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CASE20191003_003
| STRUCTURAL HEART DISEASE - Congenital Heart Disease (ASD, PDA, PFO, VSD) | |
| The Vanishing Act | |
| Panduranga Prashanth1 | |
| National Heart Center, Oman1, | |
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[Clinical Information]
- Patient initials or identifier number:
AS
-Relevant clinical history and physical exam:
Mr. AS, a 26-year old male underwent successful atrial septal defect (ASD) device closure using 16mm Amplatzer septal occluder (ASO) device. Next day CXR and transthoracic echocardiogram showed device-in-situ with no residual shunt. He was discharged and advised 1month follow-up as per department protocol, but he defaulted.After 4-months, clinical examination revealed grade 3/6 ejection systolic murmur pulmonic area. He was asymptomatic.
 Video 1.mp4-Relevant test results prior to catheterization:
An echocardiogram showed no device in the atrial septum with persistenceof ASD with left to right shunt [Video 1].Comprehensive echo search showed the device seen embolized to distal aortic arch fixed to aortic wall post left subclavian artery (LSCA) [Video 2].Chest X-ray confirmed the device seen in distal aortic arch.
Video 2.mp4  - Relevant catheterization findings:
Cath-Device seen embolized to distal aortic arch fixed to aortic wall post LSCA [Video 2a].
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[Interventional Management]
- Procedural step:
Percutaneous retrieval was attempted using a snare, but could not be detached from aortic wall [Video 3].Underwent successful aortotomy and surgical retrieval of the device [Figure 1] and ASD closure. Aortic intima was disrupted at the posterior aspect close to origin of LSCA which was repaired using 6-0 prolene. In another similar patient device embolization to aortic arch was seen next day which could be retrieved by snaring [Video 4].Multiple factors are involved in device embolization, namely;
Video 3.mp4 Video 4 2nd pt.mp4 - Case Summary:
This case brings in two important messages: 1. Need for regular follow-up of these patients with Chest-X-ray and echocardiography as silent embolism of these devices are becoming common. 2. Longer the duration of device closure and embolization, it is better not to attempt percutaneous approach to retrieve it and go directly for surgical removal as the device fixes deeply in the tissue and may cause damage during percutaneous removal. |
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