Hybrid placement and subsequent successful hybrid repositioning of unbuttoned Amplatzer Septal Occluder through mini- anterior-thoracotomy in a premature infant

A 4-month-old premature infant with moderate secundum atrial septal defect (ASD) and pulmonary hypertension (on inhaled nitric oxide and sildenafil) underwent successful closure of the ASD via a hybrid per-atrial approach through a surgical right anterior mini-thoracotomy. Two days later the 8 mm Amplatzer Septal Occluder (ASO) was noted to be malpositioned with the right atrial disc partly in the left atrium. The malpositioned device was approached via the same surgical right anterior mini-thoracotomy and a hybrid approach. An 8 fr sheath was introduced per-atrially. A 10 mm Amplatz Gooseneck Snare was positioned over the microscrew and snared. The right atrial disc was partially recaptured, and the device successfully redeployed across the atrial septum. This is the first report of successful hybrid retrieval and repositioning of malpositioned ASD occluder in a premature infant. Early detection of malposition when the occluder was still partially attached to the septum enabled us to attempt hybrid snare retrieval through mini-thoracotomy. It could be considered as a good alternative given limited exposure to fluoroscopy and avoiding CPB.