Kumar Ujjawal, Aslam Usman, Cooper Anthony, Khalpey Zain
School of Clinical Medicine University of Cambridge Cambridge UK.
Department of Cardiothoracic Surgery HonorHealth Scottsdale Arizona USA.
Clin Case Rep. 2024 Dec 15;12(12):e70006. doi: 10.1002/ccr3.70006. eCollection 2024 Dec.
Patent foramen ovale (PFO) closure using percutaneous devices, such as the Amplatzer occluder, is a common treatment for patients with a history of cryptogenic stroke or transient ischemic attack (TIA). Although generally well-tolerated, some patients may develop adverse reactions to the device materials, particularly in the presence of a nickel allergy. Symptoms can include chest pain, rashes, and migraines, which may necessitate surgical removal of the device. In such cases, careful surgical planning and execution are essential to ensure successful outcomes and symptom resolution. We present the case of a 39-year-old female with existing PFO closure using an Amplatzer device, who developed severe, persistent atypical chest pain radiating to her upper extremities and occasional migraines 1 month after Amplatzer implantation. Patch testing confirmed a nickel allergy, prompting a referral to our service for surgical explantation of the device. The patient underwent Amplatzer device removal and reconstruction of the interatrial septum via sternotomy. The surgical technique involved meticulous excision of the device while preserving maximal septal tissue, allowing for primary closure of the interatrial septum without the need for a pericardial patch. Intraoperatively, significant scar tissue and inflammation were observed surrounding the device and atrial septal tissue, necessitating careful excision while preserving healthy tissue. The left atrial appendage was oversewn using a polypropylene suture for thromboembolism prophylaxis. Amniotic membrane allograft and autologous platelet-rich plasma were applied to promote wound healing, with specialized suture tapes used for chest closure to avoid using stainless steel sternal wires (the most common alloy, 316 L surgical steel contains around 15% nickel) and minimize the risk of sternal complications. The patient tolerated the procedure well, with complete resolution of symptoms following device removal. At follow-up, she reported improved exercise tolerance, enhanced quality of life, and was able to discontinue her pregabalin medication after 30 months of use (600 mg once daily). She returned to work with light duties 6 weeks postoperatively. This case highlights the importance of preoperative allergy testing to consider nickel allergy in patients before implanting devices such as an Amplatzer, as well as after considering de novo nickel sensitization as a potential cause when such symptoms develop after implantation. This case also highlights the value of surgical intervention in alleviating symptoms and optimizing patient outcomes in cases of device-related complications.
使用经皮装置（如Amplatzer封堵器）闭合卵圆孔未闭（PFO）是有隐源性卒中或短暂性脑缺血发作（TIA）病史患者的常见治疗方法。尽管通常耐受性良好，但一些患者可能会对装置材料产生不良反应，尤其是在存在镍过敏的情况下。症状可能包括胸痛、皮疹和偏头痛，这可能需要手术取出装置。在这种情况下，仔细的手术规划和执行对于确保成功的结果和症状缓解至关重要。我们报告一例39岁女性，其使用Amplatzer装置已完成PFO闭合，在植入Amplatzer装置1个月后出现严重、持续的非典型胸痛并放射至上肢，偶尔伴有偏头痛。斑贴试验证实存在镍过敏，促使其转诊至我们科室进行装置的手术取出。患者接受了经胸骨切开术取出Amplatzer装置并重建房间隔。手术技术包括在保留最大量间隔组织的同时细致切除装置，从而实现房间隔的一期闭合，无需心包补片。术中，在装置和房间隔组织周围观察到大量瘢痕组织和炎症，需要在保留健康组织的同时仔细切除。使用聚丙烯缝线缝合左心耳以预防血栓栓塞。应用羊膜同种异体移植物和自体富血小板血浆促进伤口愈合，使用专门的缝合带进行胸部闭合，以避免使用不锈钢胸骨钢丝（最常见的合金，316L外科不锈钢含约15%镍）并将胸骨并发症的风险降至最低。患者对手术耐受性良好，装置取出后症状完全缓解。随访时，她报告运动耐量改善、生活质量提高，并且在使用30个月（每日一次，600mg）的普瑞巴林药物后能够停药。术后6周她恢复了轻体力工作。该病例强调了术前过敏试验的重要性，以便在植入Amplatzer等装置之前考虑患者是否存在镍过敏，以及在植入后出现此类症状时将新发镍致敏作为潜在原因进行考虑。该病例还强调了手术干预在缓解与装置相关并发症的症状和优化患者预后方面的价值。
