Percutaneous closure of patent foramen ovale: a case series and literature review

Abstract

Patent foramen ovale (PFO) is an anatomical variant of the interatrial septum with an overall prevalence of 27% in autopsy studies. PFOs have a potential role in causation of stroke, platypneaorthodeoxia, decompression sickness, right to left shunt and migraine headaches. Data regarding percutaneous closure of PFO in low volume tertiary care centers is lacking. Retrospective review of 14 percutaneous PFO closures done in our facility from March 2005 to August 2006 was performed for efficacy of procedure and safety. All patients received clopidogrel for a period of 3 months, and aspirin and subacute bacterial endocarditis prophylaxis for 6 months. Mean age of the study population was 54 years. Fifty percent (7 of 14) of patients experienced an atrial septal aneurysm and 14% (2 patients) exhibited a hypercoagulable state. The indication for closure in 13 patients was transient ischemic attacks or strokes, while one patient had persistent hypoxia due to a severe right to left shunt at PFO. Patients received either a CardioSEAL or Amplatzer device. Deployment rate was 100%. All patients completed a minimum of 6 months of follow-up, with a mean follow-up time of 14.9 +/- 7.6 months. No immediate or late bleeding complication occurred in any patient. One patient developed paroxysmal atrial fibrillation and one patient developed thrombotic complications at 7 months post-procedure secondary to the progression of her anal carcinoma and subsequently died. Pending the results of the four large randomized trials that are enrolling patients, percutaneous closure of PFO for cryptogenic strokes is an attractive alternative to lifelong anticoagulation with relatively few complications, even in low volume centers. There are many challenges in the management of this subset of patients, the foremost being the selection of a target patient population. Role of PFO in migraines is less clear.

Figure 1.

Intracardiac echocardiogram confirming device placement.

Figure 2.

CardioSEAL device.

Figure 3.

Amplatzer device.

Figure 4.

Transthoracic echocardiogram (TTE) with bubbles in right atrium.

Figure 5.

TTE depicting passage of saline contrast from RA to LA across a PFO.

Figure 6.

Transesophageal echocardiography (TEE) with color Doppler showing evidence of blood flow from left to right atrium across a PFO.

Figure 7.

TEE with morphological representation of atrial septal aneurysm with evidence of bulging of the septum from the left atrium to the right atrium.

Figure 8.

TEE with morphological representation of paradoxical septal motion associated with paradoxical embolism in cryptogenic stroke.