Introduction: Persistence of patent foramen ovale (PFO) has been associated with cryptogenic stroke due to a paradoxical systemic embolism. In these cases, a percutaneous closure allows to decrease the risk of redo cerebral ischemic events. However, the presence of a complex anatomy might prevent a correct device-deployment with a high-risk o residual shunt and/or device embolization. We describe our experience about alternative technique after a failed device closure attempt
Methods: We reviewed six cases wherein the device was not able to close effectively the PFO. In these cases, alternative techniques and skills were adopted to close the PFO.
Results: From 2021 to 2023, 194 PFO were closed in the congenital catheterization laboratory of Monaldi Hospital (Naples). In the most of cases (188/194 pts, 96.9%) an effective device closure was obtained. However, in 6 cases (3.1%) the device failed to have a PFO closure. In these 6 patients, the PFO anatomy was characterized by: a severe hypertrophy of the septum secundum (2 cases, 33%), an aneurysmatic interatrial septum (3 cases, 50%), a long stiff tunnel (6 cases, 100%). In three cases a deviceless suture-mediated system (NoblestichTM) was effective to achieve a complete PFO closure; whereas, in two cases a combined approach (suture-mediated system followed by a device deployment) allowed to achieve a complete PFO closure. In a patient with Ebstein anomaly and significant cyanosis due to right-to-left PFO shunt, a partial PFO closure (with mild residual right-to-left shunt) was obtained after NoblestichTM deployment. In this setting, the partial PFO closure was effective to achieve a significant improvement of the patient’s arterial saturation and the procedure stopped without to complete the PFO closure with a device.
Conclusion: Trans-catheter device closure is often effective to achieve a complete PFO closure. However, in some circumstances, the device was unable to have an appropriate PFO closure. A suture-mediated system or a combined approach (suture-mediated system with concomitant device deployment) are effective to achieve the PFO closure in these complex scenarios.
