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Epidural/Echo/Coagulation

Transmitral occluder device embolization during transcatheter closure of an atrial septal defect: role of transoesophageal echocardiography: 126

Botero, M.; Berson, D.; Thomas, J.

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European Journal of Anaesthesiology: June 2004 - Volume 21 - Issue - p 35-36

Introduction: Transoesophageal echocardiography (TOE) is a reliable imaging technique for guidance of transcatheter closure of secundum-type atrial septal defect (ASD) [1,2]. Embolization of the occluder device to an unreported location, which required emergent surgical intervention is described.

Case Report: A 35 yr old man was admitted to the hospital for elective transcatheter closure of a secundum type ASD. His history was significant for hypertension, intermittent atrial fibrillation and occasional shortness of breath and chest pain. Cardiac catheterization was performed under conscious sedation using intracardiac echocardiography. Except for a 16 mm secundum type defect, normal cardiac anatomy was confirmed and a slightly elevated right ventricular pressure was found. A Qp/Qs of 15:1 was calculated. A 32 mm Amplatzer septal occluder device (AGA Medical, Golden Valley, MN) was prepared. During deployment and release of the device through a 7 Fr sheath, it failed to align parallel to the septum, dislocating towards the left atrium. Several attempts to retrieve the device were unsuccessful. The patient was transferred emergently to the operating room for surgical intervention. General anaesthesia was accomplished with oxygen, isoflurane and fentanyl. Pancuronium was used for muscle relaxation. Intraoperative TOE showed that the occluder device was migrating through the mitral annulus (Figure 1).

Any manipulation of the left side of the heart worsened the mitral inflow obstruction and caused severe hypotension.

Cardiopulmonary bypass (CPB) was instituted rapidly. The device was removed. The ASD was closed. The patient was separated from CPB without difficulty.

Discussion: The Amplatzer septal occluder device consists of a self-expanding double disk made of nitinol wire mesh. A short and thin waist links the two disks which are filled with polyester patches. Although rare, reports of complications with the Amplatzer septal occluder device includes left atrial thrombus, incidental device infection secondary to generalized septicaemia, embolization to the left atrium and right ventricle [3], and cardiac perforation. This to our knowledge is the first reported case of trans-mitral embolization of this device requiring emergent surgical intervention.

References:

1 Salaymeh KJ, Taeed R, Michelfelder EC, et al. Unique echocardiographic features associated with the deployment of the Amplatzer atrial septal defect device. J Am Soc Ecocardiogr 2110; 14: 128-137.
2 Chan KC, Godman MJ, Walsh K, et al. Transcatheter closure of atrial septal defect and interatrial communications with a new self expanding nitinol double disc device (Amplatzer septal occluder): multicentre UK experience. Heart 1999; 82: 300-306.
3 Kapoor MC, Singh S, Sharma S, et al. Embolization of an atrial occluder device. J Cardiothorac Vasc Anesth 2003; 17: 755-763.
© 2004 European Society of Anaesthesiology