Objective

Percutaneous closure of the patent foramen ovale (PFO) is well established, though residual shunts or iatrogenic atrial septal defects increase the risk of recurrent events by upto fourfold. Treatment options include medical therapy, surgery or possible percutaneous implantation of second device. The best therapeutic approach is not clear; it is also not clear if a second device implantation is feasible, what are the risks and long-term follow-up?
We report four cases with percutaneous management of significant residual atrial shunting.

Methods

Between 01/2000-12/2006, 1100 patients underwent percutaneous PFO closure. A significant proportion had history of paradoxical embolism or migraine. The patients were followed-up at 1,6,12 months (Transcranial Doppler at 6 months). Amongst these, four had a significant residual shunt and/or a second neurological event and underwent cardiac catheterisation.

Results

All four had significant residual shunts and underwent an Amplatzer device implantation (See Table) under fluoroscopy and echocardiographic guidance. They were discharged on Aspirin 300mgs for 6-months. None had any residual shunt post-procedure and are doing well on follow-up at 3yrs.

Conclusion

All patients had the second device closure at least 6-months after the first device, by which, the endothelisation of the initial device was likely to be complete. Technically, the second device implantation was no more challenging than the first procedure. In this small series, the second ‘interval’ device implantation has proved to be safe and effective in eliminating a significant residual or iatrogenic shunt and the associated neurological risks. A larger series and a longer follow-up are mandatory.