CARDIOVASCULAR JOURNAL OF AFRICA • Volume 25, No 3, May/June 2014
AFRICA
e1
Case Report
Delayed embolisation of Amplatzer ASD closure device
caused partial obstruction of left ventricular outflow tract
Sang-Hoon Kim, Kyung Ho Kim, Yeong Min Lim, Jae-Youn Moon, Woo-In Yang, In Jai Kim, Sang-Wook Lim
Abstract
A 54-year-old male presented with symptoms of dyspnoea,
and oedema of the lower extremities. Transthoracic echocar-
diography (TTE) revealed secondum-type atrial septal defect
(ASD). He successfully received a 30-mm Amplatzer ASD
closure device percutaneously. Echocardiography immedi-
ately after the procedure and the next day showed a well-
positioned device. He was discharged the next day on 100
mg aspirin daily and warfarinisation due to atrial fibrillation.
A month later, he revisited the hospital due to recurrence of
dyspnoea and a grade 2 systolic murmur was heard on the
left parasternal border. A chest X-ray showed abnormal loca-
tion of the closure device and TTE revealed re-appearance
of the ASD and an embolised Amplatzer device in the left
ventricular outflow tract (LVOT) with partial obstruction.
He requested surgery to remove the Amplatzer device and
received an ASD patch repair, tricuspid valve repair and
modified Maze operation concurrently. He is now in routine
follow up without any other complications.
Keywords:
atrial septal defect, closure device, embolisation
Submitted 7/2/14, accepted 22/4/14
Cardiovasc J Afr
2014;
25
: e1–e3
DOI: 10.5830/CVJA-2014-019
Percutaneous atrial septal closure with a closure device has been
proven safe and effective, and has become the standard treatment
for secondum-type atrial septal defect (ASD). Transcatheter ASD
closure is a relatively safe procedure with a low complication
rate. However some complications can occur, such as device
embolisation, erosion, pericardial effusion with tamponade,
thrombus, stroke and endocarditis.
1
The reported rate of device embolisation is about 0.55 to 1.7%.
2
Generally, most cases of device embolisation are apparent during
the procedure, but delayed embolisation may also occur.
1
We
report on this rare complication of an ASD closure device, which
occurred about a month after successful implantation. It caused
partial obstruction of the left ventricular outflow tract (LVOT).
Case report
A 54-year-old male visited the out-patient clinic due to symptoms
of dyspnoea, and oedema of the lower extremities. He showed
atrial fibrillation on electrocardiography, and cardiomegaly
on chest X-ray. Transthoracic echocardiography (TTE) was
performed, which revealed a secondum-type atrial septal defect
(ASD). The estimated size of the ASD on TTE was 23 mm, and
a markedly enlarged right atrium and right ventricle, moderate
pulmonary hypertension (right ventricular systolic pressure: 53.3
mmHg) and severe tricuspid regurgitation were observed. He
was admitted for percutaneous ASD closure.
Transoesophageal echocardiography (TEE) confirmed the
presence of a moderately large secundum ASD that measured 25
mm, and all the rims of the ASD were adequate for device closure.
The procedure was performed under general anaesthesia with TEE
guidance. Right-side catheterisation revealed Qp/Qs of 2.22. A
34-mm balloon was positioned across the defect and measured
with both quantitative angiography and TEE at 25 mm. A 30-mm
Amplatzer ASD closure device was implanted successfully.
Echocardiography immediately after the procedure (Fig. 1a)
and the next day (Fig. 1b) showed a well-positioned device. The
patient was discharged the following day on 100 mg aspirin daily
and warfarinisation due to atrial fibrillation.
A month later, he revisited the hospital due to recurrence of
dyspnoea, and a grade 2 systolic murmur was heard on the left
parasternal border. Chest X-ray showed abnormal location of the
closure device (Fig. 2). TTE revealed reappearance of the ASD
and an embolised Amplatzer device in the LVOT with partial
obstruction (Fig. 3).
As the Amplatzer device was trapped in the LVOT, it would be
dangerous to retrieve it percutaneously, so we requested surgery
to remove the device. The patient received an ASD patch repair,
tricuspid valve repair and modified Maze operation concurrently.
He is now in routine follow up without any other complications.
Discussion
King and Mills reported on the first patient to receive
percutaneous ASD closure in 1974.
3
Since then the technology
Department of Cardiology, CHA Bundang Medical Centre,
CHA University, Seongnam, Korea
Sang-Hoon Kim, MD
Kyung Ho Kim, MD
Yeong Min Lim, MD
Jae-Youn Moon, MD
Woo-In Yang, MD
In Jai Kim, MD
Sang-Wook Lim, MD,
