Silent Embolization of an Atrial Septal Defect Occluder Into the Right Ventricle Detected 20 Months Post-Implantation

Abstract

A 64-year-old woman, who had undergone transcatheter closure of a secundum-type atrial septal defect (ASD) with a 38-mm Amplatzer septal occluder (ASO) 20 months earlier, was admitted with palpitations for 1 day. She had not received routine follow-up after the procedure. Cardiac examination revealed a grade III/VI systolic ejection murmur at the left upper sternal border. Chest x-ray revealed that the ASO device was located in the right ventricular area (Fig. 1A). Immediate transthoracic echocardiography confirmed that the ASO device had become dislodged and embolized into the right ventricle. The embolized device was oriented in the longitudinal plane, parallel to the direction of blood flow across the tricuspid valve (Fig. 1B). Although the patient remained hemodynamically stable, she was referred for urgent surgical retrieval of the device and closure of the defect. In surgery, the embolized occluder was identified in the right ventricular inflow tract and appeared to be firmly adhering to the tricuspid valve apparatus (Fig. 1C). The inferoposterior rim of the ASD was also found to be inadequate. The endothelialization status of the retrieved device revealed that embolization must have occurred months earlier (Fig. 1D). The ASD was closed with a bovine pericardial patch through the right atriotomy, and the tricuspid valve was repaired with a 32-mm CosgroveEdwards annuloplasty band (Edwards Lifesciences, Irvine,