Emergency surgical approach to device emboli due to migration of the atrial septal defect occluder

Abstract

Introduction: Atrial septal defect (ASD) transcatheter occlusion techniques are now established as the preferred method and have become an alternative to surgery under extracorporeal circulation. In this study, we aimed to present our emergency surgical approach to cases of device embolization due to migration of the atrial septal defect occluder.

Material and methods: Between June 2009 and June 2011, 6 patients underwent emergency operations due to device emboli secondary to migration of the transcatheter atrial septal defect occluder during the early period. Mean age was 25.5 years (15-45) and 3 of the patients were female (50%). The diagnosis was made via transthoracic echocardiography (TTE) preoperatively.

Results: All of these 6 patients underwent emergency operations. Mean postoperative intensive care unit (ICU) stay was 2.2 days and mean hospital stay was 6 days. No early or late postoperative mortality was seen. Mean postoperative follow-up time was 19.3 months (range: 5-28 months). Early- and late-period TTE examinations showed no residual interatrial shunting. One patient developed a right atrial thrombus in the postoperative 22(nd) month as a complication of long-term follow-up. He was treated with anticoagulant therapy for 6 months with complete resolution at the TTE.

Conclusions: Transcatheter occlusion of secundum type ASD provides prominent clinical improvement, as well as a regression in dimensions of cardiac chambers. Nevertheless, this technique has drawbacks such as distal migration and residual shunts. Consequently, we think that unfavorable anatomy and device diameter are major issues in device migration. Oversizing also increases the migration risk.

Keywords: Amplatzer septal occluder; embolization; migration; secundum type atrial septal defect.

Figure 1

Chest X-ray view of our 3^rd patient showing the embolized device in the pulmonary conus

Figure 2

TTE view of our 4^th patient showing migration of the Amplatzer occluder device into the main pulmonary artery 24 h after its deployment

Figure 3

Perioperative view after median sternotomy showing embolized Amplatzer occluder device within main pulmonary artery

Figure 4

Simultaneous perioperative views of the embolized device after pulmonary arteriotomy and fossa ovalis type secundum ASD after right atriotomy

Figure 5

TTE view of one of our patients showing hypoechoic mobile mass lesion of 30 mm × 16 mm inside the right atrium consistent with thrombus material and successful closure of ASD