Table Of ContentMohiteetal.JournalofCardiothoracicSurgery2013,8:10
http://www.cardiothoracicsurgery.org/content/8/1/10
LETTERS TO THE EDITOR Open Access
Suture fixation of migrated septal occluder device
to prevent further migration: a simple surgical
technique
Prashant N Mohite1,2*, Sachin A Kuthe1, Shrirang D Ranade1, Pravin P Kulkarni1, Anton Sabashnikov1
and Aron F Popov2,3
Abstract
As the useof percutaneous intervention is increasing for theclosure ofthe atrial septal defect, theprocedure
related complicationsare also on rise, migrationof the device being most common. The migrated devices with
failed percutaneous retrievalmust be removed surgically under cardiopulmonary bypass. During establishmentof
cardiopulmonary bypass, thehandling of heart may cause further migration ofthedevice into other chambers of
heart which leads to difficulty in finding and retrieval ofthedevice. The authors propose a simple and unique
technique to preventfurther migrationof the septal occluder device.
Keywords: Atrial septal defect, Septal occlude device, Transcatheterclosure,Migration ofocclude device
Introduction the wall of the chamber passing through the migrated
The transcatheter closure of the atrial septal defect device and knot is tied (Figure 1). Aorto- bicaval cannu-
(ASD) has been proposed as an alternative to surgical lationisthendone andcardiopulmonarybypassisestab-
therapy for the ostium secundum ASD. The transca- lished. Heart arrested with topical hypothermia and high
theter closure ASDs was first described by King and potassium cardioplegia. Right atrium is incised obliquely
Mills in 1976 [1]. It is considered an effective and safe and the device is found stuck to the atrial wall with the
procedure, and although rare but potentially fatal com- polypropelene suture. The device is retrieved after cut-
plications have been reported. Migration of the septal ting the suture and atrial septal defect is closed directly
occluder devices is a common complication of the proce- orwithpatch.
dure [2]. The migrated devices with failed percutaneous
retrieval must be removed surgically under cardiopulmo-
Discussion
narybypass.
Recently, percutaneous transcatheter procedures emer-
ged as therapeutic alternatives for closure of both atrial
Methods septal defects and patent foramen ovale. Percutaneous
As soon as the pericardium is opened, the migrated de- closure of ASDs is an excellent therapeutic option for
vice is palpated. Pre-operative fluoroscopy or simply the appropriate patient, yielding comparable results to
transthoracic echocardiography locates the migrated de- surgery with minimal morbidity and complications. Un-
vice. As the device is palpated, it is held in the pair of fortunately, however, such percutaneous procedures may
forceps along with the wall of the chamber, mostly right require surgical intervention for early or late complica-
atrium. A 3-0 polypropelene suture is entered through tions. Percutaneous ASD closure has proven to be re-
liable, safe, and effective [3]. The reported success rate
*Correspondence:[email protected]
of these devices in closing ASD is as high as 98% [4].
1DepartmentofCardiothoracicandVascularsurgery,PostgraduationInstitute
ofMedicalResearchandEducation,Sector-12,Chandigarh160012,India Periprocedural complications include air embolism, de-
2DepartmentofCardiothoracicTransplantationandMechanicalSupport, vice migration, cardiac tamponade, device erosion, atrial
RoyalBromptonandHarefieldNHSTrust,HillEndRoad,UB96JH,London,
arrhythmias, and those related to vascular access [2].
UK
Fulllistofauthorinformationisavailableattheendofthearticle Moreover, device related complications include device
©2013Mohiteetal.;licenseeBioMedCentralLtd.ThisisanOpenAccessarticledistributedunderthetermsoftheCreative
CommonsAttributionLicense(http://creativecommons.org/licenses/by/2.0),whichpermitsunrestricteduse,distribution,and
reproductioninanymedium,providedtheoriginalworkisproperlycited.
Mohiteetal.JournalofCardiothoracicSurgery2013,8:10 Page2of3
http://www.cardiothoracicsurgery.org/content/8/1/10
Figure1Suturepassingthroughtheoccludedevicefromoutsidetherightatrium.
migration, device fracture, device thrombosis, and device palpating the migrated device gently and holding it with
erosion. Device embolization occurs in about 0.55% of the pair of forceps. The device is then sutured from out-
cases, regardless of ASD size, device size, or the physi- side to the wall of the chamber containing it with fine
cian’sexpertise[5]. polypropelene suture. Once the device is thus secured to
There are several reasons for the acute failure of these the chamber wall, procedure can be progressed without
devices. Themostimportantissuboptimalpatientand/or hesitation and fear of further migration of device. This
device selection [6,7]. Other suggested mechanisms of technique which does not consume much time is useful
acute failure are device related failure, inadequate expe- in occluder device migration in any patient irrespective
rience, poor defect rim to hold the device [4-6], and tear- ofageorurgencyoftheprocedure.
ing of the interatrial septum as a result of catheter and
devicemanipulations [7].Ithas been reported by Balbi M
Competinginterests
et al. that percutaneous retrieval was successful in 50% of
Theauthorsdeclarethattheyhavenocompetinginterests.
the casesofASOembolizationthathavebeenreportedin
theliterature[8].
Authors’contribution
Once the device is migrated, it may slip into right
PNM:Concept,wrotethemanuscript;SDR,PPKandAS:gaveimportant
atrium, right ventricle to pulmonary artery or into left comments;AFP:madecriticalrevisionofthearticleanddraftedthe
atrium, left ventricle to aorta. Surgical intervention manuscript.Allauthorsreadandapprovedthefinalmanuscript.
becomes mandatory when the migrated device could not
Authordetails
be retrieved by percutaneous catheter intervention [9]. 1DepartmentofCardiothoracicandVascularsurgery,PostgraduationInstitute
Urgent surgery and device retrieval is necessary when ofMedicalResearchandEducation,Sector-12,Chandigarh160012,India.
2DepartmentofCardiothoracicTransplantationandMechanicalSupport,
device gets migrated into heart chambers and causes
RoyalBromptonandHarefieldNHSTrust,HillEndRoad,UB96JH,London,
arrhythmiaorhemodynamic compromise. UK.3DepartmentofThoracicCardiovascularSurgery,UniversityofGöttingen,
The migrated septal occluder device may be further Robert-Koch-Strasse40,37099,Göttingen,Germany.
migrated due to manipulation of the heart while putting
Received:21August2012Accepted:11January2013
patient on cardiopulmonary bypass. Authors suggest Published:16January2013
Mohiteetal.JournalofCardiothoracicSurgery2013,8:10 Page3of3
http://www.cardiothoracicsurgery.org/content/8/1/10
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doi:10.1186/1749-8090-8-10
Citethisarticleas:Mohiteetal.:Suturefixationofmigratedseptal
occluderdevicetopreventfurthermigration:asimplesurgical
technique.JournalofCardiothoracicSurgery20138:10.
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