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Residual Shunt After PFO Closure
Study Questions:
What is the incidence and mechanism of persistently positive shunt using agitated saline contrast injection after transcatheter closure of a patent foramen ovale (PFO)?
Methods:
In this single-center, nonrandomized, retrospective review, the medical records and echocardiograms of patients who were treated with clinically indicated transcatheter closure of a PFO for cryptogenic stroke were reviewed.
Results:
From January 1998 through December 2015, 880 patients were taken to the catheterization laboratory for PFO closure, of whom 568 patients (mean age 48.1 ± 12.9 years, 320 [56.3%] men), underwent transcatheter closure of a PFO using an Amplatzer PFO Occluder. The incidence of right-to-left (R-L) shunting was 19.5% at a mean follow-up of 4 ± 2 months, which decreased to 8.4% at 11 ± 2 months. Sources of R-L shunt were identified in 10 patients (1.8%), and included pulmonary arteriovenous malformation in four, leak through the occluder device in three, atrial septal fenestrations in two, and persistent left superior vena cava with an unroofed coronary sinus in one patient. All patients with identified sources of additional R-L shunt were treated percutaneously. At 2-year follow-up, 16 patients (2.8%) had a persistent, small R-L shunt on agitated saline contrast injection, with no apparent additional source of shunting.
Conclusions:
Coexistence of a PFO and an additional lesion responsible for RLS is uncommon, but not rare; the majority are amenable to transcatheter or surgical intervention.
Perspective:
Transcatheter intervention for PFO closure is reasonable among a highly selected group of patients <60 years of age who suffered a cryptogenic stroke and who had an otherwise negative cardiac and neurologic workup. This single-center, observational study suggests that a residual or persistent R-L shunt is present in approximately 20% of patients 4 months after intervention, decreasing to approximately 8% at 11 months; a source of residual or persistent shunt was identifiable in 10 of 24 patients. The clinical impact of a residual shunt is unknown, and whether additional interventions are warranted to address those shunts requires additional investigation.
Keywords: Arteriovenous Fistula, Arteriovenous Malformations, Cardiac Catheterization, Cardiac Surgical Procedures, Cardiology Interventions, Coronary Sinus, Echocardiography, Foramen Ovale, Patent, Heart Defects, Congenital, Secondary Prevention, Septal Occluder Device, Stroke, Vena Cava, Superior
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