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.