Patent Foramen Ovale Closure Research Articles

Comparison of Cardiovascular Procedure Rates in Patients With Supplementary vs Basic Insurance in Switzerland

Switzerland's mandatory health insurance provides universal coverage, but residents can opt for supplementary private insurance for nonessential, nonvital amenities. It is debated whether people with supplementary private insurance receive overtreatment due to financial incentives. To assess whether incidence rates of cardiovascular procedures in people with supplementary private insurance are higher than in those with basic insurance only. A population-based weighted cohort comparative effectiveness study, using administrative claims data from Switzerland assessing incidence rates (IRs), was conducted in adults undergoing a nonemergency cardiovascular inpatient procedure from January 1, 2012, to December 31, 2020. Analysis included primary or secondary discharge procedure codes for 1 of the following: percutaneous transluminal coronary angioplasty (PTCA), left atrial appendage (LAA) occlusion, patent foramen ovale (PFO) closure, transcatheter aortic valve replacement (TAVR), mitral valve clip implantation, cardiac pacemaker implantation, and atrial fibrillation/atrial flutter ablation. Supplementary private health insurance. Incidence rates of cardiovascular procedures between insurance groups calculated by negative binomial regression adjusted by inverse probability weights. Of 590 919 admissions (median age, 68 years; IQR, 57-77 years), 55.5% male, 15.7% non-Swiss nationality), 70.1% had basic insurance only. Independent of insurance status, IR for all cardiovascular procedures steadily increased over the study years. In general, people with supplementary private insurance received cardiovascular procedures more frequently (IR ratio [IRR], 1.11; 99% CI, 1.10-1.11) than people with basic insurance only. There was also an increase for every procedure: PTCA (IRR, 1.12; 99% CI, 1.12-1.13), LAA closure (IRR, 1.15; 99% CI, 1.13-1.16), mitral valve clip implantation (IRR, 1.08; 99% CI, 1.07-1.09), TAVR (IRR, 1.04; 99% CI, 1.03-1.06), PFO closure (IRR, 1.01; 99% CI, 1.00-1.02), pacemaker implantation (IRR, 1.08; 99% CI, 1.07-1.09), and atrial fibrillation/atrial flutter ablation (IRR, 1.12; 99% CI, 1.11-1.12). Sensitivity analyses, including side procedures, stratification by length of stay, and propensity score matching, suggested robustness of the results. This study found an association between supplementary private insurance and a higher likelihood of receiving nonemergency cardiovascular procedures. Whether this higher rate of procedures in people with supplementary private insurance is based on clinical reasoning or due to financial incentives warrants further exploration.

Patent foramen ovale occlusion with the Cocoon PFO Occluder. The PROS-IT collaborative project.

The Cocoon patent foramen ovale (PFO) Occluder is a new generation nitinol alloy double-disk device coated with nanoplatinum, likely useful in patients with nickel hypersensitivity. Early results and mid-term outcomes of this device in percutaneous PFO closure are missing. To assess the preliminary efficacy and safety profile of PFO closure with Cocoon device in an Italian multi-center registry. This is a prospective registry of 189 consecutive adult patients treated with the Cocoon PFO Occluder at 15 Italian centers from May 2017 till May 2020. Patients were followed up for 2 years. Closure of the PFO with Cocoon Occluder was carried out successfully in all patients, with complete closure without residual shunt in 94.7% of the patients and minimal shunt in 5.3%. Except from a case of paroxysmal supraventricular tachycardia and a major vascular bleeding, no procedural and in-hospital device-related complications occurred. No patient developed cardiac erosions, allergic reactions to nickel, or any other major complications during the follow-up. During the follow-up period, 2 cases of new-onset atrial fibrillation occurred within thirty-day. Percutaneous closure of PFO with Cocoon Occluder provided satisfactory procedural and mid-term clinical follow-up results in a real-world registry.

Risk factors and complications associated with intra-operative or post-operative identification of a PFO in cardiac surgery patients: A cohort study.

It is unknown whether patent foramen ovale (PFO) reopening in the peri-operative setting of cardiac surgery affects the risk for stroke and post-operative outcomes. We performed a single-center, retrospective study based on a prospectively collected database in a tertiary cardiac surgery center. Using logistic regression, we assessed risk factors of PFO finding around surgery and subsequent clinical complications. Between January 2007 and July 2019, 11034 patients who underwent cardiac surgery in our center were included. A total of 233 patients (2.1%) presented a finding of PFO including 138 per-operative disclosures and 95 post-operative finding for hypoxemia. In the whole cohort, the mean age was 68.4 ± 11.5 years including 73.9% of men. Post-operative PFO finding was associated with more ischemic strokes compared with per-operative finding and control group [7(7.4%) vs. 3(2.2%) vs. 236(2.2), respectively; p = 0.003]. Moreover, patients with post-operative PFO reopening experienced a higher rate of pneumonia, reintubation, and longer length of stay in the ICU. Post-operative reopening of PFO, but not per-operative finding, was independently associated with ischemic strokes {adjusted odds-ratio = 3.5, 95% confidence interval (CI) [1.6-7.8]; p = 0.002}. Other variables associated with stroke incidence included age, mitral valve surgery, and ascending aorta surgery. Per- or post-operative PFO closure was associated with reduced adverse respiratory outcomes and a trend of the lower cerebral ischemic event. Patent foramen ovale finding incidence in peri-operative cardiac surgery care was rare (2%) but post-operative finding of PFO was associated with a increased risk of ischemic strokes, worsened respiratory outcomes, and prolonged hospitalization.

ADAMTS-13 activity in stroke of known and unknown cause: Relation to vascular risk factor burden.

The identification of the underlying mechanism in ischemic stroke has important implications for secondary prevention. A disintegrin and metalloprotease with a thrombospondin type 1 motif, member 13 (ADAMTS-13) has antithrombotic properties and was repeatedly implicated in the pathophysiology of stroke. In this study, we, therefore, aimed to investigate whether ADAMTS-13 is associated with stroke etiology and the burden of vascular risk factors. We determined ADAMTS-13 activity in two prospectively recruited stroke cohorts in the long-term course after the event. Cohort 1 (n = 88) consisted of patients who suffered a stroke due to embolic stroke of undetermined source (ESUS), cardioembolic stroke due to atrial fibrillation (AF), large-artery atherosclerosis, or small vessel disease. In cohort 2, patients with cryptogenic stroke and patent foramen ovale (PFO) scheduled for PFO closure (n = 38) were enrolled. As measures of vascular risk factor burden, the CHA2DS2VASC score, the Essen Stroke Risk Score (ESRS), and the Risk of Paradoxical Embolism (RoPE) score were calculated, as appropriate. ADAMTS-13 activity was lower in patients with AF-related stroke compared to patients with ESUS (p = 0.0227), which was, however, due to confounding by vascular risk factors. ADAMTS-13 activity inversely correlated with the ESRS (r = -0.452, p < 0.001) and CHA2DS2VASC (r = -0.375, p < 0.001) in cohort 1. In accordance with these findings, we found a positive correlation between ADAMTS-13 activity and the RoPE score in cohort 2 (r = 0.413, p = 0.010). ADAMTS-13 activity is inversely correlated with the number of vascular risk factors across different stroke etiologies. Further study is warranted to establish ADAMTS-13 as a mediator of cerebrovascular risk.

Complications Associated With Transesophageal Echocardiography in Transcatheter Structural Cardiac Interventions

Transesophageal echocardiograms (TEEs) performed during transcatheter structural cardiac interventions may result in greater complications than those performed in the nonoperative setting or even those performed during cardiac surgery. However, there are limited data on complications associated with TEE during these procedures. We evaluated the prevalence of major complications among these patients in the United States. A retrospective cohort study was conducted using an electronic health record database (TriNetX Research Network) from large academic medical centers across the United States for patients undergoing TEE during transcatheter structural interventions from January 2012 to January 2022. Using the American Society of Echocardiography-endorsed International Statistical Classification of Diseases and Related Health Problems Clinical Modifications (10th edition) codes, patients undergoing TEE during a transcatheter structural cardiac intervention, including transaortic, mitral or tricuspid valve repair, left atrial appendage occlusion, atrial septal defect closure, patent foramen ovale closure, and paravalvular leak repair, were identified. The primary outcome was major complications within 72hours of the procedure (composite of bleeding and esophageal and upper respiratory tract injury). The secondary aim was the frequency of major complications, death, or cardiac arrest within 72hours in patients who completed intraoperative TEE during surgical valve replacement. Among 12,043 adult patients (mean age, 74years old; 42% female) undergoing TEE for transcatheter structural cardiac interventions, 429 (3.6%) patients had a major complication. Complication frequency was higher in patients on anticoagulation or antiplatelet therapy compared with those not on therapy (3.9% vs 0.5%; risk ratio [RR]= 8.09, P<.001). Compared with those patients <65years of age, patients ≥65years of age had a higher frequency of major complications (3.9% vs 2.2%; RR= 1.75, P<.001). Complication frequency was similar among male and female patients (3.5% vs 3.7%; RR= 0.96, P=.67). Among 28,848 patients who completed surgical valve replacement with TEE guidance, 728 (2.5%) experienced a major complication. This study found that more than 3% of patients undergoing TEE during transcatheter structural cardiac interventions have a major complication, which is more common among those on anticoagulant or antiplatelet therapy or who are elderly. With a shift of poor surgical candidates to less invasive percutaneous procedures, the future of TEE-guided procedures relies on comprehensive risk discussion and updating practices beyond conventional methods to minimize risk for TEE-related complications.

Experience in patent foramen ovale closure with the CERA Lifetech occluder in patients with cryptogenic stroke.

Nowadays, percutaneous closure of patent foramen ovale (PFO) in patients after cryptogenic stroke is becoming a dominating strategy. The most commonly used and investigated device is the Amplatzer occluder. However, several other devices have been designed for transcatheter closure of PFO, which are not so well examined. To assess the effectiveness and safety of PFO closure with the Lifetech CERA occluder. A prospective, single-arm registry of patients with PFO treated with CERA occluder (Lifetech Scientific, Shenzhen, China) implantation was conducted. We assessed peri-procedural and 12-month follow-up. Patients were screened for the residual shunt in transcranial Doppler/transesophageal echocardiography. Ninety-six patients entered the registry. Most patients were women (76%) and the analyzed group was relatively young (mean age of 42.3 ±13.6 years). Before closure, most patients had a large shunt through the PFO. Procedures of PFO closure were performed under TEE guidance. All procedures were made under local anesthesia and all patients had the PFO successfully closed. No device-related complications were reported in the peri-procedural period or during follow-up. No recurrent neurological ischemic events were reported at 12 months. During follow-up we observed a 9% rate of residual shunts, which were mostly small. The study confirmed excellent immediate and 12-month results of CERA occluder implantation in patients with PFO.

Sex Differences in Transcatheter Structural Heart Disease Interventions: How Much Do We Know?

The number of structural heart disease interventions has greatly increased in the past decade. Moreover, interest in the sex-specific outcomes of various cardiovascular conditions and procedures has increased. In this review, we discuss the sex differences in the clinical profiles and outcomes of patients undergoing the most commonly performed structural procedures: transcatheter aortic valve replacement, transcatheter edge to edge repair of the mitral and tricuspid valve, transcatheter pulmonary valve replacement, patent foramen ovale closure and left atrial appendage occlusion. We shed light on potential reasons for these differences and emphasize the importance of increasing the representation of women in randomized clinical trials, to understand these differences and support the application of these cutting-edge technologies.

СРАВНИТЕЛЬНАЯ КЛИНИЧЕСКАЯ ХАРАКТЕРИСТИКА ДЕТЕЙ С ОТКРЫТЫМ ОВАЛЬНЫМ ОТВЕРСТИЕМ В ВОЗРАСТНОМ АСПЕКТЕ

Resume. In this research the question regarding the clinical characteristics of children with a patent foramen ovale (PFO) was raised. Today, this small anomaly of the heart, while common, has the potential to cause serious complications for children in rare cases. In this study we evaluated the patient family histories of cardiovascular diseases and connective tissue dysplasia, the course of pregnancy, the level of physical development of the children, laboratory findings, echocardiography and ECG data, the dynamics of PFO closure in 37 children of the main group and 37 children of the control group aged from birth to 6 years of age. Among the children of the main group, the following subgroups were identified: with the closure of the PFO at 1, 3 and 6 years, as well as the absence of PFO closure by the age of six years. It was found that boys predominated among the children of the main group. The closure of the PFO was noted to happen later in boys. In the group with the absence of PFO closure boys also predominated. Pregnancy with children of the main group was often accompanied by hypothyroidism and chronic nicotine intoxication in the mothers. In the family histories of the children of the main group connective tissue dysplasia was more frequent. A below-average level of physical development prevailed in children with a PFO low physical development was noted in children with a non-closed PFO. Among children with a non-closed PFO by age six, a negative trend emerged with the PFO showing a tendency to increase in diameter.

Incidence, predictive factors, and prognostic impact of residual shunt after percutenous patent foramen ovale closure

Incidence, predictive factors, and prognostic impact of residual shunt after percutenous patent foramen ovale closure

Assessment of clinical outcomes after percutaneous patent foramen ovale closure in adult patients diagnosed with cryptogenic stroke

Assessment of clinical outcomes after percutaneous patent foramen ovale closure in adult patients diagnosed with cryptogenic stroke

Platypnea-Orthodeoxia Syndrome in an Elderly Patient Treated with Percutaneous Patent Foramen Ovale Closure: Report of a Case and Review of the Literature

Platypnea-Orthodeoxia Syndrome in an Elderly Patient Treated with Percutaneous Patent Foramen Ovale Closure: Report of a Case and Review of the Literature

A Case Report : Patent Foramen Ovale Closure in Young Male Patient with Recurrent Cryptogenic Stroke

Patent foramen ovale is one of the most common congenital abnormalities in children. In PFO, there is a valve-like opening between the atrial septum secundum and primum at the fossa ovalis of the heart. A cryptogenic stroke is a stroke for which no clear cause can be identified. In some cases, the PFO can be wide open, allowing paradoxical embolism to pass from the vein into the arterial circulation, that cause cryptogenic stroke. The prevalence of PFO associated with cryptogenic stroke are relatively high, especially in young age. The thorough evaluation was needed to assure the causative relationship between the PFO and stroke or just a merely coincident, which can help to decide the best treatment strategy. Many studies recommend the closure of PFO in patient with cryptogenic stroke to prevent recurrent incident of stroke. This case report transcatheter PFO closure in a young male patient with history of recurrent stroke after serial examination to evaluate the likelihood of PFO as the cause of his stroke.

Migraine with aura after clopidogrel withdrawal: evidence of inflammation as a migraine trigger? – Case report

This article presents the case of a PFO (patent foramen ovale) closure patient with double antiplatelet therapy in whom aspirin was discontinued before clopidogrel and that, at clopidogrel withdrawal, presented “de novo” migraine with visual aura attacks. Migraines with aura associated with atrial right-to-left shunts (PFO and other atrial septal defects) are attributed to the arrival of vasoactive substances in the brain, since not cleared by the lungs. In this case, discontinuation of clopidogrel one year after PFO closure induced “de novo” migraine with aura. Conclusion Rather than confirming the prophylactic effects of clopidogrel for migraine with aura, its triggering at clopidogrel withdrawal is more likely related to a proinflammatory effect of discontinuing clopidogrel. This proinflammatory effect has been described in cardiological research, and reinforces that patients receiving dual antiplatelet therapy (clopidogrel and aspirin) should always have clopidogrel discontinued before aspirin in order to avoid proinflammatory or pro-thrombotic events.

Closure of a Patent Foramen Ovale (PFO): An Intervention Sequence

A patent foramen ovale (PFO) persists in about one-quarter of people and is the source of up to 25% of all ischemic strokes, especially strokes in young adults. PFO can be easily diagnosed by transthoracic contrast and/or transesophageal echocardiography. Interventional closure of the PFO via the femoral vein is a commonly used cardiological procedure since several trials have demonstrated the superiority of PFO closure over standard medical therapy in patients with PFO and who have experienced post ischemic, cardioembolic, or cryptogenic stroke. The current paper and video show the procedure of PFO closure in a step-by-step manner.

215 PREDICTORS OF RECURRENT CEREBRAL ISCHEMIA AFTER PATENT FORAMEN OVALE CLOSURE: A SINGLE CENTER OBSERVATIONAL STUDY

Abstract Background Transcatheter patent foramen ovale (PFO) closure is an effective therapy in patients with cryptogenic stroke (CS) or transient ischemic attack (TIA) and evidence of PFO. However, the incidence of recurrent cerebral ischemia is not negligible and underlying pathogenic mechanisms remain largely unknown. We sought to evaluate the magnitude of the problem and to assess predictors of recurrent stroke/TIA after transcatheter PFO closure. Methods We enrolled non-randomized consecutive patients who underwent PFO closure for secondary prevention of neurological ischemic events at the University Hospital of Parma between 2004 and 2021. Clinical, echocardiographic and procedure-related features were collected for each patient. The incidence of recurrent ischemic neurological events was assessed at follow-up. Results We enrolled a total of 154 patients. The primary indication for PFO closure was previous stroke (85 [55.2%] subjects) and a third of patients (51 [33.1%]) suffered from migraine, 22 [14.3%] with and 29 [18.8%] without aura. Moreover, mean Risk of Paradoxycal Embolism (ROPE) score at hospital admission was 6.4 ± 1.5. After a median follow-up of 112 months, the incidence of recurrent cerebral ischemia occurred in 13 [8.4%] patients, with an annualized rate of 0.92/100 patients. The presence of migraine, obesity and ROPE &amp;lt; 7 were independent positive predictors of recurrent stroke/TIA. Conclusion The presence of obesity, a familiar history of CVD, ROPE &amp;lt; 7 and migraine were independent positive predictors of recurrent ischemic neurological events after PFO closure.

1049 PREVALENCE OF ATRIAL FIBRILLATION AND FEASIBILITY OF PULMONARY VEIN ISOLATION AFTER PATENT FORAMEN OVALE CLOSURE

Abstract Background Data about prevalence and the risk of atrial fibrillation, stroke, and need for pulmonary vein isolation (PVI) after device closure of a patent foramen ovale (PFO) are still lacking. We aim to investigate the prevalence and the risk of atrial fibrillation after PFO closure and the feasibility of PVI in a PFO closure cohort compared to contemporary PVI without PFO closure. Methods retrospective observational study of consecutive patients undergoing PFO closure enrolled from February 2013 to September 2020. Patients were divided into 3 groups: i) patients without AF before and after the procedure (n=132), ii) patients with paroxysmal AF prior to the procedure (n=21), iii) patients with documented AF after the procedure (n=13). All patients with AF occurrence were treated with adequate anticoagulation therapy according to the current ESC Guidelines. We compared the procedural data of these patients to a matched contemporary cohort without previous PFO closure undergoing PVI in our center. AF and stroke prevalence and PVI feasibility after PFO closure were assessed at follow up. Results one-hundred and sixty-six consecutive PFO closure patients were enrolled; the mean age was 54 ± 13 years. Median follow-up was 3.5 + 2.5 years. During the study period, 21 patients had AF before or after the PFO closure (group 2) and 13 (7.8%) new onset AF (group 3). Stroke after the PFO closure occurred in 8 patients (4.8%), of which 4 in the group with new onset AF (30% of the group 3). Among the 34 patients with AF, 10 patients (6%) underwent a PVI. Compared to a contemporary matched PVI cohort, total procedural times and fluoroscopy times were significantly higher in the patients with previous PFO closure (108±15 vs 75±29, p=0.002 and 3±1.5 vs 8±7, p&amp;lt;0.001). Similar rate of AF relapses (p=0.198) was observed between the two groups, with a trend for higher rate of complication (pericardial effusion) for the cohort with previous PFO closure (p=0.06). Conclusion This study shows that a more accurate screening and treatment of AF is needed in patients with cryptogenic stroke despite the presence of a PFO, possibly a bystander. In our study, 30% of patients with new onset AF after PFO closure, experienced a further stroke after the procedure. In case of AF, the indication for PVI should be considered prior to the PFO closure since it turns out to be more difficult in terms of procedural and fluoroscopy times and risks of complications after PFO closure.

823 MIGRAINE IN PFO PATIENTS: CHARACTERIZATION OF A PLATELET-ASSOCIATED PATHOPHYSIOLOGICAL MECHANISM BEFORE AND AFTER PFO CLOSURE: THE LEARNER STUDY

Abstract Background A strong relationship links migraine with aura (MHA) and patent foramen ovale (PFO). Increased platelet aggregation and oxidative stress were documented in migraineurs. To date, no mechanisms connecting MHA to PFO have been demonstrated. Objectives To perform a comprehensive analysis of platelet activation, inflammation, and oxidative stress status in 78 aspirin-treated MHA-patients before (T0) and 6-months after (T1) PFO closure (LEARNER Study-NCT03521193-clinicaltrials.gov). The primary endpoint was migraine regression rate in relation to these parameters. Methods P-selectinpos-, activated-glycoprotein IIbIIIa (aGPIIbIIIa)pos-, Tissue Factor (TF)pos-, reactive oxygen species (ROS)pos-platelets, platelet-leukocyte aggregates (PLA) and microvesicles (MVs) were evaluated by flow cytometry; thrombin generation (TG) by Calibrated Automated Thrombogram (CAT) assay; oxidative stress status by mass spectrometry; serotonin and cytokines by ELISA. 12 aspirin-treated-healthy subjects (HS) were enrolled for comparison. Results Migraine resolution occurred in 69.7%, a significant reduction in 27%, while no effect was observed in 2 patients (3.2%). Only ROSpos-platelets, and TFpos-platelets and -MVs were significantly higher at T0, sustaining a TG capacity that was associated with an altered blood GSSG/GSH (Oxidized/Reduced Glutathione). This phenotype reverted to HS levels at T1. MHA-PFO plasma, added to HS blood, mirrored the in vivo platelet activation and N-acetylcysteine blunted it. GSSG in vitro reproduced the in vivo condition. Aspirin had little effect on the platelet prothrombotic phenotype which was effectively inhibited by a P2Y12-antagonist. Conclusion This study suggests a pathophysiological mechanism linking PFO, or its right-to-left shunt, with MHA. MHA-PFO patients show a platelet-associated prothrombotic phenotype, sustained by altered oxidative stress status. This phenotype, not fully controlled by aspirin but by P2Y12-antagonism, could play a primary role in producing the prodromal symptoms of migraine, and it is reverted after PFO closure together with a complete migraine remission

378 VERY-LATE THROMBUS-RELATED STROKE AFTER PERCUTANEOUS PFO CLOSURE: MEDICAL MANAGEMENT OF A RARE COMPLICATION

Abstract In May 2020, a 45-years-old woman was admitted to the Emergency Department due to transient ischemic attack. The thrombophilia screening showed hemizygous prothrombin gene mutation (Factor II) and homozygous MTHFR mutation. The transthoracic echocardiography was normal, with a left ventricular ejection fraction of 60% and no morphological or functional valve disease. The 24-h Holter ECG and the past medical history did not show any specific cause of the neurologic manifestations. In the absence of a specific and plausible cause of the transient ischemic attack, a diagnosis of cryptogenic stroke was made. The patient then underwent transcranial Doppler, which showed a high-grade shunt (curtain effect), and transesophageal echocardiography with bubble test, which showed the presence of a massive right-to-left shunt through a patent foramen ovale (PFO) during the Valsalva maneuver. A therapy with warfarin (achieving a target INR between 2 and 3) was therefore started, and the indication for a percutaneous PFO closure was given. In January 2021 the patient underwent successful percutaneous PFO closure with the Gore Cardioform Septal Occluder 25/25 mm (W.L. Gore and Associates, Inc.) through intracardiac echocardiographic guidance with no complication and without any residual shunt. The patient was discharged on dual antiplatelet therapy with aspirin 100 mg daily plus clopidogrel 75 mg daily for six months, and pantoprazole 20 mg daily, followed by aspirin 100 mg daily chronically. After 6 months the patient underwent transcranial Doppler, which was negative for shunt. 12 months after the implantation the patient stopped aspirin by her own initiative. In August 2022, due to the diagnosis of an ovarian cyst, the gynecologist prescribed estro-progestogen pill: in that occasion, the patient did not mention her thrombophilia. After 10 days, sudden onset of weakness of the right upper limb and aphasia. The patient was then admitted to the Emergency Department, were the computer tomography showed two acute lesions on the left cerebral hemisphere. Therefore, the patient underwent intravenous thrombolysis, with complete regression of the neurological symptoms: a diagnosis of stroke was then formulated. To understand the origin of such stroke, the neurologist gave indication to cardiological evaluation. The patient did not have any palpitation in the previous months and the electrocardiogram showed normal sinus rhythm. However, the transthoracic echocardiographic evaluation showed a dubious image of a mass attached to the interatrial septum, for which the patient underwent transesophageal echocardiography, which showed a 10×9 mm fluctuating thrombus attached to the left side of the previously implanted PFO closure device. Therefore, an oral anticoagulation therapy with warfarin plus a subcutaneous therapy with enoxaparin 6000 UI twice daily (as bridge to obtain the desired INR between 2 and 3) was started. After ten days, the patient underwent a new transesophageal echocardiography, which showed a substantial reduction in the dimensions of the thrombus (4×3 mm). The patient was then discharged in warfarin therapy with no residual neurological symptoms.

767 NEVER TOO LATE TO SHOW-UP: A RARE CASE OF PLATYPNEA-ORTHODEOXIA SYNDROME

Abstract Patient presentation. We present the case of an 85-years old woman, hypercholesterolemic, with a previous history of microvascular angina treated with nitrates, ASA and ranolazine. She presented in our emergency department for repeated episodes of seizure and “drop attacks” and she underwent neurological and cardiological evaluation. ECG showed sinus tachycardia, 110/min, left anterior hemiblock. Transthoracic echocardiogram was normal. Head CT-scan and cerebral magnetic resonance documented mild hyperintense areas in the subcortical part of white matter suggestive for chronic cerebrovascular disease. Carotid Doppler was negative for significant stenosis. Thus, suspecting an unexplained syncope, she underwent loop recorder implantation. One month later she was admitted to the emergency room for dysarthria, left hemiparesis and ataxia, that completely regressed after 24-hours, posing the diagnosis of transient ischemic stroke. Physical examination was normal. During in-hospital stay, the patient progressively developed dyspnoea and oxygen desaturation (SpO2 &amp;lt; 90%). Initial work-up. Due to oxygen desaturation non-invasive ventilation with Venturi mask (60%) was started. Blood tests were normal. The arterial blood gas analysis in Venturi mask showed: pH 7.47, pCO2 48 mmHg, pO2 136 mmHg, P/F 226. Despite non-invasive ventilation with Venturi mask, P/F remained low and so continuous positive airway pressure (CPAP) was started. A repeated echocardiogram showed a mild reduction of ejection fraction (45-50%) due to hypokinesia of the septum, secondary to right ventricular overload and compression. Pulmonary embolism was excluded by angio-CT. Medical management with vasodilators and diuretics finally allowed to wean off the non-invasive ventilation, still maintaining oxygen support with nasal cannulas. However, surprisingly, the mobilization of the patient in a sitting position resulted impossible, due to the occurrence of sudden desaturation. Diagnosis and Management. Suspecting a manifestation of platypnea-orthodeoxia syndrome (POS) a transoesophageal echocardiogram was performed. It revealed a wide patent foramen ovale (PFO), maximum diameter 1.5 cm, with a baseline mild right-to-left shunt, confirmed with sonicated contrast, that increased in the sitting position. Therefore, the diagnosis of POS syndrome and paradoxical cerebral embolization was posed. Elective PFO closure with the percutaneous positioning of an atrial septal defect (ASD) Occluder n.15 was successfully performed. Conclusions The platypnea-orthodeoxia syndrome is a rare cause of hypoxemia. The most common structural abnormality associated with this syndrome is the PFO, which can remain asymptomatic for decades. A shift in the relationship between right-and left intra-cardiac pressures, a change in the anatomy of the adjoining structures with age, stretching the atrial septum and favouring the blood inflow into the PFO (as ascending aorta dilatation or Thoracic Kyphosis) can lead to POS. The closure of the atrial defect is generally resolutive. However, the heterogeneous clinical presentations, the rarity of the disease and the confounding role of comorbidities can often result misleading, especially in advanced age.

288 LAY LADY LAY, A TRICKY CASE OF PLATYPNEA ORTHODEOXIA SYNDROME

Abstract Platypnea orthodeoxia syndrome (POS) is characterized by dispnoea and a fall in oxygen saturation levels when in the upright position that resolves lying down in the supine position. It is secondary to a right to left shunt (R-L shunt), typically trough a patent foramen ovale (PFO). Normally, in the presence of a PFO, R-L shunt does not occur unless there is a clinical condition that raises right side pressures like venous thromboembolism, hydrothorax, pneumothorax or chronic pulmunary hypertension. Although its physiopathological mechanisms are not entirely understood, in the POS, R-L shunt mostly occurs due to anatomical alteration of the interatrial septum in the upright position. Venous flow therefore can pass from the inferior vena cava through the PFO or an atrial septal defect (ASD) to the left side of the heart. We present a case of a 77 y.o. woman with no relevant past medical hystory, that was admitted to hospital care because of a mild pulmonary embolism and deep vein trombosis of the right popliteal vein. She was promptly treated for PE with direct oral anticoagulation achieving the resolution of the embolism. Despite the CT scan showed the complete resolution of the embolism her dysponoea did not improve. Her blood gas analysis showed normocapnic hypoxiemic respiratory insufficiency with a suspicious lowering of oxygen saturation levels when in the upright position which however improved in the supine position. She also had a transient episode of dysarthria and hypostenia to the right upper limb, the negative head CT scan was suggestive of a transient ischaemic attack. A pulmonary scintigraphy showed arterious renal perfusion as in a right to left shunt. She then underwent a transoesophageal echocardiography which showed an hypermobile interatrial septum with evidence of a patent foramen ovale with left to right shunt. The exame was in fact executed in the supine position. Given these findings, we concluded for a diagnosis of POS. Because of this records, the severity of the shunt and the suggestive clinical hystory of ortodeoxya she underwent PFO closure positioning an Amplatzer PFO Occluder 25 mm. The procedure was carried out without complications and led to complete resolution of the symptoms and the signs of platipnoea-ortodeoxya.