Persistent Foramen Ovale Closure Research Articles

Same-day discharge after percutaneous closure of persistent foramen ovale using intracardiac echocardiography and the Gore Septal Occluder.

Periprocedural and postinterventional care of patients undergoing closure of patent foramen ovale (PFO) varies significantly across care providers. Same-day discharge (SDD) after transcatheter interventions is an evolving concept. This study aimed to assess the same-day discharge rate and incidence of complications in patients undergoing PFO closure with intracardiac echocardiography (ICE) using the Gore®Cardioform Septal Occluder (GSO) device. The secondary aim was to analyse the efficacy of femoral vein closure with Perclose ProGlide. Patients who underwent PFO closure with the GSO device at a university hospital in Stockholm, Sweden, were retrospectively included between March 1, 2017, and June 30, 2020, all with cryptogenic stroke as the indication for the procedure. All patients underwent PFO closure with conscious sedation and local anaesthesia. The indication for all patients was a cryptogenic stroke. Periprocedural imaging was performed using ICE and fluoroscopy in all patients. Patient characteristics and periprocedural data were collected from patient charts. Patients were kept on bed rest for 4-6 h post-intervention. Transthoracic echocardiography and clinical examination, including groin status, were performed before discharge. No clinical routine follow-up was performed the day following the intervention. Clinical follow-up was done by phone call two weeks after the procedure, and echocardiographic follow-up was done after 12 months. Data were analysed using linear and logistic regression models. In total, 262 patients were included, of which 246 (94%) had SDD. 166 patients (63%) received the ProGlide™ system for femoral vein access closure. Post-procedural arrhythmias occurred in 17 (6%) patients, and vascular complications in 9 patients (3%). The overall closure rate at follow-up was 98.5%. 25 out of 264 patients (9.5%) had to be readmitted within the first eight weeks after PFO closure, 16 due to atrial fibrillation warranting electric cardioversion, one due to an arteriovenous fistula that was operated, four due to chest pain/pain at the access site, and four patients developed fever. There was no difference in SDD among patients who received ProGlide™ vs. patients who did not receive ProGlide™. SDD appears safe after transcatheter PFO closure with the GSO device with high procedural success rates. Low rates of complications and readmissions make the intervention suitable for this patient-friendly and cost-effective concept.

Comparative analysis between transcranial doppler and transesophageal echocardiogram in diagnosing residual shunt after persistent foramen ovale closure

Abstract Background The degree of residual shunt (RS) after patent foramen ovale (PFO) closure is a potent predictor for the recurrence of stroke. Evaluating the extent of residual shunt grade is thus essential. Currently, there is no gold standard on guidelines of how to evaluate RS. Although transesophageal echocardiography (TEE) is known to be most accurate in evaluating RS, it is not routinely performed due to its invasiveness and expensive costs. Conversely, the transcranial doppler (TCD) test is a less invasive convenient test for detecting RS. Accordingly, we sought to comparatively analyze the accuracy of TCD compared to TEE on assessing RS after PFO closure. Methods We analyzed patients who underwent PFO closure for cryptogenic stroke (CS), who received a TCD and TEE test within 1 year of procedure. All patients received TEE and TCD on the same day within one year (288±38 days) after PFO closure. Results We analyzed a total of 55 patients (age: 55.2 ± 11.1, male sex: 74.2%, PFO grade ≥ moderate: 83.6%, follow up duration: 28.9 ± 14.9 months). RS was confirmed in 24 (44%) and 23 (42%) of patients in the TCD and TEE test, respectively. The sensitivity and specificity of TCD was 0.77 and 0.96 for predicting the presence of RS, respectively. The predictive performance of TCD was consistent over age ≤65 (sensitivity 0.73, specificity 0.96) and RS≤mild (sensitivity 0.83, specificity 0.96) subgroups. Positive TCD (adjusted odds ratio 101.2; 95%CI, 9.5-1074.8; p<0.0001) was a highly significant independent predictor for the presence of RS. Conclusion We demonstrate for the first time that TCD may be a reliable non-invasive test for substituting TEE in evaluating RS. Physicians may be able to rule out the presence of RS and minimize the prescription of TEE when TCD test is negative due to the high specificity.

Effect of history of atrial arrhythmias on the rate of recurrent stroke in patients after PFO closure

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Although the importance of persistent foramen ovale (PFO) closure is well established, it is far from complete its role in patients with atrial arrhythmias. Patients with a history of atrial arrhythmias, especially younger and healthy persons with PFO after a stroke, are indicated for PFO closure. This is despite the uncertainty of whether atrial arrhythmia (it means silent atrial fibrillation) is the actual cause of the stroke. Objectives To describe prospective observations comparing cohort PFO closure patients with and without atrial arrhythmias. Method A retrospective analysis of the real world of a prospective registry of patients after PFO closure. This is a set of patients from one cardiac center over 19 years; each patient was followed up once a year for seven years. The recurrence of ischemic stroke was monitored. Results A total of 712, 378 females (53.1%) and 334 males, aged 50 (+/-12) years, were indicated for PFO closure mostly due to stroke (436 i.e. 61.4%) and systemic embolization (56 i.e. 7.9%). DM was present in 55 patients ( i.e. 7.7%), and arterial hypertension was also in 306 patients (i.e. 43%). See other demographic data in Table 1. A history of atrial arrhythmias ( salvage SVES or intrinsic atrial fibrillation) before PFO closure was described in 50 patients ( 7.1%). During the 7-year follow-up, recurrent stroke was detected in a total of 14 cases, 13 in the group without previous arrhythmic history (4.3%) and 1 with previous arrhythmic history (3.8%, p=0.912). A surprising finding was the statistically higher representation of women in the cohort with previous arrhythmic history (p=0.001), in the cohort of shorter (p=0.012) and thinner (p=0.022) women, and thus in the cohort with lower BSA (p=0.006). On the other hand, unsurprisingly, there was a statistically higher proportion of diabetics (p0.024) and patients with coronary artery disease (p=0.013) in the cohort with atrial arrhythmias in the pre-hospital period. Detailed results are in table 1. Conclusion There was no difference in the incidence of recurrent stroke between the cohorts of patients with and without a prior history of atrial arrhythmias in the seven-year follow-up after PFO closure. The cohort of patients with a previous history of atrial arrhythmias was, unsurprisingly, statistically larger in patients with diabetes and coronary artery disease.

Impact of left ventricular inspection employing cardiopulmonary bypass on outcome after implantation of left ventricular assist device.

Cardiopulmonary bypass (CPB) during left ventricular assist device (LVAD) implantation provides circulatory support and allows for safe inspection of the left ventricle (LV), whereas circulatory support by veno-arterial extracorporeal life support (va-ECLS) or off-pump implantation may reduce postoperative bleeding and inflammatory response. Retrospective analysis of 616consecutive adult patients who received an LVAD via median sternotomy between January 1, 2015 and December 31, 2019. All patients undergoing concomitant intracardiac procedures other than closure of persistent foramen ovale or atrial septal defect and redo surgeries were excluded from the analysis. The remaining patients (n=222) were divided into two groups and 1:1 propensity score-matched regarding preoperative parameters: patients who underwent LVAD implantation with LV inspection employing CPB (CPB group, n=62) and without LV inspection on va-ECLS or off-pump (non-CPB group, n=62). The groups were well balanced with regard to preoperative baseline characteristics (standard difference <0.1). Patients in the CPB group required more blood transfusions (median 2 vs. 0 units, p=0.031) during surgery and in the first 24h afterwards. The median intensive care unit stay was longer in the CPB group (18 vs. 11days, p=0.021). The CPB group showed an absence of perioperative stroke and a smaller number of events per patient-year for postoperative ischemic stroke (0.02 vs. 0.12, p=0.003). 30-day survival (87% vs. 87.1%) and 1-year survival (80.3% vs. 74%) were similar in both groups (p=0.78). Visual LV inspection on CPB may reduce the risk of postoperative ischemic stroke. Despite the negative effects of employing CPB in lieu of other intraoperative strategies, survival was similar in both groups.

Development of severe intrapulmonary shunting in a patient with carcinoid heart disease after closure of a persistent foramen ovale: a case report

BackgroundNeuroendocrine tumours (NETs) can affect the cardiopulmonary system causing carcinoid heart disease (CHD) and valve destruction. Persistent foramen ovale (PFO) occlusion is indicated in patients with CHD and shunt-related left heart valve involvement.Case summaryWe report the case of a 54-year-old female patient with metastatic NET originating from the small bowel. The patient was on medication with octreotide and telotristat. One year after diagnosis, cardiac involvement of carcinoid developed with regurgitation of right-sided and, due to PFO, left-sided heart valves. Closure of PFO was performed (Occlutech 16/18 mm). One year later, she presented with recurrent severe dyspnoea. The PFO occluder was in situ without residual shunt. Valvular heart disease, including left-sided disease, and metastatic spread of NET were stable. Blood gas analysis revealed arterial hypoxaemia (pO2 = 44 mmHg/5.87 kPa), which was related to extensive intrapulmonary shunting (31% shunt fraction) confirmed using contrast-enhanced echocardiography. The patient was prescribed long-term oxygen supplementation as symptomatic therapy and anti-tumoural therapy was intensified with selective internal radiotherapy (SIRT) of the liver metastases to improve biochemical control of the carcinoid syndrome. At a follow-up visit 4 months after SIRT, the patient-reported stable dyspnoea; however, magnetic resonance imaging revealed progression of osseous metastases.DiscussionAn echocardiographic assessment of the presence of a PFO is recommended in patients with NET as PFO closure minimizes the risk of left-sided carcinoid valve disease. Deterioration of symptomatic status in metastasized NET might also be due to a hepatopulmonary-like physiology with intrapulmonary shunting and arterial desaturation thought to be caused by vasoactive substances secreted by the tumour. This is a rare case describing the development of this syndrome after PFO closure.

Long-term benefits and risks in patients after persistent foramen ovale closure: a contemporary approach to guide clinical decision making.

Persistent foramen ovale (PFO) is a congenital heart disease which represents 80% of atrial septal defects. It is a remnant of fetal circulation that functions in postnatal conditions as a transient interatrial right‑to‑‑left shunt of variable magnitude. Persistent foramen ovale may be implicated in the pathogenesis of several medical conditions, such as cryptogenic stroke, cryptogenic left circulation thromboembolism, migraine syndromes, and decompression sickness. The most frequent indication for PFO closure remains PFO‑associated left circulation thromboembolism. In select patients, PFO closure reduces stroke recurrence in comparison with medical therapy after more than 3 years of follow‑up on average, especially in patients with a high risk of recurrence. While in PFO‑associated left circulation embolism, there is now conclusive evidence on the growing benefit of PFO closure in long‑term follow‑up, in many other clinical conditions, the degree of certainty of the results is deceiving. In this paper, we will review the benefits and risks that one can expect in the long term after percutaneous PFO closure in various clinical scenarios in order to facilitate therapeutic decision making.

P1706 Trilogy of stroke

Abstract A 53 y/o female patient presented with clinical signs of stroke. Substantial cardiovascular risk factors were present with arterial hypertension, hyperlipidemia, impaired glucose tolerance, and a history of smoking. Transthoracic echocardiography revealed a suspicious structure on the aortic valve. Consequently, transesophageal echocardiography (TEE) was ordered. In TEE, the structure proved to be highly suspicious for fibroelastoma. In addition, significant plaque of the aortic arch, and a persistent foramen ovale (PFO) were diagnosed in this examination. The patient was referred to cardiac surgery for excision of the mass on the aortic valve and for PFO closure. This case stresses the importance of echo in patients presenting with stroke. Apart from left atrial thrombus, several other possible embolic substrates can be diagnosed. Abstract P1706 figure 1

285Arrhythmias after transcatheter closure of persistent foramen ovale are related to the type and size of the implanted device

Abstract Transient supraventricular arrhythmias may occur in patients following persistent foramen ovale (PFO) closure. Therefore, the aim of the study was to prospectively perform 24-hour ECG monitoring to assess the electrocardiographic effects of transcatheter closure of PFO depending on the type of implanted devices. Material and methods 351 consecutive adult subjects (196 F, 155M; mean age: 40.9±15.3) were enrolled into the study to undergo PFO closure with an Amplatzer Septal Occluder - ASO (157 pts: 117 occluders – size 25; 40 pts – size 30), and Cardia device (194 pts: 163 occluders – size 25; 31 – size 30). Holter monitoring was performed on all patients before, at 1 and 12 months after the procedure. Results The success rate of PFO closure was 97.8% (351 cases from 359 qualified in TEE), in 8 cases the PFO tunnels were too small to be forced by a catheter, in one case the PFO device caused an injury of the septum and an ASD Amplatzer device was implanted. During the procedure in 3 (0.85%) cases transient supraventricular arrhythmia and in 1 (0.28%) case bradycardia to 27 bpm occurred. At 1 month: in 7 (2%) pts changes in AV conduction occurred: 1 pt (0.28%) had complete AV dissociation, 6 (1.7%) pts intermittent first degree AV block; paroxysmal atrial fibrillation (pAF) occurred in 6 (1.7%) pts, 2 of whom had pAF prior to closure. A significant increase in the number of SVE premature beats/24h was noted at 1 month after the procedure: 1167.9±409 (27–9976) compared to baseline data 60.2±44 (0–601) (p&lt;0.0001), at 12 months the SVE number decreased to 57.2±51 (7–752) and did not differ significantly from the baseline data. There was no change in the mean number of ventricular arrhythmias/24h after the procedure. There was a significant correlation between SVE premature beats/24h at 1 month after the procedure and device size (p&lt;0.001 r=97211). Pts with ASO device had a significantly higher number of SVE ectopy at 1 month after PFO closure (19123.9±70) compared to pts with Cardia device (811.9±324), p&lt;0.0001. Conclusions 1. Transcatheter closure of PFO is associated with a transient increase in supraventricular premature beats and a small risk of AV conduction abnormalities and paroxysmal atrial fibrillation in the early follow-up. There is regression of periprocedural arrhythmias after 12 months of PFO closure. 2. Transcatheter closure of PFO with Cardia device is related to a lower risk of supraventricular arrhythmias in the early follow-up. 3. The smaller device is implanted the lower risk of periprocedural arrhythmias is expected.

Persistent foramen ovale closure in divers with ahistory of decompression sickness.

ObjectiveTo study the effect of percutaneous patent foramen ovale (PFO) closure in divers with a history of decompression sickness (DCS).Study design(1) Retrospective study of patient records and (2) telephonic follow-up. Patients with unexplained decompression sickness, who were referred to a cardiologist with a focus on diving medicine between 2000 and 2017, were included in the studyResultsA total of 62 divers with DCS were included. In all cases transoesophageal echocardiography (TEE) was performed, showing 29 PFOs and 6 atrial septum defects (ASDs) in total n = 35 (56%). The highest prevalence was found in divers with cutaneous and vestibular DCS. At follow-up (mean follow-up duration 6.8 years), 21 PFOs/ASDs were closed using a percutaneous procedure. One diver was lost to follow-up. One diver quit diving. The remaining divers were able to resume unrestricted diving; there was no recurrence of major DCS. Of the divers with an open PFO or ASD, 14 were included of whom 7 are currently diving. All (except one diver with a small PFO) divers are using a conservative diving profile to reduce nitrogen load and the appearance of venous nitrogen bubbles. There was no recurrence of major DCS in this group.ConclusionPercutaneous PFO closure may be an effective and safe treatment for divers who have suffered a major DCS to return to unrestricted diving. Alternatively, conservative treatment seems safe when divers refrain from unrestricted diving and use a conservative technique in order to reduce nitrogen load.

Patent foramen ovale and atrial fibrillation as causes of cryptogenic stroke: is treatment with surgery superior to device closure and anticoagulation? A review of the literature.

Closure of persistent foramen ovale (PFO) to avoid cryptogenic strokes is performed globally with enthusiasm but lacks prove of efficacy. We present a 79-year-old man who had had a PFO device introduced nine years previously because of cryptogenic strokes presenting as syncopes. The patient was referred from his general practitioner with two new syncopes. Transthoracic echocardiography revealed no cardiac causes of embolism. Transesophageal echocardiography (TEE) revealed a misplaced device like an umbrella in a storm, but no septum defects. Holter revealed seconds-long episodes of atrial fibrillation (AF). The patient was successfully treated with anticoagulation.A literature review showed that: (i) the efficacy of PFO closure devices has not been proven in any trial, but was demonstrated in a meta-analysis comparing three different devices; (ii) PFO devices are rarely controlled by TEE during or after insertion; (iii) residual shunts are detected in up to 45% of cases; (iv) there is an increased rate of post-arrhythmic complications; (v) the risk of AF in congenital heart disease increases with increasing age, with a 13% risk of transient ischemic attacks and stroke; and (vi) surgical treatment of PFO was found to have a 4.1% risk of complications including stroke.The question to be asked is whether device closure of PFO should be avoided, considering that PFO is a congenital heart defect with risks of AF and (cryptogenic) stroke? Heart surgery should be a treatment option for symptomatic PFO.

P6382Atrial fibrillation after closure of persistent foramen ovale in the REDUCE clinical trial

P6382Atrial fibrillation after closure of persistent foramen ovale in the REDUCE clinical trial

Migraine with aura and persistent foramen ovale.

The association between migraine with aura and persistent foramen ovale (PFO), as well as other right-to-left shunts, is described. A hypothesis that might explain this association is discussed. Observational studies suggested that when a PFO is closed patients who have migraine with aura are usually improved. The Migraine Intervention with STARFlex Technology (MIST) Trial was a randomised double-blind trial in patients with severe intractable migraine with aura and a moderate-large PFO that compared implantation of STARFlex devices with the intention of closing their PFO versus a sham procedure. It was hoped that the trial would demonstrate whether PFO closure would cure migraine. A series of problems in design and execution of the trial are discussed.

Znaczenie przetrwałego otworu owalnego u pacjenta kwalifikowanego do zabiegu ortotopowego przeszczepienia wątroby

Persistent foramen ovale (PFO) is a congenital defect of interatrial septum, that in majority of patients stays asymptomatic. However, in conditions that lead to increased pressure in right atrium over left atrium, it may lead to blood shunt from the right to the left atrium. We are presenting a case report of 63-years-old male who was referred to the qualification for the orthotopic liver transplantation due to the decompensated liver cirrhosis. During transesophageal echocardiography with contrast PFO was detected. In the literature cases suggesting increased perioperative risk in patients with PFO are described. It is both related to air embolisms connected with the transplantation itself and possibility of crossed embolisms. For this reason, the patient was scheduled to the transcatheter PFO closure, after which he could have liver transplantation. The operation was performed a month later, uneventfully.

P4890Arrhythmias after transcatheter closure of persistent foramen ovale are related to the type and size of the implanted device

P4890Arrhythmias after transcatheter closure of persistent foramen ovale are related to the type and size of the implanted device

Randomized trials of closure of persistent foramen ovale (PFO) vs medical therapy for patients with cryptogenic stroke — Effect of lost-to-follow-up and withdrawal of consent

Randomized trials of closure of persistent foramen ovale (PFO) vs medical therapy for patients with cryptogenic stroke — Effect of lost-to-follow-up and withdrawal of consent

Ten years of experience with closure of persistent foramen ovale: Patient characteristics and outcomes

BackgroundOptimal management of patients with persistent foramen ovale (PFO) following cryptogenic stroke or transient ischemic attack (TIA) suspected for paradoxical embolic events is still unclear. PFO closure has the potential benefit of preventing recurrent embolic events and avoiding serious bleeding resulting from long-term anticoagulation. Despite the widespread usage of closure devices, no randomized trial supports the general percutaneous closure approach. In addition, only mid-term, but not long-term, outcomes have been reported until now. The aim of the study is to assess clinical characteristics and long-term clinical outcome of patients undergoing percutaneous PFO closure. MethodsIncluded in this single-center registry trial were 146 consecutive patients who underwent percutaneous closure of PFO at the University Hospital Frankfurt from 2000 to 2009. Periprocedural outcomes and long-term events were assessed. Follow-up was available in 146 patients (100%) with a mean follow-up of 7.8±3.1 years (cumulative 1148 patient-years). ResultsThe cerebroischemic event leading to indicate percutaneous PFO closure was TIA (34.9%), stroke without sequels (38.4%), stroke with sequels (24.7%), amaurosis fugax (N=2; 1.4%), and peripheral emboli (N=1; 0.7%). Only one severe periprocedural complication occurred (device dislocation). The majority of patients (N=143; 97.9%) experienced no further events during follow-up. ConclusionThis “all-comers” population documents the safety of percutaneous PFO closure. The cardiovascular event rate is slightly lower (0.26 per 100 patient years) compared to the recently published randomized trials and maintained persistently low rate for more than 8 years.

Does the amplatzer septal occluder device alter ventricular contraction pattern? A ventricular motion analysis by MR tagging

To assess by cardiovascular magnetic resonance (CMR) and CMR tagging if the Amplatzer Septal Occluder affects right ventricular (RV) and left ventricular (LV) motion pattern. Sixteen consecutive patients with significant atrial septal defect (ASD) and nine consecutive patients with persistent foramen ovale (PFO) as controls were studied before and a median of 14 days after defect closure by an Amplatzer occluder. By CMR end-diastolic (EDV) and end-systolic (ESV) RV and LV volumes were determined. Aortic and pulmonary artery flow was measured for assessment of left-to-right shunt (Qp/Qs). By CMR tagging circumferential strain and radial shortening, maximal rotation and torsion were measured, In ASD patients RV-EDV and RV-ESV decreased (P < 0.05). LV-EDV and LV-ESV increased after ASD closure (P < 0.005). Qp/Qs dropped from 1.8 to 1.0 (P < 0.001). PFO patients showed no ventricular volume change after PFO closure. In ASD patients circumferential strain and radial shortening and maximal rotation of the RV decreased by ASD closure (P < 0.01). In LV only maximal rotation at the base and apex decreased significantly (P < 0.05). Torsion remained constant. In PFO patients no tagging parameter changed after defect closure. The Amplatzer occluder itself does not change the ventricular contraction pattern. All volume and myocardial deformation changes were caused by ventricular loading shifts.

Closure of persistent foramen ovale with the BioSTAR biodegradable PFO closure device: Feasibility and long-term outcome

Objectives. The presence of a patent foramen ovale (PFO) has been associated with recurrent cryptogenic cerebrovascular event (CVE). The BioSTAR is a partly biodegradeable atrial septal repair implant. We investigated the feasibility and efficacy of the BioSTAR PFO-occluder. Design. From October 2007 to December 2008, 59 consecutive patients underwent PFO closure at our institution with a history of at least one cryptogenic CVE defined by a neurologist. During the study period, all patients, who fulfilled our institutional criteria for PFO closure, were included. No patients were lost to follow-up. Results. Of the 59 patients treated, a BioSTAR device could be implanted in 30 and in 29 patients another device, almost exclusively an Amplatzer, had to be used. No serious complications were observed during implantation of either. Four of 30 patients suffered a recurrent CVE after BioSTAR implantation as compared to 2/29 in the comparison group. At long-term follow-up 29/30 patients in the BioSTAR group had complete closure of their PFO as compared to 23 of 29 in the comparison group. Conclusions. The BioSTAR device could be selected for use in small shunts less than 10 mm while the Amplatzer may be chosen for larger defects or more complicated anatomy.

Re-evaluation of the relationship between migraine and persistent foramen ovale and other right-to-left shunts

Right-to-left shunts (usually persistent foramen ovale) are responsible for a large proportion of cases of decompression illness [1,2]. Previously, we reported in Clinical Science [3] a review of the medical records of 200 consecutive individuals investigated for the cause of their decompression illness that showed that those with a large right-to-left shunt had a considerably increased prevalence of migraine with aura in daily life unconnected with diving, but not of migraine without aura. They also had an increased incidence of migraine aura after dives that liberate venous bubbles [3]. Transcatheter closure of persistent foramen ovale and atrial septal defects usually reduces the severity and frequency of attacks of migraine with aura [4]. Atrial shunts are dominantly inherited and this inheritance is closely associated with the inheritance of familial migraine with aura [5]. However, a significant role for right-to-left shunts in migraine aetiology does not accord with the generally accepted theories that migraine is a primary disorder of the brain [6]. Accordingly, we re-evaluated the observations reported previously in Clinical Science [3] in a further consecutive series. Data was collected from the next 200 consecutive divers (61 female) who attended our special clinic for investigation of decompression illness after the series we reported previously [3]. As part of clinical assessment, the history and the … Right-to-left shunts (usually persistent foramen ovale) are responsible for a large proportion of cases of decompression illness [1,2]. Previously, we reported in Clinical Science [3] a review of the medical records of 200 consecutive individuals investigated for the cause of their decompression illness that showed that those with a large right-to-left shunt had a considerably increased prevalence of migraine with aura in daily life unconnected with diving, but not of migraine without aura. They also had an increased incidence of migraine aura after dives that liberate venous bubbles [3]. Transcatheter closure of persistent foramen ovale and atrial septal defects usually reduces the severity and frequency of attacks of migraine with aura [4]. Atrial shunts are dominantly inherited and this inheritance is closely associated with the inheritance of familial migraine with aura [5]. However, a significant role for right-to-left shunts in migraine aetiology does not accord with the generally accepted theories that migraine is a primary disorder of the brain [6]. Accordingly, we re-evaluated the observations reported previously in Clinical Science [3] in a further consecutive series. Data was collected from the next 200 consecutive divers (61 female) who attended our special clinic for investigation of decompression illness after the series we reported previously [3]. As part of clinical assessment, the history and the …

Rare case of pulmonary arteriovenous fistula simulating residual defect after transcatheter closure of patent foramen ovale for recurrent paradoxical embolism

We report on a patient suffering from recurrent cerebrovascular events despite previous transcatheter closure of persistent foramen ovale (PFO) with a Helex occluder. There was evidence of persistent left-to-right atrial shunt shown by transesophageal contrast echocardiography and the patient was admitted to our institution for interventional closure of the supposed residual defect. However, the PFO was completely closed by the device and left pulmonary artery injections showed a pulmonary arteriovenous fistula in the left lower lobe. This rare malformation may well explain the recurrent paradoxical embolism. Transcatheter fistula closure with coils was performed successfully. This case underlines that the existence of an isolated pulmonary arteriovenous fistula as a right-to-left shunt in patients with cryptogenic stroke should not be overlooked, even if a PFO is present and pulmonary arteriovenous fistula is not suggested by the initial physical findings or chest X-ray.