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ASD Device Embolization: Caught in the Act

A 52-year-old woman with ostium secundum atrial septal defect (ASD), moderate pulmonary arterial hypertension, and normal coronary angiogram was taken up for percutaneous ASD device closure. Transesophageal echocardiography (TEE) (Philips iE33, Philips Healthcare, Andover, MA, USA) showed an oval 26 9 16 mm ASD with absent aortic rim and adequate other rims. As per institutional preference, balloon sizing of the defect was not done. In view of the oval shaped defect (Figs. 1 and 2), initially a 24mm HEART R septal occluder (Lifetech Scientific, Shenzhen, P.R.China) (double-disc self centering occluder comprised of Nitinol mesh with polyester fabric inside – waist diameter: 24 mm, left atrial disc: 36 mm, right atrial disc: 32 mm) was chosen and deployed across the defect. The device size was selected with the objective of securely closing the defect as well as avoiding long-term erosion. TEE confirmed that all rims were well caught with the device splayed on the aorta with no residual ASD. Surprisingly, immediately after releasing the device under TEE guidance it embolized into the right heart and right pulmonary artery (movie clip S1). The embolized device was retrieved percutaneously (Fig. 3) and the defect was reassessed by TEE which confirmed the previous findings. The device was upsized to 32 mm HEART R septal occluder (Lifetech Scientific) (waist diameter: 32 mm, left atrial disc: 44 mm, right atrial disc: 40 mm) which was deployed across the ASD. After confirming the stability of the device by TEE, it was released successfully (Fig. 4). The larger diameter of an oval shaped ASD may reduce in size on deployment of a self-centering ASD device due to stretching along the smaller diameter of the defect. However, this may not guarantee the stability of a device smaller than the largest diameter of the ASD measured by TEE as shown in this