We report the case of a 59-year-old man with cryptogenic stroke who was found to have both an ostium secundum atrial septal defect and a patent foramen ovale (PFO) by intracardiac echocardiography. Both defects were successfully occluded using a single 35-mm Amplatzer PFO occluder device inserted through the atrial septal defect.
Patients with cryptogenic stroke who are found to have an atrial septal defect (ASD) or a patent foramen ovale (PFO) are often referred for percutaneous closure of the defect in an attempt to prevent future paradoxic embolism, although the effectiveness of this approach has not been proven in randomized controlled trials. Frequently, multiple ASDs are discovered at the time of the procedure in those patients , often necessitating use of multiple closure devices .
We describe a patient with cryptogenic stroke who was found by intracardiac echocardiography to have both an ASD and a PFO. Successful closure of both defects was achieved using a single 35-mm Amplatzer PFO occluder device (AGA Medical, Plymouth, MN, USA) inserted through the ASD.
A 59-year-old man presented with complete, acute right hemiplegia and was diagnosed with a stroke. He had an extensive evaluation that included carotid Doppler ultrasonography and magnetic resonance angiography of the head and neck, all of which were normal. Transesophageal echocardiography demonstrated a secundum ASD. The patient was placed on oral anticoagulation with warfarin and was subsequently referred for percutaneous ASD closure. After discussion of the risks and potential benefits of the procedure emphasizing the lack of prospective randomized-controlled data on the efficacy of ASD or PFO closure for the prevention of recurrent strokes, the patient elected to proceed with percutaneous closure of the defect as part of a prospective study.
On right heart catheterization, the right atrial pressure was 10 mmHg, the right ventricular pressure was 28/7 mmHg, the pulmonary artery pressure was 26/11 mmHg (mean 19 mmHg), and the mean pulmonary capillary wedge pressure was 11 mmHg. No oxygen saturation step-up could be identified. Intracardiac echocardiography confirmed the presence of the ASD but also revealed a previously undiscovered PFO ( Fig. 1 ). Intermittent right to left shunting through both defects was seen by color Doppler imaging ( Fig. 1 A and C) and was confirmed by agitated saline administration. The distance between the ASD and the PFO was 12 mm. The distance between the PFO and the aorta was 13 mm, and the distance between the PFO and the superior vena cava was 12 mm. The PFO measured 7.6 mm by intracardiac echocardiography imaging and 7.8 mm by balloon sizing ( Fig. 1 D). We were unable to advance the sizing balloon through the ASD, likely because of its small size.
Closure of each defect using separate devices was initially considered using two Amplatzer devices: a PFO and an ASD occluder device. According to the manufacturer’s recommendation, if the shortest distance between the PFO to either the aorta or the superior vena cava is between 9.0 and 12.4 mm, then an 18-mm device is recommended. If the shortest distance is between 12.5 and 17.4 mm, then a 25-mm device is recommended. We first deployed an 18-mm Amplatzer PFO occluder through the PFO, but residual shunt remained through the ASD, and the PFO device edge was very close to the ASD making implantation of a second ASD device difficult. The PFO occluder was recaptured and we elected to attempt closure of both defects using a single device. A 25-mm Amplatzer PFO occluder was inserted through the PFO stopping shunting through the PFO, but residual shunting through the ASD remained ( Fig. 2 A ).
Due to its small size, the ASD was difficult to wire, yet wiring was successful after the PFO was transiently occluded with the 25-mm Amplatzer PFO occluder. We attempted closure of both defects using the same 25-mm Amplatzer PFO occluder device, now inserted through the ASD. Color Doppler again demonstrated residual shunting through the PFO ( Fig. 2 B). At the time of this procedure, the cribriform ASD occluder was not available.
The 25-mm device was recaptured, and a 35-mm Amplatzer PFO occluder device was inserted through the ASD, occluding flow through both the ASD and the PFO. The device appeared to be well seated and did not impinge on the aortic root. The PFO Amplatzer device was released. Intracardiac echocardiography showed good seating of the device with minor central residual shunt ( Fig. 2 C). Over the following month, the patient’s hemiplegia completely resolved. Follow-up transthoracic echocardiographic imaging was obtained 1 month after closure and showed no residual interatrial shunting by color flow Doppler or with agitated saline administration ( Fig. 3 ). Thirteen months after this cerebrovascular event and 12 months since closure of the defects, he did not have any recurrent neurologic events.