Onorato Eustaquio M, Alamanni Francesco, Monizzi Giovanni, Mastrangelo Angelo, Bartorelli Antonio Luca
University Cardiology Department, I.R.C.C.S. Ospedale Galeazzi- Sant'Ambrogio, Milan, Italy.
University Cardiac Surgery Department, I.R.C.C.S. Ospedale Galeazzi- Sant'Ambrogio, Milan, Italy.
Front Cardiovasc Med. 2024 Jul 2;11:1367515. doi: 10.3389/fcvm.2024.1367515. eCollection 2024.
Even though the optimal management of a moderate or large residual shunt following patent foramen ovale (PFO) closure is open to question, recent data confirmed that it is associated with an increased risk of stroke recurrence.
A 48-year-old woman, a migraineur with visual aura, was diagnosed with a PFO associated with a huge multifenestrated atrial septal aneurysm (mfASA) and a moderate right-to-left shunt, detectable only after a Valsalva maneuver on contrast-transthoracic echocardiography. Brain magnetic resonance imaging showed a 1-mm silent white matter lesion in the right frontal lobe. Although the indication was not supported by guidelines, a transcatheter PFO closure was performed at another center with implantation of a large, equally sized, double-disc device (Figulla UNI 33/33 mm). At 6-month follow-up, a 2D/3D transesophageal echocardiography (TEE) color Doppler showed incorrect orientation of the device, which was not parallel to the interatrial septum, with two discs failing to capture the aortic muscular rim and partially protruding in the right atrium; furthermore, a 4 mm × 7 mm ASA fenestration was documented with a residual bidirectional shunt. Thereafter, the same team performed a minimally invasive cardiac surgery under femoro-femoral cardiopulmonary bypass; however, the procedure proved ineffective and was complicated by postoperative pericarditis with pericardial effusion, requiring further rehospitalization 1 month later due to persistent pericarditis, bilateral pleuritis, phrenic nerve palsy, and atrial flutter, which was treated with amiodarone. The patient asked for a second opinion, and our multidisciplinary heart team decided to offer a percutaneous redo intervention. An uneventful implantation of a regular PFO occluder (Figulla Flex II 16/18 mm) across the septal defect was performed successfully. Twelve-month follow-up with 2D TTE color Doppler and contrast transcranial Doppler showed correct position and good interaction between the two devices, with no residual shunt.
In addition to the incorrect indication for PFO closure and the failure of minimally invasive surgery, the procedural mishap in this case could have been due to the inappropriate implantation of the first large device within the tunnel. It would have been better to deploy the same large device in the most central fenestration, covering the PFO and a greater part of the remaining mfASA at the same time.
尽管卵圆孔未闭（PFO）封堵术后中度或大量残余分流的最佳管理存在疑问，但近期数据证实其与中风复发风险增加相关。
一名48岁女性，有视觉先兆偏头痛，被诊断为PFO合并巨大多孔房间隔瘤（mfASA）及中度右向左分流，仅在经胸超声心动图造影时行Valsalva动作后可检测到。脑磁共振成像显示右额叶有一个1毫米的无症状白质病变。尽管指南未支持该适应症，但在另一家中心进行了经导管PFO封堵术，植入了一个大型、尺寸相同的双盘装置（菲古拉UNI 33/33毫米）。在6个月随访时，二维/三维经食管超声心动图（TEE）彩色多普勒显示装置方向错误，不与房间隔平行，两个盘未能捕获主动脉肌性边缘且部分突入右心房；此外，记录到一个4毫米×7毫米的ASA窗孔并有残余双向分流。此后，同一团队在股-股体外循环下进行了微创心脏手术；然而，该手术证明无效，术后并发心包炎伴心包积液，1个月后因持续性心包炎、双侧胸膜炎、膈神经麻痹和心房扑动需再次住院，给予胺碘酮治疗。患者寻求第二种意见，我们的多学科心脏团队决定进行经皮再次干预。成功地在房间隔缺损处顺利植入了一个常规PFO封堵器（菲古拉Flex II 16/18毫米）。二维经胸超声心动图（TTE）彩色多普勒和经颅多普勒造影12个月随访显示两个装置位置正确且相互作用良好，无残余分流。
除了PFO封堵适应症不正确和微创手术失败外，该病例中的手术失误可能是由于第一个大型装置在隧道内植入不当。最好将同一个大型装置部署在最中央的窗孔处，同时覆盖PFO和其余mfASA的大部分。
