Role of Echocardiography during Transcatheter Closure of an
Atrial Septal Defect:
A Case Report
Nicole Dobija, DDS MD, Monica Botero, MD,
Department of Anesthesiology, University of Florida, Gainesville, Florida
Background: Echocardiography, has been used for reliable imaging during
cardiac surgery and for guidance of catheter placement during transcatheter
closure of atrial septal defects, (ASD). We describe a case of embolization
of the occluder device to the mitral annulus, requiring emergent surgical
intervention. Intraoperative transesophageal echocardiography (TEE) was
instrumental in guiding the surgical intervention.
Case Report: A 35-year-old man was admitted to the hospital for elective
transcatheter closure of his medium size atrial septal defect in the cardiac
catheterization laboratory.. His medical history was significant for
hypertension, intermittent atrial fibrillation, and worsening shortness of
breath and chest pain. He has had no evidence of stroke or transient
ischemic attacks. Cardiac catheterization was initiated with continuous
conscious sedation utilizing intracardiac echocardiography. The cardiac
catheterization demonstrated normal cardiac anatomy except for a 16 mm
secundum-type ASD and slightly elevated right ventricular pressures. A 32 mm
Amplatzer septal occluder device (AGA Medical, Golden Valley, MN) was
prepared. It consists of two self-expanding discs made of nitinol wire mesh
and covered with polyester that are connected by a thin waist. During
deployment of the device, it failed to align parallel to the right and left
atrial septums and dislocated to the left atrium. Several attempts to
dislodge the device were unsuccessful. The patient was transferred
emergently to the operating room for surgical intervention. General
anesthesia was induced emergently with oxygen, fentanyl, pancuronium, and
isoflurane.
Intraoperative TEE showed that the occluder device had migrated through the
mitral annulus and had positioned itself to occupy the entire mitral valve
opening. Any manipulation of the heart worsened the mitral valve inflow
obstruction and resulted in severe hypotension. Therefore, cardiopulmonary
bypass was instituted rapidly. The device was removed and the ASD was
surgically repaired. The patient was separated from cardiopulmonary bypass
without difficulty and transferred to the cardiothoracic intensive care unit
for postoperative management.
Conclusion: A septal occluder has become an alternative to surgery, for
closure of small to medium-sized ASDs. Large ASDs, greater than 36 mm, can
be closed with this method but are prone to complication such as pericardial
effusions, indentations and wear on the aortic root, as well as pericardial
tamponade. This is the first reported case of an Amplatzer device with
transmitral embolization requiring emergent surgical intervention. There has
been one other case of device migration into the aortic root thirty days
post placement requiring surgical removal. In both cases TEE was
instrumental for locating the device and evaluating the hemodynamic effects
caused by the migrated occluder.