Device closure of a small atrial septal defect with an unusual set of post-operative complications

BACKGROUND: Percutaneous closure of secundum atrial septal defects (ASDs) is a standard procedure. However, it is not without risk, and complications can be severe even in apparently straightforward cases. CASE PRESENTATION: A 19-year-old male (80 kg, 170 cm), with a history of infantile strabismus, underwent percutaneous closure of a small (11 × 12 mm) secundum ASD with adequate rims using an 18 mm Occlutech septal occluder.The procedure was performed under general anesthesia and transesophageal echocardiography (TEE) guidance, and the device initially appeared well positioned. The following day, routine transthoracic echocardiography (TTE) failed to visualize the device, and a diagnostic error led to the device’s location being misinterpreted as a pulmonary artery on fluoroscopy. Emergency surgery was performed to remove the device and close the defect, but the device was not found. Post-operatively, real-time 3D Computed Tomography (CT) located the device in the aortic arch. It was subsequently retrieved percutaneously. During extubation, the patient developed agitation and confusion, and a cranial CT revealed a right posterior cerebral artery infarction, resulting in left homonymous hemianopsia. Follow-up neurological assessment and MRI confirmed the ischemic sequelae. Interestingly, the patient’s pre-existing strabismus completely resolved. The potential etiology of the cerebral ischemic event includes thromboembolism from the device or catheter manipulation. CONCLUSIONS: This case highlights that severe complications, including device embolization to unexpected systemic locations and subsequent cerebrovascular events, can occur even in low-risk ASD closures. It underscores the critical importance of meticulous, multi-view intra procedural and post-procedural imaging to prevent diagnostic errors. The unexpected resolution of strabismus following a posterior cerebral artery infarct suggests a complex neuro-ophthalmological phenomenon requiring further investigation.