Embolization and retrieval of the Amplatzer septal occluder

Patent Foramen Ovale and Atrial Septal Defect

Patent foramen ovale (PFO) and atrial septal defects (ASDs) are two types of interatrial communications with unique clinical presentations and management strategies. The PFO is a normal part of fetal development that typically closes shortly after birth but may persist in as many as 25% to 30% of adults. The communication between atria may result in paradoxic embolism and embolic stroke. On the other hand, ASDs (anatomically defined as secundum, primum, sinus venosus, and coronary sinus in order of prevalence) typically result in right heart volume overload and are often associated with other congenital defects. The diagnostic methods, treatment options including surgical and percutaneous approaches, and potential complications are described. Both conditions underline the significance of precise diagnosis and appropriate management to mitigate risks and ensure optimal patient outcomes.

Embolization of Patent Foramen Ovale Closure Device-Rare Complication and Unique Management Approach

Percutaneous closure of the patent foramen ovale (PFO) is generally regarded as a safe and effective procedure, indicated in patients with a prior PFO-associated stroke. While it is highly safe, rarely, it could be accompanied by a migration of the device, mainly caused by the interplay of a specific PFO morphology and inappropriate device sizing. Herein, we outline a seldom-observed complication of an unintentional detachment of the PFO closure device during implantation, leading to its migration into the abdominal aorta, and a unique management approach. Due to the inability to recapture the occluder with a snare, which is considered to be a mainstay of endovascular retrieval methods, two coronary guidewires were maneuvered through the mesh of the occluder and then captured with a snare proximally to the occluder. This innovative dual-wire-snare system was carefully pulled to the common femoral artery, a position deemed suitable for surgical extraction via arteriotomy, which was achieved successfully.

Long-term follow-up of percutaneous secundum-type atrial septal defect closure using Amplatzer Septal Occluder since 1995: a single-centre study

INTRODUCTION

The goal of this single-centre study was to evaluate long-term results of percutaneous closure of secundum-type atrial septal defect using Amplatzer Septal Occluder with the follow-up to 25 years.

METHODS

A retrospective analysis of patients who underwent percutaneous closure of secundum-type atrial septal defect between September 1995 and October 2012 in our institution was performed. All procedures were performed after fulfilling strict indication criteria. More than 5 years follow-up was reached in 651/803 patients (81%) with median follow-up time of 12 (5-25) years.

RESULTS

The mean stretched defect diameter was 14,0 ± 5,2 mm. Early reintervention due to moderate or severe residual atrial septal defect had to be performed in 3/803 patients (0,03%). The incidence of long-term moderate or severe residual atrial septal defect was 0,0%. The complete closure rate at 10-year follow-up was 98,5%, as trivial residual shunts persisted in 8/508 patients (1,5%). A significant rate of the echocardiographic right ventricular end-diastolic diameter post-procedural normalisation (p < 0,05) was encountered. The rate of major complications was 0,5%. One device embolisation, one thrombus formation at the occluder surface, and one cardiac erosion in periprocedural or short post-procedural course were experienced. Only one late complication of infective endocarditis at the region of implanted occluder and the aortic valve was detected. The survival rate of all followed patients was 100%.

CONCLUSIONS

Percutaneous closure of secundum-type atrial septal defect using Amplatzer Septal Occluder is a safe and effective procedure accounting for a very low incidence of major complications in the long-term follow-up.

Transcatheter retrieval of atrial septal defect and patent ductus arteriosus occluder: a guidance for device retrieval based on comprehensive bench tests

OBJECTIVES

The aim of this study is to establish a guidance for device retrieval based on comprehensive bench tests.

BACKGROUND

Device embolisation remains a major complication in transcatheter closure of atrial septal defect and patent ductus arteriosus. Although percutaneous retrieval is feasible in the majority of cases, surgical retrieval may be required in complicated circumstances. However, the methods of transcatheter device retrieval have not been completely established.

METHODS

Bench tests of device retrieval were performed to verify the appropriate retrieval method according to device type/size. The devices used for testing were Amplatzer Septal Occluder (Abbott, Chicago, IL, United States of America), Figulla Flex II (Occlutech GmbH, Jena, Germany), Amplatzer Duct Occluder-I (Abbott), Amplatzer Duct Occluder-II (Abbott), and Amplatzer Vascular Plug-II (Abbott). The retrieval equipment constituted diagnostic catheters (multipurpose catheter and right Judkins catheter, 4-Fr or 5-Fr, Gadelius Medical, Tokyo, Japan), delivery sheath and cables for each device, Amplatz goose neck snares (Medtronic, Minneapolis, MN, United States of America), OSYPKA CATCHER (Osypka ag, Rheinfelden-Herten, Germany), and OSYPKA LASSOS (Osypka). We investigated the retrieval equipment and sheath sizes required for a successful retrieval procedure for variously sized devices.

RESULTS

For patent ductus arteriosus devices, the type of snare and the snaring position are considered important. For atrial septal defect devices, simple snare capture or a double-snare technique with a sufficiently large sheath is effective. Special care should be taken when using the OSYPKA CATCHER for device retrieval.

CONCLUSIONS

The results of this study may assist in the selection of both capture devices and a retrieval sheath or a catheter for complete retrieval.

Atrial septal defect occluder device embolization: Experience of a tertiary care cardiac center

Background

Percutaneous device closure of atrial septal defect (ASD) has become an increasingly popular procedure as it offers several advantages. However, it is associated with infrequent, but life-threatening complications such as device embolization.

Objective

To analyze the risk factors, common sites of embolization, associated complications, timing of embolization, and the treatment executed.

Settings and Design

A retrospective study was performed at a tertiary referral center for cardiac services.

Material and Methods

Pre-procedure, intra-procedure, and post-procedure data of patients whose ASD device embolized was collected retrospectively and analyzed for risk factors, common sites of embolization, associated complications, timing of embolization, and the treatment executed. Results: Thirty devices were embolized, out of which 13 were retrieved percutaneously in the Catheter laboratory, whereas 17 patients underwent surgery. Fourteen patients had an unfavorable septal morphology for device closure. Ten devices were embolized in the catheter laboratory, five in the intensive care unit, and two in the ward. The devices were embolized to almost all chambers of the heart and great vessels. One patient had an inferior vena cava rim tear while attempting percutaneous retrieval. One patient required a short period of total circulatory arrest (TCA) for retrieval of the device from ascending aorta, while another required a lateral position for retrieval from descending aorta. One patient required re-exploration for bleeding, while another had an air embolism and succumbed.

Conclusions

Once embolization occurs, the risks associated increase manifold. Most of the surgical extractions are uneventful; however, there could be certain complications that may need repair of valvular apparatus, the institution of TCA, or the need for the lateral position. Air embolization though very rare can occur which could be fatal.

Successful retrieval of embolised Occlutech atrial septal defect occluder from descending aorta in a 4-year-old child using a "mother and child" technique: a case report and literature review

A 9 mm Occlutech septal occluder Flex II device was retrieved in a 4-year-old 22 kg child; A 6 Fr Cook® Flexor sheath (child) was inserted into a 9 Fr Occlutech® ASD Delivery Set (mother). Once the tip of the smaller sheath was close to the device, a 4 Fr right Judkins catheter was introduced with a snare. The right atrial hub was captured and withdrawn to the level of the 6 Fr sheath which was then withdrawn into the 9 Fr sheath before being removed completely. The "mother and child" technique offers a greater likelihood of slenderising and retrieving embolised devices.

Comparative effectiveness of devices for transcatheter closure of atrial septal defects: Systematic review and network meta-analysis

Atrial septal defect is a common congenital heart disease, producing a left-to-right shunt in the atrial septum; the current preferred treatment is transcatheter device closure. The aim is to conduct a systematic review to synthesize information on the comparative effectiveness and safety of atrial septal defect closure devices. The methods used: a comprehensive search of Ovid MEDLINE®, Embase, and Cochrane Central databases was conducted. Studies comparing procedural and follow-up outcomes of atrial septal defect devices were included. Network meta-analyses were conducted to generate direct and indirect evidence for comparative effectiveness and safety outcomes between devices. The results are as follows: Twelve studies met our inclusion criteria and were compared in network meta-analyses. The meta-analyses evaluated contemporary devices: the AMPLATZER Septal Occluder; the GORE CARDIOFORM Septal Occluder; the Figulla Flexible II Occluder; the CeraFlex Septal Occluder; and the HELEX Septal Occluder. These studies represented 3998 patients. The primary safety and efficacy outcomes were device embolization and follow-up residual shunt, respectively. Secondary clinical outcomes included procedural success and major and minor complications. No differences were found between devices in terms of device embolization and secondary clinical outcomes. Follow-up residual shunt was higher with the HELEX Septal Occluder compared with the AMPLATZER Septal Occluder (odds ratio 2.92, 95% confidence interval 1.12-7.61). To conclude: although most outcomes were similar between devices, evidence was largely based on observational low-quality studies. There were inconsistencies in outcome reporting and definitions; this merits future studies, with head-to-head device comparisons and standardization of outcomes.

Surgical Removal of Migrated Atrial Septal Defect Closure Device: A Case Report

Percutaneous closure of atrial septal defects (ASDs) has emerged as an alternative to surgical treatment; however, several early and late complications have been reported. In this report, we present the case of a patient who underwent surgical removal of a migrated ‘Figulla Flex II’ ASD occlusion device at the aortic bifurcation 2 months after ASD occlusion.

Practical Therapeutic Management of Percutaneous Atrial Septal Defect Closure

Atrial septal defects (ASDs) are one of the most common congenital heart disorders encountered by cardiologists. Percutaneous ASD closure for secundum ASD is commonly performed not only for children but also for adults, given its non-inferiority to surgical repair. The choice of closure technique should be based on assessing a patient's baseline comorbidities, including the presence of pulmonary hypertension, supraventricular tachycardias, and left ventricular diastolic dysfunction. Furthermore, anatomical features and defect types determined using echocardiography need to be considered when developing a management plan. Percutaneous closure is often the preferred method, given its comparable successful rate to surgical repair while also being far less invasive.

Safety and Cost Implications of Same-Day Discharge Following Elective Percutaneous Closure of Patent Foramen Ovale and Atrial Septal Defects in Australia

Background: Percutaneous closure of patent foramen ovale (PFO) and atrial septal defects (ASD) is being more commonly performed due to changes in international guidelines supporting its use. This study was performed to determine the clinical outcomes, safety and cost implications of same-day discharge (SDD) following such procedures and place this in an Australian context. Methods: This was a retrospective, observational study of patients undergoing elective percutaneous PFO or ASD closure at St. George Hospital, Australia between January 2011 and January 2020. Primary outcomes included 30-day major adverse cardiovascular endpoints (MACE) and readmission to hospital within 30 days. Results: Twenty-four patients were included in the primary analysis. Ten (41.7%) patients underwent elective ASD closure while 14 (58.3%) underwent PFO closure. Among the 24 patients who underwent elective percutaneous closure of structural heart disease, 23 patients (95.8%) were managed with SDD. There were no MACE outcomes at 30 days. No patients were re-admitted to hospital at 30 days following these procedures. When compared to overnight admission to hospital post-elective percutaneous structural heart condition closure, SDD yielded a cost saving of AUD 5999 per case. Conclusion: SDD following elective percutaneous closure of ASD and PFO was demonstrated to be a safe and effective strategy for managing patients. With more widespread use, it can lead to significant cost savings for hospitals without compromising patient care.

Emergent surgical removal of a migrated atrial septal defect occluder: case report

BACKGROUND

Atrial septal defect (ASD) closure has been widely accepted and is now routinely performed using a percutaneous approach under especially echocardiographic guidance Transesophageal echocardiography (TEE). One major complication is dislocation of occluder device during or after the device implantation. Surgical removal may be required, especially when the device stuck in the left ventricular outflow tract (LVOT).

CASE INTRODUCTION

A 21-year-old female was admitted to our department for percutaneous closure of secundum ASD. Percutaneous closure under the guidance of TEE was recommended for the patients. During device implantation, the TEE showed dislocation of the 22 mm ASD occluder device, stucked into the LVOT and behind the anterior mitral leaflet, producing severe LVOT obstruction Fig. 1). We herein present a safe and quick technique for surgical removal of an ASD occlude device located in the LVOT.

CONCLUSION

This technique provides a safe method for surgical removal of malposition and migration ASD occluder device.

Embolization of an Atrial Septal Defect Occluder Device Into the Left Ventricle

Amplatzer Atrial Septal Occluder device has been routinely and successfully used as a percutaneous alternative to cardiac surgery for closure of atrial septal defects. It has shown to the safe with a low complication profile. Complications that most commonly occur with atrial septal defect (ASD) closure devices include malposition or embolization, residual shunt, atrial arrhythmias, thrombosis over the vena cava or atrium, erosion and perforation of the heart, and infective endocarditis. The most common complications associated with an ASD occluder device appear to be embolization and malposition with embolization usually occurring in the main pulmonary artery. We present a case in which the ASO device, Amplatzer^TM (Abbott, USA), embolized into the left ventricle.

Hybrid retrieval of embolized device in abdominal aorta after transcatheter closure of large patent ductus arteriosus

Patients with a large patent ductus arteriosus (PDA) can have several presentations. Many will be asymptomatic, some could develop severe pulmonary hypertension, and others can develop Eisenmenger syndrome. We have presented a case in which a PDA correction device was embolized to the abdominal aorta, 2 months after transcatheter closure of a large PDA. The patient presented with an acute abdomen. In the management of the case, we implemented a hybrid technique in the process of device retrieval. Transbrachial access and a lower abdominal midline incision were accomplished to dislodge the device from the supraceliac aorta to the aortic bifurcation. The Amplatzer Ductal Occluder (St Jude Medical Inc, St Paul, Minn) was extracted through a small arteriotomy of the distal abdominal aorta. The procedure was followed by a dramatic improvement of the ischemic liver and bowel, evidenced by the vanishing of the cyanotic hue of the liver and normalization of the bluish discoloration of the intestine.

Role of Transesophageal Echocardiography in Retrieval of Dislodged Atrial Septal Defect Device Occluder

Transcatheter atrial septal defect (ASD) device closure has emerged as a safe and effective alternative procedure for surgical ASD repair. However, ASD device malposition and embolization has been reported with an incidence of 0.5 to 1.1%. We report here a case of a 32-year-old male, who presented to the hospital 5 months after ASD device closure for routine follow-up. This case reports highlights the significance of transesophageal echocardiography (TEE) evaluation in successful surgical retrieval of a dislodged ASD Amplatzer device.

Transcatheter Closure of Atrial Septal Defects with Cardiac Computed Tomography Sizing: Eight-Year Single-Center Practice

INTRODUCTION

An accurate evaluation of atrial septal defect (ASD) is important for the success of interventional treatment. Cardiac computed tomography (CT) has unique advantages for ASD assessment, although transesophageal echocardiography (TEE) remains the accepted method.

OBJECTIVE

This study aimed to evaluate the safety and feasibility of transcatheter closure of ASD with cardiac CT sizing but without TEE measurement.

METHODS

Among 134 patients undergoing transcatheter closure, 13 underwent TEE in addition to a cardiac CT examination, and 121 underwent only cardiac CT. Propensity score matching was used to analyze the outcomes of the groups treated with (group 1) or without (group 2) TEE examinations. The success rate and complications among the 121 ASD patients with only cardiac CT sizing were recorded and analyzed. The maximal diameters of the defects remeasured on CT images were compared to the echocardiography results and correlated with the device size by Student t test and Pearson's linear regression analysis, respectively.

RESULTS

No significant differences (p > 0.05) were found between groups 1 and 2 in the success rate, complications, or ratio of the device size to the maximum diameter of the defect measured by cardiac CT. In group 1, the maximum diameters of the ASD derived from cardiac CT and TEE were comparable (22.08 ± 9.68 vs. 21.50 ± 10.24; p = 0.351). The success rate among the 121 patients who underwent transcatheter closure with only cardiac CT sizing was 99.2%; however, within 1 month of follow-up, 2 patients had arrhythmia, 1 patient had residual shunting, 1 patient had an infection, and 1 patient had a hematoma, but all patients recovered within a short time.

CONCLUSIONS

Cardiac CT seems to be comparable to TEE in the assessment of ASD, and transcatheter closure of ASD based on CT sizing alone is safe and feasible.

Transseptal occluder migration after transcatheter atrial septal aneurysm and double secondary septal defect correction: A case report

We present a case of secondary atrial septal defect transcatheter correction attempt in a 72 years old male, complicated by the device migration. The occluder was captured, pulled down to the common femoral artery and retrieved through the arteriotomy site. Second attempt was successfully performed using combination of transesophageal echo (TEE) and sizing balloon to accurately measure the defect diameter. This case underscores the importance of TEE ultrasound, sizing balloon, and contrast fluoroscopy combination to achieve accurate device sizing. Our calculation approach significantly increased the success rate of the septal defect closure procedure and potentially reduced the risk of immediate and mid-term complications. Combination of measuring methods should be used in order to accurately assess the device diameter.

Migration and Surgical Retrieval of an Amplatzer Septal Occluder into Abdominal Aorta

BACKGROUND

Structural heart defects, secondary to congenital malformations, have been commonly repaired by open cardiac surgery. Endovascular technology enables these repairs to be performed with fewer complications and better recovery. However, endovascular therapy can be associated with major complications as device dislocation or embolization. We present the case of migration of an Amplatzer occluder device into the abdominal aorta and its surgical retrieval.

CLINICAL CASE

A 10-year-old child with ostium secundum-type interatrial communication underwent endovascular repair in our center. Cardiologists sorted out the atrial communication by endovascular deployment of an Amplatzer device. The 24-h ultrasound control study showed the loss of the occluder. An angio-CT scan showed the migration of the Amplatzer into the juxtarenal abdominal aorta. Initially, an endovascular rescue was attempted but was not effective. Our vascular team performed a median laparotomy, control of the abdominal aorta proximal to the renal arteries, and control of the renal arteries and the infrarenal aorta. We performed a transverse arteriotomy, and the material was removed. Subsequently, the arteriotomy was closed directly without any patch. Postoperative evolution was uneventful.

COMMENTS

Most of the migrations and embolizations of the devices to close interatrial communications remain intracardiac. Although embolization of the abdominal aorta is only reported sporadically, it could cause a major vascular complication. Percutaneous retrieval of the device is currently recommended, with conventional surgery being the efficient treatment in case of endovascular failure or severe damage to the aorta.

Current practice in atrial septal defect occlusion in children and adults

INTRODUCTION

Atrial septal defect (ASD) is one of the most common congenital heart diseases (CHD) in children and adults. This group of malformations includes several types of atrial communications allowing shunting of blood between the systemic and the pulmonary circulations. Early diagnosis and treatment carries favorable outcomes. Patients diagnosed during adulthood often present with complications related to longstanding volume overload such as pulmonary artery hypertension (PAH), atrial dysrhythmias, and right (RV) and left (LV) ventricular dysfunction.

AREA COVERED

This article intended to review all aspects of ASD; anatomy, pathophysiology, clinical presentation, natural history, and indication for treatment. Also, we covered the transcatheter therapy in detail, including the procedural aspect, available devices, and outcomes.

EXPERT OPINION

There has been a remarkable improvement in the treatment strategy of ASD over the last few decades. Transcatheter closure of ASD is currently accepted as the treatment of choice in most patients with appropriately selected secundum ASDs. This review will focus on the most recent advances in diagnosis and treatment strategy of secundum ASD.

Rescue Cardiac Surgeries After Pediatric Catheter-Based Interventions: A Ten-Year Retrospective Study

BACKGROUND

Catheter-based interventions for treating congenital cardiac defects have gained wide acceptance as they reduce the risks associated with surgery. However, these procedures are associated with some complications, such as the embolization of devices or stents and the injury of surrounding structures, which might need a rescue surgical intervention.

METHODS

Data from 25 patients who needed rescue surgery following interventional catheterization between January 2008 and January 2018 were retrospectively collected and statistically analyzed to review the decision and timing of surgery as well as the surgical techniques and results.

RESULTS

There were 24 cases of rescue surgery after device embolization, including 9 cases of atrial septal defect closure, 8 cases of patent ductus arteriosus closure, 4 cases of pulmonary artery balloon dilatation with stenting, 3 cases of muscular ventricular septal defect closure, and 1 case of right ventricular outflow tract injury during balloon valvuloplasty. Median age was 4 years (range, 2 months to 12 years). All rescue surgeries were done via median sternotomy. The mean time interval between the decision to remove the device surgically and the actual surgical procedure was 75 ± 14 minutes. There were no reported cases of postoperative complications or mortality among the patients who underwent surgery.

CONCLUSION

Our single-center experience confirms that early rescue cardiac surgery to correct adverse events after pediatric transcatheter interventions is safe and effective. Surgical strategies should be tailored according to the situation in each case.

Back to Fundamentals: Radiographic Evaluation of Thoracic Lines and Tubes in Children

OBJECTIVE. The purpose of this article is to provide an up-to-date review of the radiographic appearance of the most commonly used thoracic lines and tubes in pediatric patients in daily clinical practice. CONCLUSION. Thoracic support lines and tubes are frequently used in children receiving hospital care. Evaluation of these devices is a fundamental skill in radiology. Many different devices are currently used, and new devices are regularly introduced. It is essential for radiologists to maintain a clear understanding of all devices currently in use.

Transcatheter retrieval of Amplatzer Septal Occluder device embolized into the abdominal aorta

The use of Amplatzer Septal Occluder device has become an alternative to surgical procedure in selected group of patients affected by atrial septal defect. Percutaneous closure of atrial septal defect has emerged as a low morbidity procedure but, at the same time, showed various complications associated to the device itself. Although embolization to the abdominal aorta is only sporadic reported, it could represent a potential vascular disaster and usually is treated by surgery. Herein, we report on the fourth, in English literature, successfully total transcatheter retrieval of an Amplatzer Septal Occluder device complicated by acute embolization into the abdominal aorta and propose a practical endovascular manoeuvre to address disc removal.

Feasibility, safety and midterm follow-up of patients after nonsurgical closure of atrial septal defects using very large 40-46 mm nitinol septal occluders

OBJECTIVES

To study the feasibility of closure of large atrial septal defects (ASDs) using occluder devices >38 mm and assess the midterm complications.

BACKGROUND

Feasibility and safety of large occluders >38 mm and their follow-up are largely unknown.

METHODS

All patients with ASDs closed using devices >38 mm were retrospectively analyzed. Since outcome of patients receiving 40 mm devices were known before, patients receiving 40 mm devices were compared with those receiving 42-46 mm devices on demographic, hemodynamic parameters and procedural characteristics.

RESULTS

A total of 17 patients with 40-mm device and 31 patients with >40-mm device formed the cohort. The mean echocardiographic defect size was 36.3 ± 3.7 mm. In total 19 patients had deficient retroaortic margin; inferior margin was deficient in one. Larger defects needed special deployment techniques more often. There was acute technical success in all patients. Two procedures failed; one device embolization next day in a patient with deficient inferior margin needed surgery. Another elderly patient with restrictive left ventricular physiology died of multiorgan dysfunction. Two late deaths on follow-up were unrelated to the procedure. All other patients had symptom improvement. There were no erosions, thromboembolism or valvar regurgitation at a median follow-up of 39 (1-60) months. Apart from late-onset atrial flutter in one, there were no arrhythmias on follow-up.

CONCLUSIONS

Occluders larger than 38 mm in appropriately selected patients are feasible, successful and safe in majority and often require special deployment techniques. Complications during and after the procedure were infrequent. Very large defects with any deficient margin except retroaortic rim should be excluded from device closure.

Endovascular Retrieval of an Embolized Atrial Septal Occluder Device From the Abdominal Aorta

Patent foramen ovale (PFO) is a common heart condition in adults. Closure with a septal occluder device is a safe, well-established treatment option with excellent clinical outcomes. One rare complication of percutaneous PFO closure is embolization of the device to the heart chambers or distal vasculature. Most device migrations are recognized during or shortly after implantation. While many endovascular retrievals of migrated devices are successful, there are still a high percentage of surgical interventions performed. We report a case of a septal occluder device that embolized to the abdominal aorta and was discovered 7 days after implantation. Endovascular techniques with a snare and endobronchial forceps were used to retrieve the device safely.

Retrieval of large Occlutech Figula Flex septal defect occluders using a commercially available bioptome: proof of concept

OBJECTIVES

This study aimed to develop a method for retrieval of the new meshed nitinol atrial septal defect occluders - Ceraflex and Occlutech.

BACKGROUND

The newly developed atrial septal defect occluders have potential benefits considering implantation, but concerns regarding their removal in case of embolisation have been raised.

METHODS

Over 21 years, 1449 patients underwent interventional atrial septal defect occlusion in our institution. We reviewed the cases of embolisation of the device, developed a strategy for device removal, and tested it on the benchside and in animal tests.

RESULTS

In 11 patients (0.8%), the intended atrial septal defect occlusion was complicated by an embolisation of the device. In contrast to the Amplatzer septal occluders, retrieval of Occlutech devices larger than 16 mm with snare techniques was impossible. In benchside tests, this was confirmed and a new method for removal of large meshed devices was developed. This involved the commercially available Maslanka® biopsy forceps. The feasibility of this technique in vivo was tested in a pig model. During animal tests, using the Maslanka biopsy forceps it was possible to interventionally retrieve embolised Ceraflex and Occlutech devices of different sizes - 10, 16, 30, and 40 mm - into a 12-F sheath.

CONCLUSION

It was impossible to retrieve Occlutech and Ceraflex devices larger than 16 mm into a large sheath in vivo and during benchside tests. However, this was feasible on the bench and in vivo using the Maslanka biopsy forceps even with the largest available devices.

Recent review of transcatheter closure of atrial septal defect

Atrial septal defect (ASD) is one of the two most common congenital heart diseases in children and adult. After the application of catheter intervention for ASD, this became an alternative treatment other than surgery from late 1990. In 2001, the procedure was further approved by the US Food and Drug Administration (FDA), and become the first choice for most cases of secundum type of ASD worldwide. The success rate is more than 98% in literature reviews, with low complication rates in percutaneous ASD closure. Major complications are around 1%, including device embolization, cardiac erosions, new-onset atrial arrhythmia, and other comorbidities. We reviewed indications for percutaneous secundum type ASD closure, technique, successful rate and major complications in this article. To complete the catheter intervention with difficult ASD conditions, various procedural techniques have been developed recently. We also report a challenging case by a current balloon-assisted technique for huge ASD closure.

Techniques for trans-catheter retrieval of embolized Nit-Occlud® PDA-R and ASD-R devices

BACKGROUND

Nit-Occlud^® (atrial septal defect) ASD-R and (patent ductus arteriosus) PDA-R devices are used outside the United States for percutaneous closure of the patent ductus arteriosus and atrial septal defects. When embolization occurs, these devices have been difficult to retrieve.

METHODS

Bench simulations of retrieval of PDA-R and ASD-R devices were performed in a vascular model. Retrieval of each device was attempted using snare techniques or with bioptome forceps with a range of devices. The same devices were then intentionally embolized in an animal model. Retrieval methods were systematically tested in a range of sheath sizes, and graded in terms of difficulty and retrieval time.

RESULTS

Devices that were grasped by the bioptome in the center of the proximal part of the devices were easily retrieved in both models. Bench studies determined the minimum sheath sizes needed for retrieval of each device with this method. In general sheathes two french sizes greater than the delivery sheath were successful with this technique. Three out of the four PDA-R devices were successfully retrieved in vivo. Two were retrieved by grasping the middle of the PA end of the PDA-R device with a Maslanka bioptome and one small PDA-R device was retrieved using a 10 mm Snare. Four of the five ASD-R devices were retrieved successfully grasping the right atrial ASD-R disc or by passing a wire through the device and snaring this loop. For ASD-R 28 and 30 mm devices, a double bioptome technique was needed to retrieve the device.

CONCLUSION

ASD-R and PDA-R devices can be successfully retrieved in the catheterization lab. It is critical to grab the center portion of the right atrial disc of the ASD-R device or pulmonary portion of the PDA-R device and to use adequately sized sheathes.

Transcatheter Retrieval of Embolized Atrial Septal Defect Occluder Device by Waist Capture Technique

This case study describes the successful percutaneous transcatheter retrieval of an embolized Amplatzer occluder device using the "waist capture technique" in a patient with an atrial septal defect. This technique allowed for stability of the Amplatzer device, compression of the atrial discs for easier removal, prevention of further embolization, and minimal injury to vasculature during device retrieval. This novel and effective technique can be used safely for the retrieval of Amplatzer devices in the venous system.

Anterior Minithoracotomy: a Safe Approach for Surgical ASD Closure & ASD Device Retrieval

Objective

Midline sternotomy is the preferred approach for device migration following transcatheter device closure of ostium secundum atrial septal defect. Results of patients operated for device migration were retrospectively reviewed after transcatheter closure of atrial septal defect.

Methods

Among the 643 patients who underwent atrial septal defect with closure device, 15 (2.3%) patients were referred for device retrieval and surgical closure of atrial septal defect. Twelve patients underwent device retrieval and surgical closure of atrial septal defect through right antero-lateral minithoracotomy with femoral cannulation. Three patients were operated through midline sternotomy.

Results

Twelve patients operated through minithoracotomy did not require conversion to sternotomy. Due to device migration to site of difficult access through thoracotomy, cardiac tamponade and hemodynamic instability, respectively, three patients were operated through midline sternotomy. Mean aortic cross-clamp time and cardiopulmonary bypass time were 28.1±17.7 and 58.3±20.4 minutes, respectively. No patient had surgical complication or mortality. Mean intensive care unit and hospital stay were 1.6±0.5 days and 7.1±2.2 days, respectively. Postoperative echocardiography confirmed absence of any residual defect and ventricular dysfunction. In a mean follow-up period of six months, no mortality was observed. All patients were in New York Heart Association class I without wound or vascular complication.

Conclusion

Minithoracotomy with femoral cannulation for cardiopulmonary bypass is a safe-approach for selected group of patients with device migration following transcatheter device closure of atrial septal defect without increasing the risk of cardiac, vascular or neurological complications and with good cosmetic and surgical results.

Safety, Feasibility, Results, and Economic Impact of Common Interventional Procedures in a Low-Volume Region of the United States

The aim of the study was to evaluate the safety, feasibility, and economic benefit of a high-volume operator performing common interventional procedures in a rural region of the United States (U.S.). Rural areas of the U.S., even with well-equipped cardiac catheterization laboratories, may not have a full-time pediatric interventional cardiologist (PIC); this requires patients to travel out of state even for simple interventions. Since 2005, we have adopted a policy of performing cardiac catheterizations and common interventional procedures with a visiting PIC. We reviewed data of all patients who underwent cardiac catheterizations from May 2005 through March 2015 at our center. Variables analyzed were type of procedure, results, and follow-up six months after procedure. 197 catheterizations were performed, of which 80 were for single atrial septal defect (ASD), 29 for fenestrated ASD, 49 for patent ductus arteriosus (PDA), and 39 for other procedures. Device closure of single ASD was successful in 75 of 79 attempts and in 27 of 28 attempts for fenestrated ASD. PDA closure was successful in 45 of 46 attempts. Follow-up data of 6 months or more were available for 127 patients. All but two patients had no cardiovascular symptoms at 6 months. There were four minor complications and no major complications. With a technical success rate of 94.9% for single ASD closure, 97.8% for PDA closure, and results comparable to those of multi-institutional registries, cardiac catheterization and interventions can be performed safely with excellent results. Performing procedures in such an arrangement is safe, feasible, and economically beneficial.

Tough, but not impossible - Retrieval of large atrial septal occluder devices embolized to left atrium

Atrial septal defect (ASD) is a congenital heart defect that is being increasingly treated using percutaneous interventions. However, these techniques are not devoid of complications. One such complication is device embolization. Removal of such closure device poses tremendous risk and consequent complications both by percutaneous retrieval and surgical removal. Herein, we present two cases of ASDs that were closed using atrial septal occluder, but the devices were subsequently embolized into left atrium. These devices were then percutaneously retrieved without any further complication or injury.

Transcatheter Retrieval of Cardiovascular Foreign Bodies in Children: A 15-Year Single Centre Experience

There has been a rapid increase in the practice of interventional catheter treatment of congenital heart disease. Catheter retrieval of embolized cardiac devices and other foreign bodies is essential, yet no large studies have been reported in the paediatric population. Retrospective 15-year review of all children who underwent transcatheter foreign body retrieval in a tertiary cardiac centre from January 1997 to September 2012. Transcatheter retrieval of foreign bodies from the cardiovascular system was attempted in 78 patients [median age 4 (0.02-16) years and median weight 15 (1.7-74) kg] including 46 embolized devices. Transcatheter retrieval was successful in 70/78 (90%), surgical retrieval was required in 6. In two patients, small embolized coils were left in situ. Gooseneck snare was the most commonly used retrieval device. Median procedure and screening times were 90 (15-316) and 31 (2-161) min, respectively. There were no procedural deaths. Transient loss of foot pulses occurred in 5 and 2 patients required blood transfusion. Transcatheter retrieval of cardiovascular foreign bodies can be performed safely in the majority of children thus obviating the need for surgery. It is essential to have a comprehensive inventory of retrieval equipment and interventional staff conversant with its use.

Transcatheter closure of secundum atrial septal defects: has fear of device erosion altered outcomes?

BACKGROUND

Transcatheter device closure has become the established standard of care for suitable atrial septal defects. Device erosion has been a recent focus and has prompted changes in the Instructions for Users documentation released by device companies. We reviewed our entire local experience with atrial septal defect device closure, focussing on the evolution of this procedure in our centre and particularly on complications.

METHODS

We carried out a retrospective review of 581 consecutive patients undergoing attempted transcatheter device closure of an atrial septal defect in Auckland from December 1997 to June 2014. We reviewed all complications recorded and compared our outcomes with the current literature. We sought to understand the impact of the evolution in recommendations and clinical practice on patient outcomes in our programme.

RESULTS

There were a total of 24 complications (4.1%), including 10 device embolisations (1.7%), nine arrhythmias (1.5%), two significant vascular access-related complications (0.3%), one device erosion (0.2%), one malposed device (0.2%), and one probable wire perforation of the left atrial appendage (0.2%). There was one mortality related to device embolisation. All device embolisations occurred following the change in Instructions for Users after publication of the first device erosion report in 2004. This increase in embolisation rate was statistically significant (p-value 0.015).

CONCLUSIONS

In our series, the incidence of device embolisation was higher than that anticipated, with a significant increase following changes to the Instructions for Users. This highlights the need for ongoing data collection on complication incidence and for ongoing review of the impact of changes in clinical practice on complication rates.

Asymptomatic late embolization of Amplatzer septal occluder device

Atrial septal defects of Ostium Secundum type with suitable anatomy and margins are commonly closed with septal occluder devices. With the increasing number of catheterization laboratories and increasing availability of different devices, the device closure procedure is very commonly performed in different institutes. Embolization of the septal occluder is one of the most dreaded complications of this procedure, which usually occurs in the early hours or days after the procedure. We report a case of silent embolization of the Amplatzer septal occluder, detected seven months after its use to close an Ostium Secundum atrial septal defect, which was detected during pre-anaesthetic evaluation and echocardiography for non-cardiac surgery. The patient denied having any symptom in-between. The device was retrieved and the defect was closed surgically.

Successful Retrieval of embolized atrial septal defect occluder and patent foramen ovale closure device using novel coronary wire trap technique

The use of atrial septal device occluders can lead to device embolization. This major complication can occur due to loose margins, deficient aorta, or thin and floppy posterior rim. Device embolization most often occurs after device release, and retrieval is essential. Many devices, including snare and bioptome, have been utilized for retrieval. However, performing these procedures can be difficult and time consuming. Failure to retrieve the embolized device requires open heart surgery. We report a novel and easy to perform method, "coronary wire trap technique," in the event of retrieval failure using conventionally available devices and snare, thereby preventing open-heart surgery. © 2017 Wiley Periodicals, Inc.

Migration of an Atrial Septal Occluder Device to the Transverse Aortic Arch Detected With Echocardiography

Atrial septal defects (ASDs) are one of the most common heart defects diagnosed in the adult population. If left unrepaired, they may lead to significant complications including right heart volume overload, pulmonary complications, and heart failure. Percutaneous transcatheter closure by use of an occluder device is clinically indicated for most patients with a secundum ASD and who are symptomatic. Although this procedure is safe, in rare instances, complications may be encountered, including atrial wall perforation, arrhythmias, and, in very rare instances, device migration. Echocardiography has become a widely used and reliable form of patient imaging that relies on the skillset of the sonographer as well as the interpreting physician. This case study illustrates the specific role of the cardiac sonographer in taking a careful clinical history, imaging of an ASD occluder device, and its location as it migrated into the aortic arch. This case also demonstrates the importance of imaging beyond the standard echocardiographic protocol, given this clinical manifestation.

Transcatheter closure of a complex atrial septal defect after occluder device embolization

Percutaneous closure is nowadays considered the treatment of choice of ostium secundum atrial septal defects (ASD). However, transcatheter closure can be highly challenging when we face an ASD with complex morphological features. The combination of different imaging modalities can be very helpful. This case shows the great value of using both intracardiac and real time 3D transesophageal echocardiography for the percutaneous closure of a complex iatrogenic ASD after device embolization.

Successful Percutaneous Retrieval of Embolized Septal Occluder Device from Aortic Arch and Placement of a Newer Septal Occluder Device in Combined Procedure

Embolization of the Amplatzer Septal Occluder (ASO) device (St. Jude Medical, Minnesota) after percutaneous closure of atrial septal defect (ASD) is a rare and potentially catastrophic complication. Percutaneous retrieval of the embolized device is gaining ground as an acceptable method, although these patients are usually subsequently referred for open surgical closure of the ASD. We present a unique case of percutaneous retrieval embolized ASO device and placement of newer larger ASO device in a single procedure.

Transcatheter closure of large atrial septal defects using 40 mm amplatzer septal occluder: Single group experience with short and intermediate term follow-up

OBJECTIVES

To assess feasibility, safety, and efficacy of the use of 40 mm Amplatzer septal occluder (ASO 40) for the closure of large atrial septal defects (ASD).

BACKGROUND

There is very little data available on closure of large ASDs with ASO 40.

MATERIALS AND METHODS

Case records of patients who underwent ASD closure with ASO 40 between 2002 and 2014 were retrospectively analyzed. All patients had clinical, transthoracic, and transesophageal echocardiographic (TEE) evaluation prior to device closure. Postclosure follow-up was done at 6 weeks, 6 months, and annually thereafter.

RESULTS

87 patients underwent ASD closure using ASO 40 during the study period. Mean age and weight of the group was 32.4 ± 11.6 years and 59.5 ± 11.3 kg respectively. Mean ASD diameter on TEE was 32 ± 2.8 mm. The balloon stretched diameter (N = 40) was 37.8 ± 1.3 mm. The balloon assisted technique was used in 80/87 patients for device deployment. The procedure was successful in 84/87 patients. Follow-up was available in 77 patients over a period of 44 ± 15.7 months. 3/77 patients had a small residual shunt. The severity of tricuspid regurgitation decreased in 40/77 patients. The pulmonary artery systolic pressure decreased from 49.7 ± 9.2 to 41.2 ± 6.2 mm Hg (N = 61; P < 0.05). The right ventricular diameter decreased from 35.1 ± 2.8 to 26.1 ± 3 mm (N = 77; P < 0.05).

CONCLUSION

ASO 40 can be used safely and effectively with promising short and intermediate term results.© 2016 Wiley Periodicals, Inc.

Techniques for transcatheter retrieval of the occlutech ASD device United Kingdom-European multicenter report

AIMS

To gather current experience in Occlutech ASD device retrieval, to determine whether snaring is an effective technique and to highlight alternative retrieval techniques; METHODS AND RESULTS: United Kingdom and European Occlutech ASD device implanters reported their experience in dealing with device embolization and retrieval. Six operators reported 12 retrieval cases. Retrieval was successful in 92% (11/12), although in most cases it was not straightforward and required multiple attempts using different techniques and equipment. When each different technique or equipment combination was considered separately, there were a total of 23 retrieval attempts. Fifteen attempts involved snaring the ball on the right atrial disc of the device ("the RA pin"). In 12/15 of these attempts the snare slipped off the RA pin. In 8/15 attempts snaring eventually failed. In two cases retrieval was facilitated by elongating the device in a blood vessel. In three cases retrieval was achieved by grasping the RA pin with the jaws of the Occlutech Flex II delivery cable; CONCLUSIONS: Snares do not grip the RA pin sufficiently to reliably retrieve the device. Funnelling the device into a blood vessel or grasping the RA pin with the jaws of the delivery cable may be successful alternatives. © 2016 Wiley Periodicals, Inc.