Novel use of the Sentinel cerebral protection device during thrombosed septal occluder explant and Atriclip appendage closure.

BACKGROUND: Our case demonstrates a novel use of the Sentinel™ cerebral protection device (SCPD) for prevention of stroke during removal of a thrombus-adherent atrial septal occluder. CASE PRESENTATION: A 45-year-old male with multiple strokes and ostium secundum atrial septal defect closed ten years prior using an Amplatzer Septal Occluder presented with recurrent neurologic symptoms. Over the ensuing year, serial transesophageal echocardiography revealed persistent and worsening device-adherent thrombus despite trial of different anticoagulants. The device appeared to be mal-deployed, prompting the decision for surgical explant. Given concern for embolization during explant, an SCPD was placed. Excision, pericardial patch repair, and Atriclip appendage closure (AAC) were performed. The device demonstrated incomplete endothelialization and microthrombi. SCPD filtration revealed embolic debris. CONCLUSIONS: We demonstrate the first successful use of an SCPD during surgical excision of a mal-deployed occluder. With its ease of use and safety, SCPD may have utility in surgeries with high cardio-embolic risk.

Caution regarding potential changes in AVR practices during the COVID-19 pandemic.

To improve resource allocation in face of the COVID-19 pandemic, hospitals around the country are restricting the performance of elective surgery to preserve ventilators, operating rooms, ICU beds and protect anesthesiologists. For patients with severe aortic stenosis, efforts to bring treatment to symptomatic patients amid this pandemic might lead to favored use of catheter based management using minimalist techniques that do not require these elements. In this context, some patients with well tested surgical indications for valve replacement may be treated by catheter-based methods. It is important that outcomes for these cases are followed closely both at respective sites and in national registries. As we recover from this pandemic, surgical cases should once again be driven by multi-disciplinary discussion and clinical trial data, and not a mentality of crisis management.

Transcatheter Aortic Valve Migration During Vascular Access Closure.

We present a novel complication of transcatheter aortic valve replacement (TAVR) involving prosthetic migration due to entanglement by a standard guidewire during non-large bore vascular access closure, followed by successful bail-out using a second transcatheter prosthesis. To our knowledge, this mechanism of prosthesis migration has not been previously described.

Hemopericardium and Cardiac Tamponade Secondary to Migrated Inferior Vena Cava Filter.

A 73-year-old female presented with cardiogenic shock secondary to hemopericardium and cardiac tamponade. Imaging revealed two fractured legs of an inferior vena cava filter, with one leg within the anterior myocardium of the right ventricle and another penetrating the inferior septum through the middle cardiac vein. Hemopericardium and cardiac tamponade were treated with pericardiocentesis. A multidisciplinary meeting resulted in deferring further action against the embedded fractured legs of the filter with consideration of the patient's age and comorbidities. This case report should alert clinicians to think about hemopericardium as a cause of cardiac tamponade and cardiogenic shock in a patient with a history of an inferior vena cava filter placement.

Myocardial Ischemia with Cannabinoid Use in an Adolescent.

A 16-year-old male presented to the emergency department with chest pain after smoking a synthetic cannabinoid from a vape pen. He had rising troponin I levels, and his exercise stress echocardiogram showed distal apical and septal hypokinesis that resolved at six-month follow-up. This case report raises concern about cardiac ischemia related to synthetic cannabinoid abuse in the pediatric population in the current era of cannabis legalization.

Myasthenia Gravis Induced by Nivolumab: A Case Report.

Nivolumab is a programmed cell death receptor (PD-1) inhibitor therapy for aggressive cancers; however, it poses a risk of immune-related adverse side effects. We present a 73-year-old male with renal cell carcinoma who developed myasthenia gravis (MG) after being treated with nivolumab, proven by acetylcholine receptor antibodies. Our patient presented with symptoms of fatigue and upper and lower extremity weakness, eventually resulting in respiratory failure as a result of MG. Nivolumab is an emerging therapy for advanced cancers but poses severe immune-related adverse events. Clinicians using PD-1 inhibitors should have a high index of suspicion of autoimmune diseases so that early discontinuation and treatment can be established to limit long-term morbidity and mortality.