HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Nikolaos B. Tsilimingas Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Tsilimingas, N. B. Articles by Hofmann, T. Search for Related Content PubMed PubMed Citation Articles by Tsilimingas, N. B. Articles by Hofmann, T. Related Collections Congenital - acyanotic

Ann Thorac Surg 2004;78:686-687
© 2004 The Society of Thoracic Surgeons

---

Case report

Surgical revision of an uncommonly dislocated self-expanding Amplatzer septal occluder device

^a Clinic of Thoracic and Cardiovascular Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany
^b Clinic of Cardiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany

Accepted for publication September 5, 2003.

^* Address reprint requests to Dr Tsilimingas, Clinic of Thoracic and Cardiovascular Surgery, University Hospital Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
e-mail: tsilimingas{at}uke.uni-hamburg.de

	Abstract

Top Abstract Introduction Comment References

 
Open heart surgery is the standard procedure for closure of ostium secundum atrial septal defects. Recently, percutaneous transcatheter procedures emerged as therapeutic alternatives for closure of both atrial septal defects and patent foramen ovale. Unfortunately, however, such percutaneous procedures may require surgical intervention for early or late complications. We report a case with emergent surgery for dislocation of the Amplatzer septal occluder into the aortic arch diagnosed 30 days after percutaneous closure of an atrial septal defect.

	Introduction

Top Abstract Introduction Comment References

 
Since King and Mills [1] reported percutaneous occlusion of an ostium secundum atrial septal defect (ASD) with a transcatheter double-disk device in 1976, several devices have been developed or are under trial for ASD occlusion, including CardioSEAL (AMT Medical, Boston, MA), Sideris (Custom Medical Devices, Amarillo, TX), Das Angel Wings (Microvena Corp, Vadnais, MN), and Amplatzer (AGA Medical Corporation, Golden Valley, MN) devices. In addition, a recent study of selected patients with ASD showed the Amplatzer septal occluder to be effective for transvenous closure of the interatrial septum [2]. Patients may be eligible for transcatheter ASD closure with an ASD of the ostium secundum type, with a left-to-right shunt across the ASD exceeding 35%, with a maximal stretched diameter of the ASD below 34 mm, and with a distance greater than 5 mm from the margins of the defect to the mitral and tricuspid valve, the superior vena cava, the right upper pulmonary vein, and the coronary sinus. We describe a patient fulfilling criteria for percutaneous ASD occlusion undergoing Amplatzer device implantation; this patient subsequently required surgical intervention because the device dislocated into the aortic arch 4 weeks after the initial intervention.

A 33-year-old man was admitted to the Clinic of Cardiology at the University of Hamburg-Eppendorf with a secundum ASD located in an aneurysm of the atrial septal membrane. The stretched ASD diameter was 20 mm with classic criteria for percutaneous septal closure. Placement of a 24-mm Amplatzer septal occluder was guided by transesophageal echocardiography. However, despite echocardiographically confirmed correct positioning, there was significant systolic-diastolic movement of the device with the mobile aneurysm of the atrial septal membrane. Surprisingly, on routine follow-up examination 30 days after initial implantation, both echocardiography and chest roentgenography failed to identify the Amplatzer device at the interatrial septal position owing to dislocation into the aortic arch (Fig 1). The patient was immediately referred to the operating room; a standard midline sternotomy was performed and cardiopulmonary bypass was established with an aortic and two separate caval cannulas. To establish antegrade arterial flow with optimal inflow perfusion of the aortic arch vessels, we cannulated the ascending aorta instead of the femoral arteries (Fig 2). After cardioplegic arrest the ASD was closed with a pericardial patch through a right atriotomy. During cooling the aortic arch and the head vessels were carefully dissected. Cardiopulmonary bypass was ceased at systemic hypothermia of 28°C. With the patient in Trendelenburg position and occlusion of the head vessels, the Amplatzer device was removed through an incision across the aortic arch. Circulatory arrest was less than 3 minutes during this maneuver; the overall operation time was 140 minutes with 66 minutes of cardiopulmonary bypass and 39 minutes of aortic cross-clamping. The patient stayed at the intensive care unit for 12 hours and was discharged after a total of 7 days of hospitalization. There were no perioperative or postoperative complications and the functional New York Heart Association class was I at discharge. Three years after the surgical procedure, the patient was doing well and the ASD remained closed without residual shunting of blood across the interatrial septum.

View larger version (124K): [in this window] [in a new window]   Fig 1. Lateral chest roentgenogram showing the dislocated Amplatzer occluder in the aortic arch (arrow).

View larger version (34K): [in this window] [in a new window]   Fig 2. Schematic illustration of arterial inflow (curved arrows) during cardiopulmonary bypass by cannulation of the proximal ascending aorta. The location of the occluder device is also displayed. The dashed line represents the aortotomy.

	Comment

Top Abstract Introduction Comment References

Conversely, surgical closure of interatrial communication is a safe and widely accepted procedure with an early mortality rate of less than 1%, an overall morbidity between 2.5% and 13%, and a probability of residual shunt formation of less than 2% [3, 4]. Moreover, recent improvements of surgical techniques with less invasive approaches through smaller incisions and improved perfusion techniques have reduced both length of hospital stay and costs. More recently, endoscopic ASD closure with telemanipulating robotic systems has become available, permitting rapid postoperative recovery with excellent cosmetic results [5].

The Amplatzer septal occluder is easy to use and the interatrial septum can usually be closed without residual shunting of blood across the septal defect. Moreover, the Amplatzer device has optimal echogenicity because of its Nitinol mesh structure. In the present case, however, the Amplatzer device was placed into an atrial septal membrane aneurysm with extreme systolic–diastolic mobility. It is likely that dislocation of the occluder might have been avoided by using a larger device to stabilize the floppy interatrial septum. The unusual dislocation of the Amplatzer device into the aortic arch necessitated immediate aortotomy. Integrity of the aortic vessel permitted cannulation of the ascending aorta instead of the femoral arteries, as is usually required for repairing pathologic defects located in the ascending aorta or the aortic arch. By using this cannulation technique, we maintained antegrade flow with optimal perfusion of the aortic arch and with only short circulatory arrest.

We conclude that the transcatheter closure of uncomplicated-type secundum ASD is a feasible alternative to open heart surgery. However, we recommend interdisciplinary collaboration with surgical stand by for managing potentially life-threatening complications.

	References

Top Abstract Introduction Comment References

 

1. King T.D., Thompson S.L., Steiner C., Mills N.L. Secundum atrial septal defects: nonoperative closure during cardiac catheterization. JAMA 1976;235:2506-2509.[Abstract/Free Full Text]
2. Thanopoulos B.D., Laskari C.V., Tsaousis G.S., Zarayelyan A., Vekiou A., Papadopoulos G.S. Closure of atrial septal defects with the Amplatzer occlusion device: preliminary results. J Am Coll Cardiol 1998;31:1110-1116.[Abstract/Free Full Text]
3. Berdat P.A., Chatterjee T., Pfammatter J.P., Windecker S., Meier B., Carrel T. Surgical management of complication after transcatheter closure of an atrial septal defect or patent foramen ovale. J Thorac Cardiovasc Surg 2000;120:1034-1039.[Abstract/Free Full Text]
4. Murphy J.G., Gersh B.J., McGoon M.D., et al. Long-term outcome after surgical repair of isolated atrial septal defect: follow-up at 27 to 32 years. N Engl J Med 1990;323:1645-1650.[Abstract]
5. Torracca L., Ismeno G., Alfieri O. Totally endoscopic computer-enhanced atrial septal defect closure in six patients. Ann Thorac Surg 2001;72:1354-1357.[Abstract/Free Full Text]

This article has been cited by other articles:

				S.-M. Yuan, A. Shinfeld, and E. Raanani Displacement of the Amplatzer occluder device from the mitral paraprosthetic leak Interactive CardioVascular and Thoracic Surgery, December 1, 2008; 7(6): 1131 - 1133. [Abstract] [Full Text] [PDF]

				A. Garcia-Valentin, S. Congiu, J. Mayol, F. Prada, C. Mortera, J.-L. Pomar, and J. M. Caffarena Device migration in hybrid technique for apical muscular ventricular septal defects closure Interactive CardioVascular and Thoracic Surgery, December 1, 2007; 6(6): 780 - 782. [Abstract] [Full Text] [PDF]

				T. Lee, I-C. Tsai, Y.-C. Fu, S.-L. Jan, C.-C. Wang, Y. Chang, and M.-C. Chen MDCT Evaluation After Closure of Atrial Septal Defect with an Amplatzer Septal Occluder Am. J. Roentgenol., May 1, 2007; 188(5): W431 - W439. [Abstract] [Full Text] [PDF]

				V. Costache, O. Chavanon, F. Thony, and D. Blin Aortic arch embolization of an Amplatzer(R) occluder after an atrial septal defect closure: hybrid operative approach without circulatory arrest Eur. J. Cardiothorac. Surg., August 1, 2005; 28(2): 340 - 342. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Nikolaos B. Tsilimingas Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Tsilimingas, N. B. Articles by Hofmann, T. Search for Related Content PubMed PubMed Citation Articles by Tsilimingas, N. B. Articles by Hofmann, T. Related Collections Congenital - acyanotic