Delayed Cardiac Tamponade Caused by Right Atrial Perforation from a Fractured Permanent Inferior Vena Cava Filter: A Case Report

INTRODUCTION: Inferior vena cava (IVC) filters are used to prevent pulmonary embolism in patients with deep vein thrombosis (DVT). Although generally safe, long-term indwelling filters may cause complications such as fracture, migration, and organ perforation. Cardiac tamponade due to right atrial (RA) perforation is extremely rare, particularly with permanent filters. CASE PRESENTATION: A 60-year-old woman presented to our institution with sudden epigastric pain. She had undergone permanent IVC filter placement 13 years earlier for DVT and had remained on warfarin thereafter. At the initial hospitalization, electrocardiography (ECG) showed mild ST-segment depression and cardiac biomarkers were slightly elevated. Transthoracic echocardiography and contrast-enhanced CT showed no pericardial effusion, and coronary angiography (CAG) revealed no significant coronary stenosis, although a linear radiopaque structure was incidentally observed near the cardiac silhouette. Vasospastic angina was suspected, and she was discharged after symptom improvement. Three days later, she returned with worsening dyspnea and general fatigue. Transthoracic echocardiography revealed pericardial effusion, and contrast-enhanced CT demonstrated a hyperdense fragment in the RA, additional fragments around the right ventricle (RV), and penetration of the filter into the duodenum. Comparison with CT obtained 4 years earlier showed a newly developed structural defect of the filter, consistent with fracture. Warfarin was discontinued, and no heparin bridging was performed because of the bleeding risk. The patient underwent a sequential open surgical approach consisting of laparotomy followed by median sternotomy, with filter removal and repair of the duodenal perforation performed during the abdominal phase and removal of the migrated fragment and repair of the RA perforation performed under cardiopulmonary bypass during the cardiac phase. Her postoperative course was uneventful, with no recurrent pericardial effusion or IVC obstruction during 2 years of follow-up. CONCLUSIONS: Late structural failure may occur even in permanent IVC filters, and migrated filter components can cause life-threatening cardiac tamponade long after implantation.