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Incidental Murmur in a Preadolescent Boy

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A preadolescent boy with a history of ventriculoperitoneal shunt placement in the first year of life was admitted to the hospital for a urinary tract infection. On examination, there was a grade II/VI systolic regurgitant murmur, a II/IV diastolic low-pitched murmur along the left sternal border, and a rub throughout the cardiac cycle. A chest radiograph obtained for fever evaluation revealed a distal shunt catheter within the cardiac silhouette (Figure, A). The patient underwent shunt revision. Intraoperative transesophageal echocardiography showed the catheter entering the internal jugular vein, passing through the right atrium and ventricle, and intermittently crossing the pulmonary valve with resultant moderate tricuspid regurgitation (Video).1,2 The catheter was removed via an incision in the internal jugular vein and replaced within the abdomen.3 On postoperative examination, the murmur had resolved. This complication likely resulted from unrecognized puncture of both walls of the internal jugular vein during the initial shunt insertion, with subsequent migration of the catheter out of the abdomen and toward the direction of venous flow into the heart.4

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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Corresponding Author: Jordan L. W. Lam, MBBS, Department of Neurosurgery, University of Michigan, 1500 E Medical Center Dr, 3552 Taubman Center, Space 5338, Ann Arbor, MI 48109 (lamjor@med.umich.edu).

Conflict of Interest Disclosures: None reported.

References
1.
Kumar  B , Badamali  AK , Jayant  A , Bhukal  I , Puri  GD .  Intraoperative localization and monitoring of migrating foreign body using transesophageal echocardiography.   Ann Card Anaesth. 2014;17(4):314-317. doi:10.4103/0971-9784.142076PubMedGoogle ScholarCrossref
2.
Mitsopoulos  G , Hanna  RF , Brejt  SZ ,  et al.  Retrieval of a dislodged catheter using combined fluoroscopy and intracardiac echocardiography.   Case Rep Radiol. 2015;2015:610362. doi:10.1155/2015/610362PubMedGoogle ScholarCrossref
3.
Semadi  IN , Koerniawan  HS , Irawan  H .  Retrieval of intravascular fractured fragment of tunneled double-lumen catheter in hemodialysis patient.   Open Access Maced J Med Sci. 2019;7(1):124-126. doi:10.3889/oamjms.2019.025PubMedGoogle ScholarCrossref
4.
Fewel  ME , Garton  HJL .  Migration of distal ventriculoperitoneal shunt catheter into the heart: case report and review of the literature.   J Neurosurg. 2004;100(2 suppl pediatrics):206-211. doi:10.3171/ped.2004.100.2.0206PubMedGoogle ScholarCrossref
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