Successful uniportal thoracoscopic removal of a new generation implantable loop recorder accidentally migrated into the left pleural cavity and concomitant re-implantation: A case report

Abstract

Introduction

With the spread of the use of implantable loop recorders (ILRs) by cardiologists for outpatient cardiac monitoring, intrathoracic migration represents a rare but possible complication occurring after the placement of these devices. Very few cases of ILRs intrathoracic migration into the pleural cavity have been reported, followed in even fewer cases by surgical removal of the devices, but in none re-implantation was performed.

Presentation of case

We report the first case of a patient with a new generation ILR accidentally migrated into the postero-inferior costophrenic recess of the left pleural cavity, successfully removed by uniportal video-assisted thoracic surgery (VATS) and submitted to re-implantation of a new ILR in the same operating session.

Discussion

To reduce the risk of ILRs intrathoracic displacement, the insertion technique must be performed in the most suitable part of the chest wall, with the correct incision and angle of penetration, by an expert operator. When migrated into the pleural cavity, surgical removal should be performed to avoid the onset of early and late complications. A mini-invasive surgical approach by uniportal VATS could be considered as the first choice, ensuring a favourable patient outcome. Re-implantation of a new ILR can be safely performed in the same operating session.

Conclusion

In case of intrathoracic migration of ILRs, early removal by mini-invasive approach is recommended as well as concomitant re-implantation. Beyond periodic monitoring of ILRs by cardiologists, strict radiological follow-up with chest X-ray is advisable after implantation, in order to early identify any abnormalities and correctly manage them.

Highlights

• •Intrathoracic migration of implantable loop recorders (ILRs) is possible.
• •Early removal of migrated ILRs is highly recommended to avoid other complications.
• •Thoracoscopic surgical approach could be considered as the first choice.
• •Re-implantation of a new ILR can be safely performed in the same operating session.
• •Chest X-ray follow-up after implantation is recommended, to identify abnormalities.

1. Introduction

Few reports have been published about intrathoracic foreign bodies resulting from accidental migration of medical devices. Intrathoracic migration of implantable loop recorders (ILRs) has rarely been reported [1]^, [2]^, [3]^, [4]^, [5]. These devices, developed since 2015 [6]^, [7], are nowadays commonly used to continuously monitor the electrocardiogram in patients with unexplained palpitations or syncope or with suspected or known atrial fibrillation [1]^, [3]^, [4], to diagnose arrhythmias. Thanks to their small size, lack of external leads, long battery life and the possibility to be implanted under local anesthesia by cardiologists, in recent years ILRs have significantly spread for outpatient cardiac monitoring [3]. However, post-implantation intrathoracic migration, especially into the pleural cavity, should be known as a possible complication, occurring even in the hands of the most experienced cardiologists [3].

We report the first case of a patient with a new generation ILR accidentally migrated into the postero-inferior costophrenic recess of the left pleural cavity, successfully removed by uniportal video-assisted thoracic surgery (VATS) and submitted to re-implantation of a new ILR in the same operating session.

The work has been reported in line with the SCARE criteria [8].

2. Presentation of case

An eighty-year-old woman with no comorbidities, except for well-controlled hypertension and diabetes, was admitted to the Cardiology Department of our University Hospital due to an episode of syncope. She underwent several medical tests (electrocardiogram, 24 h-Holter electrocardiogram, echocardiography, endocavitary electrophysiological study, total body computed tomography - CT) which were unremarkable and the origin and cause of syncope remained unknown; for this reason a new generation ILR (BioMonitor 3, Biotronik SE & Co, Berlin, Germany, smaller and characterized by a small flexible antenna, compared to its predecessor) was implanted in the left anterior chest wall, under local anesthesia, on an inpatient basis, with the aim of monitoring the heart rhythm, supposing an arrhythmogenic origin. Neither complications, nor respiratory symptoms were reported during and immediately after the procedure, thus no post-procedure chest X-ray was performed.

One week after the implantation, during routine monitoring, the cardiologists found that it was not possible to telemetrically interrogate the loop recorder. Thus, the patient underwent chest X-ray and subsequent chest CT scan showing the cardiac device dislocated in the postero-inferior left pleural space, with no pleuro-pulmonary lesions (Fig. 1).

Fig. 1.

Chest CT scan showing the implantable loop recorder dislocated in the postero-inferior left pleural cavity, with no pleuro-pulmonary lesions.

After a multidisciplinary discussion, an early surgical removal of the migrated device was planned with the aims both of allowing an easier intervention avoiding development of adhesions or potential infection and of preventing any delayed complications (further migration, lesion of intrathoracic organs, late infection, other). Re-implantation of a new ILR in the same operating session was planned, too, obtaining the informed consent of the patient.

Three days later, the patient was admitted to our Thoracic Surgery Unit and underwent surgical removal of the intrathoracic foreign body by uniportal VATS (Fig. 2). Under general anesthesia with a double-lumen tube and in right lateral decubitus, a single port access of 1 cm was performed in the fifth left intercostal space at the mid-axillary line: at thoracoscopic exploration the device was identified in the postero-inferior costophrenic recess of the pleural cavity and easily retrieved with grasping forceps; no pleuro-pulmonary lesions were detected. During the same operating session, the cardiology team performed the subcutaneous re-implantation of a new ILR, at the same site of the previous one, in the left anterior chest wall.

Fig. 2.

(a) Uniportal VATS and intraoperative thoracoscopic identification of the migrated implantable loop recorder, retrieved with grasping forceps; (b) retrieved new generation implantable loop recorder (BioMonitor 3, Biotronik).

Post-operative course was uneventful and the chest X-ray at two weeks from the procedures showed no pleuro-pulmonary complications and a correct placement of the ILR (Fig. 3).

Fig. 3.

Chest X-ray at two weeks from surgical procedures showing no pleuro-pulmonary complications and a correct placement of the ILR.

The patient is currently doing her periodic cardiologic checks and the loop recorder is well working.

3. Discussion

The first reports of the diagnosis and treatment of intrathoracic foreign bodies concerned people who survived the Second World War [9]. In 1945 Garland [10] stated that the main indications for intrathoracic metallic foreign bodies removal were: symptom-producing foreign bodies and localization in the posterior mediastinum and diaphragm. On the other hand, Sommer [11] et al. preferred the removal in any case: even after many years of asymptomatic retention, foreign bodies could cause dangerous complications (hemoptysis, bronchiectasis, lung abscess).

Recently, cases of intrathoracic foreign bodies represented by migrated medical devices have been reported, such as Kirschner wires utilized for surgical stabilization of clavicle fractures migrated into the lung; removal by thoracoscopy was the preferred approach [12]^, [13]. The migration mechanism remains unclear, however might include muscular activity, movements of the shoulder, breathing movements, negative intrathoracic pressure with respiratory excursion, gravitational force [12].

Actually, the intrathoracic displacement of a medical device such as ILRs could be associated with a technical mistake: the thin chest wall structure and the negative pressure of the pleural cavity could determine the intrathoracic migration. Therefore, the insertion technique must be performed in the most suitable part of the thorax, with the correct incision and angle of penetration and by an expert operator. Modern ILRs are provided with a specifically designed insertion tool set which allows easy subcutaneous insertion [2]. The device is commonly implanted by cardiologists, using local anesthesia, with the insertion tool positioned at the left anterior fourth intercostal space, approximately 2–3 cm lateral to the sternum [1]^, [2]^, [5]. However, if an excessive angle of penetration (of more than 40°) is applied, the pocket tool might be inadvertently inserted through the intercostal space until the pleural cavity [2]^, [4]. Thus, it is recommended that the subcutaneous implantation should be done with a minimal penetration angle and following a direction parallel to the sternum and to the chest plane [2]^, [4].

In general, few cases of ILRs intrathoracic migration into the pleural cavity have been reported. To the best of our knowledge, five cases have been published: four migrated into the left pleural cavity, finally located in its postero-inferior recess in two cases, one (Medtronic Reveal LINQ) removed by uniportal VATS [1] and one (BioMonitor 2, Biotronik) left on site, to be removed only in case of complications [2], and in its antero-inferior recess in two (BioMonitor 3, Biotronik and Medtronic Reveal LINQ) removed by uniportal VATS [4]^, [5]; one migrated to the antero-lateral thoraco-abdominal wall posterior to the left eighth rib (Medtronic Reveal LINQ) removed by the general surgeon [3]. In the three cases of ILRs removed by uniportal VATS and in the case removed by the general surgeon, no re-implantation was performed [1]^, [3]^, [4]^, [5].

Therefore, our case is the first reported in Literature with a new generation ILR (BioMonitor 3, Biotronik) accidentally migrated into the postero-inferior recess of the left pleural cavity, successfully removed by uniportal VATS and submitted to re-implantation of a new ILR in the same operating session (Table 1).

Table 1.

Characteristics of the previous cases of migrated ILR described in the literature, compared to our case.

References	Type of ILR	Post-implant migration evidence (days)	Symptoms	Diagnosis	Working ILR	Site of migration	Surgical removal	Operating surgeons	Technique of removal	Concomitant ILR re-implantation by cardiologists
Preminger 2017 [1]	Medtronic Reveal LINQ	35	Chest pain	Chest X-ray and CT	No	Left postero-inferior pleural cavity	Yes	Thoracic	Uniportal VATS	No
Brignole 2018 [2]	BioMonitor 2 Biotronik	Not specified	Not specified	Chest X-ray	Yes	Left postero-inferior pleural cavity	No	–	–	–
Hasnie 2019 [3]	Medtronic Reveal LINQ	5	Chest pain	Chest X-ray and chest-abdomen CT	No	Antero-lateral thoraco-abdominal wall	Yes	General	Pro-peritoneal space access by open muscular dissection	No
Rahkovich 2021 [4]	BioMonitor 3 Biotronik	7	None	Chest X-ray and CT	Yes	Left antero-inferior pleural cavity	Yes	Thoracic	Uniportal VATS	No
Ang 2022 [5]	Medtronic Reveal LINQ	28	None	Chest X-ray and CT	Yes	Left antero-inferior pleural cavity	Yes	Thoracic	Uniportal VATS	No
Signore 2022	BioMonitor 3 Biotronik	7	None	Chest X-ray and CT	No	Left postero-inferior pleural cavity	Yes	Thoracic	Uniportal VATS	Yes

Some Authors hypothesized that the tip of the insertion tool could have penetrated the muscle fibers of the pectoralis major up to the intercostal muscle and therefore that the ILR was located within the muscle rather than in the subcutaneous layer of the chest wall [1]^, [3]^, [4]^, [5]. Besides, the patient's manually pushing probably could have contributed to the migration into the pleural cavity [4].

Of the five published cases, evidence of ILR migration occurred on the 5th [3], 7th [4], 28th [5] and 35th [1] days after implant in four cases, respectively, and was characterized by sharp sudden chest pain in two [1]^, [3] and it was asymptomatic in two [4]^, [5]; no details have been reported about the time of diagnosis and symptoms in one case, that did not undergo surgical removal [2]. In this last case, the device (BioMonitor 2, Biotronik) could be interrogated and properly programmed [2]; in two cases there was inability to interrogate the devices (Medtronic Reveal LINQ) [1]^, [3]; in one case it was possible to interrogate the device (BioMonitor 3, Biotronik) from the left lower chest area [4]; in one case the device (Medtronic Reveal LINQ) allowed to diagnose a sick sinus syndrome [5]. In our patient, device migration was suspected one week after the implantation, as it was not possible to interrogate the loop recorder; the patient resulted asymptomatic.

In all reported cases comprising this one, diagnosis of migrated loop recorder was achieved at first with a chest X-ray [1]^, [2]^, [3]^, [4]^, [5]; chest CT scan was necessary in three cases undergoing surgical removal, to precisely identify the localization of the foreign body into the pleural cavity, exclude any related complication and properly plan the thoracoscopic surgical approach [1]^, [4]^, [5], as in our patient; in one case chest-abdomen CT scan was performed to locate the device into the antero-lateral thoraco-abdominal wall and allow removal by the general surgeon [3].

Uniportal VATS allowed an easy identification, successful and safe retrieval of the device migrated in the left pleural cavity and could be considered as the first choice surgical approach, ensuring a favourable patient outcome [1]^, [4]^, [5].

Moreover, in our patient there were no complications after ILR re-implantation, confirming that it can be safely performed in the same operating session.

4. Conclusion

In case of intrathoracic migration of ILRs, early removal by mini-invasive approach is recommended as well as concomitant re-implantation. In addition to periodic monitoring by cardiologists, strict radiological follow-up with chest X-ray is advisable after ILRs implantation, in order to early identify any abnormalities and promptly treat them.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethical approval

The study is exempt from ethical approval in our institution.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Guarantor

Prof. Angela De Palma, MD, PhD.

Research registration number

This is a case report so it does not require registration.

CRediT authorship contribution statement

Francesca Signore: Conceptualization, Data curation, Writing – original draft. Valentina Simone: Data curation, Visualization, Investigation. Matteo Anaclerio: Data curation, Methodology, Investigation. Nicola Bozza: Data curation, Methodology, Investigation. Giuseppe Marulli: Methodology, Visualization, Writing – review & editing, Supervision. Angela De Palma: Data curation, Methodology, Writing – review & editing, Supervision.

Conflict of interest

The authors have no conflicts of interest to declare.