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Percutaneous Closure of a Complex Intradevice Residual Patent Foramen Ovale Under Transesophageal Echocardiographic Guidance

VanLoozen, Dennis MD*; Amin, Zahid MD*; Javaheri, Sean DO; Agarwal, Shvetank MD, FASE

doi: 10.1213/XAA.0000000000000971
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From the *Division of Pediatric Cardiology, Children’s Hospital of Georgia, Augusta University, Augusta, Georgia

Divisions of Cardiology

Anesthesiology and Perioperative Medicine, Augusta University, Augusta, Georgia.

Accepted for publication December 12, 2018.

Funding: None.

Conflicts of Interest: See Disclosures at the end of the article.

Supplemental digital content is available for this article. Direct URL citations are provided in the HTML and PDF versions of this article on the journal’s website.

Address correspondence to Shvetank Agarwal, MD, FASE, Department of Anesthesiology and Perioperative Medicine, Augusta University, 1120 15th St, BIW-2144, Augusta, GA 30912. Address e-mail to sagarwal@augusta.edu.

A 36-year-old woman with a history of pulmonary arteriovenous malformations and transient ischemic attacks underwent device closure for a large patent foramen ovale with a 35-mm Amplatzer cribriform occluder (Abbott, Abbott Park, IL) at an outside institution; type of imaging used to facilitate device placement is unknown. Two years later, she presented to our institution because of repeat transient ischemic attacks; a bubble study done at this time demonstrated a grade 2 residual shunt through the discs of the device. Due to the risk of recurrent stroke, she underwent device closure of the residual intradevice shunt with transesophageal echocardiographic (TEE) guidance.

Preprocedure midesophageal bicaval view with color Doppler demonstrated a large cribriform device with a right-to-left shunt within the discs of the device exiting into the left atrium (Supplemental Digital Content, Video 1A, http://links.lww.com/AACR/A249; Figure 1A). A bubble study without Valsalva release in the modified midesophageal right ventricular inflow-outflow view revealed a significant residual gap between the occluder discs (Supplemental Digital Content, Video 1B, http://links.lww.com/AACR/A249) which measured 8 mm in width and 20 mm in length in the midesophageal bicaval view (Figure 2). Initially, a 10-mm Amplatzer muscular ventricular septal defect occluder (Abbott, Abbott Park, IL) was deployed within the discs of the cribriform device. TEE demonstrated a residual shunt, so the occluder was removed. Ultimately, a 14-mm ventricular septal defect occluder was deployed within the discs of the cribriform device. The left disc was completely deployed, while the right disc was lodged within the cribriform discs, with complete obliteration of the shunt.

Figure 1.

Figure 1.

Figure 2.

Figure 2.

Postprocedure 2-dimensional midesophageal bicaval views with color Doppler (Supplemental Digital Content, Video 2A, http://links.lww.com/AACR/A250; Figure 1B) as well as 3-dimensional en face view from the left atrium perspective (Supplemental Digital Content, Video 2B, http://links.lww.com/AACR/A250) demonstrated a well-seated ventricular septal defect occluder with the left disc in the left atrium held by the cribriform plate while the waist and the right atrial disc remained in the tunnel of the cribriform device. During the postprocedure bubble study, there was an appearance of bubbles in the left atrium after 3–4 cardiac cycles in the midesophageal 4-chamber view. However, the bubbles did not cross the device but instead arose from the left upper pulmonary vein in a “ramp-up” pattern which was suggestive of a pulmonary arteriovenous malformations (Supplemental Digital Content, Video 2C, http://links.lww.com/AACR/A250) that was later confirmed by computed tomographic angiography.

Written consent was obtained from the patient for this manuscript and the authors were compliant with Health Insurance Portability and Accountability Act privacy regulations.

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DISCUSSION

Transcatheter patent foramen ovale closure is indicated in patients with a history of cryptogenic embolic stroke, with recent studies demonstrating a significant reduction in the rate of recurrent stroke when compared to medical therapy.1,2 A double-disc device connected with a waist is advanced through a catheter across the patent foramen ovale and then the discs are deployed along their respective atrial walls, resolving the shunt (Figure 3A). However, 1 known complication is the presence of a residual shunt after device closure. Any amount of residual shunt is undesirable, because there is a possibility of recurrent stroke. Residual shunts are most often associated with defects with discrepant septum primum and septum secundum sizes (a very thin septum primum with a thick septum secundum), an aneurysmal atrial septum (Figure 3B), multiple septal fenestrations, and oversized devices. Oversizing can be determined by TEE that would show poor approximation of discs to rims and a gap between the discs.3

Figure 3.

Figure 3.

Multiple studies have demonstrated the presence of a residual patent foramen ovale shunt in 2%–10% of patients at 6-month follow-up after a percutaneous patent foramen ovale closure.4 The majority of residual shunts occur around the existing device; however, a subset of patients exhibit an intradisc shunt3,4 (Figure 3C), as was the case with our patient. While the scale for determining the grade of patent foramen ovale shunt by bubble study is not widely agreed on, a commonly used scale defines grade 1 as <5 bubbles, grade 2 as 5–25 bubbles, grade 3 as >25 bubbles, and grade 4 as opacification of the left atrium.5 Because patients with a grade 2 or larger shunt remain at risk of a recurrent stroke,3 efforts should be made to close the residual patent foramen ovale shunt.

Choosing the correct device for closure of a residual patent foramen ovale is challenging. Several different devices have been utilized, including coils, double-disc devices, and vascular plugs. In rare instances, multiple devices are required.4 There are scant data regarding device placement in a residual intradisc shunt. Ultimately, the Amplatzer muscular ventricular septal defect occluder was chosen for our patient due to its double-disc design, adequate length between the discs to stretch through the discs of the existing device, and the presence of Dacron mesh to reduce the risk of residual shunting. Device sizing and selection to close residual defects can be challenging. Careful TEE interrogation demonstrated intradisc residual shunting with the smaller device. Due to the high risk of embolization of a small device and the residual shunt, a 14-mm ventricular septal defect occluder was chosen. The left disc extended outside the existing device, while the waist and right disc of the ventricular septal defect occluder remained within the tunnel of the cribriform device (Figure 3D). TEE demonstrated complete resolution of the residual shunt through the device, but revealed a pulmonary arteriovenous malformation, with bubbles arising from the left pulmonary veins in a “ramped-up” fashion. Traditionally, the “3 beat rule” on agitated saline contrast study has been used to differentiate intracardiac from intrapulmonary shunting, with late appearance of bubbles pointing toward pulmonary arteriovenous malformations; however, considerable variability in the timing has been seen.6 Therefore, the presence of increasing bubble load in the left atrium with each beat, the so-called ramped-up pattern may have a more definitive diagnostic significance.6

TEE guidance was essential to accurately characterize the size and shape of the residual defect to select the most appropriate device for closure. Previous studies have demonstrated that, when utilizing TEE for procedural imaging, results were reproducible and similar to intracardiac echocardiogram in regard to device selection for patent foramen ovale occlusion, except in the case of patients with an aneurysmal atrial septum.7 In this case, 2- and 3-dimensional TEEs were utilized for device sizing and placement.

To the best of our knowledge, this is the first case of percutaneous closure of a residual patent foramen ovale utilizing an Amplatzer muscular ventricular septal defect occluder for an intradisc shunt. The utilization of 2- and 3-dimensional TEEs allowed for accurate sizing of this complex defect and ultimately led to the correct device choice and complete closure of the residual shunt.

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ACKNOWLEDGMENTS

We thank Rhonda Powell for the medical illustrations and Nadine Odo for editing assistance.

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DISCLOSURES

Name: Dennis VanLoozen, MD.

Contribution: This author helped write and edit the manuscript.

Conflicts of Interest: None.

Name: Zahid Amin, MD.

Contribution: This author helped edit the manuscript.

Conflicts of Interest: Dr Amin is a proctor for Abbott.

Name: Sean Javaheri, DO.

Contribution: This author helped edit the manuscript.

Conflicts of Interest: None.

Name: Shvetank Agarwal, MD, FASE.

Contribution: This author helped write and edit the manuscript.

Conflicts of Interest: None.

This manuscript was handled by: Kent H. Rehfeldt, MD.

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REFERENCES

1. Saver JL, Carroll JD, Thaler DE, et al.; RESPECT Investigators. Long-term outcomes of patent foramen ovale closure or medical therapy after stroke. N Engl J Med. 2017;377:1022–1032.
2. Amin Z, Hijazi ZM, Bass JL, Cheatham JP, Hellenbrand W, Kleinman CS. PFO closure complications from the AGA registry. Catheter Cardiovasc Interv. 2008;72:74–79.
3. Butera G, Sarabia JF, Saracino A, Chessa M, Piazza L, Carminati M. Residual shunting after percutaneous PFO closure: how to manage and how to close. Catheter Cardiovasc Interv. 2013;82:950–958.
4. Santoro G, Giugno L, Gaio G, Capogrosso C, Iacono C, Russo MG. Trans-catheter treatment of residual leak after PFO device closure. Int J Cardiol. 2014;174:e13–e15.
5. Rana BS, Thomas MR, Calvert PA, Monaghan MJ, Hildick-Smith D. Echocardiographic evaluation of patent foramen ovale prior to device closure. JACC: Cardiovasc Imaging. 2010;3:749–760.
6. Jyothidasan A, Gyanendra S, Garg A, et al. Novel method for distinguishing intrapulmonary shunting from interatrial shunting based on the “ramping up” pattern of bubble appearance in the left heart. Angiogenesis. 2015;18:543.
7. Vigna C, Marchese N, Zanchetta M, et al. Echocardiographic guidance of percutaneous patent foramen ovale closure: head-to-head comparison of transesophageal versus rotational intracardiac echocardiography. Echocardiography. 2012;29:1103–1110.

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