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Relevant clinical history and physical exam
A 35 years old female patient was transferred from local hospital because of systolic murmur and facial edema. Her vital signs were stable and within normal limit. She had no cardiovascular risk factor and past medical history. Chest PA showed both atrial enlargement and cardiomegaly.
Relevant test results prior to catheterization
TTE and TEE revealed dilated right heart and D-shaped LV and abnormal left to right shuntflows through maximally 25.0 mm and 5.9 mm - sized two ASD and the calculated ratioof pulmonary (Qp) to systemic blood flow (Qs) was 3.1. There are no aorticrim and 23 mm sized posterior rim in 90 degree view of TEE and 15mm sized IVC rim and 13 mm sized SVC rim on bicaval view of TEE.
Relevant catheterization findings
Computed tomography of heart showed the same finding of TEE. A right heart catheterization revealed SaO2 jump up in right atrium and the calculated ratio of pulmonary (Qp) to systemic blood flow (Qs) by catheterization was 3.4.
Under the TTE and fluoroscopicguidance, percutaneous device closure of ASD performed using Amplatz septaloccluder (ASO). Balloon-sizing diameter of ASD measured as 29 mm usingstop-flow technique, and thereby 30 mm-sized ASO implanted in the defect. Intag test, the device dislodged two times but finally, the result of tag testwas successful. Final TTE revealed good apposition of ASO devices with minimalresidual shunt flow.
The patient experienced transientchest discomfort on the next day. On the portable echocardiography, anembolized device was found in her right atrium. We decided to retrieve thedevice and close the defect surgically because the final TTE showed that thedevice was large to her interatrial septum and we are worried about contact ofbigger device with mitral valve structure. The embolized device retrieved surgicallyand the defect closed with bovine pericardial patch. In surgeon’s view, there wasno aortic rim in surgeon’s view from 11 to 3 o’clock. The patient had no complication and event after the operationand discharged. For 1 year of clinical, follow up.
It is essential to prevent device embolization in precutaneous atrial septal occlusion that we should focus on pre-evaluation of ASD and surrounding structure with caution. In this case surgeon's real view of ASD showed the area without a aortic rim was very large. That seems to be one of important risk factor of device embolization and that TEE guided procedure is mandatory.