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\begin{document}

\title{Surgical management of embolized Amplatzer septal occluder into the left
ventricle tangled with the mitral valve}



\author[1]{Jose Manuel Martínez-Comendador}%
\author[1]{Elio Martín}%
\author[2]{Javier Gualis}%
\author[1]{Mario Castaño}%
\affil[1]{Affiliation not available}%
\affil[2]{Hospital Universitario de León}%


\vspace{-1em}



  
  \date{May 25, 2024}


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\selectlanguage{english}
\begin{abstract}
Device embolization is a rare major complication of atrial septal defect
percutaneous closures that requires surgical management if non-invasive
retrieval fails. We report a symptomatic delayed embolization of an
Amplatzer septal occluder device into the left ventricle outflow tract
tangled with the mitral valve, complicated with ventricular arrhythmias
and cardiac tamponade during percutaneous retrieval attempt. Emergent
surgical treatment was performed, requiring combined approach through
the right atrium and the aorta for surgical removal.%
\end{abstract}%



\sloppy


\textbf{KEYWORDS}

Atrial septal defect, Device embolization, Cardiac surgery

\textbf{1 INTRODUCTION}

Surgical repair has been traditionally considered the treatment of
choice for atrial septal defect (ASD) repair during decades. However,
nowadays the percutaneous deployment of Amplatzer septal occluder (ASO)
devices has become the standard technique for favourable ASD
closure\textsuperscript{1,2}. These procedures are considered safe and
effective, with low rates of mortality and morbidity, and avoid
open-heart surgery\textsuperscript{2}. However, device embolization to
different sites of the circulatory system or cardiac chambers is a
serious potential complication. In these cases, when the percutaneous
retrieval of the device fails, surgical removal is
needed\textsuperscript{3}. We report a rare case of symptomatic
embolization of an ASO into the left ventricular outflow tract (LVOT)
after 24 hours of device deployment. During percutaneous retrieval the
device tangled with the mitral valve and the left ventricle was injured,
requiring emergent surgical removal with combined right atrial and
aortic approaches, and patch repair of the left ventricle.

\textbf{2 CASE PRESENTATION}

An asymtomatic 66-year-old woman with history of paroxysmal atrial
fibrillation was diagnosed by transesophageal echocardiography (TEE) of
a 18-mm round shaped secundum ASD with adequate rims. She was referred
for invasive treatment because of a significantly increased
pulmonary/systemic flow ratio (Qp/Qs=2.2).

A 20-mm ASO and a 20-mm left atrial appendage occluder (Amplatzer\selectlanguage{ngerman}® and
Amplatzer Amulet® respectively, St. Jude Medical, Inc., St. Paul, Minn)
were successfully delivered without intraprocedural complications. After
20 hours the patient complained of chest pain and palpitations.
Transthoracic echocardiography showed recurrent left-to-right
interatrial shunt and dislodgment of the ASO device, located in the LVOT
and tangled with the subvalvular mitral valve apparatus (Figure 1 A).
Percutaneous retrieval of the device was attempted despite the difficult
access between the chordae tendinae of the mitral valve (Figure 1 B).
The procedure was complicated with a severe pericardial effusion and
ventricular tachyarrhythmias with hemodynamic instability. The patient
was transferred to the operating room for emergent surgical device
removal. After full median sternotomy and pericardiotomy a haemorrhagic
pericardial effusion was found. Under cardiopulmonary bypass, the aorta
was cross-clamped and antegrade blood cardioplegia was infused. An
intramyocardial dissecting hematoma of the left ventricular inferior
wall was observed (Figure 2 A). A longitudinal right atriotomy was
performed. The waist of the device was tangled with the mitral valve
chordae, that prevented its detachment even after trying to fold it with
two forceps. So, we decided to cut the waist of the device and separate
the right and left ASO components. This maneuver untangled both parts
and allowed to retrieve them separately from the right atrium the right
part (through the mitral valve and the ASD) and from the aorta the left
one (through the aortic valve) (Figure 2 B,C,D). The mitral valve was
carefully assesed and no abnormal findings were found. The ASD was
repaired with an autologous pericardial patch using a running 4/0
polipropilene suture. A bovine heterologous pericardial patch attached
with biological glue was used for cardiac rupture repair. The
postoperative course was uneventful and the patient was discharged on
the 7\textsuperscript{th} postoperative day.

\textbf{3 DISCUSSION}

Management of ASO embolizations has been previously described in the
literature as single case reports and very few multicenter experiences
have been reported\textsuperscript{1-5}. Embolization sites can be the
right atrium, right ventricle, pulmonary valve, tricuspid valve, and
much less frequently, the LVOT\textsuperscript{2}. The surgical
technique performed in these cases is usually gentle direct retrieval of
the deployed device through the mitral valve\textsuperscript{3}. To our
knowledge, this is the first reported case of a symptomatic ASO
embolization to the LVOT requiring emergent surgical retrieval through a
combined approach (right atrium and ascending aorta) because of device
tangling with the mitral subvalvular apparatus.

Cardiac tamponade is a rare complication, ranging from 0.1\% to
0.3\%\textsuperscript{2}. In our case, the perforation of the left
ventricular free wall during percutaneous retrieval attempts induced the
pericardial bleeding.

Although percutaneous retrieval of the device is effective in
approximately 70\% of the cases\textsuperscript{3}, when the occluder is
located at the LVOT and involves the chordae tendineae of the mitral
valve, percutaneous retrieval must not be attempted to avoid damage of
the leaflets, the subvalvular apparatus or the LV\textsuperscript{2-4}.

\textbf{AUTHORS CONTRIBUTIONS}

JMC drafted the manuscript. EM, JG and MC edited and revised the
manuscript for important intellectual content. All authors read and
approved the final manuscript.

\textbf{Conflict of interest:} none declared.

\textbf{Figure Legends}

\textbf{Figure 1.} Transthoracic echocardiogaphy showing Amplatzer
atrial septal occluder tangled with mitral anterior leaflet chordal
apparatus (A). Cath-lab fluoroscopy of percutaneous retrieval attempt
procedure, with the left atrial appendage occluder implanted and the
dislodged atrial septal occluder snared through its waist by means of a
loop (B).

\textbf{Figure 2.} Left ventricular inferior dissecting hematoma
(A).~Right atrial disk viewed through the atrial septal defect with its
waist tangled with the mitral valve (B). Transaortic retrieval of the
left atrial disk after dividing the device through its waist (C). Two
halves of the atrial septal occluder retrieved (D).

REFERENCES

{[}1{]} Gokaslan G, Ustunsoy H, Deniz H, Ozcaliskan O, Yasim A, Baspinar
O et al. Urgent surgical management for embolized occluder devices in
childhood: single center experience. \emph{J Cardiothorac Surg} .
2012;7(7):127.

{[}2{]} Wagdi P. Closure of Interatrial Septal Communications: Adverse
Events and Lessons Learned. \emph{Cardiol Res} . 2011;2(1):7-15.

{[}3{]} Errahmouni A, Hattaoui ME, Drighil A, Boumzebra D. Silent
embolization of an Amplatzer septal occluder into the left ventricular
outflow tract requiring emergent surgical retrieval. \emph{Ann Pediatr
Cardiol} . 2012;5(1):89-91.

{[}4{]} Cianciulli TF, Redruello HJ, Rubio MA, Poveda Camargo RL, Granja
MA, Barrero CM et al. Surgical rescue of embolized amplatzer septal
occluder. \emph{Can J Cardiol.} 2014;30(4):465 e3-4.\selectlanguage{english}
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