Sesión CACI@PCR: "Argentina shares its most Educational Cases" 23 de mayo 2013 - EuroPCR 2013.

1. Early Periprosthetic Leak After
Percutaneous Closure of a
Patent Foramen Ovale
Jose A. G. ÁLVAREZ MD MTSAC FSCAI
Head of Interventional Cardiology
British Hospital in Buenos Aires

2. Potential conflicts of interest
Speaker's name: José Amadeo Guillermo Álvarez
 I do not have any potential conflict of interest

3. - 67 year old male. Smoker. Lung cancer.
- Platypnea –orthodeoxia syndrome post
right pneumonectomy.
(dyspnea and severe arterial desaturation in the upright position
that relives with recumbency)
-Trans-esopagheal echo → patent foramen ovale with a “huge”
atrial septal aneurysm.
-Treatment → percutaneous closure with an Amplatzer
PFO ® 35 mm device.
-Post intervention course:
→ Asymptomatic, oxygen saturation 95% (standing).
Hospital discharge (# 3º day)

4. First Percutaneous closure with a 35 mm
Amplatzer®
PFO Occluder
Post deployment angio:
correct position of the device, non significant residual shunt.

5. Out hospital course
# 40 days post discharge
→ Dyspnea FC III with orthodeoxia.
→ Transesophageal echo: Right Atrium to Left Atrium shunt with
Valsalva maneuver through a small atrial septal defect at the
posterior rim of the device.
→ Positional angiography in right atrium
→ Right Atrium to Left Atrium shunt in sitting position
Diagnosis
→ Periprosthetic leak: early device erosion.
Treatment
→ Percutaneous closure with a second Amplatzer ®
PFO occluder.

6. Positional angiography
Supine decubitus Sitting
RA to LA shunt in sitting position increased with Valsalva
maneuver. Shunt disappeared in supine decubitus.
Amplatzer PFO
LA
RA
Amplatzer PFO
Shunt
LA
RA

7. Second Percutaneous closure with a 25 mm
Amplatzer®
PFO Occluder
Angio 80 days after deployment: periprosthetic leak is more
evident and can be visualized in decubitus supinus

8. Second Percutaneous closure with a 25 mm
Amplatzer®
PFO Occluder
Percutaneous deployment of a 25 mm Amplatzer PFO occluder involving
the superior right pulmonary vein. (remember pneumonectomy)

9. Second Percutaneous closure with a 25 mm
Amplatzer®
PFO Occluder
Percutaneous deployment of a 25 mm Amplatzer PFO occluder involving
the superior right pulmonary vein. (remember pneumonectomy)

10. Second Percutaneous closure with a 25 mm
Amplatzer®
PFO Occluder
Angio PRE and POST deployment of a second PFO device (25mm)

11. Out hospital course
Asymptomatic eversince (3 years of follow
up)
In transesophageal echo performed 1 year
after the procedure, there was no evidence
of residual Right Atrium to Left Atrium shunt

12. Early periprosthetic leak after percutaneous
closure of a Patent Foramen Ovale
Take Home Message
 Erosion of the extra atrial space after implantation of an
Amplatzer PFO occluder is very unusual, but erosion of the
inter-atrial septum may be more frequent and underdiagnosed)
 In patients with atrial septal aneurysm, size and choice of
the device is an “open matter”.
 Positional angiography is an effective technique to diagnose
“functional shunts”.
 A second device is a therapeutic option and has to be
considered.