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 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 3  |  Issue : 3  |  Page : 76-78

An Interesting Case Report of Unexpected VSD Device Embolization and its Challenging Percutaneous Retrieval


Department of Cardiology, Sapthagiri Institute of Medical Sciences, Hessarghatta, Bangalore, Karnataka, India

Date of Web Publication7-Sep-2015

Correspondence Address:
Dr. Vinod Raghunath Revankar
Department of Cardiology, Sapthagiri Institute of Medical Sciences, Hessarghatta Main Road, Bangalore - 560 090, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2321-449X.157278

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  Abstract 

Device closure of Ventricular septal defect (VSD) is gaining popularity as a preferred method of treatment in suitable patients. The decreased morbidity and mortality associated with the procedure as compared to open heart surgery is the main reason behind this. Device embolization is a dreaded complication that occurs rarely with this procedure. While surgical retrieval of the device is preferred at most centres, the device can be retrieved per cutaneously by employing suitable maneuvers. We are reporting a case where we successfully retrieved an embolized ADOII device in our patient. We intend to emphasize the need for thorough pre operative assessment of the patient before proceeding with device closure in order to prevent this complication from occurring.

Keywords: Congenital heart disease, per cutaneous retrieval, VSD device embolization


How to cite this article:
Revankar VR, Varghese TG, Papanna M. An Interesting Case Report of Unexpected VSD Device Embolization and its Challenging Percutaneous Retrieval. Heart India 2015;3:76-8

How to cite this URL:
Revankar VR, Varghese TG, Papanna M. An Interesting Case Report of Unexpected VSD Device Embolization and its Challenging Percutaneous Retrieval. Heart India [serial online] 2015 [cited 2020 Aug 12];3:76-8. Available from: http://www.heartindia.net/text.asp?2015/3/3/76/157278


  Introduction Top


Ventricular septal defects (VSD) are common congenital heart defects with an incidence of around 20%. [1]

They can occur in isolation or in association with other cardiac anomalies. In the present day, VSD device closure is a widely accepted mode of treatment for suitable patients with VSDs. The procedure is associated with a few complications that include arrhythmias (the commonest being congenital atrio-ventricular block), vascular complications such as thromboembolism, hemolysis and infection. [2]

Device embolization is a very rare complication; a study conducted in 2007 reported an incidence of 0.9%. [3]

It is however a very dreaded event. When device embolization occurs, surgery to retrieve the device is almost always indicated; however, in suitable candidates percutaneous retrieval of the device is possible.


  Case Report Top


Ms. S, a 15-year-old female patient, presented to us with complaints of exertional dyspnea NYHA grade II-III.

Two-dimensional ECHO revealed perimembranous VSD measuring 4-5mm shunting left to right with a gradient of 65 mm Hg, dilated left atrium/left ventricle (LA/LV) and mild pulmonary stenosis (PS) with a pulmonary valve gradient of 25 mm Hg.

She was advised percutaneous VSD device closure using Amplatzer duct occluder II (ADO II) in view of the type and size of the defect. After taking informed consent, she was taken up for the procedure.

During the procedure of LV angiogram, a 3 mm VSD shunting left to right was revealed. Prior to device implantation, right heart catheterization was done to rule out right ventricular outflow tract obstruction; the right mid-ventricular obstruction pull back pressure gradient recorded across pulmonary valve was around 10 mm Hg, which is clinically not significant. She successfully underwent VSD device closure with ADO II (6 × 4 mm) device.

LV angiogram did not show any residual VSD. On clinical examination, there was no murmur detected in the left parasternal region and ECHO done showed device in situ with no residual VSD. The immediate post-procedural period was uneventful. Thirty-six hours following device closure, the patient complained of pain in the left upper parasternal region and a sense of discomfort in the chest.

Clinical examination revealed a harsh pan-systolic murmur grade 4/6 in the left upper parasternal region and left infraclavicular region; a clinical suspicion of device embolization was suspected. ECHO showed instability of the device; the right half was showing floppy movement and stretching of the device, which was getting pulled into the RV.

Right ventricle outflow tract (RVOT) gradient of 60 mm Hg was recorded, which was eventually confirmed by cardiac catheterization. A careful and detailed repeat ECHO revealed that the VSD was a subaortic outlet VSD with mildly restrictive double chamber right ventricle (DCRV), which got precipitated to severe DCRV after device implantation. The choice of combined retrieval of the device with surgical closure of the VSD was advised as the next step in the course of action, but owing to unwillingness on the part of the relatives for surgery, percutaneous device retrieval was attempted.

Device retrieval involved a lot of challenges mainly due to the anatomy of right ventricle (RV) and RVOT. Hooking the device with the snare almost took an hour's effort, which involved the use of 6F, 7F JR catheters, multipurpose catheters and even a Mullen sheath. Eventually the device was retrieved by basket snare up to inferior vena cava (IVC) but it was met with a daunting task of retrieving the device within the sheath due to its dumbbell-shaped architecture [Figure 1].
Figure 1: Fluoroscopic image showing snaring of device

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We had to enter through the left femoral vein with a larger Mullen sheath, measuring 8F that was introduced and placed across the device in the IVC. Since we did not have another snare at hand, we used a regular emerald guide wire of 0.35, which was shaped for the snare retrieval [Figure 2] and [Figure 3].
Figure 2: Fluoroscopic image showing continued manipulation through the Mullen sheath, RCA catheter with 0.35 converted into a snare

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Figure 3: Fluoroscopic image showing continued manipulation with snare

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The device was hooked and snared with this wire but it could not be snared into 8F Mullen sheath as the device had got tangled within the basket snare. With repeated manipulation of the snare with the device in AP, right oblique and left oblique views, the device could be released from the basket snare and successfully retrieved through the 8F Mullen sheath in the left side through the left femoral vein [Figure 4] and [Figure 5].
Figure 4: Fluoroscopic image showing device retrieved into the Mullen sheath and brought into IVC

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Figure 5: Fluoroscopic image showing device retrieval successful in the Mullen sheath through left femoral vein

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The patient underwent surgical closure of the VSD successfully; 3 days after device retrieval, postoperative period was uneventful.


  Discussion Top


VSDs are the most common congenital cardiac anomalies. The surgical approach performed for the first time by Lillehei et al., in 1954 [4] is considered to be the gold standard; however, it is associated with some complications, including complete atrio ventricular block (cAVB), significant residual VSD, the need for repeat surgery in 2% of the patients, and infections, postoperative morbidity and complications associated with anesthesia. [5],[6]

Following the introduction of the Amplatzer family of septal occluding devices, percutaneous closure has gained popularity and widespread acceptance. [7],[8],[9],[10]

The procedure is not without its flaws. Complications such as cAVB, unexpected vascular events, hemolysis, device embolization and erosion are known to occur albeit to a lesser extent. A thorough and detailed patient analysis is most important for patient selection for device closure.

It is of prime importance to rule out any form of DCRV prior to device closure because as seen in the case presented, a mild form of DCRV may get precipitated into a severe form and cause device deformity and device instability owing to the complaint nature of the ADO II device.

Since device embolization is an emergency, surgery is the preferred mode of retrieval; however, percutaneous device retrieval is possible with careful manipulation and dexterity. Even though it can be a time-consuming process, we strongly feel that in the right setting it must be attempted in order to prevent the mortality and morbidities associated with an open surgical approach for the same.

 
  References Top

1.
Rudolph AM. Ventricular septal defect. In: Rudolph AM, editor. Congenital diseases of the heart: Clinical-physiological considerations. 2 nd ed. Armonk: Futura Publishing Company; 2001. p. 197-244.  Back to cited text no. 1
    
2.
Holzer R, Balzer D, Cao QL, Lock K, Hijazi ZM. Amplatzer Muscular Ventricular Septal Defect Investigators. Device closure of muscular ventricular septal defects using the Amplatzer muscular ventricular septal defect occlude: Immediate and mid-term results of a U. S. registry. J Am Coll Cardiol 2004;43:1257-63.  Back to cited text no. 2
    
3.
Carminati M, Butera G, Chessa M, De Giovanni J, Fisher G, Gewillig M, et al. Investigators of the European VSD Registry. Transcatheter closure of congenital ventricular septal defects: Results of the European Registry. Eur Heart J 2007;28:2361-8.  Back to cited text no. 3
    
4.
Lillehei CW, Cohen M, Warden HE, Ziegler NR, Varco RL. The results of direct vision closure of ventricular septal defects in eight patients by means of controlled cross circulation. Surg Gynecol Obstet 1955;101:446-66.  Back to cited text no. 4
    
5.
Bol-Raap G, Weerheim J, Kappetein AP, Witsenburg M, Bogers AJ. Follow-up after surgical closure of congenital ventricular septal defect. Eur J Cardiothorac Surg 2003;24:511-5.  Back to cited text no. 5
    
6.
Mavroudis C, Backer CL, Jacobs JP. Ventricular septal defect. In: Mavroudis C, Backer CL, editors. 3 rd ed. Pediatric Cardiac Surgery.Mosby, Inc.; 2003. p. 298-320.  Back to cited text no. 6
    
7.
Thanopoulos BD, Rigby ML. Outcome of transcatheter closure of muscular ventricular septal defects with the Amplatzer ventricular septal defect occluder. Heart 2005;91:513-6.  Back to cited text no. 7
    
8.
Arora R, Trehan V, Thakur AK, Mehta V, Sengupta PP, Nigam N. Transcatheter closure of congenital muscular ventricular septal defect. J Interv Cardiol 2004;17:109-15.  Back to cited text no. 8
    
9.
Bass JL, Kalra GS, Arora R, Masura J, Gavora P, Thanoupoulos BD, et al. Initial human experience with the Amplatzer perimembranous ventricular septal occluder device. Catheter Cardiovasc Interv 2003;58:238-45.  Back to cited text no. 9
    
10.
Fu YC, Bass J, Amin Z, Radtke W, Cheatham JP, Hellenbrand WE, et al. Transcatheter closure of perimembranous ventricular septal defects using the new Amplatzer membranous VSD occluder: Results of the U. S. phase I trial. J Am Coll Cardiol 2006;47:319-25.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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