applied, and antegrade cold blood cardioplegia was administered. A right atriotomy was performed, and the device was visualized through the ASD to be lying in the left ventricle, entangled in the chordae of the mitral valve. The device was retrieved through the ASD. Direct closure of the ASD was performed with Prolene sutures (Ethicon, Inc, Somerville, NJ). The right atriotomy incision was closed. Postoperative echocardiographic analysis did not reveal any residual defect or mitral or aortic valve insufficiency. The patient made a smooth postoperative recovery and was discharged in a week. ASOs have been used successfully in the adult population, with a low failure rate.1Spies C. Timmermanns I. Schrader R. Transcatheter closure of secundum atrial septal defects in adults with the Amplatzer septal occluder: intermediate and long-term results.Clin Res Cardiol. 2007; 96: 340-346Crossref PubMed Scopus (59) Google Scholar Device embolization or malposition is the most frequently reported complication, and in one series it was 3.5%.2Chessa M. Carminati M. Butera G. Bini R.M. Drago M. Rosti L. et al.Early and late complications associated with transcatheter occlusion of secundum atrial septal defect.J Am Coll Cardiol. 2002; 39: 1061-1065Abstract Full Text Full Text PDF PubMed Scopus (473) Google Scholar It is reported that there is an age-related decrease in the rate of complications for device closure of ASD, with studies involving children having the lowest complication rates.4Du Z.D. Hijazi Z.M. Kleinman C.S. Silverman N.H. Larntz K. Amplatzer Investigators. Comparison between transcatheter and surgical closure of secundum atrial septal defect in children and adults: results of a multicenter nonrandomized trial.J Am Coll Cardiol. 2002; 39: 1836-1844Abstract Full Text Full Text PDF PubMed Scopus (739) Google Scholar Embolization of a device in an adult has rarely been reported. We did not attempt to retrieve the device percutaneously because of the fear of more distal embolization. The patient was taken to the operating room soon after the diagnosis was made. An interesting situation arose when the device could not be found in the ascending aorta, where it was initially reported to be present. We think that initiation of femoral bypass resulted in the device being pushed back into the proximal aorta. With subsequent aortic crossclamping and antegrade cold blood cardioplegia, it slipped through the aortic valve into the left ventricle and got entangled in the submitral apparatus. The decision to start the patient on deep hypothermia with plans of circulatory arrest was made for fear of distal embolization during aortic manipulation. It seems that the femoral artery bypass pressure helped by pushing the device back near the aortic valve and, with subsequent antegrade cardioplegia, pushed the device through the aortic valve into the left ventricle and then toward the left atrium, and this saved the patient from an aortic intervention. This phenomenon has not been described in the literature to the best of our knowledge. We propose that when an ASO has embolized to the aorta, femoral cannulation and cardiopulmonary bypass, along with transesophageal echocardiography and fluoroscopy to localize the device accurately, should be used.