Migration of amplatzer device in the aortic arch due to failed closure of atrial septal defect by interventionism, removal of device and closure of interatrial communication by surgical technique: a case report

Abstract

We present the case of a 3-year-old female, who had an ostium secundum type atrial septal defect and who had been scheduled for interventional closure with an amplatzer occluder device. Pediatric hemodynamics service notified us of the device migration and her hemodynamic instability due to the failed attempt to recapture the device with an umbrella technique and its consequent migration to the aortic arch. Urgent surgery is performed through conventional medial (median full) sternotomy, dissection by planes, opening and marsupialization (opening) of anterior pericardium with 0 silk, placement of reins with 1-0 silk, purse-string like suture on aorta with 3-0 ethibond, and in the right atrium and the inferior vena cava 3-0 prolene suture. Administration of 200 units of heparin, placement of arterial cannula and venous cannula in both superior and inferior vena cava, partial occlusion of cavas, dissection of the transverse aorta up to aortic arch until visualization of left subclavian artery and ductus arteriosus occupied with stent. Reins are placed with 1-0 silk in the brachiocephalic trunk, carotid artery and left subclavian artery in an individualized manner, and an amplatzer type device is evidenced and palpated in the zone between the left subclavian artery and the ductus arteriosus, a purse-string like suture is made with 4-0 prolene, a 5 mm incision is made with a scalpel, and with 3 mosquito clamps and a traction- countertraction maneuver complete removal of the amplatzer device is obtained. Posterior closure of the purse-string like suture is performed without complications and without evidence of active bleeding in the incision area. Aortic clamping is performed, cardiopulmonary bypass, and the administration of 300cc of custodiol solution until the visualization of the heart´s electromechanical stop, temperature drop to 28 degrees, right atrium opening, inspection of ostium secundum type of interatrial communication of approximately 5-6 mm in diameter, placement of reins in right atrium with closure of interatrial communication. A bovine pericardium patch is made and placed with 5-0 prolene continuous suture, the absence of leaks is verified, closure of right atrium, increase of temperature to normothermia and partial occlusion of cavas removed, the right atrium is purged, hemostasis is verified without complications. Extracorporeal circulation is stopped on the first attempt with output to sinus rhythm , pacemaker cables are placed with exteriorization by counter opening, removal of inferior venous cannula first and then superior venous cannula, purging of the root and removal of arterial cannula, administration of 300 IU of protamine is started, complete textile count is verified and a 19 Fr mediastinal tube is placed, verification of hemostasis, sternal closure with one no 5 wire in manubrium in an x style knot and two in the middle and lower third with 2-0 ethibond suture, hemostasis is verified and subcutaneous cellular tissue is closed with 1-0 vycril suture, skin is closed with 3-0 monocryl suture, and the surgical event is concluded.

Keywords

• aortic arch
• atrial septal defect
• removal of device
• interatrial communication
• surgical technique