Case Presentation
A 52-year-old male patient came to our Echocardiography Laboratory at
the San Carlo Hospital in Milan on 31st December 2020,
following the onset of dyspnoea with light exertion and chest pain
radiated to both upper limbs. He denied having cardiovascular risk
factors, but reported being a carrier of bicuspid aortic valve (BAV) and
having been operated for aortic coarctation (AC) at the age of 14. In
June 2020, he had been admitted to another hospital Neurology ward for
an ischemic stroke of the vertebrobasilar circulation; the transthoracic
echocardiogram (TTE) had shown a slight spontaneous left-right shunt and
positive bubble-study, with final diagnosis of PFO. In October 2020,
percutaneous PFO closure by endovascular positioning of an Occlutech
device (23/25 mm) had been performed; then, he had been discharged on
dual antiplatelet and statin therapy without performing a TTE before
discharge, only suggesting to perform a TTE with bubble study 4-6 months
after the intervention. About 7 days after discharge, upon resuming work
(employee in septic service), he started feeling shortness of breath
with light efforts and chest pain radiated to the upper limbs (described
as myalgia) everyday but only upon awakening. For this reason, he went
to our Laboratory for a physical examination with TTE. The physical
examination was normal, while the only ECG finding was a right bundle
branch block. The TTE showed the absence of the occluder device in
place, with spontaneous left-right shunt (Fig. 1); in addition, the
transoesophageal echocardiogram (TEE) detected the absence of the
device, an ASA and a long tunnel (Fig. 2). A chest/abdomen CT scan with
contrast showed the device into the abdominal aorta, at the first lumbar
vertebra (L1), near the origin of the coeliac trunk (from which the
superior mesenteric artery also arose) and just proximal to the origin
of the renal arteries (Fig. 3). An abdominal aorta ultrasound showed the
device completely intact (two hemidiscs), blocked into the aortic lumen
at the origin of the coeliac trunk (Fig. 4): the device partially
occluded both vessels without causing gastrointestinal or lower limb
symptoms. The patient was then admitted to our Cardiology ward, still
presenting myalgias during the night and in the morning (no fever,
negative Sars-Cov-2 RT-PCR swab test, normal creatine kinase). Finally,
the device retrieval was performed through an hybrid percutaneous and
surgical procedure at the referral centre on 5thJanuary 2021. Through right femoral access, the device was captured and
pulled with a 35 mm Goose Neck snare (Fig. 5) and then with a 50 cm
bioptome, however losing the device twice. Therefore, the device was
finally surgically removed from the right femoral artery. After the
device removal, the patient felt no more myalgias. A new PFO closure
with Noblestitch was proposed to the patient but he decided not to
underwent another procedure for at least 1-2 months.