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Case Reports in Cardiology

Volume 2016, Article ID 1032801, 3 pages
http://dx.doi.org/10.1155/2016/1032801

Case Report
Successful Percutaneous Retrieval of Embolized Septal
Occluder Device from Aortic Arch and Placement of a Newer
Septal Occluder Device in Combined Procedure

Natraj Katta, Sandeep Gautam, and Richard Webel

Division of Cardiovascular Medicine, University of Missouri School of Medicine, Columbia, MO, USA

Correspondence should be addressed to Natraj Katta; kattan@health.missouri.edu

Received 25 October 2016; Accepted 14 December 2016

Academic Editor: Ramazan Akdemir

Copyright © 2016 Natraj Katta et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Embolization of the Amplatzer Septal Occluder (ASO) device (St. Jude Medical, Minnesota) after percutaneous closure of atrial
septal defect (ASD) is a rare and potentially catastrophic complication. Percutaneous retrieval of the embolized device is gaining
ground as an acceptable method, although these patients are usually subsequently referred for open surgical closure of the ASD.
We present a unique case of percutaneous retrieval embolized ASO device and placement of newer larger ASO device in a single
procedure.

1. Case Report pigtail catheter (Figure 2(b)). 6 F sheath was then exchanged
with a 10 F × 80 cm long cook sheath (Cook Medical Inc.
A 75-year-old female patient with history of persistent atrial Indiana). Using 6 F 12–20 mm × 120 cm En-Snare System
fibrillation after multiple failed cardioversions and septum (Merit Medical Systems, Inc., Utah) through a 6 F Hockey
secundum type of ASD presented with worsening exertional Stick II guiding catheter (Medtronic Inc., Minnesota), we
dyspnea of six-month duration. She was previously intoler- were able to snare the metallic tip on the right atrial disc
ant to amiodarone. She underwent elective catheter based of ASO device (Figure 2(c)). Subsequently, entire device was
atrial fibrillation ablation followed by closure of the ASD collapsed into the long sheath which was safely removed
during a combined percutaneous procedure. ASD closure (Figure 2(d)). Thereafter, a 20 mm ASO device placed using a
was performed using a 16 mm Amplatzer Septal Occluder 9 F Amplatzer delivery system (St. Jude Medical, Minnesota),
(ASO) device after measuring the diameter of the defect at after resizing of the defect. This time the sizing balloon
15.4 ± 1.0 mm (Figure 1(a)) with sizing balloon and 15 mm yielded diameter of 17.41 mm (Figure 3(a)) and ICE of 18 mm
(Figure 1(b)) with intracardiac echocardiogram (ICE). After (Figure 3(b)). Both ICE and TTE showed properly positioned
the deployment of the device, ICE showed minimal residual ASO device with minimal residual shunt. No procedure
shunt flow confirming correct position. The following day, related complications occurred. Patient was discharged 2 days
a transthoracic echocardiogram (TTE) revealed severe right later.
to left shunt indicating recurrence of ASD, without visual-
ization of the ASO device. A chest radiograph (Figure 2(a)) 2. Discussion
showed the embolized ASO device in the aortic arch. Patient
had no new symptoms except recurrence of atrial fibrilla- The incidence of occluder device embolization after ASD
tion requiring cardioversion. Patient was taken to cardiac closure is 0.55%–1.4% [1, 2]. Nearly half of the embolized
catheterization laboratory for possible percutaneous retrieval ASO devices tend to lodge in the left atrium and aorta
of the embolized ASO device and placement of a newer [3]. According to the MAUDE (Manufacturer and User
device. 6 F × 11 cm sheath was placed in right femoral artery. Facility Device Experience) database, only a minority (16.7%)
Aortic arch angiography was performed with a 5 F × 110 cm of embolized devices are retrieved using percutaneous
2 Case Reports in Cardiology

(a) (b)

Figure 1: (a) Sizing balloon showing the diameter of the ASD. (b) Intracardiac echocardiogram showing the diameter of the ASD.

(a) (b)

(c) (d)

Figure 2: (a) Chest radiograph, lateral view showing the embolized ASO. (b) Aortic arch angiography using angled pigtail catheter. (c) Using
En-Snare, capturing of the metallic tip of the right atrial disc of the ASO. (d) Retraction of the entire ASO into the long cook sheath.

approach [2]. Undersized device, floppy or inadequate rim, case reports, Gooseneck type of snare system was used [4–
device malposition, and excessive tension on the delivery 6], whereas we are able to retrieve the device using the
cable during the deployment are the possible mechanisms En-Snare System, showing that there are various options in
for device embolization [2]. In our case, we believe that choosing the retrieval system, although merits of one system
undersizing was the possible mechanism, which in turn was over the others are unclear. According to a survey of the
probably due to noncircular shape of the defect. In previous ASO company-designated proctors, approximately half of
Case Reports in Cardiology 3

(a) (b)

Figure 3: (a) Resizing of the ASD using the sizing balloon. (b) Resizing of the ASD using the intracardiac echocardiogram.

the patients had percutaneous closure of the ASD after the cardiac surgery database,” The Journal of Thoracic and Cardio-
embolized device retrieval, but it is not reported whether they vascular Surgery, vol. 137, no. 6, pp. 1334–1341, 2009.
were done as a combined procedure or at a later date [7]. To [4] A. S. Basoor, J. F. Cotant, A. R. Halabi, M. DeGregorio, H.
the best of our knowledge, our case is the first reported case of Chughtai, and K. C. Patel, “Minimally invasive retrieval of
percutaneous retrieval of embolized device and percutaneous patent foramen ovale closure device: after device migration to
placement of newer device performed as combined proce- the descending aorta,” Texas Heart Institute Journal, vol. 39, no.
dure. We also performed atrial fibrillation ablation with ASD 4, pp. 582–584, 2012.
closure on the same day. As arrhythmia control is difficult [5] J. Y. Cho, K. H. Kim, H. J. Yoon et al., “Percutaneous retrieval of
to achieve with ASD closure alone in patients with atrial embolized Amplatzer Septal Occluder after treatment of double
fibrillation and technical challenges associated with trans- atrial septal defect: a case report,” Journal of Korean Medical
Science, vol. 30, no. 9, pp. 1361–1366, 2015.
septal access after device closure, it is considered appropriate
to perform atrial fibrillation ablation prior to ASD closure [6] M. Guimaraes, C. E. Denton, R. Uflacker, C. Schonholz, B. Selby
Jr., and C. Hannegan, “Percutaneous retrieval of an Amplatzer
[8, 9].
septal occluder device that had migrated to the aortic arch,”
CardioVascular and Interventional Radiology, vol. 35, no. 2, pp.
3. Conclusion 430–433, 2012.
[7] D. S. Levi and J. W. Moore, “Embolization and retrieval of the
Percutaneous retrieval of the embolized ASO device is still Amplatzer septal occluder,” Catheterization and Cardiovascular
not widely performed. Also, there is no consensus regarding Interventions, vol. 61, no. 4, pp. 543–547, 2004.
the appropriate timing of the reclosure of the ASD percuta- [8] F. Berger, M. Vogel, A. Kramer et al., “Incidence of atrial
neously after the retrieval of embolized device. With proper flutter/fibrillation in adults with atrial septal defect before and
planning, percutaneous retrieval and placement of newer after surgery,” Annals of Thoracic Surgery, vol. 68, no. 1, pp. 75–
device can be safely performed in single setting. We also 78, 1999.
believe that, in patients with atrial fibrillation and atrial septal [9] J.-G. Nie, J.-Z. Dong, M. Salim et al., “Catheter ablation of
defect, it is reasonable to perform atrial fibrillation ablation atrial fibrillation in patients with atrial septal defect: long-term
prior to ASD closure. follow-up results,” Journal of Interventional Cardiac Electrophys-
iology, vol. 42, no. 1, pp. 43–49, 2015.

Competing Interests
The authors declare that there is no conflict of interests
regarding the publication of this paper.

References
[1] M. M. Amanullah, M. T. Siddiqui, M. Z. Khan, and M. A. Atiq,
“Surgical rescue of embolized amplatzer devices,” Journal of
Cardiac Surgery, vol. 26, no. 3, pp. 254–258, 2011.
[2] J. Moore, S. Hegde, H. El-Said et al., “Transcatheter device
closure of atrial septal defects: a safety review,” JACC: Cardio-
vascular Interventions, vol. 6, no. 5, pp. 433–442, 2013.
[3] D. J. DiBardino, D. B. McElhinney, A. K. Kaza, and J. E.
Mayer Jr., “Analysis of the US Food and Drug Administration
Manufacturer and User Facility Device Experience database for
adverse events involving Amplatzer septal occluder devices and
comparison with the Society of Thoracic Surgery congenital
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