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\begin{document}

\title{Surgical retrieval of embolized atrial septum defect closure device from
right pulmonary vein}



\author[1]{Fei Zhao}%
\author[2]{Yongjun Qian}%
\affil[1]{Sichuan University West China Hospital Department of Radiology}%
\affil[2]{Sichuan University West China Hospital}%


\vspace{-1em}



  
  \date{May 27, 2024}


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\selectlanguage{english}
\begin{abstract}
A 69-year-old woman presented to the emergency department for symptoms
of acute right heart failure including progressive exertional dyspnea
and limbs weakness. Physical examination showed slight cyanosis and cold
limbs. She underwent percutaneous transcatheter closure of a secundum
ASD through femoral vein eight months before. On further investigation,
transthoracic echocardiography (TTE) revealed severe tricuspid
regurgitation and the migrated ASD device (Figure 1), and the
embolization seemed to be located near the left ventricular inflow
tract. Computed tomography (CT) and three-dimensional reconstruction
confirmed the left-side migration of the device, and revealed
obstruction of RPV caused by the embolization (Figure 2).%
\end{abstract}%



\sloppy


\textbf{Title Page}

\textbf{Surgical retrieval of embolized atrial septum defect closure
device from right pulmonary vein}

Fei Zhao\textsuperscript{1}, Yongjun Qian\textsuperscript{2\#}

\textsuperscript{1} Department of Radiology, West China Hospital,
Sichuan University, Guoxuexiang 37th, 610041 Chengdu, Sichuan, P.R.
China.

\textsuperscript{2} Department of Cardiovascular Surgery, West China
Hospital, Sichuan University, Guoxuexiang 37th, 610041 Chengdu, Sichuan,
P.R. China.

\textsuperscript{\#} Correspondence: Yongjun Qian, No. 37 GuoXue Xiang,
Chengdu, Sichuan, 610041, People's Republic of China; fax: + 86 28
85422897; e-mail: \emph{qianyongjun@scu.edu.cn} .

\textbf{Surgical retrieval of embolized atrial septum defect closure
device from right pulmonary vein}

Fei Zhao\textsuperscript{1}, Yongjun Qian\textsuperscript{2\#}

\textsuperscript{1} Department of Radiology, West China Hospital,
Sichuan University, Guoxuexiang 37th, 610041 Chengdu, Sichuan, P.R.
China.

\textsuperscript{2} Department of Cardiovascular Surgery, West China
Hospital, Sichuan University, Guoxuexiang 37th, 610041 Chengdu, Sichuan,
P.R. China.

\textsuperscript{\#} Correspondence: Yongjun Qian, No. 37 GuoXue Xiang,
Chengdu, Sichuan, 610041, People's Republic of China; fax: + 86 28
85422897; e-mail: \emph{qianyongjun@scu.edu.cn} .

A 69-year-old woman presented to the emergency department for symptoms
of acute right heart failure including progressive exertional dyspnea
and limbs weakness. Physical examination showed slight cyanosis and cold
limbs. She underwent percutaneous transcatheter closure of a secundum
ASD through femoral vein eight months before. On further investigation,
transthoracic echocardiography (TTE) revealed severe tricuspid
regurgitation and the migrated ASD device (Figure 1), and the
embolization seemed to be located near the left ventricular inflow
tract. Computed tomography (CT) and three-dimensional reconstruction
confirmed the left-side migration of the device, and revealed
obstruction of RPV caused by the embolization (Figure 2). Given the
clinical features and radiological findings, the diagnosis of ASD
closure device migration was decided, and symptoms of heart failure were
caused by RPV obstruction. In consideration of eight months after
percutaneous closure, a safe surgical retrieval procedure reported by
our center before was performed {[}1{]}. Standard median sternotomy and
cardiopulmonary bypass were performed first, access was via right
atrium. Then removed the endothelialized tissue around the device, and
the ``knot'' of device was held up and cut off, the fine wires were
spread out and retrieved one by one. Finally, the device was easily
retrieved when only two wires remained, and the ASD was closed
surgically.

Postoperative vital signs were stable and the patient was discharged for
home without symptoms of right heart failure. At the follow up one month
later, TTE revealed no significant residual leaks at the ASD level, and
no dyspnea or weakness was found.

Many complications such as deice embolization, erosion, bleeding,
arrhythmias, infection, air embolism and thromboembolism have been
reported in previous studies {[}2,3{]}, embolization has the highest
incidence rate among all complications.The major time of embolization is
reported in the first 24h, and the most common sites are the main or
branched pulmonary artery and atrioventricular valve, rarely migrate to
the left side.However, several weeks or months after deployment, because
of endothelialization, device is firmly fixed in the tissue, there is
little chance for device to migrate. On the other hand, once these
devices of endothelial happen to migrate, retrieving the embolization
percutaneously is hard and dangerous. Surgical retrieval could be
selected and done with less risks and better results when failing or
hard to retrieve percutaneously. Techniques such as direct retrieval and
using two forceps to fold the device have been reported {[}4{]}. In this
case, we performed a safe procedure to retrieve the migrated device, as
our center has used this procedure to retrieve migrated ventricular
septal defect closure device {[}1{]}, which could minimize valve and
conduction system complications.

\textbf{DECLARATION OF PATIENT CONSENT}

The authors certify that they have obtained all appropriate patient
consent forms. The patients understand that their names and initials
will not be published and due efforts will be made to conceal their
identity, but anonymity cannot be guaranteed.

\textbf{CONFLICT OF INTERESTS}

The authors declare that there are no conflict of interests.

\textbf{REFERENCES}

1. Lin G, Su Y, Qian YJ. Safe Surgical Retrieval of Endothelialized
Ventricular Septal Defect Closure Device. Heart Surg Forum. 2020 May
6;23(3):E285-E286.

2. Karampinis I, Pfleger S, Nowak K. Extracardial migration of an atrial
septal defect occluder device. J Invasive Cardiol. 2013
Dec;25(12):E219-20.

3. Yang MC, Wu JR. Recent review of transcatheter closure of atrial
septal defect. Kaohsiung J Med Sci. 2018 Jul;34(7):363-369.

4. Yates MT, Anderson DR. Safe Surgical Retrieval of Embolized Atrial
Septal Defect Closure Device. Ann Thorac Surg. 2017
Feb;103(2):e213-e214.

\textbf{Figures}

Figure 1. Transthoracic echocardiography revealed tricuspid
regurgitation and malposition of the device. (RA= right atrium, RV=
right ventricle, TV= tricuspid valve, D= device)

Figure 2. Three-dimensional reconstruction demonstrated right pulmonary
vein obstruction caused by migrated device. (The green object is device;
D= device, RPV= right pulmonary vein)\selectlanguage{english}
\begin{figure}[H]
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\includegraphics[width=0.70\columnwidth]{figures/Figure-1/Figure-1}

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\end{figure}\selectlanguage{english}
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\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-2/Figure-2}

\end{center}
\end{figure}

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