title: Sometimes they come back: recurrent noncardiac right-to-left shunt after percutaneous patent foramen ovale closure.
abstract: : An increasing number of patients are being evaluated for percutaneous patent foramen ovale (PFO) closure to prevent recurrent cerebrovascular events, but debate still exists on therapeutic indications and off-label closure device implantation. Pulmonary arteriovenous fistulas (PAVFs) are a rare and heterogeneous malformation prevalently associated with Rendu-Osler-Weber syndrome, and may mimic PFO right-to-left shunt (RLS), leading to unnecessary interventions and in some cases to relapses. Residual shunt is increasingly being observed both after PFO closure and PAVF embolization, even at long-term follow-up, with unclear clinical relevance. This instrumental and possibly therapeutic failure could lie in the presence of pulmonary microfistulas, either pre-existing or following the intervention. Hence, if RLS persists after optimal device placement and reasonable endothelialization time, the presence of a PAVF should be assumed and investigated; if RLS recurs after previous, negative echocontrast studies, presence of device-related complications or pulmonary microfistulas should be taken into consideration.
authors.affiliation: Cardiology Unit, Department of Internal Medicine, University of Genova, Viale Benedetto, Genova, Italy.
authors.forename: Manrico
authors.initials: M
authors.lastname: Balbi
authors.forename: Marco
authors.initials: M
authors.lastname: Canepa
authors.forename: Martino
authors.initials: M
authors.lastname: Cheli
authors.forename: Gian P
authors.initials: GP
authors.lastname: Bezante
authors.forename: Claudio
authors.initials: C
authors.lastname: Brunelli
mesh_terms: D000328:Adult; D001164:Arteriovenous Fistula / Q000000981:diagnostic imaging* / Q000209:etiology; D019320:Embolism, Paradoxical / Q000601:surgery*; D005260:Female; D005471:Fluoroscopy; D054092:Foramen Ovale, Patent / Q000601:surgery*; D006801:Humans; D008875:Middle Aged; D011651:Pulmonary Artery / Q000002:abnormalities* / Q000000981:diagnostic imaging; D011667:Pulmonary Veins / Q000002:abnormalities* / Q000000981:diagnostic imaging; D012008:Recurrence; D055989:Septal Occluder Device / Q000009:adverse effects*; D020521:Stroke / Q000517:prevention & control; D016896:Treatment Outcome; D017585:Ultrasonography, Doppler, Transcranial