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Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 14  |  Issue : 1  |  Page : 173-176  

Surgical retrieval of embolized patent ductus arteriosus occluder device in an adult after 12 years of initial deployment: A case report with perioperative considerations and decision-making in resource-limited settings


1 Department of Anaesthesiology and Critical Care, Uttar Pradesh University of Medical Sciences, Saifai, Etawah, Uttar Pradesh, India
2 Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India

Date of Submission10-May-2020
Date of Decision17-May-2020
Date of Acceptance24-May-2020
Date of Web Publication22-Jun-2020

Correspondence Address:
Dr. Pooja Singh
M-19, Arvind Vihar, Baghmugalia, Bhopal - 462 043, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aer.AER_38_20

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   Abstract 

Transcatheter closure of patent ductus arteriosus (PDA) is a well-established technique worldwide, with minimal incidence of associated major and minor complications. Surgical closure of PDA is equally effective with negligible mortality risk. We describe a case of an adult with unexpected diagnosis of PDA occluder device embolization in main pulmonary artery, presenting after 12 years of initial device deployment during childhood. Due to persistent duct flow, patient developed severe pulmonary hypertension and congestive heart failure. In this report, we are focusing on perioperative management of surgical retrieval of the embolized device along with the need of intermediate and sometimes long term follow up of patients planned for percutaneous closure, in order to avoid procedure-related complications and associated morbidity and mortality risk. At the same time, the socio-economic aspects of the patient should also be considered in decision-making in terms of choice of transcatheter versus surgical closure of the shunt.

Keywords: Embolization, follow-up, late complications, patent ductus arteriosus occluder device, socio-economic aspects


How to cite this article:
Singh D, Singh P, Karna ST. Surgical retrieval of embolized patent ductus arteriosus occluder device in an adult after 12 years of initial deployment: A case report with perioperative considerations and decision-making in resource-limited settings. Anesth Essays Res 2020;14:173-6

How to cite this URL:
Singh D, Singh P, Karna ST. Surgical retrieval of embolized patent ductus arteriosus occluder device in an adult after 12 years of initial deployment: A case report with perioperative considerations and decision-making in resource-limited settings. Anesth Essays Res [serial online] 2020 [cited 2020 Jul 11];14:173-6. Available from: http://www.aeronline.org/text.asp?2020/14/1/173/287403


   Introduction Top


Transcatheter closure of patent ductus arteriosus (PDA) is a well-established technique, with reasonable safety and high success rate.[1] Major complication associated with the procedure is embolization and protusion of occluder disc into either pulmonary artery (PA) or descending aorta causing obstruction.[2] In most cases, device embolization is detected either immediately or within 48 hours and can be retrieved either by transcatheter or, in rare cases, surgical route.[3],[4]

We report a rare case of an 18-year-old male who presented after 12 years of initial device deployment, with persistent ductal flow due to late detection of device embolization and embedment in the PA, leading to complications, such as severe pulmonary hypertension and congestive heart failure.


   Case Report Top


An 18-year-old male, with a body mass index of 18, belonging to lower socioeconomic status, residing in rural area, presented to the cardiology outpatient department with symptoms of easy fatigability, palpitation, and shortness of breath. The patient had a history of recurrent chest infections and inability to gain weight since childhood. The patient also gave a history of transcatheter device closure of PDA at 6 years of age in another hospital but was lost to his follow-up evaluation.

Physical examination revealed continuous murmur in his infraclavicular area and bilateral basal chest crepitations. Electrocardiography (ECG) indicated left-axis deviation. Chest X-ray showed cardiomegaly and increased pulmonary vascular markings with a device shadow [Figure 1]. Echocardiography confirmed large ductal shunt with dilated left atrium and ventricle along with a PDA occluder, which was found to be stuck at the main PA (MPA). During cardiac catheterization, Qp:Qs ratio was 2.2:1 with a mean PA pressure of 55 mmHg. The systolic gradient between PA and aorta over PDA was 92 mmHg. The patient was admitted, and the medical management of congestive heart failure with injection (inj.) furosemide 20 mg intravenous and tablet (Tab.) enalapril 2.5 mg twice daily was started. Inj. digoxin 200 μg was given as half the loading dose, and the remaining 200 μg was given eight hourly in divided doses. Tab. digoxin 0.25 mg was started as maintenance dose. Serum potassium level was regularly monitored and maintained above 3.5 mEq.dl − 1. After 5 days of therapy and symptomatic improvement, percutaneous transcatheter retrieval of the embolized device was planned. However, unfortunately, the device could not be retrieved percutaneously as it was well embedded into the wall of the PA. Owing to the presence of large symptomatic ductal shunt, the patient was sent for surgical retrieval of the device on cardiopulmonary bypass (CPB) and duct ligation.
Figure 1: Chest X-ray showing embolized patent ductus arteriosus occluder device shadow in pulmonary artery

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The patient was premedicated with Tab. ranitidine 150 mg and Tab. alprazolam 0.25 mg in the morning of the surgery with a sip of water. All standard and invasive monitors such as ECG, oxygen saturation, capnography, intra-arterial blood pressure, and temperature monitoring were attached. After preoxygenation, the patient was induced with inj. midazolam 0.02 mg.kg−1, inj. fentanyl 5 μg.kg−1, and inj. etomidate 0.4 mg.kg−1. Muscle relaxation was achieved with inj. vecuronium 0.1 mg.kg−1. The surgery was performed with median sternotomy. Inj. heparin 4 mg.kg−1 was given to achieve the activated clotting time of 480 seconds. After securing aortic and venous cannulation, PDA was ligated before initiation of CPB. The embolized device was palpated over the PA. After initiation of CPB, pulmonary arteriotomy was performed to expose the device [Figure 2]. The device was completely endothelized and had become deeply embedded into the intimal layer of the PA [Video 1]. After removal of the device, PA was primarily closed as medial layer was uninvolved, and the patient was weaned off from CPB on mild inotropic support. The patient was extubated the next day and discharged from the hospital on the 7th postoperative day [Table 1]. The patient was thoroughly instructed about the monthly follow-up visits for minimum of 3 months. Surgical ligation of PDA led to significant improvement in the symptoms of the patient. Endocarditis prophylaxis was given until 6 months of the treatment.
Figure 2: Surgical retrieval of embolized patent ductus arteriosus occluder device from pulmonary artery

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Table 1: Timeline - Course of the patient from presentation to outpatient department till the discharge from the hospital after surgery

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   Discussion Top


The incidence of PDA is 1 in 2000 in full-term infants and contributes to 5%–10% of all the congenital heart disease.[5] Mortality of untreated PDA in 2–19 years of age is about 0.49% per year.[6] Transcatheter device closure of PDA was first described by Porstmann in 1971. Although it is a recommended and safe technique for PDA closure in both children and adults, the procedure is associated with few complications, such as residual shunt, left PA narrowing, peripheral arterial complication, and hemolysis.[2]

Device embolization is a significant complication of transcatheter closure of PDA, with an incidence rate ranging from 3% to 20%, and occurs mostly in acute stages.[3],[7] In reported case, the patient presented with symptoms after 12 years of initial device deployment, which is a rarity. Embolization of PDA occluder is more common in pulmonary circulation than the systemic circulation and largely depends on pressure gradient between PA and aorta over PDA.[8] In our case, it was hypothesized that the device was embolized early but could not be diagnosed as the patient was lost to follow-up echocardiographic evaluation. The embolized device stayed in the MPA and got endothelized to fix it firmly within the arterial wall. Consequently, the uncorrected ductal shunt remained undiagnosed and led to severe pulmonary hypertension and symptoms of the left heart overload. Percutaneous transcatheter removal of device was planned initially to avoid the need of CPB; however, unfortunately, device could not be retrieved. Surgery was planned through median sternotomy to gain better control of the major vessels and institution of CPB.[4] PA wall tissue was suspected to be friable due to long-standing embedment of the device into the wall of the artery.[4],[9] Therefore, we decided to retrieve the device on CPB for meticulous repair of the PA.

Long-standing uncorrected PDA is also a risk factor for the development of infective endocarditis (IE).[10] Although no recent data have been published on incidence, several isolated cases were reported from 2002 to 2008, indicating IE in patients with PDA. Due to low morbidity related to closure and the risk of IE, routine closure of any PDA in children and young adults is highly recommended, as endocarditis is responsible for approximately half of the death in patients with untreated PDA.[5]

The report also aims to highlights the importance of postprocedural follow-up of the patients who are planned for either transcatheter or surgical closure. It is important not only to ascertain the efficacy of the procedure but also for timely discovery of the complications, such as device embolization and PA narrowing, which could later deteriorate the symptoms of the patients. Although several literature suggests that most complications of transcatheter closure are diagnosed early and long-term follow-up is usually not required,[11] certain patients may require interval echocardiography testing depending upon the postprocedure physiology of the lesion.[12] A study done by Narayan et al. recommended a follow-up until 3 months of transcatheter procedure to detect embolization of device.[11] Further studies should be conducted to compare the long-term outcome of PDA closure through surgical versus transcatheter route, especially in developing countries where regular follow-up is usually not feasible due to poor patient compliance, economic constraints, and nonaccessibility of medical facilities for evaluation.


   Conclusion Top


PDA closure is indicated in all patients irrespective of the severity of symptoms and ductus size to prevent the development of endocarditis. Endocarditis prophylaxis is usually given in patients with long-standing left-to-right shunt in view of the risk of right-sided IE, although routine administration is not recommended.[10] The decision-making in terms of transcatheter versus surgical closure of PDA should also consider socio-economic aspect, availability of medical resources, and compliance of the patient, especially in resource-limited settings, as intermediate-term and sometimes long-term follow-up of the patients may be required to avoid sequelae of pathology as well as procedure-related complications.

Consent

The author/s confirm that written consent for submission and publication of this case report including image (s) and associated text has been obtained from the patient in line with COPE guidance.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Masura J, Tittel P, Gavora P, Podnar T. Long-term outcome of transcatheter patent ductus arteriosus closure using Amplatzer duct occluders. Am Heart J 2006;151:755e7-10.  Back to cited text no. 1
    
2.
Jang GY, Son CS, Lee JW, Lee JY, Kim SJ. Complications after transcatheter closure of patent ductus arteriosus. J Korean Med Sci 2007;22:484-90.  Back to cited text no. 2
    
3.
Tripathi RR, Agarwal R, Premsekar R. Late surgical removal of an embolized patent ductus arteriosus device causing erosion of the aortic wall. Pediatr Cardiol 2012;33:1453-5.  Back to cited text no. 3
    
4.
Shahabuddin S, Atiq M, Hamid M, Amanullah M. Surgical removal of an embolised patent ductus arteriosus amplatzer occluding device in a 4-year-old girl. Interact Cardiovasc Thorac Surg 2007;6:572-3.  Back to cited text no. 4
    
5.
Schneider DJ, Moore JW. Patent ductus arteriosus. Circulation 2006;114:1873-82.  Back to cited text no. 5
    
6.
Campbell M. Natural history of persistent ductus arteriosus. Br Heart J 1968;30:4-13.  Back to cited text no. 6
    
7.
Thanopoulos BD, Hakim FA, Hiari A, Goussous Y, Basta E, Zarayelyan AA, et al. Further experience with transcatheter closure of the patent ductus arteriosus using the Amplatzer duct occluder. J Am Coll Cardiol 2000;35:1016-21.  Back to cited text no. 7
    
8.
Atik FA, Jatene FB, Costa PH, Atik E, Barbero-Marcial M, Oliveira SA. Surgical treatment of coil embolization to the pulmonary artery after an attempt at percutaneous closure of patent ductus arteriosus. Arq Bras Cardiol 2004;83:80-2.  Back to cited text no. 8
    
9.
Gokaslan G, Ustunsoy H, Deniz H, Ozcaliskan O, Yasim A, Baspinar O, et al. Urgent surgical management for embolized occluder devices in childhood: Single center experience. J Cardiothorac Surg 2012;7:127.  Back to cited text no. 9
    
10.
10 Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: A guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation 2007;116:1736-54.  Back to cited text no. 10
    
11.
Narayan SA, Elmahdi E, Rosenthal E, Qureshi SA, Krasemann T. Long-term follow-up is not indicated after routine interventional closure of persistent arterial ducts. Cathet Cardiovasc Intervent 2015;86:100-4.  Back to cited text no. 11
    
12.
Stout KK, Daniels CJ, Aboulhosn JA, Bozkurt B, Broberg CS, Colman JM, et al. 2018 AHA/ACC Guideline for the management of adults with congenital heart disease: Executive summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines J Am Coll Cardiol 2019;73:1494-563.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1]



 

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