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Chapter 48. Percutaneous Closure of Atrial Septal Defect and Patent Foramen Ovale

A 32-year-old woman is referred to you because of an abnormal electrocardiogram (ECG) showing an incomplete right bundle branch block. She has mild exertional dyspnea, and an echocardiogram is ordered because you hear a widely split S2 on examination and she reports a history of a “hole in her heart” when she was young. A transesophageal echocardiogram reveals a 12-mm secundum atrial septal defect (ASD) and mildly dilated right ventricle (RV), with an RV systolic pressure estimated at 44 mm Hg. What do you tell her?

A. Her ASD is not clinically significant.

B. Her ASD should be closed percutaneously.

C. Her ASD should be closed surgically.

D. You need further review of the transesophageal echocardiogram (TEE) to determine the likelihood of success for percutaneous closure.

The correct answer is D

It is likely that her shunt is clinically significant, given her symptoms as well as the RV findings. Safe and successful percutaneous closure would require adequate rims to secure a device, and the TEE would need to be reviewed more closely. It could be closed surgically, but there are no data suggesting that surgical closure would be any better than percutaneous closure pending the anatomic review.

Recent data from trials involving patent foramen ovale (PFO) closure devices suggest which of the following?

A. For cryptogenic stroke or transient ischemic attack (TIA), closure is statistically superior to medical therapy.

B. Migraine headaches are easily treated with PFO closure.

C. There is no statistical benefit for PFO closure in cryptogenic stroke or TIA.

D. PFO closure is dangerous and should be avoided in all cases.

The correct answer is C

Data from several PFO closure trials (CLOSURE-I, RESPECT-PFO, PC) showed no statistical improvement in outcomes with PFO closure versus best medical therapy as dictated by a neurologist. Data regarding migraine headaches and PFO closure are mixed at best. PFO closure has been demonstrated to be relatively safe in these large trials.

Which type of ASD can be safely and reliably closed using a percutaneous device?

A. Ostium primum with good rim

B. Ostium secundum with multiple fenestrations but with adequate rim

C. Ostium secundum with inferior rim of <1 mm


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