Surgical Retrieval of Atrial Septal Occluder Device after Late Embolization in Right Ventricle

Atrial septal defect (ASD) is the fourth most common congenital heart disease in the world. It was treated with surgical closure with the help of CPB in the earlier days. Now there are two approaches available, open surgery under CPB and transcatheter closure. Here we are going to present late complication of transcatheter closure of ASD.


Introduction
Atrial septal defects (ASDs) are one of the most common congenital heart defects, with a prevalence estimated to affect 100 of 100,000 live births [1].Ostium secundum (OS) defect is the most common type of ASD accounting for 75% of all ASD cases, and 7% of all congenital cardiac defects [2].Both surgical and nonsurgical closures of this septal defect are available, provided that specific indications and criteria are met for each procedure.The first transcatheter closure [3] using a double umbrella device in human being was performed in 1976.
There are many advantages of transcatheter closure.Transcatheter closure with the Amplatzer TM septal device occluder has gained popularity in OS-ASD.Embolisation is the commonest reason for surgical intervention among other complications.In this report, we present three cases who underwent successful surgical retrieval of an ASD occluder device embolized to right ventricle, months

Case 1
A 9 yr old girl presented in cardiology OPD with history of insidious onset, gradually progressive palpitation along with frequent upper respiratory tract infection.She was diagnosed as a case of Ostium Secondum Atrial Septal defect (OS-ASD) (28 mm) with left to right shunt and was undergone ASD closure with Cera R ASD occluder (LT-ASD-30).During her regular visit to OPD, Chest X Ray (Figure 1), Transthoracic Echocardiographic (TTE) evaluation was performed.It was found that the device embolized in the right ventricular outflow tract (RVOT).Fluoroscopy guided retrieval with 20 mm snare retrieval forceps was attempted but it was unsuccessful.In RV angiogram (Figure 2) it was seen to be adherent to RV.The patient had no symptoms, such as chest discomfort or  The operation was started under general anesthesia.Informed consent was taken.In supine position median sternotomy was done and pericardial patch was harvested.After systemic heparinisation aortobicaval cannulation and cardiopulmonary bypass was established.Topical ice slush was put over heart.Aortic Cross clamp was applied and aortic root cardioplegia (DelNido 500 ml) was given.Temperature was drifted to 31 degree celcius.SVC and IVC were snugged.RA was opened via standard atriotomy and the device was found impacted in RVOT.It was retrieved safely (Figure 3(A), Figure 3(B)).ASD was closed with pericardial patch with continuous 5-0 prolene suture.Rewarming was started.RA was closed.Cross clamp was removed after standard deairing and gradually was weaned off from CPB. Protamine was given.Epicardial pacing wire was put over RV.After adequate haemostasis, sternum was closed using stainless steel wire.The total procedure was uneventful.Patient was shifted to ICU on elective mechanical ventilation.The postoperative course was uneventful and the patient was discharged with full recovery.

Case 2
A 16 years old female patient presented to Cardiology OPD with history of acute onset palpitation and chest pain.She had history of ostium secondum ASD of 20 mm with left to right shunt.The ASD was closed using Amplatzer TM ASD occluder system six months back.Physical examination showed atrial fibrillation.
Chest Xray PA view (Figure 4) was suggestive of embolization of device and Transthoracic echocardiography revealed embolization of the device in the Right ventricle.Fluroscopy confirmed that the device was embolised in the RV.The patient was referred to CTVS dept for further management.The patient was taken up for surgery immediately after due consent.

Case 3
A 26 years old male patient presented to Cardiology OPD with history of insidious

Discussion
There are different types of devices are available for Transcatheter closure of ASD, like Amplatzer Septal Occluder, Figulla Flexible Occlutech Septal Occluder, Gore Helex Septal Occluder, Gore Cardioform Septal Occluder etc.

Lifetech Cera is new, less expensive double disk ASD occluder.
There are some of the major sequelae documented in percutaneous device closure like device migration/embolization, cardiac erosion, perforation, arrhythmias, thrombosis, and sepsis etc.The incidence of occluder device embolization after ASD closure [4] is 0.55% -1.4%.According to the MAUDE (Manufacturer and User Facility Device Experience) database, 77.2% case device was retrieved surgically and only 16.7% was retrieved using percutaneous technique [5].The device embolization can occur within the first few days as well as few years after the intervention as reported in the literature.Most of the embolization reported in the literature occurred in the recent post operative period, within days of the procedure.In our series, device embolization occurred after 4 months, 6 months and 4 & half months of the procedure.
The reported sites of embolisation include right ventricle, RVOT, pulmonary artery [6], left atrium, LVOT, arch of aorta, descending thoracic aorta, abdomi- The common reasons for the device embolization are very large defect, undersized ASD device, small left atrium to accommodate the device, inadequate margin of ASD and technical issues.
Patients with large ASD (>38 mm) defects with deficient rims are usually not offered transcatheter closure but are referred for surgical closure at our institution.In our case defect size was 28 mm, 24 mm 24 mm.Transthoracic echocardiography in all the cases were favourable for device closure.The device mobility after the implantation and the aortic rim narrower than 5 mm also increase the risk of early and late embolization [7].
Retrieval of the ASD device can be done by both percutaneous and surgical approach.Previous case reports [8] showed percutaneous retrieval was successfully done with Gooseneck snare, En-Snare System, endomyocardial biopsy forceps etc.In our series, device was adherent to right ventricular wall so percutaneous retrieval failed.In one case retrieval was not attempted due to preoperative haemodynamic instability.There was a chance of thrombosis and endothelization of the device in the right ventricular wall, so surgical retrieval of devices were done.ASD was closed with pericardial patch.The endothelialization status of the retrieved device (Figure 5) showed that embolization may have occurred months earlier.Simple Transthoracic Echocardiographic evaluation in the early follow up period can confirm the position of the device.

Figure 1 .
Figure 1.Chest X ray PA and lateral view showing embolization of the device at RV.The arrows indicate the embolised device.

Figure 3 .
Figure 3. (A) Intraoperative view after retracting the tricuspid valve showing device embolization in right ventricle at outflow tract.(B) Intraoperative trans right at rial view before removal of the device.

Figure 4 .
Figure 4. Chest X ray PA view showing embolosation of device at right ventricle (RV).The arrow indicates the embolised device.

S
. Saha et al.DOI: 10.4236/wjcs.2018.812023237 World Journal of Cardiovascular Surgery nal aorta, common iliac artery.In our series device was embolized to right ventricular outflow tract and right ventricle.
ASD are mostly closed by device nowadays.The procedure has many advantages with a few complications like we have presented.In early postoperative period the chances of embolization are more.We have presented three cases where all of the patients have embolization of device in the late post operative period.