Eur J Cardiothorac Surg 2005;28:340-342
© 2005 Elsevier Science NL
Aortic arch embolization of an Amplatzer® occluder after an atrial septal defect closure: hybrid operative approach without circulatory arrest
Victor Costache
a
,
Olivier Chavanon
a
,
*
,
Frédéric Thony
b
,
Dominique Blin
a
a Department of Cardiac Surgery, Grenoble University Hospital, BP 217 Grenoble cedex 9, France
b Department of Interventional Radiology, Grenoble University Hospital, BP 217 Grenoble cedex 9, France
Received 28 January 2005;
received in revised form 19 April 2005;
accepted 20 April 2005.
* Corresponding author. Tel.: +33 4 76 76 54 62; fax: +33 4 76 76 52 64. (Email: ochavanon{at}chu-grenoble.fr).
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Abstract
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Percutaneous closure of the secundum type atrial septal defects is becoming increasingly popular. We report the case of a 49-year-old man who presented for an unusual embolization of an Amplatzer® occluder (AO) 6 weeks after a percutaneous closure of his secundum type atrial septal defect. Emergency cardiac surgery was performed and the device was safely removed by a combined surgical and endovascular approach with no need of circulatory arrest or of profound hypothermia.
Key Words: Amplatzer® occluder • Aortic arch • Embolization • Atrial septal defect
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1. Introduction
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Percutaneous closure of secundum atrial septal defect (ASD) has become a widely accepted option to the surgical repair. Several devices have been designed for this purpose like the clamshell septal occluder, the Sideris prosthesis, the Amplatzer® occluder (AO), the Das Angel Wing and the Pavcnik monodisk. The AO has overcome the drawbacks of its predecessors and has become the device of choice for many cardiologists because of its good hemodynamic properties and high success rate. However, several complications have been reported: cardiac arrhythmias, device embolism, thrombus formation. One of the most common complications seems to be device or marker band migration, a radio-opaque component of the device. Its degree of gravity varies, depending on the site of embolization, requiring percutaneous or sometimes surgical removal. We report the case of a secondary migration of an Amplatzer® occluder in the aortic arch, successfully removed through a combined surgical and radiological approach.
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2. Case report
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A 49-year-old patient consulted his general practitioner for a history of two transient ischemic attacks, progressive exercise intolerance and palpitations. A secundum type atrial defect was diagnosed clinically and by transthoracic echocardiography and the patient was referred to our institution for transcatheter closure with an Amplatzer® septal occluder device (AGA Medical Corporation, Golden Valley, MN). The procedure was uneventful; after balloon sizing under fluoroscopic and transesophageal echocardiographic control, a 24mm device was carefully placed with no residual shunt. The patient was discharged the following day and he remained well thereafter.
Surprisingly, the chest X-ray (Fig. 1
) and the echocardiographic control performed at 6-week follow-up showed the embolization of the Amplatzer® at the level of the aortic arch, between the innominate and the left common carotid arteries. The patient was referred for emergency surgery, being completely asymptomatic. At operation, the aorta, the superior and the inferior vena cava were canulated as for a standard ASD repair, and a transesophageal echocardiography probe was used throughout the procedure. The AO was easily localized, but fluoroscopy and transesophageal echographic control revealed a secondary migration of the device from the proximal part of the aortic arch as seen on the chest X-ray, towards its distal segment. Aortic clamping was thus possible as usual, but, in order to avoid a more invasive procedure on the aortic arch and on the cerebral vessels, we decided to remove the Amplatzer® using an endovascular forceps, placed over a guidewire in the proximal segment of the ascending aorta after the atrial septal defect closure. After aortic clamping with combined antegrade and retrograde cardioplegia, the septal defect was repaired with a running suture through a right atrial approach. After declamping the aorta, the ascending aorta was punctured with the introducer, the guidewire was carefully placed under fluoroscopy and the AO was grasped with an endovascular retrieving forceps (Cook-William Cook Europe, DK-4632 Bjaeverskov, Denmark) and pulled from its impaction site to the ascending aorta. The aorta was briefly clamped with no additional cardioplegia and we performed a vertical aortotomy to extract the AO in one piece. The entire surface of the AO was completely thrombosed (Fig. 2
). The aortotomy was closed and the aorta declamped. This procedure was fast and straightforward (about 6min). The entire operation was performed under mild hypothermia at 34°C; there was no circulatory arrest.
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Fig. 1. Postero-anterior (a) and lateral (b) chest X-ray revealing the embolization of the Amplatzer® occluder at the level of the proximal aortic arch (arrow).
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Fig. 2. AO removed by endovascular forceps, with thrombus inside (arrow). The metal wire on top is the retrieving tip of the endovascular forceps.
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The patient spent 19h in the intensive care unit and was discharged home on the eighth postoperative day. He was secondarily treated for a mild pericardial effusion and for atrial flutter. The pericardial effusion completely resolved with steroids, whereas radiofrequency ablation was successfully performed for atrial flutter 3 months after cardiac surgery. The patient was well at 4-month follow-up; transthoracic echocardiography showing complete closure of the septal defect with no residual shunting.
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3. Discussion
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Here, we describe a case of an unusual Amplatzer® embolization following a percutaneous closure of a secundum type ASD.
ASD is a common cardiac condition, accounting for approximately 10% of all congenital heart defects. More than three decades after the first non-surgical closure of a congenital heart defect (Patent ductus arteriosus by Portsman and ASD by King and Mills) [1,2], percutaneous closure has become a well-established alternative to surgical closure. Various devices have been developed for the purpose, the Amplatzer® being the occluder of choice for many cardiologists. The US pivotal study that resulted in the approval of the Amplatzer® device by the FDA proved that patients who underwent surgical closure had 24% incidence of minor and major complications vs. only 7.2% in the group undergoing percutaneous closure [3]. Device or marker band embolism is a major complication reported to occur in 1.4% of the subjects from the percutaneous closure group; however, only 0.4% required surgical removal [3]. Such complications appear to occur when the surrounding tissue rim is missing and when the defect is wide as it was the case of our patient. Indeed, in the literature most of the migrating devices are 24mm or larger or occur at the beginning of the operator's learning curve [3,4]. Embolization occurs, first of all, in the pulmonary circulation; systemic embolization is a rare but feared complication. In a recent review of 258 Amplatzer® closure for atrial septal defects, four devices migrated after implantation; one (a 24mm device) being removed from the left leg a year after the closure [5]. Intriguingly, the same study [5] reported the sudden death of a 29-year-old patient, 1.5 years after the percutaneous closure of his septal defect with an Amplatzer® occluder. In a recent case report, another systemic embolism of a 24mm Amplatzer® device was reported at the level of the aortic arch [6].
This later case report is similar to ours in terms of device embolization and clinical presentation, both patients being still asymptomatic. However, we have chosen a different approach in the removal of the displaced device. Instead of performing a dissection of the head vessels and incising the aortic arch under deep hypothermia and circulatory arrest, we preferred to use an endovascular forceps and remove the occluder under fluoroscopic control through a small arteriotomy at the level of the ascending aorta. Our choice was motivated especially by the intraoperative finding of the secondary migration of the AO towards the distal part of the aortic arch. We believe that combining cardiac surgery with endovascular techniques is a simple and efficient method of retrieving a device dislocated at the level of the aortic arch.
As clinical experience with the Amplatzer® Septal Occluder increases, every such unusual complication should be reported. Strategies should be presented in order to prepare the medical community for accurate management of such rare but potentially lethal complications.
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References
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- Porstmann W, Wierny L, Warnke H, Gerstberger G, Romaniuk P. Catheter closure of patent ductus arteriosus. 62 cases treated without thoracotomy. Radiol Clin North Am 1971;9:203-218.[Medline]
- King T, Mills N. Nonoperative closure of atrial septal defects. Surgery 1974;75:383-388.[Medline]
- Du Z, Hijazi Z, Kleinman C, Silverman N, Larntz K. Comparison between transcatheter and surgical closure of secundum atrial septal defect in children and adults: results of a multicenter nonrandomized trial. J Am Coll Cardiol 2002;39:1836-1844.[Abstract/Free Full Text]
- Hijazi Z, Cao Q, Patel H, Rhodes J, Hanlon K. Transesophageal echocardiographic results of catheter closure of atrial septal defect in children and adults using the Amplatzer® device. Am J Cardiol 2000;85:1387-1390.[CrossRef][Medline]
- Chessa M, Carminati M, Butera G, Bini R, Drago M, Rosti L, Giamberti A, Pome G, Bossone E, Frigiola A. Early and late complications associated with transcatheter occlusion of secundum atrial septal defect. J Am Coll Cardiol 2002;39:1061-1065.[Abstract/Free Full Text]
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Abstract
1. Introduction
