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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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Prashanth Panduranga (Royal Hospital) Aug 07, 2020
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| In this patient the balloon stretched diameter of the defect was 16 mm and same size device was used, probably must have used larger device then it would not have embolized. Also it is important to assess TEE size of defect in different views and make use of 3D sizing of the defect. | |
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Prashanth Panduranga (Royal Hospital) Aug 07, 2020
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| Good question. Generally DAPT is given for 3 months and then aspirin for total 6 months for all shunt devices | |
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Prashanth Panduranga (Royal Hospital) Aug 07, 2020
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| Thanks for your comments. Yes, post ASD device closure patients nee to avoid lifting weight or any strenous sport activity for at least 3 months. These can cause valsalva like affect with sudden increase in left side afterload and underfilling of right side lead to device embolization. In addtion, should prevent or avoid continues cough which also can cause device embolization. | |
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Baher Hanna (NMC Specialty Hospital, Muscat) Aug 07, 2020
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| What are the possible causes of device embolization here ? | |
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Baher Hanna (NMC Specialty Hospital, Muscat) Aug 07, 2020
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| For how long do you recommend DAPT post device closure and Is it recommended post PDA closure also or no need in case of PDA device closure ? | |
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Baher Hanna (NMC Specialty Hospital, Muscat) Aug 07, 2020
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| Interesting case, Thank you for sharing, Is any special advice should we give to pts post Device closure ? Like avoid strenuous exercise for Specific period. | |