Transcatheter PFO closure with GORE®septal occluder: Early and mid-term clinical results

Rescue Transcatheter Native Aortic Valve Closure to Treat Severe Aortic Regurgitation in a Patient With Single Ventricular Physiology and Decompensated Heart Failure

Semilunar valve regurgitation in single ventricular physiology is rare but portends a poor prognosis. Medical therapy is often ineffective particularly in the context of structural valve abnormality, and surgical valve repair or replacement can be associated with poor outcomes. We report an innovative use of a highly occlusive and conformable Gore Septal Occluder for transcatheter treatment of severe native aortic regurgitation in a symptomatic patient with hypoplastic left heart syndrome and severe systemic right ventricular dysfunction, resulting in safe and complete occlusion of the aortic regurgitant orifice and clinical benefit.

Clinical Performance of the Gore Septal Occluder in Patent Foramen Ovale Closure in Different Septal Anatomies: 1-Year Results from a Single-Center Experience

BACKGROUND

PFO (Patent foramen ovale) is a common defect that affects about 25% of the population. Although its presence is asymptomatic in the majority of the cases, the remaining part becomes overt with different symptoms, including cryptogenic stroke. PFO closure is currently a widely available procedure in complex anatomy, with Amplatzer PFO Occluder (APO) being the most commonly used tool. However, the performance of another device, the GORE Septal Occluder (GSO), has not been completely explored with regard to different septal anatomies.

METHODS

From March 2012 to June 2020, 118 consecutive patients with an indication of PFO closure were treated using the GSO system, included in a prospective analysis, and followed. After 12 months, every patient underwent transcranial Doppler ultrasound to evaluate the effectiveness of treatment.

RESULTS

Of 111 patients evaluated, 107 showed effective PFO closure (96.4%), and 4 showed a residual shunt (3.6%). To better evaluate the device performance, the overall population was sorted into two clusters based on the echocardiographic characteristics. The main difference between groups was for PFO width (4.85 ± 1.8 vs. 2.9 ± 1 mm, p < 0.001) and PFO tunnel length (12.6 ± 3.8 vs. 7.2 ± 2, p < 0.001), allowing complex and simple anatomies to be identified, respectively. Regardless of the aforementioned cluster, the GSO performance required to reach an effective closure was independent of anatomy type and the chosen device size.

CONCLUSION

The GSO device showed a high closure rate at 1-year follow-up in patients, with at least one anatomical factor of complexity of PFO irrespective of the level of complexity itself.

Use of the NobleStitch™ EL for the treatment of patients with residual right-to-left shunt following device closure of PFO

The unique design of the NobleStitch™ EL allows it to be used to close residual defects following failed device PFO closure without impacting the integrity of previously placed double-disk Gore occluders.

Efficacy and safety of percutaneous patent foramen ovale closure devices for recurrent stroke: A systemic review and network metaanalysis

Background:

Randomized controlled trials (RCTs) that directly compare the efficacy and safety of percutaneous patent foramen ovale (PFO) closure devices have not been conducted. Thus, we performed a network meta-analysis to identify the efficacy and safety of occluder devices.

Methods:

From 1st January, 2000 to 1st May, 2018, we searched Embase, PubMed, and Cochrane Library for RCTs about percutaneous closure devices (such as STARFlex, GORE, and Amplatzer) and medical therapy for cryptogenic cerebral ischemic patients with PFO. The occurrence rate of recurrent stroke, atrial fibrillation (AF), major vascular complication (MVC), headache, transient ischemic attack, and bleeding were compared with the frequentist and Bayesian methods using R statistics.

Results:

We included 3747 patients from six RCTs. The GORE and Amplatzer occluders were found to be significantly associated with a decreased risk of recurrent stroke [relative risk (RR): 0.37 and 0.49; 95% confidence interval (CI): 0.17–0.81, 0.29–0.83, respectively]. Moreover, STARFlex was correlated to an increased risk of postoperative AF and MVCs (RR: 11.66 and 7.63; 95% CI: 4.87–21.91, 2.34–24.88).

Conclusions:

Among the three devices, the GORE and Amplatzer occluders are found to be the most effective in preventing secondary stroke in patients with PFO. Meanwhile, STARFlex is the least recommended device because it cannot decrease the risk of recurrent stroke and is the most likely to cause adverse events.

Patent foramen ovale closure with GORE HELEX or CARDIOFORM Septal Occluder vs. antiplatelet therapy for reduction of recurrent stroke or new brain infarct in patients with prior cryptogenic stroke: Design of the randomized Gore REDUCE Clinical Study

Rationale The utility of patent foramen ovale (PFO) closure for secondary prevention in patients with prior cryptogenic stroke is uncertain despite multiple randomized trials completed to date. Aims The Gore REDUCE Clinical Study (REDUCE) aims to establish superiority of patent foramen ovale closure in conjunction with antiplatelet therapy over antiplatelet therapy alone in reducing the risk of recurrent clinical ischemic stroke or new silent brain infarct in patients who have had a cryptogenic stroke. Methods and design This controlled, open-label trial randomized 664 subjects with cryptogenic stroke at 63 multinational sites in a 2:1 ratio to either antiplatelet therapy plus patent foramen ovale closure (with GORE® HELEX® Septal Occluder or GORE® CARDIOFORM Septal Occluder) or antiplatelet therapy alone. Subjects will be prospectively followed for up to five years. Neuroimaging is required for all subjects at baseline and at two years or study exit. Study outcomes The two co-primary endpoints for the study are freedom from recurrent clinical ischemic stroke through at least 24 months post-randomization and incidence of new brain infarct (defined as clinical ischemic stroke or silent brain infarct) through 24 months. The primary analyses are an unadjusted log-rank test and a binomial test of subject-based proportions, respectively, both on the intent-to-treat population, with adjustment for testing multiplicity. Discussion The REDUCE trial aims to target a patient population with truly cryptogenic strokes. Medical therapy is limited to antiplatelet agents in both arms thereby reducing confounding. The trial should determine whether patent foramen ovale closure with the Gore septal occluders is safe and more effective than medical therapy alone for the prevention of recurrent clinical ischemic stroke or new silent brain infarct; the neuroimaging data will provide an opportunity to further support the proof of concept. The main results are anticipated in 2017. Registration Clinical trial registration-URL: http://clinicaltrials.gov/show/NCT00738894.

Closure of patent foramen ovale defects using GORE® CARDIOFORM septal occluder: Results from a prospective European multicenter study

AIMS

The GORE® CARDIOFORM Septal Occluder (GSO) is a novel device designed for rapid and effective closure of patent foramen ovale (PFO) which has distinctive features making it suitable for a broad spectrum of anatomical variations. We report the procedural and 6 months follow-up results of the first prospective, multicenter study using GSO.

METHODS AND RESULTS

This single-arm study included 150 subjects undergoing closure of PFO in 10 European centers. In 149 out of 150 patients implantation of a GSO device was successful. One patient had a different PFO-closure device implanted. Periprocedural complications were few including one patient with suspected transient ischemic attack, two access site bleedings, and one patient with AV-fistula. No device embolization occurred. During the 6-month follow-up period one patient had a transient asymptomatic thrombus on the device and four patients (2.6%) were diagnosed new onset paroxysmal atrial fibrillation, which were successfully treated. No thrombembolic events occurred. Closure was successful in 94.2% of subjects at discharge evaluation and 96.9% at 6 months follow-up.

CONCLUSION

This prospective, multicenter study adds to previous published data and suggests that GSO is a versatile device for PFO closure with high procedural and closure success rates and low complication rates through mid-term follow-up. © 2017 Wiley Periodicals, Inc.

Transseptal puncture to facilitate device closure of "long-tunnel" patent foramen ovale

BACKGROUND

Patent foramen ovale (PFO) is common and may predispose to paradoxical embolism. Transcatheter device closure of PFO can be challenging in certain cases of "long-tunnel" PFO morphology. We report our experience with device closure of long-tunnel PFO using transseptal puncture.

METHODS

We retrospectively reviewed all cases of PFO device closure using transseptal puncture at the Mayo Clinic from January 1, 2010 to September 30, 2013. We arbitrarily defined a PFO tunnel configuration as a tunnel length ≥ 12 mm as observed in intracardiac echocardiography (ICE) at the time of device closure.

RESULTS

Twelve patients (mean age 40.8 [range 15-67] years; 7 males [58%]) underwent PFO device closure with transseptal puncture. The most common indication for PFO closure was previous stroke (n = 7, 58%). Median tunnel length measured by ICE was 15 mm (12-20 mm). GORE® HELEX® Septal Occluder was used for closure in all but one patient. The only significant procedural complication was a minor perforation of the left atrial wall during attempted septal puncture, which resulted in a trivial pericardial effusion that resolved without intervention. At latest follow-up (mean 543 days, [range 170-1162]) one patient had a residual shunt and subsequently died due to complications during surgical PFO closure. No recurrent strokes or TIAs were reported.

CONCLUSION

Though not without risk, transseptal puncture can be a valuable tool for facilitating device closure of long-tunnel type PFOs. GORE® HELEX® Septal Occluder may be an effective option for facilitating device closure for patients with long-tunnel type PFO.