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\begin{document}

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



\author[1]{Yu Xiong}%
\author[2]{Yongjun Qian}%
\affil[1]{West China Hospital of Sichuan University}%
\affil[2]{Sichuan University}%


\vspace{-1em}



  
  \date{May 26, 2024}


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\textbf{Title Page}

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

Yu Xiong\textsuperscript{1}, Yongjun Qian\textsuperscript{2\#}

\textsuperscript{1} Operating Room, Department of Anesthesiology, West
China Hospital, Sichuan University/West China School of Nursing, Sichuan
University, Chengdu, Sichuan, 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}

Yu Xiong\textsuperscript{1}, Yongjun Qian\textsuperscript{2\#}

\textsuperscript{1} Operating Room, Department of Anesthesiology, West
China Hospital, Sichuan University/West China School of Nursing, Sichuan
University, Chengdu, Sichuan, 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{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. She underwent percutaneous transcatheter closure of
a secundum ASD through femoral vein eight months before. Transthoracic
echocardiography (TTE) revealed severe tricuspid regurgitation and the
migrated ASD device (Figure 1), we performed a safe procedure to
retrieve the migrated device by deploying from a sheath. 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.

\textbf{KEYWORDS:} Atrial septal defect;Device embolization;Surgical
retrieval

\textbf{1 | INTRODUCTION}

Atrial septal defect (ASD) is the most common congenital heart disease.
Percutaneous closure of ASDs has become increasingly common. Device
embolization is one of the major complication. The device can be
retrieved percutaneously when the event occurs some hours after deploy,
surgical removal is necessary when the device was deployed for long
time, it is diffificult to remove the device without damage to the
valvar apparatus. We herein performed a safe procedure to retrieve the
migrated device by deploying from a sheath, which could minimize valve
and conduction system complications.

\textbf{2| CASE PRESENTATION}

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 A 3-0 prolene suture is placed through the middle

of the device. The suture is passed through a large (12F) soft plastic
snugger which is advanced well into the atrium, 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.

\textbf{3|DISCUSSION}

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 by
deploying from a sheath (Figure 3), which could minimize valve and
conduction system complications.

\textbf{4|CONCLUSION}

This technique provides a safe and reproducible method for surgical
removal of an embolized ASD closure device several weeks or months after
deployment .

\textbf{AUTHOR CONTRIBUTIONS}

All authors were involved in the conception and design, critical
revision, manuscript writing, final approval, and agreed to be
accountable for all aspects of the work.

\textbf{FUNDING INFORMATION}

No funding was required in the preparation of this case report.

\textbf{DATA AVAILABILITY STATEMENT}

All data generated or analyzed during this study are included in this
published article.

\textbf{ETHICS STATEMENT}

This study is in compliance with the declaration of Helsinki.

\textbf{CONSENT}

Written informed consent was obtained from the patient for publication
of this case report in accordance with the journal's patient consent
policy.

\textbf{REFERENCES}

1. Lin G, Su Y, Qian YJ. Safe Surgical Retrieval of Endothelialized
Ventricular Septal Defect Closure Device. \emph{Heart Surg Forum.} 2020
;23:E285-E286.

2. Karampinis I, Pfleger S, Nowak K. Extracardial migration of an atrial
septal defect occluder device. \emph{J Invasive Cardiol} .
2013;25:E219-20.

3. Yang MC, Wu JR. Recent review of transcatheter closure of atrial
septal defect. \emph{Kaohsiung J Med Sci} . 2018;34:363-369.

4. Yates MT, Anderson DR. Safe Surgical Retrieval of Embolized Atrial
Septal Defect Closure Device. \emph{Ann Thorac Surg} . 2017
;103: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)

Figure 3 Retrieval of ASD closure device into a soft plastic snugger to
facilitate safe removal from the left atrium.\selectlanguage{english}
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