Case Report: Migration of a Varicocele Coil to the Right Heart

Percutaneous embolization of the testicular vein with coils is a commonly performed treatment of varicocele. Reports of intravascular migration of embolization coils are rare. A case report published recently in JACC discusses multimodality-imaging based diagnosis and management of such a coil migration to the right ventricle (RV). This is the first-ever case of varicose-vein coil translocation to the heart.

Case Presentation

A 29-year-old male patient presented with atypical left-sided chest pain and cold fingers and hands. He had a history of smoking. His physical examination was unremarkable. At the age of 15 years, he had a varicocele operation when approximately 14 microcoils were inserted (measuring 7 x 70 mm).

He was referred to the rheumatology team in 2015 to investigate the cause of his peripheral vasospastic symptoms and exclude a connective tissue disorder, vasculitis, or primary Raynaud phenomenon. He had a chest radiograph that revealed a foreign structure (Figure). Further cardiac investigations including cardiac magnetic resonance imaging, a 3-dimensional transthoracic echocardiogram, and a computed tomogram were performed. The computed tomography confirmed a foreign body in the heart; however, the mass could not be localized because of artefact from the foreign body (Figure). It was also difficult to assess the exact location on cardiac magnetic resonance imaging. A 2-dimensional and 3-dimensional transthoracic echocardiogram (Figure) identified a well-defined 3.3-cm foreign object in the basal right ventricle attached to the posterior annulus of the tricuspid valve measuring. There was mild tricuspid insufficiency. The biventricular size and function were normal.

Treatment and Outcome

A heart valve multidisciplinary meeting discussed the best approach to coil removal. There was concern regarding damage to the tricuspid valve apparatus using percutaneous methods, therefore a surgical option was preferred. Surgical extraction of the coil was performed via a median sternotomy using full cardiopulmonary bypass and cardiac arrest with antegrade cardioplegia. The right atrium was opened and the coil was identified in the subtricuspid valvular apparatus of the right ventricle in close proximity to the septal and posterior leaflets (Figure). The coil was carefully removed and the tricuspid was repaired with a 4.0 Prolene commissural stitch.

The patient made an uncomplicated recovery. Three days post-procedure, an echocardiogram revealed a normal size right ventricle. The tricuspid repair was functioning well, with no restriction and trivial regurgitation. He was discharged home on the fifth post-operative day.

Discussion

The current case report is unique in that the coil became lodged within the right ventricle of the heart in close proximity to the tricuspid valve. The use of multimodality imaging allowed the exact location of the coil to be determined. Embolization to the right ventricle has never been reported in the literature. The potential risk of having a foreign body in the RV, and the patient's wish, were key to making a decision for surgical removal.

Source

JACC case reports. Nina Karia, Damian Balmforth, Kulvinder Lall, Sandy Gupta, Sanjeev Bhattacharyya, Migration of a Varicocele Coil to the Right Heart, JACC: Case Reports, Volume 2, Issue 15, 2020, Pages 2312-2317, ISSN 2666-0849, https://doi.org/10.1016/j.jaccas.2020.07.035.