Percutaneous closure of patent foramen ovale: pathophysiology, indications, and technique

Long-term follow-up after percutaneous closure of patent foramen ovale with Amplatzer PFO Occluder: a single center experience

Introduction

Patent foramen ovale (PFO) is associated with the occurrence of cryptogenic strokes, transient neurological ischemic attacks (TIA) and migraine. Therefore despite the recent ambiguous results of prospective controlled trials, percutaneous closure of PFO is still performed in many centers.

Aim

To evaluate the safety and effectiveness of percutaneous PFO closure in the prevention of recurrence of neurologic events and migraine symptoms in long-term observation.

Material and methods

In 70 patients (31 male, age: 38 ±18 years) percutaneous PFO closure was successfully performed with the Amplatzer PFO Occluder. An interview in conjunction with neurological follow-up was performed in all patients to reveal recurrence of embolism such as TIA or stroke and the presence of migraine symptoms before and after the procedure.

Results

The mean follow-up period was 857 ±363 days (median: 571 days). No serious complications of the procedure and no death were observed. Neurological events recurred in 5 (7.1%) patients – stroke in 1 patient, TIA in 3 patients, ocular embolism in 1 patient. All of these patients were over 40 years old or had other cardiovascular risk factors. Migraine was observed in 21 (30%) patients before the procedure and in 11 (15.7%) after the procedure (p = 0.04).

Conclusions

The complication rate and recurrence of neurological events in young patients after PFO closure are low. However, careful qualification and postprocedural monitoring of the patients are necessary. Patent foramen ovale closure seems to result in attenuation of migraine symptoms.

Percutaneous implantation of a second device in patients with residual right-to-left shunt after patent foramen ovale closure

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.

Heart, brain, and mind: a case series of multifactorial ischemic strokes in children

Ischemic strokes in children, although generally rare events, are more prevalent than commonly believed and can adversely affect brain development. Ischemic strokes in children have been associated with various risk factors, including coagulation defects, cardiac anomalies, inborn errors of metabolism, infections, trauma, and even migraine headaches. We present four children with two or more of these risk factors, indicating multifactorial causes of strokes in children. Neuropsychologic testing in two of our cases also underscores cognitive decline as a result of recurrent strokes.