title: Management of residual shunts after initial percutaneous patent foramen ovale closure: a single center experience with immediate and long-term follow-up.
abstract: BACKGROUND
  Moderate-to-large residual shunts following percutaneous patent foramen ovale (PFO) closure are clinically important and associated with recurrent neuroembolic events. However, their management has not been clearly established in clinical practice. We report our experience in patients of these patients with a prior history of cryptogenic stroke and/or transient ischemic attack (TIA).
  
  
  METHODS
  All patients undergoing percutaneous PFO closure were routinely screened at six-months for residual shunts using transthoracic 2D echocardiography with antecubital administration of agitated saline contrast and color flow Doppler. Patients with evidence of moderate-to-large residual shunts were selected to undergo reintervention with shunt closure. Post-reintervention follow-up was performed at 24-hr, 30 days, and every six months thereafter. Clinical predictors of the moderate-to-large residual shunts, and the feasibility, safety and long-term efficacy of percutaneous residual shunt closure using a second device implant were examined.
  
  
  RESULTS
  Between 1995 and 2007, a total of 424 patients underwent PFO closure. Of these, 5% (21/424) had moderate-to-large residual shunts. Baseline characteristics among patients with moderate-to-large residual shunts and those with only none or small defects (n = 403) were similar. Multivariate analysis identified the 24-hr postprocedure shunt as the only independent predictor of residual shunting at six months. Of the 21 study patients with moderate-to-large residual shunt (mean age, 47 +/- 14), one underwent successful elective surgical repair, while the remaining 20 underwent transcatheter closure using a second device. The technique was successful in 95% (19/20), and all but one patient had complete shunt closure at six months of their percutaneous reintervention. We report no deaths, recurrent strokes or TIAs during the long-term mean follow-up period of 2.9 years.
  
  
  CONCLUSIONS
  Our study suggests that in patients with moderate-to-large residual PFO shunts, percutaneous reintervention using a second device implant is safe and effective.
authors.affiliation: Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Tulio
authors.initials: T
authors.lastname: Diaz
authors.forename: Roberto J
authors.initials: RJ
authors.lastname: Cubeddu
authors.forename: Pablo A
authors.initials: PA
authors.lastname: Rengifo-Moreno
authors.forename: Ignacio
authors.initials: I
authors.lastname: Cruz-Gonzalez
authors.forename: Jorge
authors.initials: J
authors.lastname: Solis-Martin
authors.forename: Ferdinando S
authors.initials: FS
authors.lastname: Buonanno
authors.forename: Ignacio
authors.initials: I
authors.lastname: Inglessis
authors.forename: Igor F
authors.initials: IF
authors.lastname: Palacios
mesh_terms: D000328:Adult; D000368:Aged; D001900:Boston; D006328:Cardiac Catheterization / Q000009:adverse effects / Q000295:instrumentation; D002404:Catheterization; D016009:Chi-Square Distribution; D018618:Echocardiography, Doppler, Color; D005260:Female; D054092:Foramen Ovale, Patent / Q000150:complications / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000628:therapy*; D006439:Hemodynamics; D006801:Humans; D002546:Ischemic Attack, Transient / Q000209:etiology / Q000503:physiopathology / Q000517:prevention & control; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D018570:Risk Assessment; D012307:Risk Factors; D055989:Septal Occluder Device; D020521:Stroke / Q000209:etiology / Q000503:physiopathology / Q000517:prevention & control; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult