Successful retrieval of embolized atrial septal defect and patent foramen ovale closure device using novel coronary wire trap (CWT) technique. Alireza Khosravi1, Ahmad Mirdamadi 2 Mohammad Reza Movahed, 3,4 Department of Cardiology, Interventional Cardiology Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran 1 Department of Cardiology, Hypertension Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran 2 Department of Medicine, University of Arizona, Tucson, AZ 3 CareMore Regional Cardiology Director of Arizona, Tucson, AZ 4

Introduction Device embolization can complicate the management of patients with atrial septal defect (ASD) This event most frequently occurs in the case of inadequately captured ASD rims usually secondary to loose margins, deficient aortic or thin and floppy posterior rim. This complication usually occurs after device release. Retrieval failure after prolonged fluoroscopy and application of various percutaneous procedures requires open heart surgery. Hereby, we report a novel and easy to perform retrieval technique, the so called “coronary wire trap technique (CWT),”in the event of retrieval failure using conventionally available devices, thus preventing open heart surgery.

Case 1 postero-superior rim: 11 mm, postero-inferior rim: 10 mm, The patient was a 37 year old female with the history of cardiomegaly. Trans-esophageal echocardiography (TEE) showed secondum type ASD larger diameter: 1.64 mm, postero-superior rim: 11 mm, postero-inferior rim: 10 mm, antero-superior rim: 2.5 mm, inferior rim 11 mm and superior rim: 6.1 cm.

The patient was scheduled for ASD occlusion using Figulla flex II ASD occluder device ASD size was 15.5 mm. ASD was successfully closed using an 18 mm device under transthoracic echocardiographic and fluoroscopic guidance. Using echo, fluo and appropriate maneuver, proper ASD position was confirmed. Next day, TTE was performed before discharge, showed embolized device It was found in the right pulmonary artery without clinical symptoms

Device retrieval Using right femoral access, a long14F sheath was inserted and advanced into the right pulmonary artery near the embolized ASD closure device and was stabilized using 0.035 guide wire in the sheath. Multiple efforts to capture the device using snare were unsuccessful due to malalignment of the dislocated round tip of its screw Retrieval trial using bioptome was also unsuccessful due to inability of the bioptome being placed in a parallel position relative to the trapped ASD closure device in the right pulmonary artery.

Unsuccessful attempts to snare the embolized device in the pulmonary artery.

Retrieval using coronary wire trap technique After using over two hours of fluoroscopy without any success, the decision was made to use coronary wire for trapping A 0.014 inch pilot 50 coronary wire was utilized. It took about 30 minutes in order to advance this wire across the outermost border of the device (AR1) At this time, the device was displaced freely in the main and left pulmonary arteries Next, the distal tip of the 0.014 pilot wire was snared, leading to the entrapment of the embolized occluder device which could then easily be pulled back into the sheath and removed

Displaced device in the main and left pulmonary artery advancing coronary wire.

The trapped embolized device being pulled back in the sheath successfully

Case 2 The patient was a 64 year old f with recurrent TIA without identifiable cause PFO was found After discussion with the neurologist the decision was made to close her PFO Her PFO was occluded using a Nit.occlud PFO 20 mm The device appeared to be unstable after deployment. During repeat TTE and fluoroscopy, it was noticed that the device was embolized and trapped in the inferior part of the descending aorta

Nit.occluder PFO 20 mm (PFM) device deployment in the patent foramen ovale

Device retrieval For approximately 120 minutes, multiple attempts to retrieve this device using snare were unsuccessful. Therefore, the decision was made to utilize CWT as described above. A coronary pilot 0.014 wire was advanced through the margin of the device similar to the first case and then the distal tip of the wire was snared to trap the device Next, the occluder was successfully pulled back into the 12F sheath and removed without any complication. It took approximately 25 minutes for the device removal using this technique.

The capture of the embolized patent foramen ovale device located in the descending Aorta.

Retrieved patent foramen ovale occluder device after using coronary wire trap technique

Detail illustration of the procedure

Conclusion Device retrieval using the coronary wire trap technique (CWT) is a new novel technique for embolized device removal It should be attempted in a patient with failed retrieval of an embolized ASD or PFO closure device. Further studies using this technique in a large population are required in order to determine the degree of successes using this technique in a diverse population.