Work

Successful percutaneous closure of a large complex patent foramen ovale with an atrial septal aneurysm and two small atrial septal defects using a novel biodegradable occluder

Year: 2023

Type: article

Abstract: The percutaneous closure of a large complex PFO using a NBO. The c-TTE and TEE preoperative detections (Panel A-D). Novel biodegradable Occluder (Panel E,F). Implantation of the PFO-NBO under TEE (Panel G-J). The c-TTE and TEE detections at 1 year and 2 years after the procedure (Panel K-P). A 29-year-old woman with a 10-year history of migraine with aura without prior patent foramen ovale (PFO)-associated stroke presented to our hospital for treatment of the same condition. Conventional medical therapy (non-steroidal anti-inflammatory painkillers) was ineffective. Symptoms lasted for a few hours. In the 10 years prior, similar episodes occurred with a frequency of 9 or 10 episodes per year. Neurological examination, electroencephalogram, and brain magnetic resonance imaging results were normal. A full haematological profile, including electrocardiographic examination, revealed negative results. The patient’s vital signs were stable. Contrast transthoracic echocardiography (c-TTE) was used for initial PFO screening; the results revealed a small right-to-left shunt (RLS) at rest and extensive RLS after the Valsalva manoeuvre (VM, Panel A). Further transoesophageal echocardiography (TEE) evaluation revealed a large complex PFO (the left atrium side size of the PFO after the VM was 3.5 mm) with an atrial septal aneurysm (ASA; an atrial septal excursion of 10 mm from the midline into the right atrium and a basal width of 25 mm) and two small atrial septal defects (ASDs; 2 and 2 mm, Panels B, C and D; see Supplementary material online, Video S1). The total length of the atrial septal is 54 mm, and the distance between the PFO and the farther ASD was 15 mm. We selected a 34 mm PFO novel biodegradable occluder (PFO-NBO) (PancyVR occluder, ChiCTR1900024036) to perform percutaneous PFO closure. The PFO-NBO was provided by Shanghai China JinKui Medical Occluder Device Company. This device is a fully biodegradable occluder, which is invisible on digital subtraction angiography (DSA, Panels E, F and G). Other features of NBO were shown in our previous literature. The procedures were performed under general anaesthesia using DSA and TEE imaging. We ensured that the sheath passed through the atrial septum from the PFO by TEE (Panel H). After the occluder was released, the invisible occluder was displayed by DSA (Panel G; see Supplementary material online, Video S2), but TEE clearly displayed the umbrella plate fitted tightly to the atrial septum (Panels I and J); Doppler colour flow imaging showed no left-to-right shunt. Follow-up was performed at 2 days and 3 months after the procedure with c-TTE and TTE, respectively, and at 6 months, 1 year, and 2 years after the procedure with c-TTE, TTE, and TEE, respectively. At 1 and 2 years, the outline of the PFO-NBO disc was clearly visible (Panels M, N, O and P; see Supplementary material online, Video S3), but the left and right diameters of the PFO-NBO disc were obviously reduced (16.8 mm and 16.4 mm vs. 16.5 mm and 16.2 mm), with degradation of the occluder device. Six months, 1 year, and 2 years after surgery, a small RLS displayed with c-TTE was confirmed to originate from the pulmonary veins by TEE (Panels K and L). Previous literature reports have shown that the transpulmonary passage of small and moderate contrast bubbles may travel through larger diameter vessels. There is direct evidence that these larger diameter (>25–50μm) intrapulmonary arteriovenous anastomoses exist in healthy human, baboon, and dog lungs. It may be a physiological shunt without special treatment. The patient showed a marked reduction in migraine episodes within 24 months following percutaneous PFO closure. Migraines occurred occasionally one to two times a year, and their severity was significantly reduced compared to that before. There was no evidence of a novel arrhythmia or other systemic adverse responses. The closure of a large complex PFO (with ASA and small ASDs) with an appropriately sized PFO-NBO can achieve a satisfactory closure effect, as long as the occluder umbrella disc and the atrial septum closely fit and the fitting part completely covered the small ASDs. Another advantage of using PFO-NBO is that a sufficiently long residual atrial septum after the degradation of the occluder device allows easier puncture through the atrial interval for future treatment of left-sided heart disease. Supplementary material is available at European Heart Journal – Case Reports. We extend our gratitude to Prof. Lijuan Zhao from Functional Department of Ningxia Hui Autonomous Region People's Hospital, for her contribution to the follow-up results of TEE at 2 years after the procedure. Consent: The authors confirm that written consent for submission and publication of this case report including images and associated text has been obtained from the patient in line with COPE guidance. Conflict of interest: None declared. Funding: This study was supported by Key Research and Development Projects of Shaanxi Pronince (no. 2020ZDLSF04-14). The raw data supporting the conclusions of this article will be made available by the corresponding author under reasonable request.

Source: European Heart Journal - Case Reports

DOI: 10.1093/ehjcr/ytad043

Authors: Yajuan Du, Hang Xie, Xingye Wang, Hui Shao, Lu He, Yushun Zhang

Institution: First Affiliated Hospital of Xi'an Jiaotong University

Language: English

Topic: Cardiovascular and Diving-Related Complications

Subfield: Pulmonary and Respiratory Medicine

Field: Medicine

Domain: Health Sciences

SDG: Good health and well-being

Open Access status: gold

Estimated APC paid: $707