A gunther tulip filter was placed in a pt who had contraindication to anticoagulation that was immobile and at risk for thromboembolization.
Ct scan 2 days after placement showed the filter in good position.
Five days following placement the pt arrested.
A chest x-ray following resuscitation demonstrated migration of the filter to the cavoatrial junction.
A subsequent echocardiogram showed the filter within the tricuspid valve.
Emergent surgical removal was required.
The pt recovered from the surgery, but remains in the intensive care unit and ventilated.