Subacute, Silent Embolization of Amplatzer Atrial Septal Defect Closure Device to the Pulmonary Artery
A 45-year-old female was admitted due to symptom of dyspnea developed several months before admission. Transthoracic echocardiography (TTE) showed a secundum ASD measuring 28 mm anterior-posteriorly at apical 4 chamber view (). Cardiac catheterization revealed pulmonary hypertension with pulmonary artery systolic pressure 46 mmHg and a large left to right shunt with a Qp/Qs 3.1. Transesophageal echocardiography (TEE) was performed and revealed a large secundum ASD measuring 27 mm, with sufficient superior vena cava (11 mm), inferior vena cava (14 mm) rim () and relative small atrioventricular rim (5 mm) (). Posterior rim was sufficient in length (13 mm) but relatively thin in nature, and aortic rim was nearly absent (). Despite relative large size of ASD with insufficient aortic rim, percutaneous device closure with Amplatzer was planned because she refused surgical treatment.\nDuring procedure, intracardiac echocardiography (ICE) was used for guiding intervention instead of TEE as our routine practice. ASD size measured by sizing balloon under fluoroscopy was 26 mm. An oversized 32 mm Amplatzer ASD device was selected because of insufficient aortic rim and deployed successfully after several failure of capturing atrioventricular rim. Prior to final release of the device, a secure and stable position of the device within the defect was checked by a push-pull maneuver and cessation of flow across the inter-atrial septum was confirmed by ICE and TTE ().\nOn the day following device closure, she was asymptomatic and routine follow up chest X-ray and TTE was performed. On chest X-ray, Amplatzer device shadow was found at the main pulmonary trunk area () and TTE revealed reappearance of the large ASD with embolized Amplatzer device in the ostium of right pulmonary artery (). The right ventricular systolic pressure was increased to 63 mmHg, but she still remained asymptomatic and hemodynamically stable. We started intravenous infusion of heparin and asked for emergency surgery to remove the Amplatzer device and repair of the ASD.\nThe operation was carried out with median sternotomy. After cardiopulmonary bypass, pulmonary artery was opened and the Amplatzer occlude was identified in the bifurcation site of pulmonary artery trunk. Some of the marginal tissue in inferoposterial portion of the atrial septum was composed with friable membranous tissue. After removing the thin and friable tissue, the size of ASD was measured up to 30 × 40 mm. The ASD was closed using pericardial patch and she discharged from the hospital on the 5th postoperative day without other complications.