Extracardial Migration of an Atrial Septal Defect Occluder Device

ABSTRACT: Several complications have been reported regarding the percutaneous closure of secondary atrial septal defects such as erosion, thromboembolic events, arrhythmias, and endocarditis. In this report, we describe the case of a 75-year-old woman who underwent percutaneous closure of a secondary atrial septal defect with a 12 mm Amplatzer septal occluder. Six months after the uneventful implantation of the device, we manifested an asymptomatic late embolization of the device in the abdominal aorta. The device was surgically retrieved.

J INVASIVE CARDIOL 2013;25(12):E219-E220

Key words: Amplatzer septal occluder, atrial septal defect, complication, embolization

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Atrial septal defect (ASD), which accounts for 8%-10% of congenital heart diseases, reflects the most common type in adults. Percutaneous transfemoral septal closure is the contemporary alternative to surgical closure.¹ Over the last years, device closure of ASD has proven to be safe and effective.^2,3 However, many complications have been reported, such as erosion, thromboembolic events, arrhythmias, and endocarditis. The most common type of complication is peri-interventional benign atrial arrhythmia.⁴ Embolic events occur mainly in the early postinterventional period.⁵ We present the case of a late embolization of the Amplatzer occluder in the abdominal aorta 6 months after device implantation.

Case Report. A 75-year-old Caucasian woman suffered a cerebrovascular accident (CVA) about 1 year prior to admission at our clinic. The diagnostic process revealed an ASD as the possible cause of the CVA. The ASD was treated with percutaneous closure with a 12 mm Amplatzer septal occluder. Transesophageal echocardiography (TEE) was performed after device implantation and confirmed the correct placement of the device.

Six months later, control TEE demonstrated a persistent ASD; therefore, we proceeded to an angiography, which showed the ASD occluder device within the abdominal aorta, at the junction of the renal arteries and superior mesenteric artery (Figure 1). In an effort to rescue the occluder, we managed to mobilize it up to the aorta bifurcation. At that point, we dissected the right arteria iliaca communis. Due to our ineffective attempt to rescue the occluder, we decided to proceed to surgical removal.

The device was removed via transabdominal surgery (Figure 2) under radioscopic control and an aortoiliac patch was applied. A patch plastic was performed in the place of the dissection, and digital subtraction angiography showed no further dissections. Post-operative recovery was uneventful. The patient was discharged on postoperative day 7, and has done well ever since. Warfarin was used for prevention of further cerebrovascular events.

Discussion. Transcatheter closure of ASD is an established treatment option in both children and adults. After the introduction of the Amplatzer septal occluder in 1997, larger defects became interventionally accessible compared to the patch plastic system. Many complications have been described, such as endocarditis, retroperitoneal bleeding, air embolism, several types of arrythmia, and embolic phenomena, with the vast majority of them occurring in the early postinterventional period. The most common place of embolization is the pulmonary artery.⁶ Ficher et al⁵ describe one episode of late embolism in 25,000 Amplatzer implantations, and therefore, suggest life-time post-interventional follow-up after device implantation. Yiqiang et al,⁷ in a series of 61 patients, describe temporary non-specific symptoms such as chest discomfort in the early postinterventional period. Severe complications such as embolism did not occur within the 5 years of follow-up.

References

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7. 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(4):496- 502.

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From ¹the Department of Surgery, Mannheim University Medical Centre, University of Heidelberg, Germany, and ²the Department of Medicine I, Mannheim University Medical Centre, University of Heidelberg, Germany.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

Manuscript submitted June 7, 2013, provisional acceptance given June 17, 2013, final version accepted July 9, 2013.

Address for correspondence: Kai Nowak, MD, Department of Surgery, Mannheim University Medical Centre, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany. Email: kai.nowak@umm.de