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Intraoperative migration of a clamshell device
Intraoperative Migration of a Clamshell Device Jos6e Lavoie, MD, Joseph J. Javorski, MD, Aldo R. Castaneda, MD, Joseph P. Mihalka, MD, Howard M. Rosenfeld, MD, and Stephen P. Sanders, MD HE FIELD OF interventional cardiac catheterization
is expanding rapidly, and procedures such as umbrella T device insertion, coil embolization, and balloon valvuloplasty are now being applied to treat various congenital heart defects. In some lesions such as patent ductus arteriosus and atrial and ventricular septal defects, the placement of a device is curative and obviates the need for surgery (Fig 1). Previous reports have suggested improved efficacy and safety for transcatheter device closure of atrial septal defects under transesophageal echocardiographlc guidance, I along with a more reliable demonstration of residual atrial level shunts after device placement. 2 With the increase in transcatheter and intraoperative device placement for the closure of ventricular septal defects (VSD), 3 transesophageal imaging of defect size and morphology as well as device position will be increasingly important 4 (Fig
2). Continuing advances in transducer technology, miniaturization of echocardiographic probes, and the recent introduction of biplane and multiplane imaging have led to a rapid increase in the use of transesophageal echocardiography (TEE) as an adjunct to standard monitoring during surgical and catheterization management of congenital heart disease. This case report describes the application of TEE for the localization of a migrated double-umbrella device that had been employed in the transcatheter closure of a VSD.
CASE REPORT A 31-year-old woman with tetralogy of Fallot and pulmonary atresia was admitted to the Children's Hospital, Boston, for surgical closure of a residual, patch margin VSD. Although diagnosed at 3 days of life with tetralogy of Fallot and pulmonary atresia, she remained relatively asymptomatic until age 29, when she developed progressive dyspnea. At age 30, she underwent a complete repair of tetralogy of Fallot with placement of a right ventricle-topulmonary artery aortic homograft, pericardial patch augmentation of the right ventrlcular outflow tract, division of aorto-pulmonary collaterals, and closure of the VSD using a fenestrated dacron patch. Given the borderline size of her native pulmonary arteries and the concern over obstructive pulmonary vascular disease, a fenestrated VSD patch was used to avoid suprasystemic right ventricular pressures in
From the Departments of Anesthesta, Dtvtston of Cardtac Anesthesta, Cardtac Surgery, and Cardtology, Chtldren's Hospital and Harvard Medtcal School, Boston, MA Address repnnt requests to JosOe Lavoze, MD, Department of Anesthesta, H6pttal Ste-Justme, 3175 Ch Cote Ste-Cathenne, Montreal, Quebec, Canada H3T IC5 Copyright © 1995 by W B Saunders Company 1053-0770/95/0905-001653 00/0 Key words, ventncular septal defect, double-umbrella vascular occluding devtce (clamshell), transesophageal echocar&ography 562
the immediate postoperative period. Seven months postoperatively, the patient underwent catheterization and placement of a double-umbrella device in the patch fenestration. An additional small, residual patch margin VSD was identified, but not closed. Recatheterization 1 month later demonstrated proper device location in the fenestration but a large residual leftto-right shunt (Qp:Qs = 2:1) caused by dehiscence of the VSD patch anterior to the device. The patient was scheduled for operative repair of the residual defect because of worsening exercise tolerance and concern over progression of the pulmonary vascular obstructive disease. A chest radiograph before surgery demonstrated the doubleumbrella device to be in proper position within the heart. Before surgery, the patient was receiving propafenone, digoxin, furosemlde, and warfarin. She was allergic to acetylsalicylic acid and dipyridamole. Physical examination showed mild circumoral cyanosis, clubbing of the digits, and a grade IV/VI pansystolic regurgitation murmur. Preoperative hematocrit was 45%. The patient was premedicated with oral dlazepam, 10 rag, and taken to the operating room. She was monitored with a five-lead electrocardiogram, pulse oximeter, and noninvasive blood pressure. After preoxygenation, an intravenous induction was performed using fentanyl, midazolam, and pancuronium. The trachea was intubated orally with a 7.0-mm ID endotracheal tube. Position was confirmed by bilateral breath sounds and an end-tidal CO2 waveform on capnography. The patient tolerated induction of anesthesia and intubation without hemodynamic changes. A 20-gauge catheter was placed in the left radial artery Anesthesia was maintained with oxygen, isoflurane, fentanyl, pancuronium, and midazolam. On cardiopulmonary bypass, the right ventrlcular cavity was explored, and the previously inserted clamshell device could not be identified. Surgical closure of the residual VSD with a dacron patch and placement of a transannular right ventricular outflow tract patch to alleviate mild pulmonary valvular stenosis were performed. While on cardiopulmonary bypass, a 13-mm biplane TEE probe (Hewlett-Packard. Worcester, MA) was inserted, and echocardlographic imaging was performed to locate the double-umbrella closure device. Examination was rendered difficult because of the collapsed, empty heart during cardlopulmonary bypass. The heart was filled wath saline to better visualize the cavities. Despite this, definite localization of the device position was not possible. However, the device did appear to be in the septum. The decision was made to wean the patient from cardiopulmonary bypass under TEE imaging. With the heart full and contracting, the device was no longer observed in the septum. The patient was initially weaned without difficulty. Approximately 2 minutes after separation the patient's oxygen saturation decreased from 100% to 85%; concomitantly, the systemic blood pressure decreased from 100/60 to
Journal of Cardlothoracm and VascularAnesthes#a, Vol 9, No 5 (October), 1995 pp 562-564
CLAMSHELL DEVICE MIGRATION
563
heart disease, and valvular surgery. 8 The role of TEE in the operating room is constantly evolving with the development of new and innovative applications• In the current case, the intraoperative identification of the migrated device allowed for safe removal before further embolization and obviated the need for additional surgical or catheterization procedures. The cause of device migration in this case is not clear. Patch dehiscence, presumably occurring before surgery, may have helped destabilize the device that became dislodged during retractor manipulation. However, once migration d~d occur, few safe options for localization were available• Identification of dewce position and possible retrieval in the catheterization laboratory
Fig 1, Transesophageal echocardiogram demonstrating a doubleumbrella clamshell device in position across an atrial septal defect.
75/40 mmHg. The device was located in the distal main pulmonary artery by TEE imaging. Cardiopulmonary bypass was reinstituted and the device was extracted via a pulmonary arteriotomy. The patient was again separated from cardiopulmonary bypass• Postbypass, TEE showed qualitatively good left ventracular function and a trivial residual VSD with left-to-right flow. The patient was transported to the cardiovascular intensive care unit postoperatively and was extubated the next day. Recovery was uncomplicated, and she was discharged to home on the sixth postoperative day.
£~'V
DISCUSSION Double-umbrella closure dewces were initially developed to close patent ductus arteriosus, but the indications have expanded as experience grows. These indications include closure of a patent ductus arteriosus or an atrial or ventricular septal defect. Also included are atrial or ventricular patch fenestration closure as part of a staged approach to management of more complex defects such as the Modified Fenestrated Fontan procedure. 5 Recent stud~ees are showing promising results for clamshell closure of the more anterior and apical muscular VSDs. 6 The transcatheter approach allows closure of VSDs that cannot be easil~ identified through the atrioventncular valves or a right venmculotomy. Avoidance of a left ventnculotomy for defect closure contributes to preservation of myocardial function and improved postoperative hemodynamics. 7 Complications associated with the use of clamshell devices include valve leaflet entrapment within the arms of the device and possible valvular dysfunction, residual shunts, and migration of the device. Intraoperative transesophageal echocardiography is fast becoming recognized as a versatile diagnostic and monitoring tool. Widely accepted applications include evaluation of left ventricular volume and ejection fraction, ischemia momtoring, assessment of adequacy of repair m congenital
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Fig 2 Drawing of a double-umbrella clamshell device in position across a septal defect
564
LAVOIE ET AL
would have required discontinuation of bypass and, in the time interval necessary to move to the catheterization laboratory, risk of occlusion of the pulmonary artery, hemodynamlc mstabihty, and further device embolization. Although intraoperative radiographic demonstration of device position was possible, this would have required additional time and patient manipulation. It is not clear when the device migrated in this case. Transesophageal imaging while on cardiopulmonary bypass appeared to show the device in the septum. However, this could have been an artifact caused by collapse of the heart and points out the limitations of imaging while on bypass. After weaning from bypass, it became apparent that the
device was not in the septum, and a search qmckly showed it to be in the pulmonary artery. This case demonstrates for the first time the use of TEE in the localization and removal of a migrated clamshell device after VSD closure. Because the majority of VSDs amenable to device closure are located in the apical and anterior septum, visualization at the time of subsequent operations may be difficult, and, thus, the dmlodgment of the device may not be appreciated while on cardiopulmonary bypass. For this reason, as well as the potential complications of a migrated device, TEE monitoring of a patient bearing an mtracardiac clamshell device should be considered.
REFERENCES
1. Hellenbrand WE. Fahey JT, McGowan FX, et al. Transesophageal echocardlographlc guidance of transcatheter closure of atrial septal defect. Am J Cardio166'207-213, 1990 2. Boutm C, Musewe NN, Smallhorn JF, et al: Echocar&ographic follow-up of atrial septal defect after catheter closure by double-umbrella device. Circulation 88"621-627, 1993 3 BridgesND, Perry SB, Keane JF, et al Preoperative transcatheter closure of congenital muscular ventricular septal defects. N Engl J Med 324:1312-1317, 1991 4. Van der Velde ME, Perry SB, Sanders SP. Transesophageal Echocardlography with Color Doppler During InterventxonalCatheterization Echocardlography 8.721-730, 1991
5 Bridges ND, LockJE, CastanedaAR Bafflefenestration with subsequent transcatheter closure. Mo&ficatlon of the Fontan operation for patients at increased risk. Circulation 82:1681-1689, 1990 6. Van Praagh R, Geva T, Kreutzer J" Ventricular septal defects: How shall we describe, name and classifythem? J Am Coll Cardiol 14:1298-1299, 1989 7. Gnffiths SP, Turi GK, Ellis K, et al' Muscular septal defects repaired with left ventnculotomy. Am J Car&o148 877-886, 1981 8 Cahalan MK, Litt L, BotvlnlCk EH, et al: Advances in nonmvaswecardiovascular imaging:Imphcatlons for the anesthesiologist. Anesthesiology 66 356-372, 1987
is expanding rapidly, and procedures such as umbrella T device insertion, coil embolization, and balloon valvuloplasty are now being applied to treat various congenital heart defects. In some lesions such as patent ductus arteriosus and atrial and ventricular septal defects, the placement of a device is curative and obviates the need for surgery (Fig 1). Previous reports have suggested improved efficacy and safety for transcatheter device closure of atrial septal defects under transesophageal echocardiographlc guidance, I along with a more reliable demonstration of residual atrial level shunts after device placement. 2 With the increase in transcatheter and intraoperative device placement for the closure of ventricular septal defects (VSD), 3 transesophageal imaging of defect size and morphology as well as device position will be increasingly important 4 (Fig
2). Continuing advances in transducer technology, miniaturization of echocardiographic probes, and the recent introduction of biplane and multiplane imaging have led to a rapid increase in the use of transesophageal echocardiography (TEE) as an adjunct to standard monitoring during surgical and catheterization management of congenital heart disease. This case report describes the application of TEE for the localization of a migrated double-umbrella device that had been employed in the transcatheter closure of a VSD.
CASE REPORT A 31-year-old woman with tetralogy of Fallot and pulmonary atresia was admitted to the Children's Hospital, Boston, for surgical closure of a residual, patch margin VSD. Although diagnosed at 3 days of life with tetralogy of Fallot and pulmonary atresia, she remained relatively asymptomatic until age 29, when she developed progressive dyspnea. At age 30, she underwent a complete repair of tetralogy of Fallot with placement of a right ventricle-topulmonary artery aortic homograft, pericardial patch augmentation of the right ventrlcular outflow tract, division of aorto-pulmonary collaterals, and closure of the VSD using a fenestrated dacron patch. Given the borderline size of her native pulmonary arteries and the concern over obstructive pulmonary vascular disease, a fenestrated VSD patch was used to avoid suprasystemic right ventricular pressures in
From the Departments of Anesthesta, Dtvtston of Cardtac Anesthesta, Cardtac Surgery, and Cardtology, Chtldren's Hospital and Harvard Medtcal School, Boston, MA Address repnnt requests to JosOe Lavoze, MD, Department of Anesthesta, H6pttal Ste-Justme, 3175 Ch Cote Ste-Cathenne, Montreal, Quebec, Canada H3T IC5 Copyright © 1995 by W B Saunders Company 1053-0770/95/0905-001653 00/0 Key words, ventncular septal defect, double-umbrella vascular occluding devtce (clamshell), transesophageal echocar&ography 562
the immediate postoperative period. Seven months postoperatively, the patient underwent catheterization and placement of a double-umbrella device in the patch fenestration. An additional small, residual patch margin VSD was identified, but not closed. Recatheterization 1 month later demonstrated proper device location in the fenestration but a large residual leftto-right shunt (Qp:Qs = 2:1) caused by dehiscence of the VSD patch anterior to the device. The patient was scheduled for operative repair of the residual defect because of worsening exercise tolerance and concern over progression of the pulmonary vascular obstructive disease. A chest radiograph before surgery demonstrated the doubleumbrella device to be in proper position within the heart. Before surgery, the patient was receiving propafenone, digoxin, furosemlde, and warfarin. She was allergic to acetylsalicylic acid and dipyridamole. Physical examination showed mild circumoral cyanosis, clubbing of the digits, and a grade IV/VI pansystolic regurgitation murmur. Preoperative hematocrit was 45%. The patient was premedicated with oral dlazepam, 10 rag, and taken to the operating room. She was monitored with a five-lead electrocardiogram, pulse oximeter, and noninvasive blood pressure. After preoxygenation, an intravenous induction was performed using fentanyl, midazolam, and pancuronium. The trachea was intubated orally with a 7.0-mm ID endotracheal tube. Position was confirmed by bilateral breath sounds and an end-tidal CO2 waveform on capnography. The patient tolerated induction of anesthesia and intubation without hemodynamic changes. A 20-gauge catheter was placed in the left radial artery Anesthesia was maintained with oxygen, isoflurane, fentanyl, pancuronium, and midazolam. On cardiopulmonary bypass, the right ventrlcular cavity was explored, and the previously inserted clamshell device could not be identified. Surgical closure of the residual VSD with a dacron patch and placement of a transannular right ventricular outflow tract patch to alleviate mild pulmonary valvular stenosis were performed. While on cardiopulmonary bypass, a 13-mm biplane TEE probe (Hewlett-Packard. Worcester, MA) was inserted, and echocardlographic imaging was performed to locate the double-umbrella closure device. Examination was rendered difficult because of the collapsed, empty heart during cardlopulmonary bypass. The heart was filled wath saline to better visualize the cavities. Despite this, definite localization of the device position was not possible. However, the device did appear to be in the septum. The decision was made to wean the patient from cardiopulmonary bypass under TEE imaging. With the heart full and contracting, the device was no longer observed in the septum. The patient was initially weaned without difficulty. Approximately 2 minutes after separation the patient's oxygen saturation decreased from 100% to 85%; concomitantly, the systemic blood pressure decreased from 100/60 to
Journal of Cardlothoracm and VascularAnesthes#a, Vol 9, No 5 (October), 1995 pp 562-564
CLAMSHELL DEVICE MIGRATION
563
heart disease, and valvular surgery. 8 The role of TEE in the operating room is constantly evolving with the development of new and innovative applications• In the current case, the intraoperative identification of the migrated device allowed for safe removal before further embolization and obviated the need for additional surgical or catheterization procedures. The cause of device migration in this case is not clear. Patch dehiscence, presumably occurring before surgery, may have helped destabilize the device that became dislodged during retractor manipulation. However, once migration d~d occur, few safe options for localization were available• Identification of dewce position and possible retrieval in the catheterization laboratory
Fig 1, Transesophageal echocardiogram demonstrating a doubleumbrella clamshell device in position across an atrial septal defect.
75/40 mmHg. The device was located in the distal main pulmonary artery by TEE imaging. Cardiopulmonary bypass was reinstituted and the device was extracted via a pulmonary arteriotomy. The patient was again separated from cardiopulmonary bypass• Postbypass, TEE showed qualitatively good left ventracular function and a trivial residual VSD with left-to-right flow. The patient was transported to the cardiovascular intensive care unit postoperatively and was extubated the next day. Recovery was uncomplicated, and she was discharged to home on the sixth postoperative day.
£~'V
DISCUSSION Double-umbrella closure dewces were initially developed to close patent ductus arteriosus, but the indications have expanded as experience grows. These indications include closure of a patent ductus arteriosus or an atrial or ventricular septal defect. Also included are atrial or ventricular patch fenestration closure as part of a staged approach to management of more complex defects such as the Modified Fenestrated Fontan procedure. 5 Recent stud~ees are showing promising results for clamshell closure of the more anterior and apical muscular VSDs. 6 The transcatheter approach allows closure of VSDs that cannot be easil~ identified through the atrioventncular valves or a right venmculotomy. Avoidance of a left ventnculotomy for defect closure contributes to preservation of myocardial function and improved postoperative hemodynamics. 7 Complications associated with the use of clamshell devices include valve leaflet entrapment within the arms of the device and possible valvular dysfunction, residual shunts, and migration of the device. Intraoperative transesophageal echocardiography is fast becoming recognized as a versatile diagnostic and monitoring tool. Widely accepted applications include evaluation of left ventricular volume and ejection fraction, ischemia momtoring, assessment of adequacy of repair m congenital
]kl)
•
• ,,,~,/re
•
S
2
Fig 2 Drawing of a double-umbrella clamshell device in position across a septal defect
564
LAVOIE ET AL
would have required discontinuation of bypass and, in the time interval necessary to move to the catheterization laboratory, risk of occlusion of the pulmonary artery, hemodynamlc mstabihty, and further device embolization. Although intraoperative radiographic demonstration of device position was possible, this would have required additional time and patient manipulation. It is not clear when the device migrated in this case. Transesophageal imaging while on cardiopulmonary bypass appeared to show the device in the septum. However, this could have been an artifact caused by collapse of the heart and points out the limitations of imaging while on bypass. After weaning from bypass, it became apparent that the
device was not in the septum, and a search qmckly showed it to be in the pulmonary artery. This case demonstrates for the first time the use of TEE in the localization and removal of a migrated clamshell device after VSD closure. Because the majority of VSDs amenable to device closure are located in the apical and anterior septum, visualization at the time of subsequent operations may be difficult, and, thus, the dmlodgment of the device may not be appreciated while on cardiopulmonary bypass. For this reason, as well as the potential complications of a migrated device, TEE monitoring of a patient bearing an mtracardiac clamshell device should be considered.
REFERENCES
1. Hellenbrand WE. Fahey JT, McGowan FX, et al. Transesophageal echocardlographlc guidance of transcatheter closure of atrial septal defect. Am J Cardio166'207-213, 1990 2. Boutm C, Musewe NN, Smallhorn JF, et al: Echocar&ographic follow-up of atrial septal defect after catheter closure by double-umbrella device. Circulation 88"621-627, 1993 3 BridgesND, Perry SB, Keane JF, et al Preoperative transcatheter closure of congenital muscular ventricular septal defects. N Engl J Med 324:1312-1317, 1991 4. Van der Velde ME, Perry SB, Sanders SP. Transesophageal Echocardlography with Color Doppler During InterventxonalCatheterization Echocardlography 8.721-730, 1991
5 Bridges ND, LockJE, CastanedaAR Bafflefenestration with subsequent transcatheter closure. Mo&ficatlon of the Fontan operation for patients at increased risk. Circulation 82:1681-1689, 1990 6. Van Praagh R, Geva T, Kreutzer J" Ventricular septal defects: How shall we describe, name and classifythem? J Am Coll Cardiol 14:1298-1299, 1989 7. Gnffiths SP, Turi GK, Ellis K, et al' Muscular septal defects repaired with left ventnculotomy. Am J Car&o148 877-886, 1981 8 Cahalan MK, Litt L, BotvlnlCk EH, et al: Advances in nonmvaswecardiovascular imaging:Imphcatlons for the anesthesiologist. Anesthesiology 66 356-372, 1987