Journal of Invasive Cardiology

ABSTRACT: The authors described a rare case of spontaneous repositioning of an embolised Amplatzer occluder into the left atrium resulting in complete occlusion of a hemodynamically significant atrial septal defect, in the fossa ovalis, in a 70-year-old man. Only a slight central residual shunting was present, as was shown by transesophageal Doppler echocardiography performed immediately after the procedure, with no apparent shunt at 30, 60 and 120 days after the intervention.

J INVAS CARDIOL 2004;16:290–292
Key words: atrial septal defect, Amplatzer, embolisation, transcatheter closure

Transcatheter closure of atrial septal defects (ASD) located in fossa ovalis is nowadays frequently used employing a number of different “closure devices” available on the market.^1–5 The Amplatzer occluder (AGA Medical, Golden Valley, Minn.) is the most often used device at this time thanks its integral construction, rapid release screw mechanism and especially due to the possibility of retrieval and safe repositioning of the connected device.⁶ On the contrary, transcatheter retrieval after release of the Amplatzer device is difficult,⁷ therefore surgical or combined interventional surgical means have been used for the removal of the devices embolised into the left atrium or left ventricle.^8,9 Recently published reports by Wilkinson and Goh¹⁰ and Peuster and all.¹¹ proved that transcatheter retrieval of the embolised Amplatzer occluder into the right or left atrium is also feasible.

We describe a rare case of “spontaneous repositioning” of the embolised Amplatzer septal occluder into the left atrium in a 70-year-old man with a hemodynamically significant atrial septal defect located in the fossa ovalis.

Case Report. A 70-year-old man with chronic atrial fibrillation was admitted to our institution for resting dyspnoea and atrial tachyfibrillation. After the application of amiodarone and beta-blockers, the tachyfibrillation was slowed down and an adequate ventricular response was achieved. Transesophageal echocardiography (TEE) revealed a 15x17 mm ASD at the fossa ovalis, with an adequate rim of septal tissue surrounding the defect, and pulmonary hypertension (Figure 1A). At cardiac catheterisation, a hemodynamically significant left-to-right shunt across the interatrial septal defect was confirmed, with a pulmonary-to-systemic perfusion ratio of^1,9 1.9:1. Interventional closure of the atrial septal defect was attempted.

Sizing (Figure 1B) of the defect was performed using Meditech sizing balloon (Meditech, Watertown, Mass.). Both fluoroscopy and TEE guidance were used throughout the sizing procedure to ensure proper positioning of the sizing balloon catheter. The stretched defect diameter was 15 mm. An Amplatzer device with a size of 19 mm was selected for defect closure. The implantation technique is by now well established and has been described in detail previously.^1–3,5,6