How to cite this article: Bouza MG, Polo López ML, Rocafort ÁG, Zurita MB. The traveller amplatzer: Surgical removal after device migration to the ventricle. Ann Pediatr Card 2018;11:113-4
How to cite this URL: Bouza MG, Polo López ML, Rocafort ÁG, Zurita MB. The traveller amplatzer: Surgical removal after device migration to the ventricle. Ann Pediatr Card [serial online] 2018 [cited 2021 Sep 20];11:113-4. Available from: https://www.annalspc.com/text.asp?2018/11/1/113/223549
A 10-month-old girl was diagnosed at birth with multiple ventricular septal defects (VSD), coarctation of aorta, and accessory mitral valve tissue. We performed coarctation repair with resection and end-to-end anastomosis along with pulmonary artery banding through left thoracotomy in the neonatal period. Seven months later, she was reoperated to close the perimembranous VSD, and the pulmonary artery was debanded. The postoperative course was complicated due to residual VSDs, which were closed with two AMPLATZER™ muscular VSD occluders (St. Jude Medical ®). The child was discharged home; but 1 month later, she was admitted to the emergency room of our hospital with tachypnea.
Transthoracic echocardiography showed two intracardiac closure septal devices. The smaller one was normally positioned in the inferior apical septum. The other was lodged in the anterior heart wall, suggesting device migration leaving a large residual VSD. Thoracic computed tomography confirmed device migration with perforation of the anterior wall of the right ventricle [Figure 1].
Figure 1: Thoracic computed tomography. Position of the Amplatzer® in the anterior wall of right ventricle near to the rib (arrow). (a) Coronal view. (b) Transversal view. (c) Three-dimensional reconstruction
We decided to perform urgent surgery to remove the migrated device, close the residual VSD, and resect the accessory mitral valve tissue. The right cervical vessels were dissected and prepared to cannulate in case of an emergent situation. A median resternotomy was performed and the cardiopulmonary bypass (CPB) established with aortic and bicaval cannulation using moderate hypothermia. After CPB, before cross-clamping the aorta, surgical adhesions were released and the migrated device was examined carefully. The midanterior interventricular septum was perforated because of the migrated device, and the left anterior descending artery was injured in relation to the device [Figure 2].
Figure 2: Intraoperative appearance of Amplatzer® device in the surface of IVS (yellow arrow) in the way of the left anterior descending artery (***) and extraoperative appearance (red arrow). Ao: Aorta, RV: Right ventricle, RA: Right atrium, IVS: Interventricular septum, R: Right, L: Left, H: Head, T: Toe
Cold cardioplegia was instituted following aortic cross-clamping. The right atrium and the interatrial septum were opened and accessory mitral valve tissue excised. The migrated device was removed [Supplementary Video 1], and the septal defect was closed with a patch through right ventriculotomy. The operation was completed without complications, and intraoperative transesophageal echocardiogram showed no residual VSD. The patient's postoperative course was uneventful, and she was discharged home after 10 days. At 1-year follow-up, the patient is asymptomatic with no residual VSD and left ventricular ejection fraction of 60% in the echocardiogram. We would like to highlight the potentially life-threatening complications of high-risk VSD closures and urge caution in undertaking these procedures particularly in infants.
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There are no conflicts of interest.
Correspondence Address: Ms. Mónica García Bouza Department of Cardiovascular Surgery, Clínico San Carlos Hospital, Madrid Spain
Source of Support: None, Conflict of Interest: None