Prevention of Embolization of a Displaced Atrial Septal Occluder

A 63-year-old man was admitted for elective percutaneous closure of a secundum atrial septal defect (ASD) with a large left-to-right shunt. A 34-mm Amplatzer septal occluder (AGA Medical Corporation; Golden Valley, Minn) was used. The procedure was performed with the patient under general anesthesia, with use of endotracheal intubation and percutaneous entry of the femoral vein. Once the device had been deployed and released under combined fluoroscopic and transesophageal echocardiographic guidance, acute displacement of the occluder on the left side of the interatrial septum occurred. Attempts to retrieve the device percutaneously were unsuccessful. A bioptome was then introduced into the right atrium through the same femoral approach and was used to temporarily grasp the device in order to prevent its embolization. The patient was then rushed to surgery where, on moderately hypothermic cardiopulmonary bypass with aortic cross-clamping, the right atrium was opened, the device was retrieved, and the defect was closed with a patch of autologous pericardium (Fig. 1). The postoperative course was uneventful.

Fig. 1 A) Intraoperative view through a right atriotomy showing the atrial septal defect and the displaced septal occluder (asterisk), which was grasped with a bioptome (arrowhead) temporarily to prevent migration. B) The explanted atrial septal occluder.

A.S. = atrial septum

Device embolization is a recognized complication of percutaneous transcatheter ASD closure. In a large series, this problem was reported to occur in 1.1% of the procedures, requiring surgical removal in 0.2% of all cases. ¹ In our patient, after acute displacement of an ASD occluder occurred, we used a bioptome to prevent device embolization before surgical intervention.