Late embolization of atrial septal defect device to abdominal aorta

Case description

A 77-year-old woman with secundum atrial septal defect (ASD) of 12 × 11 mm, with thin and hypermobile superior rim and limited inferior and posterior rims (4–5 mm), underwent successful percutaneous closure using a 14 mm Amplatzer™ Septal Occluder device (Abbot, USA) in 2010, with 6-month dual-antiplatelet therapy. Echocardiographic control 3 and 12 months later showed good results. Unfortunately, she was lost to follow-up after then.

In 2022, she sought medical attention due to new-onset dyspnoea and oedema, which progressively worsened during the last years. Transthoracic echocardiogram (Figure 1A–C) revealed right chamber dilation and migration of the ASD device, with residual left–right shunt and severe pulmonary hypertension. After then, complicating matters, the patient suffered a hip fracture and subsequent haemorrhagic shock.

Figure 1.

(A) Transthoracic echocardiogram of ostium secundum atrial septal defect (white arrow) from a subcostal view. (B) Transthoracic echocardiogram of atrial septal defect from apical four-chamber view. (C) Tricuspid regurgitation showed severe pulmonary hypertension. (D–F) A computed tomography scan confirmed device embolization (white arrow) to the abdominal aorta at the level of the renal arteries.

A computed tomography (CT) scan (Figure 1D–F) confirmed device embolization to the abdominal aorta at the level of the renal arteries, causing moderate stenosis but without restrictive flow. Right heart catheterization confirmed pulmonary hypertension, with systolic and mean pressures measuring 68 and 38 mmHg, respectively. Pulmonary vascular resistances (PVRs) were elevated (9 Wood units), while wedge pressure remained normal.

This complex case was presented in a multidisciplinary session. Considering the patient’s negative decision for open surgery, the unknown time lapse of device embolization, and the associated high morbidity and mortality risks, a non-operative management was chosen. The patient underwent close follow-up with regular imaging tests. The initiation of pulmonary vasodilators resulted in clinical improvement and a decrease in PVR (6 Wood units), with no migration/major stenosis in successive imaging tests up to now.

Atrial septal defect device embolization is rare, occurring in only 0.1–1% of cases.^1,2 It commonly migrates to the left atrium (24.6%), aorta (18.4%), or right ventricle (16.7%), mostly within the first 24 h.² As recommended after ASD closure, regular echocardiographic follow-up should have been performed. Factors contributing to embolization include large defect size, small device, posterior rim absence, or insufficient/thin rims, as in our case.^2,3 Early embolization can often be salvaged through percutaneous intervention, while late embolization usually requires open surgery.^2,3

Consent: The authors confirm that written consent for submission and publication of this case has been obtained from the patient in line with COPE guidance.

Funding: None declared.

Data availability

All data generated or analysed during this study are included in this published article.