CASE REPORT article
Front. Cardiovasc. Med.
Sec. Structural Interventional Cardiology
Volume 12 - 2025 | doi: 10.3389/fcvm.2025.1622543
This article is part of the Research TopicPerioperative Management and Clinical Challenges in Elderly Major Surgical PatientsView all articles
Is there an age cut off beyond which PFO closure should not be offered? A case report
Provisionally accepted- U.O. Cardiologia Universitaria, Ospedale Galeazzi - Sant’Ambrogio, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
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Background. While randomized controlled trials have confirmed that patent foramen ovale (PFO) closure over medical therapy is considered the preferred treatment of young paSents with embolic stroke of undetermined source (ESUS), the efficacy of percutaneous closure in elderly subjects with high-risk PFO remains unclear since no randomized trials are currently available.A 65-year-old man with a past medical history of hyperuricemia, chronic gastroesophageal reflux disease, intesSnal diverSculosis and long-lasSng arterial hypertension with enlargement of the aorSc root was admi\ed for evaluaSon of sudden onset of diplopia, postural instability and subtotal loss of consciousness. Brain magneSc resonance imaging (MRI) confirmed acute le] thalamo-mesencephalic infarct. ConSnous ECG monitoring ruled out atrial fibrillaSon (AFib). Two-dimensional (2D) transthoracic/transesophageal echocardiography (TTE/TEE) color Doppler showed a significant right-to-le] shunt (RLS) via a tunnel-type PFO associated with hypermobile floppy septum primum (HSP) and prominent Eustachian valve (EV). Of note, a significant enlargement of the aorSc root and ascending aorta resulted in a remarkable compression of the right atrial cavity and reducSon of the interatrial atrial septum (IAS) lenght, proporSonally increasing its mobility and thus the amount of RLS. Following heart-brain team discussion transcatheter PFO closure was recommended. A]er wri\en informed consent, the paSent underwent a successful percutaneous PFO closure with a self-expanding double-disc niSnol mesh PFO device (18/24 mm Memopart) under local anesthesia, mild sedaSon, with fluoroscopic and rotaSonal intracardiac echocardiography (rICE) guidance using a 9F-9MHz Ultra ICE catheter-based ultrasound probe. Two-month follow-up with 2D contrast TTE color Doppler and contrast-enhanced transcranial Doppler (c-TCD) showed correct device posiSon, with no residual shunt.Discussion. Enlargement of the aorSc root with increasing age may reorientate horizontally the IAS allowing part of the flow to stream directly towards the PFO, decrease the size and lenght of IAS, proporSonally increase its mobility thus uncovering latent or previously trivial RLSs in older hypertensive paSents suffering from ESUS.
Keywords: patent foramen ovale, right-to-le] shunt, embolic stroke of undetermined source, aorSc root dilaSon, ascending aorta elongaSon, arterial hypertension, case report
Received: 03 May 2025; Accepted: 28 Jul 2025.
Copyright: © 2025 Onorato, Melotti, Doldi, Monizzi, Mastrangelo, Mallia, Andreini and Bartorelli. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
* Correspondence: Eustaquio Maria Onorato, U.O. Cardiologia Universitaria, Ospedale Galeazzi - Sant’Ambrogio, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
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