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 (AmplatzerĀ® and
Amplatzer AmuletĀ® 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 7th postoperative day.