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J Thorac Cardiovasc Surg 2006;132:1234-1235
© 2006 The American Association for Thoracic Surgery

Brief Communication

Emergency surgical intervention for runaway atrial septal defect closure devices: A word of caution

Constantinos A. Contrafouris, MD*, Andrew C. Chatzis, MD, Nicolas M. Giannopoulos, MD, Michael Milonakis, MD, Theofili Kousi, MD, George Kirvassilis, MD, George E. Sarris, MD

Department of Pediatric and Congenital Heart Surgery, Onassis Cardiac Surgery Center, Athens, Greece.

Received for publication May 19, 2006; accepted for publication May 30, 2006.

* Address for reprints: Constantinos A. Contrafouris, MD, Department of Pediatric and Congenital Heart Surgery, Onassis Cardiac Surgery Center, 356 Sygrou Ave, 17674 Kallithea, Athens, Greece. (Email: ccontraf{at}panafonet.gr).

The use of occluder devices is gaining increasing popularity for the closure of secundum atrial septal defects (ASD).1-3Go It is possible, however, that during its release from the introducing catheter, it will become misplaced or even embolize further and therefore require urgent surgical retrieval. We report 2 cases of attempted percutaneous transcatheter ASD closure complicated by embolization necessitating emergency surgical intervention.

Clinical Summary

Patient 1
An asymptomatic 24-year-old woman with an ASD underwent transesophageal echocardiography, which showed a 17- to 19-mm-diameter ASD, and transvenous closure was attempted. A 43-mm Starflex device (NMT Medical, Inc., Boston, Mass) was implanted and seemed in good position. During extubation, the patient experienced an episode of ventricular tachycardia. Repeat transesophageal echocardiography showed translocation of the device and embolization into the right pulmonary artery. Transcatheter retrieval was unsuccessful (Figure 1). At emergency operation, the device was identified and retrieved through the right pulmonary artery through a transverse main pulmonary arteriotomy. The ASD was closed with direct sutures through a right atriotomy. The patient recovered without complications and remains well 6 years later.


Figure 1
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  		Figure 1. The Starflex device in the right pulmonary artery.

 
Patient 2
An asymptomatic 11-year-old boy was found to have a large (2.5 x 2 cm) ASD on transthoracic echocardiography. Transesophageal echocardiography was not performed. Transcatheter closure was attempted, and a 40-mm Amplatzer device (AGA Medical Corp., Golden Valley, Minn) was implanted. After the device was released, it slipped entirely into the left atrium, protruding into the mitral orifice. Retrieval efforts fraught with the risk of mitral disruption or occlusion were unsuccessful. At emergency operation, the ASD was found with no shelf at the inferior margin. The device, covered with recent red thrombus, had embolized entirely into the left atrium, lying on the anterior mitral valve leaflet protruding into its orifice and orientated toward the left atrial appendage (Figure 2). Through the ASD, the device was retrieved without injury to the mitral valve, and the defect was closed with autologous pericardium. The patient had an uneventful recovery and was discharged a week later. He remains well at 1-year follow-up.


Figure 2
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  		Figure 2. The Amplatzer device in the left atrium. LAA, Left atrial appendage; IVC, inferior vena cava.

 
Discussion

Transcatheter occlusion techniques have become an increasingly used alternative to surgical closure of the ASD, and various devices are available for this.1-3Go Comparison of transcatheter and surgical closure of secundum ASD in children and adults reveals a lower complication rate in the device closure group.3,4Go Moreover, in patients experiencing unsatisfactory device position, retrieval is usually feasible at the time of implantation, followed by elective surgical closure. If embolization (for which transcatheter retrieval is unsuccessful) occurs, urgent surgical therapy is necessary.2,3,5Go

The most important reason for acute failure of these devices is poor patient selection, device selection, or both.1,5Go Other suggested mechanisms are device-related failure, inadequate experience,2,5Go poor defect rim to hold the device,1-3Go and tearing of the interatrial septum caused by catheter and device manipulation.2,5Go A part or the entire device might embolize to the right or left atrium, main pulmonary artery, or even to other parts of the vascular tree on both the right and left sides of the circulation. Once the device is detached from its cable, it becomes difficult to retrieve, and depending on its location, it might even become lethal.

Although transcatheter devices represent useful alternatives to surgical closure in selected cases, they can be associated with failures and, most importantly, with life-threatening complications. Thus proper selection of patient and device is mandatory. Close monitoring and facilities for emergency surgical intervention should be available for all patients.

References

  1. Berger F, Vogel M, Alexi-Meskishvili V, Lange P. Comparison of results and complications of surgical and Amplatzer device closure of atrial septal defects. J Thorac Cardiovasc Surg 1999;118:674-680.[Abstract/Free Full Text]
  2. Chessa M, Carminatti M, Butera G, Binni RM, Drago M, Rosti L, et al. Early and late complications associated with transcatheter occlusion of atrial septal defect. J Am Coll Cardiol 2002;39:1061-1065.[Abstract/Free Full Text]
  3. Thomson J, Aburawi E, Watterson K, Van Doorn C, Gibbs J. Surgical and transcatheter (Amplatzer) closure of atrial septal defects: a prospective comparison of results and cost. Heart 2002;87:466-469.[Abstract/Free Full Text]
  4. Du Zhong-Dong, Hijazzi Z, Kleinman C, Silverman N, Larntz K. Comparison between transcatheter and surgical closure of secundum atrial septal defect in children and adults. J Am Coll Cardiol 2002;39:1836-1844.[Abstract/Free Full Text]
  5. Agarwal SK, Ghosh P, Mittal P. 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]



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