Author + information
- Received October 26, 2017
- Revision received February 5, 2018
- Accepted March 6, 2018
- Published online June 4, 2018.
- Ashish H. Shah, MD, MD-Researcha,
- Mark Osten, MDa,
- Lee Benson, MDb,
- Sami Alnasser, MDa,
- Yvonne Bach, BScHa,
- Rohan Vishwanath, BSca,
- Alex Van De Bruaene, MD, PhDa,
- Healey Shulman, BSca,
- Jeneka Navaranjan, BSca,
- Rafique Khan, BHSca and
- Eric Horlick, MDCMa,∗ ()
- aPeter Munk Cardiac Centre and Toronto Congenital Cardiac Centre for Adults, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- bThe Labatt Family Heart Centre, The Hospital for Sick Children, Division of Cardiology, The University of Toronto School of Medicine, Toronto, Ontario, Canada
- ↵∗Address for correspondence:
Dr. Eric Horlick, Toronto General Hospital, 200 Elizabeth Street, Room 6E-249, Toronto, Ontario M5G 2C4, Canada.
Objectives The aim of this study was to assess the incidence of persistently positive results on agitated saline contrast injection after patent foramen ovale (PFO) closure, the underlying mechanism, and management.
Background Transcatheter intervention to close a PFO is reasonable in highly selected patients younger than 60 years, after a thorough cardioneurological investigation following a cryptogenic stroke, particularly in the presence of thromboembolic disease or in patients at high risk for venous thrombosis. The U.S. Food and Drug Administration approved the Amplatzer PFO Occluder in October 2016 for such an indication. Confirmation of PFO closure is usually verified by an agitated saline contrast injection during an echocardiographic examination. The appearance of bubbles in the left atrium raises the concern of incomplete closure or other sources of shunting.
Methods The medical records and echocardiograms of patients who were treated with transcatheter closure of a PFO for cryptogenic stroke were reviewed.
Results From January 1998 through December 2015, 880 patients were taken to the catheter laboratory for PFO closure, of whom 568 patients, 320 men (56.3%), underwent transcatheter closure of a PFO using an Amplatzer PFO Occluder, at a mean age of 48.1 ± 12.9 years. The incidence of right-to-left shunting (RLS) was 19.5% at a mean of 4 months’ follow-up, which reduced to 8.4% at 11 ± 2 months. Sources of RLS were identified in 10 (1.8%); pulmonary arteriovenous malformation (n = 4) was the most common etiology, followed by leak through the device (n = 3). All patients with additional sources of RLS were treated percutaneously. At 2-year follow-up, 16 patients (2.8%) persisted with only mildly positive results on agitated saline contrast injection, without an 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.
The structural heart disease program at the Toronto General Hospital receives support for its educational and research missions from Abbott Vascular. Dr. Horlick is supported by the Peter Munk Chair in Structural and Congenital Heart Disease Intervention. Dr. Horlick is a proctor and consultant for Abbott Vascular. Dr. Osten is a consultant for Abbott Vascular. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received October 26, 2017.
- Revision received February 5, 2018.
- Accepted March 6, 2018.
- 2018 American College of Cardiology Foundation