CASE 47 Patent Foramen Ovale Closure for Recurrent Stroke

Lawrence W. Gimple, MD, FACC, FSCAI , D. Scott Lim, MD, FACC, FSCAI

Case presentation

A 46-year-old man with a history of recent stroke underwent a head MRI scan and was found to have evidence for both an acute posterior parietal infarct as well as an older frontal infarct. He originally presented with right facial droop and slurred speech; this gradually improved over several months. He underwent several studies to explore the cause of his stroke; a carotid ultrasound with Doppler and hematologic evaluation for a hypercoagulable state found no abnormalities. A transesophageal echocardiogram was performed and demonstrated a long, tunnel-like patent foramen ovale (PFO). Right-to-left shunting on a contrast echo “bubble study” was seen at rest and was apparent even without a Valsalva maneuver. His medications included atorvastatin and aspirin. There was no history of drug or nickel allergy. The medical history was otherwise significant for snoring and he had a family history of premature coronary artery disease. On physical examination, the patient was normotensive and the oxygen saturation was 98% on room air. Jugular venous pressure was normal, the lungs were clear, and there were no pathological murmurs. There was no cyanosis or edema and the pulses were symmetric. The ECG exhibited sinus rhythm and was otherwise normal.

Cardiac catheterization

The patient was referred for percutaneous closure of the patent foramen ovale. The operator attained venous access in the right femoral vein using two vascular sheaths, 11 Fr and 9 Fr respectively. No contrast was used during this procedure, and the PFO closure was done using fluoroscopic and intracardiac echocardiographic guidance. An ACUSON AcuNav™ intracardiac ultrasound catheter was advanced through the 11 Fr sheath to the right atrium. The ICE catheter was rotated clockwise to attain views of the tricuspid valve and, subsequently, of the aortic valve. The catheter was retroflexed to view the septum (Video 47-1). After the intraatrial septum was well visualized and the absence of a thrombus attached to the PFO was confirmed, the patient was given 75 U/kg of unfractionated heparin. Subsequently, a 6 French multipurpose A2 catheter was passed to the right atrium through the 9 French sheath. The catheter was rotated posteriorly, easily crossing the patent foramen ovale into the left atrium with minimal manipulation. A 0.035 inch J-tip Amplatzer exchange length guidewire was passed into the left atrium and the multipurpose catheter removed. Stable wire position in a left pulmonary vein was confirmed by respiratory, but not cardiac, motion of the wire. A 9 French, 45 degree curved Amplatzer delivery sheath preloaded with a 25 mm Amplatzer Cribiform Septal Occluder was advanced across the interatrial septum and the left atrial disk was delivered under fluoroscopic and intracardiac echocardiographic guidance (Figure 47-1 and Video 47-2). The delivery catheter was pulled back until the left atrial disk was snugly apposed to the septum, and the right atrial disk was delivered out of the sheath but remained attached to the delivery cable while positioning was confirmed both by fluoroscopy and by intracardiac echocardiography (Figure 47-2

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