Implantation of a second closure device in patients with residual shunt after percutaneous closure of patent foramen ovale

Abstract

Percutaneous closure of patent foramen ovale (PFO) in patients with presumed paradoxical embolism yields complete occlusion in > 90% of patients using contemporary closure devices. Patients with a residual shunt after percutaneous PFO closure have been found at increased risk for recurrent paradoxical events. Treatment options for such patients include medical treatment using antiplatelet drugs or oral anticoagulation, surgical device removal and patch closure, and percutaneous implantation of a second closure device. We report our experience with implantation of a second closure device in 10 patients with more than a minimal residual shunt < or = 6 months after percutaneous PFO closure. Procedure and fluoroscopy times were similar for the initial and repeat intervention (32 vs. 30 min and 5 vs. 6 min, respectively; P = NS). There were no procedural complications during implantation of the second closure device. Follow-up transesophageal echocardiography 6 months after the second percutaneous intervention revealed complete PFO closure in nine (90%) patients. Therefore, implantation of a second closure device in patients with persistence of more than a residual shunt after percutaneous PFO closure appears safe and effective.

Determinants and clinical significance of persistent residual shunting in patients with percutaneous patent foramen ovale closure devices

“…The complete elimination of two moderate sized residual shunts at 18 month echocardiographic follow-up, however, supports the notion that residual shunting may resolve over time secondary to an endothelialization process with no clinical consequence [10]. The practice of placing an additional device on top of a previously placed PFO closure device with a moderate to large sized shunt may not be necessary as these shunts usually resolve over time with no increased risk of stroke or TIAs.…”

Management of residual shunts after initial percutaneous patent foramen ovale closure: A single center experience with immediate and long‐term follow‐up

“…To our knowledge, there has only been one prior study reporting the use of a percutaneous second device implant for patients with residual PFO shunts, [11] and although Schwerzmann's et al series included only 10 patients, in their series the percutaneous treatment strategy was associated with no procedural complications and successful residual shunt closure in 90% of the patients. Unfortunately, detailed description with longterm clinical follow-up was not available in their series.…”

“…However, in patients with moderate-to-large residual shunts, a fourfold increase risk in recurrent paradoxical embolic events has been reported [8]. These patients represent a current medical challenge, and although it would be intuitive to advise reintervention for shunt closure the data supporting this or any other alternative strategy is limited and not clearly established [9][10][11].…”

Closure of patent foramen ovale for secondary prevention of cerebrovascular events

“…(48,51,54) The same holds true for residual shunts and thrombus formation. (55) Erosions of the free atrial wall, more a threat with the larger devices used but rather optically facilitated (56) (Figure 5).…”