Strut through the Heart: Acute Pericarditis and Hemopericardium
from an Embolized IVC Filter Strut
Author: Ellen Liu, MD, Additional Authors**
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Introduction/Objective
Inferior vena cava (IVC) filters are used for prevention of pulmonary embolism when anticoagulation is contraindicated or ineffective. Use of retrievable IVC filters has increased significantly, yet the retrieval rate remains low. Longer dwell time is associated with increased adverse events, including migration of filters and fractured parts which, although rare, can lead to potentially life-threatening cardiovascular complications.
Case Presentation
A 71 year old male with a history of deep vein thrombosis on Warfarin status post IVC filter placement eight years ago presented to his local emergency department with chest pain. HS-troponin was 1036.2 pg/mL. Electrocardiogram (ECG) revealed sinus bradycardia without any ST segment changes. Computed tomography angiography of the chest was negative for acute pulmonary embolism, though a linear density was noted in the right ventricle. Transthoracic echocardiogram (TTE) revealed a normal ejection fraction and trivial effusion. He underwent coronary angiography which revealed normal coronary arteries. Fluoroscopic images demonstrated a linear density associated with the right ventricle and the presence of an IVC filter. He was transferred to OSU Wexner Medical Center. On arrival, a repeat ECG revealed new diffuse ST segment elevation consistent with pericarditis. A bedside TTE was performed (Figure 1), showing an enlarging pericardial effusion (asterisk) with a linear echo density (arrow) within the pericardial space adjacent to the right atrium and ventricle, concerning for strut migration into the pericardial space. The patient was brought urgently to the operating room where bloody pericardial fluid was evacuated and an IVC filter strut was removed from the inferior wall of the right ventricle.
Discussion
Our case reiterates the importance of filter retrieval and the risks associated with increased dwell time. Prompt removal of IVC filters is recommended by the Food and Drug Administration, although the reported retrieval rate remains suboptimal. Migration of IVC filters or fractured filter struts to the heart can lead to complications including pericarditis, ventricular arrhythmias and tamponade, which are rare complications reported in the literature. Filters or struts that have migrated to the right ventricle require surgical or endovascular retrieval, although surveillance of embolized struts has also been reported.
This case also demonstrates the importance of monitoring for progression of embolized parts. The patient had an unremarkable ECG on presentation and initial echocardiogram revealed only a trivial effusion. The development of acute pericarditis and enlarging effusion was consistent with strut migration from within the ventricle into the pericardial space. Due to anticoagulation use and potential for hemopericardium and tamponade, prompt retrieval of the strut and drainage of pericardial fluid was necessary.
Conclusion
Although the overall incidence of filter fracture and embolization is low, the potential of complications warrants careful selection of patients and timely removal of IVC filters when its use is no longer indicated. A migrated IVC filter or fractured strut should be on the differential for a patient with a history of IVC filter placement who presents with an acute cardiovascular event.
**Additional Authors:
Ellen Liu, MD, The Ohio State University Wexner Medical Center, Columbus, OH
Laurie Bossory Goike, MD, The Ohio State University Wexner Medical Center, Columbus, OH
Obiora Egbuche, MBBS, MPH, The Ohio State University Wexner Medical Center, Columbus, OH
Alexander Meyer, MD, The Ohio State University Wexner Medical Center, Columbus, OH
Asvin Ganapthi, MD, The Ohio State University Wexner Medical Center, Columbus, OH
