Objective: Presentation of possible systemic embolism sources found incidentally during transdermal patent foramen ovale (PFO) closure.

Methods: Patients’ data with neurological symptoms due to suspected systemic emboli secondary to the presence of a PFO, who underwent transdermal closure of their defect were reviewed. Emphasis was given in incidental anatomic anomalies identified by transesophageal echocardiograpy (TEE) or angiography during the procedure.

Results: Incidental identification of possible thrombotic sources other than a PFO were found in two patients with neurological symptoms and an echocardiographically diagnosed PFO with right-to-left shunt. Case #1, a 44 year old woman with history of ischemic strokes, during catheterization for PFO closure and routine pulmonary angiography was found to have a large pulmonary arteriovenous fistula in her left lower lobe. This was embolized successfully with an Amplatzer plug following her PFO closure. Case #2, a 20 year old man with history of migraines and syncope attributed to transient ischemic attacks, during PFO closure was found to have by TEE myocardial non-compaction involving both the LV and RV; this was confirmed by ventriculography of both ventricles during catheterization. The PFO was closed and myocardial biopsy results are pending.

Conclusions: The presence of a PFO with right-to- left shunting in view of neurological symptoms attributed to transient central nervous ischemia might not always be the culprit for systemic embolization. Thorough TEE examination and angiography might reveal other less common sources of systemic embolism; both imagers and interventionalists should be alert for the identification of such uncommon lesions.