Correspondence Address: Dr. Mohit Sharma Department of Cardiovascular and Thoracic Surgery, S.M.S. Medical College and Group of Hospitals, Jaipur, Rajasthan India
Source of Support: None, Conflict of Interest: None
Surgery is the standard procedure for closure of atrial septal defects (ASDs). Recently, percutaneous transcatheter procedures emerged as therapeutic alternatives for closure of both ASDs and patent foramen ovale. Here, we report a 21-year-old young female underwent ASD closure using an Amplatzer device, unfortunately, however the device misplaced to the right atrium during procedure. Percutaneous extraction of the device was failed; patient was taken for immediate surgical intervention in cardiogenic shock. Amplatzer device was removed surgically on cardiopulmonary bypass successfully, patient recovered well.
Atrial septal defect (ASD) is the prevalent congential heart disease (3.78/10000 live births).  Surgical treatment is safe and effective, but the complications related to thoracotomy are bleeding, arrhythmia, postpericardectomy syndrome, and residual defects.  There have been some creative efforts by interventional cardiologists in closing ASD using various devices. ASD closure device was first described by Ring etal. in 1976. The devices used for closure are composed of cardioseal, amplatzer septal occluder (ASO), and the angelwings.  Limited data is available on Amplatzer device explantation surgically, especially in Indian scenario.
A 21-year-old young female was admitted to the cardiology department of S.M.S. Hospital, Jaipur with a secundum ASD. The stretched diameter of ASD was 30 mm with classic criteria for percutaneous septal closure. The patient was taken for transcatheter ASD closure. After positioning and releasing, the device was misplaced to right atrium (RA). Efforts for percutanous extraction of the device were failed, and the patient was immediately transferred to the operation theatre in cardiogenic shock.
A midline sternotomy incision was made, mediastenal cavity opened, and cardiopulmonary bypass (CPB) established using two venous cannulae and caval tapes. We made an incision in RA, misplaced device found and removed. ASD closed primarily and smooth off bypass. Postoperative echocardiography showed no residual ASD after an uneventful postoperative period. The patient was discharged from hospital with uneventful follow-up [Figure 1] and [Figure 2] and Video 1.
Surgical ASD closure has been performed since 1948 with good results and low mortality and morbidity. The operation needs a sternotomy or less commonly thoracotomy incision, CPB and 3-7 days of hospital admission. Past few years, different devices for percutanous closure of ASD have been used worldwide. The superiorities of Amplatzer are its simple use and possibility of changing its position. This is due to the composition of nitinol (memory wire) and excellent design, which could retract into the catheter and removed if it was not properly placed in the heart. Most ASD secundums can be closed by Amplatzer. Common criteria for a patient being suitable for closure by Amplatzer included maximum stretched diameter of defect with less than or equal to 34 mm, a 4-5 mm rim of septal tissue surrounding the defect and sufficient distances from surrounding valves and structures. 
The hazards of ASO are thick profile of the device and high amount of nitinol in device and the potential for nikle toxicity.  Complications of percutanous ASD closure are air embolism, vascular trauma resulting from large sheathes, device embolization, clot embolization through arteriovenous valve, occlusion of pulmonary or systemic venous return, perforation of atrial septum, aortic perforation, infective endocarditis, atrial arrhythmia, device malposition necessitating its removal, delayed breakdown of device and residual atrial. ,,
According to reports of Food and Drug Administration, the most common complications following Amplatzer insertion are erosion and perforation of the heart. There are some reports of this complication occurring many years after insertion.  Embolization does not commonly occur but if developed, the reasons were insufficient rim around the defect, early release of device, and mismatch between the size of ASD and Amplatzer which was due to the use of small Amplatzer for a large ASD. In a study conducted by Berger etal.  in one of 61 cases of ASD closure using Amplatzer, embolization of the Amplatzer device was observed in the left ventricle. The device could be retrieved from the heart, but vascular surgery was required to extract it from the femoral artery.  In our patient nonsurgical retrieval was not possible. Transcatheter closure of secundum ASDs with the Amplatzer device has the advantage of fewer complications, shorter hospitalization, and reduced need for blood products. In comparative studies performed by Berger etal., no difference was found between the prevalence of complications in surgical or ASO closure of ASD. Embolization and percuatanous extraxtion of ASO, after releasing the device from its position, was reported, though the prevalence and causes of embolization and effective methods for extraction were not described systematically in a company-designated analysis.
We concluded that device embolization is an uncommon complication of Amplatzer ASD closure, that can be managed surgically or by percutaneous extraction methods. The transcatheter closure of uncomplicated-type secundum ASD is a feasible alternative to open heart surgery. However, we recommend interdisciplinary collaboration with a surgical stand by for managing potentially life-threatening complications. As the limited data is available in Indian scenario and no comparative study has been conducted yet this case study will help to open new discussions.
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