Ann Thorac Surg 2008;85:319-321. doi:10.1016/j.athoracsur.2007.03.043
© 2008 The Society of Thoracic Surgeons
Case Reports
Emergent Surgical Retrieval of Embolized Atrial Septal Defect Closure Device
Christopher J. Knott-Craig, MDa,*,
Steven P. Goldberg, MDb
a Department of Thoracic and Cardiovascular Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
b Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Alabama
Accepted for publication March 15, 2007.
* Address correspondence to Dr Knott-Craig, University of Alabama at Birmingham, 716 Ziegler Research Building, 703 19th St S, Birmingham, AL 35294 (Email: ckc{at}uab.edu).
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Abstract
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We present a case of an atrial septal defect closure device that embolized to the aortic valve and left main coronary artery ostium, which required emergent surgical retrieval in an unstable child.
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Introduction
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Since the catheter-based device closure era of atrial septal defects (ASDs) began in 1976, the results have been overwhelmingly favorable, with some authors reporting success rates in the 94% range [1]. However, there have been numerous reports of significant complications, including cardiac perforation, fistula formation [2], thrombosis [1], and device dislodgement both to the systemic [3] and pulmonary circulation [4, 5]. These have resulted in varying symptoms and degrees of hemodynamic compromise, most requiring surgical retrieval. This is in contrast to surgical closure, which in the current era carries a risk of significant complications of <1% [6]. We report a case of an ASD closure device with profound circulatory collapse due to compromise of the left ventricular outflow tract and the ostium of the left main coronary artery. We believe that this has not been previously described.
At 3 years, 11 months of age, a girl weighing 16 kg was taken to the interventional cardiology suite at Children’s Hospital of Oklahoma for multiple procedures, including coil embolization of a patent ductus arteriosus and closure of a secundum ASD with an Amplatzer septal occlusion device (AGA Medical, Golden Valley, MN). The atrial septal defect was measured with a balloon and estimated to be 14 to 15 mm. Unstretched, the defect was believed to be 10 x 5 mm in size. After unsuccessfully deploying both a 14-mm Amplatzer device (AGA Medical) and an 8-mm device, a 10-mm device was successfully deployed. The ductus was then occluded with a 4 cm x 3 mm standard coil. Transesophageal echocardiography and aortography confirmed success. The patient initially tolerated the procedure well and was convalescing comfortably in a regular ward with clinical evidence of good overall perfusion. At 3:00 AM the following morning after the procedure, the patient abruptly complained of respiratory difficulty. A chest roentgenogram was obtained, which demonstrated pulmonary edema. When two doses of furosemide failed to reverse her respiratory distress, an immediate echocardiogram was obtained, demonstrating the ASD closure device had embolized to the left ventricular outflow tract, obstructing the aortic valve. She was then rapidly taken to the operating room in critical condition.
The patient was taken emergently to the operating room, becoming critically hypotensive and hypoxemic during anesthetic induction. Her cardiopulmonary embarrassment was temporized with hand-bagged ventilation and changing her position on the operating table. Emergent sternotomy was performed, and cardiopulmonary bypass was initiated with bi-caval cannulation. The hematocrit was maintained above 32, and the patient was cooled to 30°C. Intraoperative transesophageal echocardiography demonstrated obstruction of the left ventricular outflow tract by the device, along with moderate aortic and mitral incompetence. Ventricular function was severely depressed, suggesting obstruction to coronary flow as well. The aorta was clamped and the heart was arrested with antegrade cardioplegia. The right atrium was opened, and we encountered a 13-mm secundum ASD, but no ASD device could be visualized either in the atria or the left ventricle through the ASD and mitral valve. Therefore the ascending aorta was opened. The device was then readily apparent, lodged within the aortic valve orifice, and clearly occluding the left main coronary artery orifice (Fig 1). The device was removed and the aorta was closed in a standard fashion. The ASD was closed with a patch through the right atrium. The patient was weaned from cardiopulmonary bypass without difficulty. By transesophageal echocardiography, both aortic and mitral valves were now competent, the left ventricular outflow tract was patent, and the right ventricular function was normal. The left ventricular function (although still somewhat diminished) had dramatically improved function from the preoperative state. The patient recovered uneventfully from the surgery and was discharged home on postoperative day 4. There was no neurologic deficit noted.
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Comment
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Complications related to, or outright failures of, catheter-based ASD closure devices are reportedly few, and for many cardiologists, percutaneous device closures of ASDs are standard treatment. This is in contrast to minimally invasive surgical closure, which in most institutions carries a negligible risk. Agarwal and colleagues [7] enumerated a number of reported complications dating back to the original implementation of ASD closure devices 30 years ago. These included residual shunts, device malposition (possibly related to device-size mismatch), caval thrombosis, systemic and pulmonary embolism, tearing of the ASD rim itself, and perforation of the heart. Although many of these were able to be corrected through other interventional means, others required urgent surgery, and were not free of long-term complications such as stroke or dysrhythmias. Patterns of failure also depend, in part, on the mechanical structure of the device itself. When the ASD is closed, the cardiac chambers usually return to normal dimensions, and this places the atrial free walls in closer apposition to the device halves. In a situation in which a device is oversized, the rocking motion of the cardiac contraction can lead to erosion of the device through the roof of the left atrium. This can result in hemopericardium and tamponade, which may occur many months or years after the device has been placed [8]. The company that produces the Amplatzer device (AGA Medical) reported in 37 cases of hemodynamic compromise from device erosion January 2006, with an incidence of 0.11% worldwide [9]. Intracameral fistula formation, which has been reported to occur between the aorta and either of the atriums, has also recently been reported more frequently [2]. We have presented a case of systemic embolization of an ASD device into the aortic valve annulus that occurred some 12 hours after its initial deployment. Had this patient been discharged from the hospital, she would almost certainly have died. In our case, the clinical situation of respiratory distress and profound decrement in ventricular function resulted in an emergency operation in an unstable child, underscoring that while less invasive procedures are rather seductive in their perceived freedom from the morbidity and mortality of open heart surgery, they do carry a recognizable risk of serious adverse events. These potentially life-threatening complications need to be weighed against the perceived advantage of a nonsurgical, outpatient procedure when counseling the patient and family regarding the alternative of minimally invasive surgical closure, which probably carries less overall risk and is less expensive.
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References
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- Bohm J, Bittigau, Köhler F, et al. Surgical removal of atrial septal defect occlusion system-devices Eur J Cardiothorac Surg 1997;12:869-872.[Abstract]
- Amin Z, Hijazi ZM, Bass JL, Cheatham JP, Hellenbrand WE, Kleinman CS. Erosion of Amplatzer septal occluder device after closure of secundum atrial septal defects: review of registry of complications and recommendations to minimize future risk Catheter Cardiovasc Interv 2004;63:496-502.[Medline]
- Verma PK, Thingnam SK, Sharma A, Teneja JS, Varma JS, Grover A. Delayed embolization of Amplatzer septal occluder device: an unknown entity—a case report Angiology 2003;54:115-118.[Medline]
- Mashman WE, King SB, Jacobs WC, Ballard WL. Two cases of late embolization of Amplatzer septal occluder devices to the pulmonary artery following closure of secundum atrial septal defects Catheter Cardiovasc Interv 2005;65:588-592.[Medline]
- Contrafouris CA, Chatzis AC, Giannopoulos NM, et al. Emergency surgical intervention for runaway atrial septal defect closure devices: a word of caution J Thorac Cardiovasc Surg 2006;132:1234-1235.[Free Full Text]
- Turrentine MW. Atrial septal defectsIn: Yang SC, Cameron DE, editors. Current therapy in thoracic and cardiovascular surgery. Philadelphia, PA: Mosby, Inc; 2004. pp. 731-737.
- Agarwal SK, Ghosh PK, Mittal PK. Failure of devices used for closure of atrial septal defects: Mechanisms and management J Thorac Cardiovasc Surg 1996;112:21-26.[Abstract/Free Full Text]
- Preventza O, Sampath-Kumar S, Wasnick J, Gold JP. Late cardiac perforation following transcatheter atrial septal defect closure Ann Thorac Surg 2004;77:1435-1437.[Abstract/Free Full Text]
- Hanzel GS. Complications of patent formaen ovale and atrial septal defect closure devices J Interven Cardiol 2006;19:160-162.[Medline]
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Abstract
Introduction
