International Journal of Cardiology 174 (2014) e13–e15
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Trans-catheter treatment of residual leak after PFO device closure Giuseppe Santoro ⁎, Luca Giugno, Gianpiero Gaio, Cristina Capogrosso, Carola Iacono, Maria Giovanna Russo Paediatric Cardiology, A.O.R.N. “Ospedali dei Colli”, 2nd University of Naples, Naples, Italy
a r t i c l e
i n f o
Article history: Received 9 March 2014 Accepted 1 April 2014 Available online 12 April 2014 Keywords: Patent foramen ovale Criptogenetic stroke Shunt Device
To the Editor: A 24-year-old patient submitted to PFO closure with a 27/30 mm Occlutech Figulla PFO occluder device (Occlutech GmbH, Jena, Germany) 18 months before, was referred to our Institution due to severe rightto-left residual shunt at trans-cranial Doppler analysis (shower-like type during Valsalva maneuver). At trans-oesophageal echocardiography, the shunt occurred in between the disks of the previously implanted device (Fig. 1), presumably due to the high mobility of the aneurismal atrial septum. Despite the lack of further critical events, the amount of the right-to-left shunt as well as the perceived psychological disability of the patient caused by this finding prompted us to attempt the occlusion of the endo-prosthesis leak. Patient informed consent and agreement with the surgical team were then obtained. Under 3D trans-oesophageal echocardiographic guide, two multipurpose 6Fr catheters and then two delivery systems were sequentially passed across the previously implanted device (Fig. 2) and located in the opposite pulmonary veins. This made possible to simultaneously deploy two Amplatzer™ Vascular Plug type II devices (St Jude, St. Paul, MN, USA) (14 mm and 12 mm, respectively) in a crosswise fashion inside the double-disk device, in order to achieve a stable anchoring and occluding capacity of the plugs. The final bubble test failed to show any residual shunt either at rest or during Valsalva maneuver. Despite the high success rate of percutaneous PFO closure [1–3], moderate-to-severe residual atrial shunt has been reported in 2–10% of patients, mainly due to multiple septal fenestrations or atrial septal ⁎ Corresponding author at: Via Camillo Sorgente, 31, 84125, Salerno, Italy. Tel./fax: + 39 081 7062683. E-mail address: [email protected] (G. Santoro).
http://dx.doi.org/10.1016/j.ijcard.2014.04.005 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
aneurysm [4,5]. Clinical relevance of this finding is still debated, although it has been related to increased risk of recurrent stroke during follow-up [1,5]. Therefore, management of residual shunt following percutaneous device PFO closure is not well established, including pharmacologic therapy, surgical removal of the previously implanted device and PFO closure or trans-catheter re-intervention [4,6–8]. Based on shunt characteristics, trans-catheter approach might consist on controlled-release coil, double-disk device or vascular plug implantation. Residual tunnel-like shunt, in between the disks of the previously deployed device, is the most difficult type of residual shunt to treat, resulting in high rate of procedural failure with the need of further surgical approach [4]. In this setting, simultaneous deployment of multiple vascular plugs inside the previously implanted device might theoretically increase the mass-effect and intra-device stability of the occluding material, thus reducing the potential for long-term residual shunt (Fig. 3). In this challenging approach, 3D-echocardiography may be crucially helpful in locating the leak site and size as well as in guiding catheter manipulation and plug deployment. References [1] Windeker S, Wahl A, Chatterjee T, et al. Percutaneous closure of patent foramen ovale in patients with paradoxical embolism: long-term risk of recurrent thrombo-embolic events. Circulation 2000;101:893–8. [2] Greutmann M, Greutmann-Yantiri M, Kretschmar O, et al. Percutaneous PFO closure with Amplatzer PFO occlude: predictors of residual shunt at 6 months follow-up. Congenit Heart Dis 2009;4:252–7. [3] Bruch L, Parsi A, Grad MO, et al. Transcatheter closure of interatrial communications for secondary prevention of paradoxical embolism: single-center experience. Circulation 2002;105:2845–8. [4] 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;82:950–8. [5] Wahl A, Meier B, Haxel B, et al. Prognosis after percutaneous closure of patent foramen ovale for paradoxical embolism. Neurology 2001;57:1330–2. [6] Diaz T, Cubeddu RJ, Rengifo-Moreno PA, et al. Management of residual shunts after initial percutaneous patent foramen ovale closure: a single center experience with immediate and long-term follow-up. Catheter Cardiovasc Interv 2010;76:145–50. [7] Schwerzmann M, Windecker S, Wahl A, et al. Implantation of a second closure device in patients with residual shunt after percutaneous closure of patent foramen ovale. Catheter Cardiovasc Interv 2004;63:490–5. [8] Majunke N, wallenborn J, Baranowski A, Wunderlich N, Sievert H. Device closure of residual shunt after percutaneous closure of patent foramen ovale. EuroIntervention 2010;5:833–7.
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G. Santoro et al. / International Journal of Cardiology 174 (2014) e13–e15
Fig. 1. At trans-oesophageal echocardiographic evaluation, the PFO device (asterisk) seems optimally located inside the aneurismal atrial septum. However, a mild left-to-right shunt is imaged in between the device disks (arrow) that increased and reverted during Valsalva maneuver, as imaged at trans-cranial Doppler analysis. Abbreviations. LA, left atrium; RA, right atrium.
Fig. 2. (A) 3D-echocardiographic imaging of the two delivery systems (arrows) passed across the PFO device through which is possible to simultaneously deploy two vascular plugs (asterisks), as imaged at fluoroscopy (B).
G. Santoro et al. / International Journal of Cardiology 174 (2014) e13–e15
e15
Fig. 3. (A) 3D-echocardiographic and (B) fluoroscopic imaging of the two occluding vascular plugs (asterisks) positioned inside the PFO device and intertwined to each other in order to increase their stability and occluding capacity.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Trans-catheter treatment of residual leak after PFO device closure Giuseppe Santoro ⁎, Luca Giugno, Gianpiero Gaio, Cristina Capogrosso, Carola Iacono, Maria Giovanna Russo Paediatric Cardiology, A.O.R.N. “Ospedali dei Colli”, 2nd University of Naples, Naples, Italy
a r t i c l e
i n f o
Article history: Received 9 March 2014 Accepted 1 April 2014 Available online 12 April 2014 Keywords: Patent foramen ovale Criptogenetic stroke Shunt Device
To the Editor: A 24-year-old patient submitted to PFO closure with a 27/30 mm Occlutech Figulla PFO occluder device (Occlutech GmbH, Jena, Germany) 18 months before, was referred to our Institution due to severe rightto-left residual shunt at trans-cranial Doppler analysis (shower-like type during Valsalva maneuver). At trans-oesophageal echocardiography, the shunt occurred in between the disks of the previously implanted device (Fig. 1), presumably due to the high mobility of the aneurismal atrial septum. Despite the lack of further critical events, the amount of the right-to-left shunt as well as the perceived psychological disability of the patient caused by this finding prompted us to attempt the occlusion of the endo-prosthesis leak. Patient informed consent and agreement with the surgical team were then obtained. Under 3D trans-oesophageal echocardiographic guide, two multipurpose 6Fr catheters and then two delivery systems were sequentially passed across the previously implanted device (Fig. 2) and located in the opposite pulmonary veins. This made possible to simultaneously deploy two Amplatzer™ Vascular Plug type II devices (St Jude, St. Paul, MN, USA) (14 mm and 12 mm, respectively) in a crosswise fashion inside the double-disk device, in order to achieve a stable anchoring and occluding capacity of the plugs. The final bubble test failed to show any residual shunt either at rest or during Valsalva maneuver. Despite the high success rate of percutaneous PFO closure [1–3], moderate-to-severe residual atrial shunt has been reported in 2–10% of patients, mainly due to multiple septal fenestrations or atrial septal ⁎ Corresponding author at: Via Camillo Sorgente, 31, 84125, Salerno, Italy. Tel./fax: + 39 081 7062683. E-mail address: [email protected] (G. Santoro).
http://dx.doi.org/10.1016/j.ijcard.2014.04.005 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
aneurysm [4,5]. Clinical relevance of this finding is still debated, although it has been related to increased risk of recurrent stroke during follow-up [1,5]. Therefore, management of residual shunt following percutaneous device PFO closure is not well established, including pharmacologic therapy, surgical removal of the previously implanted device and PFO closure or trans-catheter re-intervention [4,6–8]. Based on shunt characteristics, trans-catheter approach might consist on controlled-release coil, double-disk device or vascular plug implantation. Residual tunnel-like shunt, in between the disks of the previously deployed device, is the most difficult type of residual shunt to treat, resulting in high rate of procedural failure with the need of further surgical approach [4]. In this setting, simultaneous deployment of multiple vascular plugs inside the previously implanted device might theoretically increase the mass-effect and intra-device stability of the occluding material, thus reducing the potential for long-term residual shunt (Fig. 3). In this challenging approach, 3D-echocardiography may be crucially helpful in locating the leak site and size as well as in guiding catheter manipulation and plug deployment. References [1] Windeker S, Wahl A, Chatterjee T, et al. Percutaneous closure of patent foramen ovale in patients with paradoxical embolism: long-term risk of recurrent thrombo-embolic events. Circulation 2000;101:893–8. [2] Greutmann M, Greutmann-Yantiri M, Kretschmar O, et al. Percutaneous PFO closure with Amplatzer PFO occlude: predictors of residual shunt at 6 months follow-up. Congenit Heart Dis 2009;4:252–7. [3] Bruch L, Parsi A, Grad MO, et al. Transcatheter closure of interatrial communications for secondary prevention of paradoxical embolism: single-center experience. Circulation 2002;105:2845–8. [4] 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;82:950–8. [5] Wahl A, Meier B, Haxel B, et al. Prognosis after percutaneous closure of patent foramen ovale for paradoxical embolism. Neurology 2001;57:1330–2. [6] Diaz T, Cubeddu RJ, Rengifo-Moreno PA, et al. Management of residual shunts after initial percutaneous patent foramen ovale closure: a single center experience with immediate and long-term follow-up. Catheter Cardiovasc Interv 2010;76:145–50. [7] Schwerzmann M, Windecker S, Wahl A, et al. Implantation of a second closure device in patients with residual shunt after percutaneous closure of patent foramen ovale. Catheter Cardiovasc Interv 2004;63:490–5. [8] Majunke N, wallenborn J, Baranowski A, Wunderlich N, Sievert H. Device closure of residual shunt after percutaneous closure of patent foramen ovale. EuroIntervention 2010;5:833–7.
e14
G. Santoro et al. / International Journal of Cardiology 174 (2014) e13–e15
Fig. 1. At trans-oesophageal echocardiographic evaluation, the PFO device (asterisk) seems optimally located inside the aneurismal atrial septum. However, a mild left-to-right shunt is imaged in between the device disks (arrow) that increased and reverted during Valsalva maneuver, as imaged at trans-cranial Doppler analysis. Abbreviations. LA, left atrium; RA, right atrium.
Fig. 2. (A) 3D-echocardiographic imaging of the two delivery systems (arrows) passed across the PFO device through which is possible to simultaneously deploy two vascular plugs (asterisks), as imaged at fluoroscopy (B).
G. Santoro et al. / International Journal of Cardiology 174 (2014) e13–e15
e15
Fig. 3. (A) 3D-echocardiographic and (B) fluoroscopic imaging of the two occluding vascular plugs (asterisks) positioned inside the PFO device and intertwined to each other in order to increase their stability and occluding capacity.
