case_images: PMC9354964_01
case_images: Chest radiography (A,B) and transthoracic echocardiography (C) preoperatively indicated that most parts of the closure were deformed, especially the left atrial side [(B), arrow]; a significant multi-bundle left-to-right shunt through the device and a small adhesion on the occluder was detected (C).
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case_images: PMC9354964_01_fcvm-09-926527-g0001.jpg
case_images: F1
case_images: X-rays (Figures 1A,B) showed that most parts of the closure were deformed, especially the left atrial side (Figure 1B, arrow) and that the nitinol frame of the occluder was not displaced and there was no evidence of a frame fracture. Transthoracic echocardiography revealed a recurrent significant multi-bundle left-to-right shunt through the device and small adhesions were visible on the occluder (Figure 1C). Considering the multiple perforations of the occluder with an unusual irregular surface of the discs (Figure 1B), and after a careful discussion with the patient and her family, an open heart surgery was scheduled and performed.
case_images: Intraoperative view of the procedure: After opening the right atrium, a deformed occluder was found in the atrial septum (A); the left side of the occluder was damaged more obvious than the right [(B), arrow]; The PVA membranes showed multiple perforations and were partly dissolved, and the diameter of the largest void was around 10 mm (C,D).
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case_images: F2
case_images: During the operation, most parts of the closure were deformed (Figure 2), especially the left atrial side closed to the edge of the pulmonary vein, which resulted in the possible cause of late-onset residual shunt. The PVA membranes showed multiple perforations and were partly dissolved, the diameter of the largest void was around 10 mm, and the left atrial side of the occluder was damaged more obvious than the right (Figure 2B, arrow).
case_images: Postoperative histological examination with hematoxylin-eosin staining showing the proliferation of fibrous collagenous tissue (A,B). (100 x, scale bar = 50 mum).
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case_images: PMC9354964_01_fcvm-09-926527-g0003.jpg
case_images: F3
case_images: Furthermore, according to the pathology report (Figure 3), the surface of the occluder has not been fully epithelialized, instead, there was an extensive proliferation of fibrous collagenous tissue.
case_images: Postoperative transthoracic echocardiography showing that no residual shunt through the atrial septum was detected.
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case_images: F4
case_images: Finally, the patient recovered uneventfully without recurrent syncope and residual shunt (Figure 4).