title: Percutaneous implantation of a second device in patients with residual right-to-left shunt after patent foramen ovale closure.
abstract: BACKGROUND
  The management of patients with residual right-to-left shunt (rRLS) after percutaneous patent foramen ovale (PFO) closure is debated. The aim of this study was to define the incidence of moderate-to-large rRLS and to report the feasibility, safety and long-term clinical outcome of transcatheter closure of rRLS.
  
  
  RESULTS
  From June 2000 to March 2013, 322 subjects underwent percutaneous PFO closure. In 39 patients (12.1%) with moderate-to-large rRLS on transcranial Doppler (TCD) and/or transesophageal echocardiogram a second cardiac catheterization was performed with the aim of completing the closure. A second closure device was implanted in 21 patients (53.8%). In the remaining 18 (46.2%), a second device was not delivered for the following reasons: in 13 (72.2%) no residual passage could be crossed, in 5 (27.8%) the residual shunt was deemed to be negligible. No complications occurred. After the second procedure, complete closure was proved by TCD in 16/21 (76.2%) subjects. One patient received a third device. During follow-up (41 ± 19 months), no cerebrovascular ischemic accidents occurred.
  
  
  CONCLUSIONS
  A second percutaneous PFO occlusion device can be safely implanted in patients with significant rRLS. However, a moderate-to-large rRLS on TCD and/or TEE may not necessarily represent a significant risk of further paradoxical embolization.
authors.affiliation: Department of Medical Sciences, Division of Cardiology, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy.
authors.forename: Chiara
authors.initials: C
authors.lastname: Rovera
authors.forename: Luigi
authors.initials: L
authors.lastname: Biasco
authors.forename: Fulvio
authors.initials: F
authors.lastname: Orzan
authors.forename: Riccardo
authors.initials: R
authors.lastname: Belli
authors.forename: Pierluigi
authors.initials: P
authors.lastname: Omedè
authors.forename: Fiorenzo
authors.initials: F
authors.lastname: Gaita
mesh_terms: D006328:Cardiac Catheterization / Q000379:methods*; D017548:Echocardiography, Transesophageal; D005240:Feasibility Studies; D005260:Female; D054092:Foramen Ovale, Patent / Q000000981:diagnostic imaging / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D012086:Reoperation; D055989:Septal Occluder Device