Atrial septal defect transcatheter occlusion techniques have become an alternative to surgical procedures. With the increasing use of this new technology, several complications have been identified. The authors present the case of a patient who was admitted to the hospital for primary percutaneous closure of a secundum atrial septal defect. On routine follow-up examination 24 hours after implantation, transthoracic echocardiography revealed a partial dislocation of the occluder into the right atrium. The patient was referred for cardiosurgical treatment. Strict selection criteria and the choice of the device may help reduce the incidence of complications such as dislocation of the occluder into the right atrium following the percutaneous device closure of an atrial septal defect.
Case Presentation
A 26-year-old woman presented with a 12-month history of declining exercise capacity (New York Heart Association class II). Two-dimensional transthoracic echocardiography showed the right ventricle as well as right atrium enlargement. Transthoracic echocardiography also revealed a large perforated atrial septal aneurysm (atrial septal defect [ASD] type II) and associated left-to-right shunt (Qp/Qs = 2:1). The aneurysmal basal width was 32 mm. Two-dimensional transesophageal echocardiography demonstrated the presence of an ASD with a total defect size of 32 × 15 mm, hypermobility of the posterior rim defect with a largest diameter of 19 mm (native), as well as a deficient aortic rim (3 mm).
The patient underwent uneventful device closure using an Amplatzer septal occluder (AGA Medical Corporation, Golden Valley, MN) under transesophageal echocardiographic guidance. A 38-mm device was successfully placed with good final results, demonstrating a well-seated device with no transesophageal echocardiographic evidence of residual shunting. At 24-hour follow-up, transthoracic echocardiography revealed a partial dislocation of the occluder into the right atrium, with a large left-to-right shunt ( Figure 1 , Video 1 ). Transesophageal echocardiography showed the device attached to the area of the posterior margin, with the rest of the device hanging loosely ( Figure 2 , Video 2 ). At surgery, the occluder was removed without any difficulties, and a pericardial patch was sutured into the defect. Intraoperative echocardiography confirmed the complete closure of the defect.
Discussion
Device dislocation is a rare and serious complication of the percutaneous closure of an ASD, and it is a common reason for surgical intervention. In the literature, device dislocation and embolism are the most frequently reported complications of transcatheter closure, with rates ranging from 4% to 21% and surgery being necessary in approximately 70% to 100% of those cases. Precise anatomic evaluation of the septum is the most important element in careful qualification of patients for device implantation. Clinically, a deficient aortic rim is considered a potential cause of device migration, but the presence of a thin or deficient aortic rim (<5 mm) superiorly has been reported not to be a contraindication to successful closure. Additionally, septal aneurysm with large defect as well as atrial septal hypermobility may be implicated as causes of the unsuccessful transcatheter device closure of an ASD. The grossly oversized occluder could also have led to erosion of this rim (device-defect mismatch). In our patient, the device dislocated possibly because of a combination of several factors: an inadequate aortic rim, an oversized device, inadequate sizing of the defect, or incorrect device placement.
Strict selection criteria governing an adequate aortic rim may help reduce the incidence of complications such as the rare but potentially fatal embolization of the device into the pulmonary artery. An accurate assessment of the morphology of the defects and the tissue rims can reduce early severe complications of transcatheter closure. Information from other imaging modalities, such as real-time three-dimensional transesophageal echocardiography, about the nature of defects and dynamic changes in the defect area may be helpful in achieving a better selection of patients for specific treatment.
Supplementary Data
Transthoracic echocardiography, 4-chamber view. Dislocation of the Amplatzer septal occluder to the right atrium.
Video 2Transesophageal echocardiography. Dislocation of the Amplatzer septal occluder to the right atrium with significant left-to-right shunt.
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