Late complications of transcatheter atrial septal defect closure requiring urgent surgery

A 21-year-old female patient was transferred to our hospital after being diagnosed with massive pulmonary thromboembolism (PTE). Three years prior to admission, she underwent transcatheter closure of the secundum ASD with a 33 mm CardioSEAL-StarFLEX occluder (NMT Medical, Boston, MA, USA). A year ago, she was involved in a car accident and sustained significant blunt chest trauma. Transthoracic echocardiography confirmed the presence of thrombi in the right atrium and the pulmonary artery, with massive dilatation of the right ventricle and the pulmonary artery, along with severe pulmonary hypertension. Also, protrusion or dislodgement of the occluder was suspected. Her deteriorated clinical conditions warranted immediate surgery. The patient was put on a cardiopulmonary bypass (CPB) and the right atrium and the pulmonary artery were opened. Several thrombi were removed, the largest being 2 × 3 cm. The ASD occluder was identified with a thrombus attached to it and evident device-arm fracture (Figure 1). The occluder underwent almost complete healing with full endocardium covering except in the rim area. The device was removed and the ASD was repaired with a patch. Unfortunately, due to right heart failure, the patient could not be successfully weaned from the CPB, not even after an artificially created interatrial shunt, and she expired. Although one cannot say with absolute certainty that massive PTE developed because of device-related thrombosis, it seems intuitive that blood turbulence around the protruded umbrella and device-arm fracture could have acted as a nidus for repeated thrombus formation with subsequent embolization. The occluder malfunction (fracture) was most likely the result of sustained blunt chest trauma a year prior to admission. We hypothesize that the sudden increase in intrathoracic pressure during trauma as well as direct compression on the heart generated a point of high wall stress around the occluder’s septal insertion, which may have led to device fracture and dislodgment.