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The retrieval of atrial septal defect closure device embolized into aortic arch.

Percutaneous atrial septal defect (ASD) closure has become an increasingly simplified procedure over the past decade. The device embolization is seen rarely but it can be fatal. Although percutaneous retrieval is feasible, surgical removal might be preferred when the endothelialization status of the device is unknown. We report a comlication of such closure in a 43-year-old woman: embolization of the ASD occluder device into aortic arch 12 months after implantation. We removed the device surgically and closed the ASD.


Introduction
Ostium secundum atrial septal defect (ASD) is one of the most common congenital heart defects in adults.
As an alternative to surgery with a high rate of safe and success, the closure of ASD by percutaneous intervention has been the standard treatment approach. Device embolization is a complication which is rarely encountered and may be potentially resulted in death during or after the process, or in the late period. It is seen in about 0.3-0.6% of the cases (1,2).

Case Report
43-year-old female patient was admitted to our clinic with the complaint of chest pain and cyanosis of the lips occurring by the exercise. It was detected in the anamnesis that the patient underwent the percutaneous ASD closure operation approximately 12 months ago in another hospital. It was also found that the patient didn't go for routine checks. Chest x-ray revealed that the Amplatzer septal occluder was located into the aortic arch ( Figure 1A). In the transthoracic echocardiography,the ASD was observed, but it was also detected that the device embolized into aortic arch ( Figure 1B). In order to be able to identify the location of the device more clearly, she was examined by fluoroscopy and thorax computed tomography. It was confirmed by fluoroscopy and thorax computed tomography that the device was in aortic arch ( Figure  1C and Figure 1D). As it was not known when the device embolized, it was decided to retrieve the device by a surgical operation considering the possibility of endothelialization into aortic arch and the thrombosis of the device.
Although the patient was stabile hemodynamically, she was taken to the operating room under emergency conditions. Axillary artery cannulation after median sternotomy, and unicaval two stage venous cannulation from right atrial appendage were performed. The patient was cooled to 24 degrees by entering the pump. The right atriotomy was made after potassium blood cardioplegia arrest. 2 × 3 cm size secundum ASD was detected. It was repaired primarily with 4/0 polypropylene suture.Then cross clamp was put to the innominate artery at 24 degrees hypothermia,and aortic arch was opened. Meanwhile, antegrade cerebral perfusion was continued with 500 mL of flow. It was observed that the embolized device was attached to the side wall of aortic arch, and it was almost completely endothelizedand largely buried in the aortic wall ( Figure  2A and Figure 2B). After carefully excised, the defect

Summary
Percutaneous atrial septal defect (ASD) closure has become an increasingly simplified procedure over the past decade. The device embolization is seen rarely but it can be fatal. Although percutaneous retrieval is feasible, surgical removal might be preferred when the endothelialization status of the device is unknown. We report a comlication of such closure in a 43-year-old woman: embolization of the ASD occluder device into aortic arch 12 months after implantation. We removed the device surgically and closed the ASD. on the aortic wall and the regions with endothelial damage were repaired from inside with the sutures reinforced with Teflon. Aortotomy was primarily repaired.After filling and air extraction process, the clamp in the innominate artery was retrieved and switched to perfusion with normal flow. While heating the patient, the right atriotomy was closed. The perfusion was completed smoothly.The postoperative course was uneventful and the patient was discharged with full recovery on the 7 th day.

Discussion
The device embolization is the most frequently seen among the complications requiring surgical intervention in the percutaneous ASD closure. This complication is seen at a rate of 0.5% (3), but has a great importance because it can be fatal. Although generally, the device embolization occurs within the first few days after the percutaneous ASD closure, it may also be seen many years after the intervention (4).

Conclusion
Device embolization is a rare but potentially fatal complication of transcatheter ASD closure. Although percutaneous retrieval is feasible, surgical removal might be preferred when the endothelialization status of the device is unknown. This case underlines the importance of proper patient selection and routine follow-up after the procedure.