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Witte LS, El Bouziani A, Beijk MAM, Robbers-Visser D, Coutinho JM, Tijssen JGP, Straver B, Bouma BJ, de Winter RJ. Persistence of residual shunt at 6 and 12 months after transoesophageal echocardiography-guided percutaneous closure of a patent foramen ovale for cryptogenic stroke. Heart 2024; 110:1172-1179. [PMID: 39122559 DOI: 10.1136/heartjnl-2024-323905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 07/23/2024] [Indexed: 08/12/2024] Open
Abstract
BACKGROUND Young patients suffering from cryptogenic stroke alongside a patent foramen ovale (PFO) are often considered for percutaneous device closure to reduce the risk of stroke recurrence. Residual right-to-left shunt after device closure may persist in approximately a quarter of the patients at 6 months, and some may close at a later time point. This study aimed to assess the prevalence and persistence of residual right-to-left shunt after percutaneous PFO closure. METHODS Consecutive patients undergoing transoesophageal echocardiography-guided PFO closure for cryptogenic stroke between 2006 and 2021, with echocardiographic follow-up including contrast bubble study and Valsalva manoeuvre, were enrolled. Follow-up transthoracic echocardiography was performed at 6 months and repeated at 12 months in case of residual right-to-left shunt. Primary outcomes included the prevalence and grade of residual right-to-left shunt at 6 and 12 months after percutaneous PFO closure. RESULTS 227 patients were included with a mean age of 43±11 years and 50.2% were women. At 6-month follow-up, 72.7% had no residual right-to-left shunt, 12.3% small residual right-to-left shunt, 6.6% moderate residual right-to-left shunt and 8.4% large residual right-to-left shunt. At 12-month follow-up, the presence of residual right-to-left shunt in all patients was 12.3%, of whom 6.6% had small residual right-to-left shunt, 2.6% had moderate residual right-to-left shunt and 3.1% had large residual right-to-left shunt. CONCLUSIONS Residual right-to-left shunts are common at 6 months after percutaneous closure of PFO. However, the majority are small and two-thirds of residual right-to-left shunts achieve complete closure between 6 and 12 months.
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Affiliation(s)
- Lars S Witte
- Department of Cardiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Abdelhak El Bouziani
- Department of Cardiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Marcel A M Beijk
- Department of Cardiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Danielle Robbers-Visser
- Department of Cardiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Jan G P Tijssen
- Department of Cardiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Bart Straver
- Department of Cardiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Berto J Bouma
- Department of Cardiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Robbert J de Winter
- Department of Cardiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
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Onorato EM, Alamanni F, Monizzi G, Mastrangelo A, Bartorelli AL. Case Report: Persistent residual shunt after a first percutaneous PFO closure followed by minimally invasive surgical failure: third time is a charm. Front Cardiovasc Med 2024; 11:1367515. [PMID: 39015678 PMCID: PMC11249728 DOI: 10.3389/fcvm.2024.1367515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 06/12/2024] [Indexed: 07/18/2024] Open
Abstract
Background Even though the optimal management of a moderate or large residual shunt following patent foramen ovale (PFO) closure is open to question, recent data confirmed that it is associated with an increased risk of stroke recurrence. Case summary A 48-year-old woman, a migraineur with visual aura, was diagnosed with a PFO associated with a huge multifenestrated atrial septal aneurysm (mfASA) and a moderate right-to-left shunt, detectable only after a Valsalva maneuver on contrast-transthoracic echocardiography. Brain magnetic resonance imaging showed a 1-mm silent white matter lesion in the right frontal lobe. Although the indication was not supported by guidelines, a transcatheter PFO closure was performed at another center with implantation of a large, equally sized, double-disc device (Figulla UNI 33/33 mm). At 6-month follow-up, a 2D/3D transesophageal echocardiography (TEE) color Doppler showed incorrect orientation of the device, which was not parallel to the interatrial septum, with two discs failing to capture the aortic muscular rim and partially protruding in the right atrium; furthermore, a 4 mm × 7 mm ASA fenestration was documented with a residual bidirectional shunt. Thereafter, the same team performed a minimally invasive cardiac surgery under femoro-femoral cardiopulmonary bypass; however, the procedure proved ineffective and was complicated by postoperative pericarditis with pericardial effusion, requiring further rehospitalization 1 month later due to persistent pericarditis, bilateral pleuritis, phrenic nerve palsy, and atrial flutter, which was treated with amiodarone. The patient asked for a second opinion, and our multidisciplinary heart team decided to offer a percutaneous redo intervention. An uneventful implantation of a regular PFO occluder (Figulla Flex II 16/18 mm) across the septal defect was performed successfully. Twelve-month follow-up with 2D TTE color Doppler and contrast transcranial Doppler showed correct position and good interaction between the two devices, with no residual shunt. Discussion In addition to the incorrect indication for PFO closure and the failure of minimally invasive surgery, the procedural mishap in this case could have been due to the inappropriate implantation of the first large device within the tunnel. It would have been better to deploy the same large device in the most central fenestration, covering the PFO and a greater part of the remaining mfASA at the same time.
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Affiliation(s)
- Eustaquio M. Onorato
- University Cardiology Department, I.R.C.C.S. Ospedale Galeazzi- Sant’Ambrogio, Milan, Italy
| | - Francesco Alamanni
- University Cardiac Surgery Department, I.R.C.C.S. Ospedale Galeazzi- Sant’Ambrogio, Milan, Italy
| | - Giovanni Monizzi
- University Cardiology Department, I.R.C.C.S. Ospedale Galeazzi- Sant’Ambrogio, Milan, Italy
| | - Angelo Mastrangelo
- University Cardiology Department, I.R.C.C.S. Ospedale Galeazzi- Sant’Ambrogio, Milan, Italy
| | - Antonio Luca Bartorelli
- University Cardiology Department, I.R.C.C.S. Ospedale Galeazzi- Sant’Ambrogio, Milan, Italy
- Department of Biomedical and Clinical Sciences, “Luigi Sacco”, University of Milan, Milan, Italy
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Melillo F, Popusoi G, Frecentese F, Miano V, Santoro A, Tesorio T, Onorato EM. Is Moderate/Large Residual Shunt After PFO Closure Justifiable for a Patient with a Prior History of Cryptogenic Stroke and Transient Ischemic Attack? Int Heart J 2024; 65:146-151. [PMID: 38296568 DOI: 10.1536/ihj.23-375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
A 36-year-old woman suffered from an embolic stroke of an undetermined source documented by magnetic resonance imaging with residual right arm weakness. She underwent percutaneous patent foramen ovale (PFO) closure with an 18/25 mm device in another center. One year later, the patient suffered from a transient ischemic attack with dysarthria. She asked for a second opinion at our institution and a contrast-transthoracic (cTTE) /transesophageal echocardiography showed a large residual right-to-left shunt (RLS) through a still patent tunnel after PFO closure. Written informed consent for a redo procedure was obtained from the patient. A catheter-based closure of the residual shunt was therefore planned under local anesthesia and rotational intracardiac echo monitoring. A second equally sized disc (18/18 mm) device was successfully implanted without complications. The patient was discharged home the following day in good clinical condition. Dual antiplatelet therapy was recommended for the first 2 months and then single antiplatelet therapy up to 6 months. At the 6-month follow-up, the cTTE color Doppler showed the stable position of the two nitinol double-disc devices and the c-transcranial Doppler confirmed the abolition of the residual RLS.
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Affiliation(s)
| | - Gregory Popusoi
- Invasive Cardiology Unit, Clinica Montevergine di Mercogliano
| | | | | | | | - Tullio Tesorio
- Invasive Cardiology Unit, Clinica Montevergine di Mercogliano
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Susuri N, Obeid S, Ulmi M, Siontis G, Wahl A, Windecker S, Nietlispach F, Meier B, Praz F. Second transcatheter closure for residual shunt following percutaneous closure of patent foramen ovale. EUROINTERVENTION 2017; 13:858-866. [DOI: 10.4244/eij-d-17-00061] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Rovera C, Biasco L, Orzan F, Belli R, Omedè P, Gaita F. Percutaneous implantation of a second device in patients with residual right-to-left shunt after patent foramen ovale closure. J Interv Cardiol 2014; 27:548-54. [PMID: 25421752 DOI: 10.1111/joic.12162] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION The management of patients with residual right-to-left shunt (rRLS) after percutaneous patent foramen ovale (PFO) closure is debated. The aim of this study was to define the incidence of moderate-to-large rRLS and to report the feasibility, safety and long-term clinical outcome of transcatheter closure of rRLS. METHODS AND RESULTS From June 2000 to March 2013, 322 subjects underwent percutaneous PFO closure. In 39 patients (12.1%) with moderate-to-large rRLS on transcranial Doppler (TCD) and/or transesophageal echocardiogram a second cardiac catheterization was performed with the aim of completing the closure. A second closure device was implanted in 21 patients (53.8%). In the remaining 18 (46.2%), a second device was not delivered for the following reasons: in 13 (72.2%) no residual passage could be crossed, in 5 (27.8%) the residual shunt was deemed to be negligible. No complications occurred. After the second procedure, complete closure was proved by TCD in 16/21 (76.2%) subjects. One patient received a third device. During follow-up (41 ± 19 months), no cerebrovascular ischemic accidents occurred. CONCLUSION A second percutaneous PFO occlusion device can be safely implanted in patients with significant rRLS. However, a moderate-to-large rRLS on TCD and/or TEE may not necessarily represent a significant risk of further paradoxical embolization.
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Affiliation(s)
- Chiara Rovera
- Department of Medical Sciences, Division of Cardiology, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
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Santoro G, Giugno L, Gaio G, Capogrosso C, Iacono C, Russo MG. Trans-catheter treatment of residual leak after PFO device closure. Int J Cardiol 2014; 174:e13-5. [PMID: 24767132 DOI: 10.1016/j.ijcard.2014.04.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2014] [Accepted: 04/01/2014] [Indexed: 10/25/2022]
Affiliation(s)
- Giuseppe Santoro
- Paediatric Cardiology, A.O.R.N. "Ospedali dei Colli", 2nd University of Naples, Naples, Italy.
| | - Luca Giugno
- Paediatric Cardiology, A.O.R.N. "Ospedali dei Colli", 2nd University of Naples, Naples, Italy
| | - Gianpiero Gaio
- Paediatric Cardiology, A.O.R.N. "Ospedali dei Colli", 2nd University of Naples, Naples, Italy
| | - Cristina Capogrosso
- Paediatric Cardiology, A.O.R.N. "Ospedali dei Colli", 2nd University of Naples, Naples, Italy
| | - Carola Iacono
- Paediatric Cardiology, A.O.R.N. "Ospedali dei Colli", 2nd University of Naples, Naples, Italy
| | - Maria Giovanna Russo
- Paediatric Cardiology, A.O.R.N. "Ospedali dei Colli", 2nd University of Naples, Naples, Italy
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Butera G, Sarabia JF, Saracino A, Chessa M, Piazza L, Carminati M. Residual shunting after percutaneous PFO closure: how to manage and how to close. Catheter Cardiovasc Interv 2013; 82:950-8. [PMID: 23804551 DOI: 10.1002/ccd.25097] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Revised: 06/05/2013] [Accepted: 06/16/2013] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Initial transcatheter Percutaneous patent foramen ovale (PFO) closure attempt may be incomplete and result in persistent residual shunting. The optimal treatment strategy for these patients remains unknown. PATIENTS AND METHODS Twenty-seven patients were diagnosed to have a moderate-large residual shunt at least 12 months after initial PFO closure associated or not to a recurrent ischemic event and underwent a second procedure. Residual shunt characteristics were classified in two types: Type I: tunnel-like or between the disk defect (11 patients); Type II: accessory defect next to a device rim or accessory defect (16 patients). RESULTS Fourteen subjects had a recurrent transient ischemic attack/stroke (52%). Median time between the first and the second PFO closure procedure was 17 months (range 12-60 months). Deployment of a second device was successful in 92% (25/27) patients. A Type I defect was closed by using a coil or Amplatzer Vascular Plugs. In two patients a surgical option was chosen as a first option. A Type II defect was closed by using a double disc device. At a median follow-up of 36 months (range 12-60 months), two subjects showed significant residual shunting between the two disks of the device (Type I) at 12 months follow-up and were sent to surgery. CONCLUSIONS Significant residual shunts can be successfully closed by using a second device. Care is required to select an optimal device depending on anatomy and original device. In some subjects, lack of endothelial covering account for the persistence of a significant residual shunting.
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Affiliation(s)
- Gianfranco Butera
- Pediatric cardiology and GUCH Unit, Policlinico San Donato IRCCS, 20097, San Donato Milanese, Italy
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Edwards-Lehr T, Franke J, Bertog SC, Bäcker C, Wunderlich N, Hofmann I, Wilson N, Piechaud JF, Sievert H. Safety and performance of the spider™ patent foramen ovale occluder. Catheter Cardiovasc Interv 2012; 81:317-23. [DOI: 10.1002/ccd.24584] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2012] [Accepted: 07/17/2012] [Indexed: 11/06/2022]
Affiliation(s)
| | | | | | | | | | | | - Neil Wilson
- John Radcliffe Hospital Oxford; Oxford; United Kingdom
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Masseli J, Bertog S, Stanczak L, Blankenbach K, Majunke N, Reiffenstein I, Renkhoff K, Lehn K, Wunderlich N, Sievert H. Transcatheter closure of multiple interatrial communications. Catheter Cardiovasc Interv 2012; 81:825-36. [PMID: 22907918 DOI: 10.1002/ccd.24329] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2011] [Accepted: 01/07/2012] [Indexed: 11/06/2022]
Abstract
OBJECTIVES We sought to examine acute and midterm results of closure of multiple interatrial communications with staged device deployment and to review the relevant literature. BACKGROUND Information about percutaneous methods of closure for multiple defects is limited. METHODS We treated 148 patients with multiple defects. Of these, 88 had a relevant left to right shunt ("LRS"), 52 had a presumed paradoxical embolism ("PPE"), five had both (LRS and PPE), and one patient, respectively, had migraine, decompression sickness, and a right to left shunt. After implantation of the first device, closure of additional septal defects was attempted only if indicated clinically. RESULTS Ninety-four patients received a single device and 53 more than one. In four patients, surgical defect closure followed. At the end of follow-up (FU; mean 4.5 ± 3.4 years), complete closure of all defects occurred in 67.6% (62.1% for LRS, 76.5% for PPE). Clinical success (small or trivial residual shunt) was achieved in 86.9% (83.9% for LRS, 90.2% for PPE). Complications included pericardial effusions in 2.7%, recurrent thromboembolic events in 4.8%, and new onset of atrial fibrillation in 10.1%. In a significant number of patients with multiple defects, after single device implantation, the likelihood of complete closure increased with FU time (26% complete closure at 1 month vs. 78% at 24 months). CONCLUSION Percutaneous closure of multiple interatrial communications is feasible and safe. Importantly, many residual defects close without further intervention at FU. Therefore, staged device delivery is an alternative to simultaneous device implantation, possibly requiring fewer and smaller second devices.
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Cruz-González I, Diaz TA, Inglessis-Azuaje I, Palacios IF. Use of a second device for the closure of patent foramen ovale. Rev Esp Cardiol 2010; 63:1384-6. [PMID: 21070737 DOI: 10.1016/s1885-5857(10)70266-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Cruz-González I, Diaz TA, Inglessis-Azuaje I, Palacios IF. Segundo dispositivo para el cierre de un foramen oval permeable. Rev Esp Cardiol (Engl Ed) 2010. [DOI: 10.1016/s0300-8932(10)70311-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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