Innovations: Technology & Techniques in Cardiothoracic & Vascular Surgery:
Amplatzer Septal Occluder Migration Into the Pulmonary Trunk: Surgical Removal Through a Totally Thoracoscopic Approach
Cresce, Giovanni Domenico MD, PhD; Favaro, Alessandro MD; Auriemma, Stefano MD; Salvador, Loris MD
From the Division of Cardiac Surgery, San Bortolo Hospital, Vicenza, Italy.
Accepted for publication August 3, 2013.
Presented at the Annual Scientific Meeting of the International Society for Minimally Invasive Cardiothoracic Surgery, May 30 – June 2, 2012, Los Angeles, CA USA.
Disclosure: The authors declare no conflicts of interest.
Address correspondence and reprint requests to Giovanni Domenico Cresce, MD, PhD, Division of Cardiac Surgery, San Bortolo Hospital, Viale Rodolfi 37 – Vicenza 36100, Italy. E-mail: email@example.com.
Abstract: The Amplatzer Septal Occluder for transcatheter closure of interatrial communications is a standard procedure and a widely accepted alternative to surgery in most patients with atrial septal defect (ASD). Device dislocation or embolization has been reported as one of the commonest complications of ASD percutaneous closure. In this case, if a transcatheter removal is not possible, it requires a surgical therapy, usually through a median sternotomy. We report on a case of a 30-year-old woman, who underwent percutaneous closure of an ostium secundum ASD. After a late embolization of the Amplatzer Septal Occluder into the pulmonary trunk 10 months later, the implant was successfully obtained via a surgical removal through a video-guided minimally invasive port-access approach. This case shows that, in experienced hands, the port-access technique for surgical procedures on the pulmonary trunk is feasible, and therefore, it might be a good alternative option to the traditional surgery, mainly in young patients.
The Amplatzer Septal Occluder (ASO; AGA Medical Corporation, Plymouth, MN USA) has been in clinical use since 1999,1 and nowadays, it is a standard procedure and a widely accepted alternative to surgery in most patients with atrial septal defect (ASD). Nevertheless, the increasing number of devices placed results in an increasing number of reported adverse events. Device dislocation or embolization has been reported as one of the commonest complications of ASD percutaneous closure.2 When a transcatheter removal is not possible, it requires a surgical therapy. Usually, the surgical removal is done with the aid of the cardiopulmonary bypass and through a full sternotomy. We report on a case of an ASO late embolization into the pulmonary trunk 10 months after the implant and the successful surgical removal through a minimally invasive video-guided port-access approach.
An ostium secundum type ASD was percutaneously closed with an ASO implant in a 30-year-old woman. The procedure was uneventful, and the predischarge echocardiography confirmed the correct position of the device. Ten months later, a transthoracic echocardiography showed the migration of the device into the pulmonary trunk. Transesophageal echocardiography confirmed the position of the device into the main pulmonary artery (Fig. 1). An angiography was performed, clearly showing the presence of the ASO into the pulmonary artery (Fig. 2). The transcatheter removal was not possible. Several attempts to retrieve the device angiographically failed, and the patient was then referred to our cardiac surgery unit. At our institution, port-access technique is routinely used for all patients undergoing mitral and tricuspid valve surgery, so we adopted this technique to remove the ASO. After a 5-cm right submammary incision, the fourth intercostal space was entered and the pericardium was opened. Cardiopulmonary bypass was established through the direct cannulation of the left femoral artery and percutaneous cannulation of the right femoral and jugular vein. The aorta was directly cross-clamped with a flexible transthoracic clamp (Cygnet; Novare Surgical System Inc, Cupertino, CA USA), and the heart was then arrested with antegrade cold crystalloid cardioplegia. A 5-mm 30-degree lens thoracoscope was introduced into the third intercostal space. A right atriotomy was performed, and the ASD was found and directly closed with a Prolene 4-0 suture. Videoscopy was extremely useful to reach the pulmonary trunk, and a transverse arteriotomy was carried out. The ASO was carefully removed, detaching the device from organized endothelial adhesions (Fig. 3). The pulmonary trunk was finally sutured. The operation was then concluded in the appropriate manner (Fig. 4).
The aortic cross-clamp and the cardiopulmonary bypass time were 51 and 61 minutes, respectively. The postoperative course was uneventful. The patient was discharged from the intensive care unit on the first postoperative day and from the hospital on the fifth postoperative day in good clinical condition.
Percutaneous transcatheter closure of ASDs is currently the standard care. It avoids open-heart surgery and its associated complications and the unavoidable scar. Many published series have shown that it is a very effective procedure because of its high success rate and low incidence of complications. However, although complications after transcatheter interventions are not frequent, they may often require a surgical evaluation and management. Once a complication leads to surgery, the mortality is significantly higher than that of primary surgery ASD closure.3 The ASO embolized into the pulmonary artery should be removed as soon as possible, to avoid the risk for adherence and endothelialization, which increase technical difficulty of removal later. The surgical retrieval is usually performed through a median sternotomy. In this report, we opted for a less invasive port-access technique, starting from our extensive experience and after the request for a minimally invasive approach by the patient. To the best of our knowledge, only one similar, but not identical, case has been previously published.4 In that case, the ascending aorta was occluded with an endoaortic balloon. After the closure of the ASD, they removed the endoaortic clamp and continued the operation on the beating heart, and they retracted the aorta to the right to reach the pulmonary trunk more easily. Our technique was quite different. We used a flexible transthoracic clamp, introduced through the same minithoracotomy incision. The Cygnet clamp is a malleable clamp, and it was not in the way during surgery. Indeed, unlike the intra-aortic occlusion, it was very convenient to manipulate the aorta during the maneuvers to expose the pulmonary artery. After the ASD closure, we were able to continue the operation under cardioplegic arrest, and we were still able to reach the pulmonary trunk and to remove the device. The videothoracoscopic approach was essential to see and to perform the operation. The 5-mm 30-degree telescope allowed great visibility and the ability to reach areas difficult to access with a 0-degree telescope.
Relative contraindications for this minimally invasive approach in patients with a migrated ASO into the pulmonary trunk are the same as those for “port-access” procedure in general, including inability to obtain peripheral artery cannulation, need for concomitant coronary procedures, and severe aortic valve insufficiency. Pleural scarring and obesity may complicate surgical approach. Patients with an aortic aneurysm should not be considered for this approach. In our opinion, the only absolute contraindication to this minimally invasive approach is the lack of extensive experience in totally video-guided cardiac surgery.
In conclusion, port-access technique is a well-accepted option and improves surgical results and patients’ satisfaction and quality of life. We believe that eliminating the need for median sternotomy greatly reduces the trauma and pain associated with open-chest surgery and improves quality of life for patients; for that reason, we adopted this technique for all patients undergoing mitral and tricuspid surgery. This case shows that, in experienced hands, the port-access technique for surgical procedures on the pulmonary trunk is feasible and may be a good alternative option to the traditional surgery, mainly in young patients.
1. Berger F, Ewert P, Björnstad PG, et al. Transcatheter closure as standard treatment for most interatrial defects: experience in 200 patients treated with the Amplatzer Septal Occluder. Cardiol Young
. 1999; 9: 468–473.
2. Chessa M, Carminati M, Butera G, et al. Early and late complications associated with transcatheter occlusion of secundum atrial septal defect. J Am Coll Cardiol
. 2002; 39: 1061–1065.
3. Sarris GE, Kirvassilis G, Zavaropoulos P, et al. Surgery for complications of trans-catheter closure of atrial septal defects: a multi-institutional study from the European Congenital Heart Surgeons Association. Eur J Cardiothorac Surg
. 2010; 37: 1285–1290.
4. De Decker C, Hamerlijnck R, Goosens D, Pletinckx P. Surgical removal of an atrial septal defect closure device embolized into the pulmonary trunk by port access technique. Ann Thorac Surg
. 2008; 85: 672–674.
Port-access technique; Amplatzer Septal Occluder embolization; Pulmonary artery; Atrial septal defect
©2013 by the International Society for Minimally Invasive Cardiothoracic Surgery
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