Case report
An extremely rare malformation of an atrial septal defect closure device and use of a new corrective technique
Uma malformação extremamente rara do dispositivo de oclusão percutânea da comunicação interauricular e uso de uma técnica terapêutica nova
Korhan Soylu
, Murat Meriç, Ufuk Yıldırım, Okan Gulel
Corresponding author
Department of Cardiology, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
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=> array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Concave deformation of the distal left atrial (LA) disc preventing full device recapture (A); the stiff and flat side of a 0.038” J-wire guided through the sheath to the LA disc (B); concave deformity rectified by engaging the hub section, and the device completely retracted into the sheath (C); final position of the 26 mm Cera device after implantation (D).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Atrial septal defect (ASD) occluder device deformations are rare complications encountered during transcatheter ASD closure. Cobrahead device malformation is the most commonly reported of these complications.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">1</span></a> Recently, a new malformation, called tulip malformation, has been reported with the LifeTech Cera ASD occluder.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">2</span></a> Our case report is the second in the literature in which a tulip malformation was seen. However, a simple and previously unused technique was used to correct the deformation.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 51-year-old woman diagnosed with secundum ASD was referred to our center for transcatheter closure. The presence of secundum ASD was confirmed by transesophageal echocardiography (TEE), which showed the patient's defect to be 19 mm in diameter. Under local anesthesia and under the guidance of TEE, a 12 F SteerEase delivery sheath (Lifetech Scientific, Shenzhen, China) was deployed in the left atrium (LA) over a 0.035” wire via the right femoral vein. A 22 mm Cera ASD device was then opened in the defect under fluoroscopic and TEE guidance. The attempt was unsuccessful because of failure of the device to approach the defect at the appropriate angle. During subsequent attempts, it was observed that the structure of the device had changed; the LA disc had become concave (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>A) and could no longer be retracted into the sheath. This deformation could not be corrected by manipulations inside the LA. The device, which was partially retracted into the sheath, was then taken into the right atrium, which was safer. When further attempts in the right atrium failed, a different solution was considered. The stiff and flat side of a 0.038” J-wire was guided through the sheath containing the device. With the delivery cable in traction and held stable, an attempt was made to advance the hub of the LA disc with the stiff side of the 0.038” J-wire under fluoroscopy. After several attempts, the concave deformity was rectified by engaging the hub section, and the device was completely retracted into the sheath (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>B and C, Video 1 and 2). The removed device was discovered to have a distorted structure, resembling a tulip (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>). A new 26 mm Cera device was then successfully deployed in the defect (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>D) and the procedure was completed.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0015" class="elsevierStylePara elsevierViewall">The cobrahead malformation during transcatheter ASD closure has been thoroughly described.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">3,4</span></a> However, a tulip-shaped occluder deformation has only been reported once previously.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">2</span></a> Hayes et al. managed to rectify the concave deformation by capturing the hub of the LA disc with a snare through the right internal jugular vein. Given the fact that the hub of the LA disc is only 1–2 mm in diameter, this procedure can be said to be technically challenging and requires dexterity. It also requires separate vascular access. In our technique, neither separate vascular access nor extensive snare experience is required.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion</span><p id="par0020" class="elsevierStylePara elsevierViewall">Transcatheter closure of secundum ASD cases is a method that is frequently and successfully applied nowadays. It is inevitable that similar device malformations will be encountered in the future with increasing frequency of the procedure. Therefore, we believe that the new technique defined in our case will provide a relatively easy, effective and rapid solution to similar device malformations.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Ethical disclosures</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Protection of human and animal subjects</span><p id="par0025" class="elsevierStylePara elsevierViewall">The authors declare that the procedures followed were in accordance with the regulations of the relevant clinical research ethics committee and with those of the Code of Ethics of the World Medical Association (Declaration of Helsinki).</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Confidentiality of data</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Right to privacy and informed consent</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflicts of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres525254" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec545492" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres525255" "titulo" => "Resumo" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec545493" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusion" ] 8 => array:3 [ "identificador" => "sec0025" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "Right to privacy and informed consent" ] ] ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-09-18" "fechaAceptado" => "2014-11-15" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec545492" "palabras" => array:3 [ 0 => "Atrial septal defect" 1 => "Tulip malformation" 2 => "Device complication" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec545493" "palabras" => array:3 [ 0 => "Comunicação interauricular" 1 => "Malformação em tulipa" 2 => "Complicação do dispositivo" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Tulip malformation is a newly defined complication of transcatheter atrial septal defect closure. This complication, in which the left atrial disc becomes concave, makes it impossible to fully retract the device into the delivery sheath. The case presented is the first report describing a simple new technique which overcomes this novel complication.</p></span>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A malformação em tulipa é uma complicação recentemente descrita da oclusão percutânea da comunicação interauricular (CIA). Esta complicação em que o disco na aurícula esquerda adquire uma forma côncava durante o implante, impedindo a reintrodução do dispositivo na bainha. O caso apresentado é o primeiro relato que descreve uma forma nova e simples de superar este complicação.</p></span>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0050" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="upi0005"></elsevierMultimedia><elsevierMultimedia ident="upi0010"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary material" "identificador" => "sec0055" ] ] ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1326 "Ancho" => 1400 "Tamanyo" => 242488 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Concave deformation of the distal left atrial (LA) disc preventing full device recapture (A); the stiff and flat side of a 0.038” J-wire guided through the sheath to the LA disc (B); concave deformity rectified by engaging the hub section, and the device completely retracted into the sheath (C); final position of the 26 mm Cera device after implantation (D).</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 617 "Ancho" => 1374 "Tamanyo" => 185492 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Images of the device after extraction.</p>" ] ] 2 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc1.mp4" "ficheroTamanyo" => 3478250 "Video" => array:2 [ "mp4" => array:2 [ "fichero" => "mmc1.m4v" "poster" => "mmc1.jpg" ] "flv" => array:5 [ "fichero" => "mmc1.flv" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] ] 3 => array:5 [ "identificador" => "upi0010" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc2.mp4" "ficheroTamanyo" => 830171 "Video" => array:2 [ "mp4" => array:2 [ "fichero" => "mmc2.m4v" "poster" => "mmc2.jpg" ] "flv" => array:5 [ "fichero" => "mmc2.flv" "poster" => "mmc2.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:4 [ 0 => array:3 [ "identificador" => "bib0025" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Experience with transcatheter closure of secundum atrial septal defects using the Amplatzer septal occluder: a single centre study in 236 consecutive patients" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "G. Fischer" 1 => "J. Stieh" 2 => "A. Uebing" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "Heart" "fecha" => "2003" "volumen" => "89" "paginaInicial" => "199" "paginaFinal" => "204" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12527678" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S188558571300073X" "estado" => "S300" "issn" => "18855857" ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0030" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tulip malformation of the left atrial disc in the Lifetech Cera ASD device: a novel complication of percutaneous ASD closure" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "N. Hayes" 1 => "E. Rosenthal" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/ccd.23246" "Revista" => array:7 [ "tituloSerie" => "Catheter Cardiovasc Interv" "fecha" => "2012" "volumen" => "79" "paginaInicial" => "675" "paginaFinal" => "677" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21805581" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0300893211001515" "estado" => "S300" "issn" => "03008932" ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0035" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cobrahead malformation of the Amplatzer septal occluder device: an avoidable complication of percutaneous ASD closure" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J.C. Cooke" 1 => "J.S. Gelman" 2 => "R.W. Harper" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Catheter Cardiovasc Interv" "fecha" => "2001" "volumen" => "52" "paginaInicial" => "83" "paginaFinal" => "85" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11146530" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0040" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cobra head deformity of Amplatzer septal occluder" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "V. Trehan" 1 => "S. Mukhopadhyay" 2 => "J. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 6 | 4 | 10 |
| 2024 October | 32 | 24 | 56 |
| 2024 September | 44 | 20 | 64 |
| 2024 August | 40 | 24 | 64 |
| 2024 July | 30 | 26 | 56 |
| 2024 June | 35 | 17 | 52 |
| 2024 May | 37 | 19 | 56 |
| 2024 April | 36 | 28 | 64 |
| 2024 March | 45 | 18 | 63 |
| 2024 February | 40 | 20 | 60 |
| 2024 January | 28 | 25 | 53 |
| 2023 December | 28 | 18 | 46 |
| 2023 November | 34 | 29 | 63 |
| 2023 October | 24 | 12 | 36 |
| 2023 September | 35 | 22 | 57 |
| 2023 August | 30 | 15 | 45 |
| 2023 July | 36 | 10 | 46 |
| 2023 June | 40 | 15 | 55 |
| 2023 May | 46 | 24 | 70 |
| 2023 April | 24 | 5 | 29 |
| 2023 March | 26 | 21 | 47 |
| 2023 February | 36 | 19 | 55 |
| 2023 January | 27 | 19 | 46 |
| 2022 December | 50 | 19 | 69 |
| 2022 November | 42 | 27 | 69 |
| 2022 October | 39 | 18 | 57 |
| 2022 September | 28 | 30 | 58 |
| 2022 August | 29 | 32 | 61 |
| 2022 July | 43 | 35 | 78 |
| 2022 June | 30 | 23 | 53 |
| 2022 May | 28 | 32 | 60 |
| 2022 April | 42 | 26 | 68 |
| 2022 March | 33 | 29 | 62 |
| 2022 February | 32 | 24 | 56 |
| 2022 January | 38 | 17 | 55 |
| 2021 December | 21 | 26 | 47 |
| 2021 November | 35 | 29 | 64 |
| 2021 October | 39 | 26 | 65 |
| 2021 September | 45 | 29 | 74 |
| 2021 August | 40 | 25 | 65 |
| 2021 July | 25 | 28 | 53 |
| 2021 June | 24 | 20 | 44 |
| 2021 May | 32 | 38 | 70 |
| 2021 April | 63 | 20 | 83 |
| 2021 March | 75 | 19 | 94 |
| 2021 February | 46 | 12 | 58 |
| 2021 January | 30 | 14 | 44 |
| 2020 December | 34 | 5 | 39 |
| 2020 November | 49 | 7 | 56 |
| 2020 October | 26 | 8 | 34 |
| 2020 September | 51 | 6 | 57 |
| 2020 August | 26 | 6 | 32 |
| 2020 July | 52 | 8 | 60 |
| 2020 June | 41 | 10 | 51 |
| 2020 May | 50 | 9 | 59 |
| 2020 April | 55 | 11 | 66 |
| 2020 March | 42 | 5 | 47 |
| 2020 February | 102 | 14 | 116 |
| 2020 January | 93 | 6 | 99 |
| 2019 December | 209 | 7 | 216 |
| 2019 November | 63 | 8 | 71 |
| 2019 October | 736 | 6 | 742 |
| 2019 September | 63 | 9 | 72 |
| 2019 August | 33 | 2 | 35 |
| 2019 July | 45 | 16 | 61 |
| 2019 June | 52 | 6 | 58 |
| 2019 May | 39 | 11 | 50 |
| 2019 April | 36 | 16 | 52 |
| 2019 March | 110 | 10 | 120 |
| 2019 February | 74 | 10 | 84 |
| 2019 January | 50 | 4 | 54 |
| 2018 December | 54 | 10 | 64 |
| 2018 November | 88 | 9 | 97 |
| 2018 October | 173 | 21 | 194 |
| 2018 September | 52 | 15 | 67 |
| 2018 August | 52 | 7 | 59 |
| 2018 July | 36 | 2 | 38 |
| 2018 June | 67 | 4 | 71 |
| 2018 May | 61 | 10 | 71 |
| 2018 April | 97 | 3 | 100 |
| 2018 March | 65 | 6 | 71 |
| 2018 February | 81 | 6 | 87 |
| 2018 January | 43 | 5 | 48 |
| 2017 December | 67 | 7 | 74 |
| 2017 November | 51 | 5 | 56 |
| 2017 October | 45 | 7 | 52 |
| 2017 September | 47 | 7 | 54 |
| 2017 August | 39 | 9 | 48 |
| 2017 July | 37 | 6 | 43 |
| 2017 June | 47 | 12 | 59 |
| 2017 May | 45 | 26 | 71 |
| 2017 April | 64 | 28 | 92 |
| 2017 March | 62 | 5 | 67 |
| 2017 February | 64 | 2 | 66 |
| 2017 January | 56 | 5 | 61 |
| 2016 December | 55 | 13 | 68 |
| 2016 November | 40 | 4 | 44 |
| 2016 October | 87 | 1 | 88 |
| 2016 September | 121 | 4 | 125 |
| 2016 August | 59 | 4 | 63 |
| 2016 July | 28 | 5 | 33 |
| 2016 June | 38 | 1 | 39 |
| 2016 May | 26 | 2 | 28 |
| 2016 April | 25 | 3 | 28 |
| 2016 March | 29 | 9 | 38 |
| 2016 February | 25 | 10 | 35 |
| 2016 January | 33 | 24 | 57 |
| 2015 December | 26 | 10 | 36 |
| 2015 November | 35 | 5 | 40 |
| 2015 October | 28 | 5 | 33 |
| 2015 September | 37 | 9 | 46 |
| 2015 August | 40 | 8 | 48 |
| 2015 July | 54 | 11 | 65 |
| 2015 June | 18 | 1 | 19 |
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