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Dislodged occluder trapped in the left ventricle
  1. Po-Yuan Shih1,
  2. Ya-Jung Cheng2,
  3. Chih-Peng Lin2
  1. 1Department of Anesthesiology, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin, Taiwan
  2. 2Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
  1. Correspondence to Dr Chih-Peng Lin, Department of Anesthesiology, National Taiwan University Hospital, No 7, Chung-Shan South Road, Taipei 100, Taiwan; cplin0123{at}gmail.com

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A 55-year-old man had mechanical aortic valve replacement for aortic regurgitation. During follow-up, precordial echocardiography revealed paravalvular leak (PVL) and moderate residual aortic regurgitation. Percutaneous closure of the leak was recommended, and Amplatzer® vascular plug (9-PLUG-012, AGA Medical Corporation, Plymouth, MN, USA) was implanted under general anaesthesia with fluoroscopic and transoesophageal echocardiography (TOE) guidance. After the procedure, sudden onset of ventricular arrhythmia was noted; echocardiogram showed dislodgement of the plug. During emergent exploration, intraoperative TOE showed vascular plug tumbling like a yo-yo in the left ventricle (LV) with neither retrograde migration to the left atrium nor occluding the aortic valve (figure 1, yellow arrow; online supplementary movie 1). Surgical extraction of the device and aortic valve replacement were performed smoothly.

Figure 1

Images of transoesophageal echocardiography. (A) left ventricle longaxis view with color doppler and (B) left ventricle long axis view.

According to the preprocedural computed tomography, one possible reason for the dislodged device being trapped in the LV was the following. During the systolic phase, the leak size decreased and so the plug could not be squeezed into the aorta (figure 2A). During the diastolic phase, the anatomical leak size increased and the pressure gradient across the leak could push the plug back into the LV (figure 2B).

Figure 2

Images of computed tomography. (A) left ventricle systolic phase and (B) left ventricle diastolic phase.

The feasibility and safety of percutaneous closure of PVL are still under debate. However, acute complications such as this case should be alerted as percutaneous closure of PVL is becoming popular. Precise preprocedural evaluation of the defect with multiple imaging modalities and intraprocedural TOE monitoring are useful precautions to prevent and identify possible dislodgement of the vascular plug.

Footnotes

  • This work was performed at the National Taiwan University Hospital.

  • Competing interests None.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; not externally peer reviewed.