(Hellenic Journal of Cardiology) HJC • 155
Hellenic J Cardiol 2012; 53: 155-159
March 17, 2010;
May 15, 2010.
St. Luke’s Hospital,
552 36 Panorama
Key words: Atrial
Cryptogenic Stroke After Percutaneous Closure of
an Atrial Septal Defect
Petros s. DarDas1, Vlasis NiNios1, Nikos Mezilis1, efstratios k. theofilogiaNNakos1,
DiMitris tsikaDeris1, Vassilis thaNoPoulos2
1Department of Cardiology, St. Luke’s Hospital, Thessaloniki, 2Department of Cardiology, Agia Sofia’s Children’s
Hospital, Athens, Greece
We present the case of a patient who underwent a percutaneous secundum atrial septal defect (ASD II) clo-
sure with an undersized septal occluder device. One week and one month later she experienced two tran-
sient ischemic attacks. Three-dimensional transesophageal echocardiography (TEE) revealed a residual pat-
ent foramen ovale (PFO) with a positive Valsalva bubble test. She underwent a second procedure under the
3D TEE guidance and the PFO was successfully closed percutaneously using a PFO occluder device that
was attached to the ASD device. Accurate ASD and PFO morphology assessment and appropriate device se-
lection are the key factors in the success of percutaneous closure. 3D TEE is an innovative diagnostic tech-
nique, providing a complete description of the cardiac defect and improving spatial orientation. Real-time 3D
TEE is the appropriate guidance for successful and accurate positioning of the device.
ovale (PFO), which has become an estab-
lished therapy, is constantly increasing.1
Transcatheter ASD closure is a safe and
effective treatment modality with excellent
long-term success rates,2 provided that the
defect is appropriate for percutaneous clo-
sure and the device is deployed successfully.
It is well known that patients who have
suffered a cryptogenic stroke, which has
been associated with PFO, are at risk of
recurrent stroke, despite being on medi-
cal treatment.3-6 The incidence of recur-
rence of the stroke in these patients varies
from 0-15% per year.7-10 This risk is par-
ticularly increased in patients who have a
combination of PFO and atrial septal an-
eurysm.5,11,12 The likeliest mechanism of
stroke in these patients is paradoxical em-
bolization through the PFO.13 It appears
that percutaneous closure of the PFO is at
least as effective as medical treatment in
he incidence of percutaneous clo-
sure of a secundum atrial septal
defect (ASD) and patent foramen
preventing the recurrence of stroke. More-
over, closure appears to be more effective
than medical treatment in patients who
have suffered more than one event.14
Amplatzer devices, specifically the Am-
platzer Septal Occluder® and Amplatzer
PFO Occluder® (AGA, Medical Corpo-
ration, Golden Valley MN, USA), have
been granted FDA approval for percutane-
ous closure of ASD and PFO, respectively.
At the moment these devices are the most
commonly used devices for percutaneous
closure of ASDs.15 The results of percuta-
neous closure with these particular devices
are quite encouraging.16,17
We present the case of a 34-year-old
woman who experienced two transient
ischemic attacks (TIA) one week and one
month after a percutaneous ASD closure,
as the result of a residual PFO.
A 34-year-old woman underwent uncom-
156 • HJC (Hellenic Journal of Cardiology)
P.S. Dardas et al
plicated percutaneous secundum ASD closure be-
cause of signs of right heart volume overload. ASD
closure was performed with an 18 mm Amplatzer
septal occluder device and she was discharged on as-
pirin (100 mg od). One week later she experienced a
TIA with sudden loss of vision in her right eye (am-
aurosis fugax). A two-dimensional transesophageal
echocardiography (2D TEE) examination showed a
possibility of thrombus on the left atrium side of the
device and she was started on warfarin. One month
later, and despite her being fully anticoagulated, she
experienced a second TIA. She was fully investigat-
ed neurologically and nothing was found. She under-
went 2D (Figure 1) and 3D (Figure 2) TEE, which
revealed a residual PFO that remained uncovered
by the ASD occluder device, with a positive Valsalva
bubble test, whereas it did not detect any thrombus in
the left atrium. The 3D images, in particular, revealed
that, due to device dislodgement, the two disks of the
Amplatzer ASD occluder device failed to embrace
the septum secundum anteriorly and superiorly and
were limited to the septum primum, occluding only
the ASD. Due to the weight of the device, the previ-
ously undiagnosed PFO was held wide open, facilitat-
ing ample passage of bubbles during the Valsalva ma-
neuver. Thus, the residual PFO was the substrate for
thrombus formation, as well as the passage to the left
atrium and consequently the reason for the TIA.
The patient underwent a second procedure and
the PFO was successfully closed percutaneously with
a 25 mm Amplatzer PFO occluder device. The pro-
cedure was performed under fluoroscopy and 2D/3D
TEE guidance. 2D and 3D (Figure 3) TEE imag-
es confirmed the complete closure of the PFO (the
PFO device was attached to the ASD device). She
was discharged on aspirin 325 mg for six months. Her
postoperative recovery was uneventful. At one-year
follow up, the patient is asymptomatic and off anti-
thrombotic medications for the last 6 months.
Transcatheter closure of an ASD is a valid alternative
to the surgical approach, with less morbidity than sur-
gical closure.18,19 It is currently indicated for the clo-
sure of hemodynamically significant (right ventricular
volume overload) ASDs with a sufficient rim of tissue
around the septal defect, so that the closure device
does not impinge upon the superior vena cava (SVC),
inferior vena cava (IVC), or the tricuspid or mitral
valves.20 Amplatz devices are clinically safe and effec-
tive in ASD closure.21 Periprocedural complications
are rare22 and late complications even rarer.23,24 An
increased incidence of transient arrhythmias (usually
new-onset atrial fibrillation) has been observed dur-
ing the post-implantation period, without any clinical
consequence.24 Device embolization, either early or
late, is usually the result of suboptimal implantation
technique, and mainly due to an undersized device
and an insufficient rim at the inferior-posterior defect
Figure 1. Mid-esophageal long axis view at 90° showing left-to-
right linear flow through a patent foramen ovale. The Amplatzer
device is visualized inferior to the defect. AD – Amplatzer device;
AO – aorta; LA – left atrium; RA – right atrium.
Figure 2. Real-time three-dimensional transesophageal echocar-
diographic image showing a wide patent foramen ovale (PFO)
that extends superiorly and posteriorly. The PFO is held open
by the Amplatzer device (AD) that, due to its relative small size,
fails to embrace the septum secundum and merely occludes the
secundum defect. SVC – superior vena cava. Other abbreviations
as in Figure 1.
(Hellenic Journal of Cardiology) HJC • 157
Stroke After Percutaneous ASD Closure
border.25 The incidence of thrombus formation on
Amplatzer devices is very low.26 In a recent study,20
the incidence of complications requiring emergency
surgery (hemopericardium, device embolization, and
pericardial tamponade) was only 0.9%. The preva-
lence of residual shunt is very low, and is associated
with the presence of large and multiple defects and
the use of multiple devices.27
In our case, the undersized Amplatzer septal oc-
cluder failed to embrace the septum secundum an-
teriorly and superiorly and was limited to the sep-
tum primum, occluding only the ASD. Due to its
weight, the previously undiagnosed PFO was held
wide open, facilitating ample passage of micro-bub-
bles during the Valsalva maneuver. However, the
previously unrecognized PFO led to a clinical syn-
drome (TIAs) due to: a) the changes in local anato-
my caused by the first Amplatzer device; and b) the
possibility that the anatomical relation of an Am-
platzer device with a PFO may became the substrate
of thrombus formation.
PFO has been associated with cryptogenic stroke.
There is a higher incidence of PFOs in patients with
cryptogenic stroke (44-66% in patients with crypto-
genic stroke vs. 9-27% in normal controls).28 As a
PFO is usually a tunnel, it has been speculated that
the thrombus formation can actually take place with-
in the PFO.28 The recurrence of strokes has been re-
lated with the PFO’s size as well as the presence of
an atrial septal aneurysm.29 The therapeutic options
regarding secondary prevention of stroke in patients
with PFO include medical treatment (antiplatelet or
anticoagulant treatment), and percutaneous or sur-
gical closure of the defect. According to contempo-
rary guidelines, the standard therapy for patients with
an ischemic stroke or TIA and a PFO is antiplatelet
medication (Class IIa, level of evidence C).30 PFO
closure may be considered for patients with recurrent
cryptogenic stroke despite optimal medical therapy
(Class IIb, level of evidence C).30 Despite our patient
being on aspirin, and subsequently on full anticoagu-
lation, she experienced two TIAs. Consequently, the
silent shunt (PFO) should have been corrected.
At present, pre-interventional evaluation (shunt
volume, defect size, relation with adjacent anatomi-
cal structures) and post-interventional follow up (de-
vice location, thrombus presence, any residual shunt
occurrence) of secundum ASDs are routinely per-
formed using 2D TEE, which is considered the gold
standard.31 However, ASDs have a complex geometry
that may be elliptical, oblong, fenestrated in shape or
may be multiple,32 precluding accurate and detailed
defect assessment by 2D TEE. 3D TEE overcomes
these limitations, facilitating the accurate descrip-
tion of ASDs. A recent study33 showed that 2D TEE
returns a smaller long-axis dimension, and a larger
short-axis dimension when compared with 3D TEE.
In our case, real-time 3D TEE facilitated the diagno-
sis of PFO and was also used to monitor the implan-
tation of the second Amplatzer device.
In the present case, the undersized occluder de-
vice was the reason for the incomplete closure of
the secundum ASD. The recognition of the residu-
al PFO was difficult, and was facilitated greatly by
the use of 3D TEE. The PFO was clinically silent
prior to the ASD occlusion, but led to significant
recurrent embolic events after the implantation of
the Amplatzer device. Percutaneous closure of the
Figure 3. Real-time three-dimensional transesophageal echocardiographic images depicting the position of the Amplatzer patent foramen
ovale (PFO) occluder device relative to the preexisting Amplatzer device (AD). The two disks embrace the septum secundum (SS) and the
atrial surface of the AD on both sides of the atrial septum, thus sealing the PFO completely. Abbreviations as in Figures 1 & 2.
158 • HJC (Hellenic Journal of Cardiology)
P.S. Dardas et al
PFO using a second device was successful and ac-
curate positioning was achieved by careful real-time
monitoring with 3D TEE. Accurate ASD morphol-
ogy assessment and appropriate device selection are
the key factors to procedural success. Real-time 3D
TEE is a more reliable complementary option to 2D
TEE for assessment ASDs and for guidance in de-
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Stroke After Percutaneous ASD Closure
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