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.