AUTHOR=Onorato Eustaquio M. , Alamanni Francesco , Monizzi Giovanni , Mastrangelo Angelo , Bartorelli Antonio Luca 

TITLE=Case Report: Persistent residual shunt after a first percutaneous PFO closure followed by minimally invasive surgical failure: third time is a charm

JOURNAL=Frontiers in Cardiovascular Medicine

VOLUME=Volume 11 - 2024

YEAR=2024

URL=https://www.frontiersin.org/journals/cardiovascular-medicine/articles/10.3389/fcvm.2024.1367515

DOI=10.3389/fcvm.2024.1367515

ISSN=2297-055X

ABSTRACT=Background: Even though the optimal management of moderate or large residual shunt after PFO closure is open to question, recent data have been published confirming that it is associated with increased risk of stroke recurrence. Case Summary: A 48-year-old woman, migraineur with visual aura, has been diagnosed with PFO associated with a huge multifenestrated atrial septal aneurysm (mfASA) and moderate right-to-left shunt (RLS) only after Valsalva maneuver on contrast-transthoracic echocardiography (cTTE). Brain magnetic resonance imaging (MRI) showed one-millimeter silent white matter lesion of the right frontal lobe. Although the indication was not supported by the guidelines, transcatheter PFO closure was performed in another center with implantation of a large, equally sized, double-disc device (Figulla UNI 33/33 mm). At six months follow-up, 2D/3D transesophageal echocardiography (TEE) color Doppler showed incorrect orientation of the device, not parallel to the interatrial septum, with two discs not capturing the aortic muscular rim, partially protruding in the right atrium; furthermore, a 4x7 mm ASA fenestration was also documented with residual bidirectional shunt. Thereafter, the same team submitted the patient to minimally invasive cardiac surgery (MICS) under femoro-femoral cardiopulmonary bypass that proved not only ineffective but also complicated by postoperative pericarditis with pericardial effusion and by a further re-hospitalization, one month later, due to persistent pericarditis, bilateral pleuritis, phrenic nerve palsy and atrial flutter treated with amiodarone. The patient asked for a second opinion and the decision was made by our multidisciplinary heart team to offer a percutaneous redo intervention. An uneventful implantation of a regular PFO occluder (Figulla Flex II 16/18 mm) across the septal defect was performed successfully. Twelve-months 2D TTE color Doppler and contrast transcranial Doppler (cTCD) followup showed correct position and good interaction between the two devices without any residual shunt. Discussion: In addition to the incorrect PFO closure indication and minimally invasive surgery failure, procedural mishap could have been due to inappropriate implantation of the first large device within the tunnel. It would have been better to deploy the  large device in the most central fenestration covering at the same time the PFO and a great part of the remaining mfASA.