PEDIATRIC AND CONGENITAL HEART DISEASE Original Studies Transseptal Technique of Percutaneous PFO Closure Results in Persistent Interatrial Shunting Aaron J. Tande, Thomas Knickelbine, MD, FACC, Ivan Chavez, MD, FACC, Michael R. Mooney, MD, FACC, Anil Poulose, MD, FACC, and Kevin M. Harris, * MD, FACC Our goal was to review the effectiveness of the transseptal and tunnel techniques of patent foramen ovale (PFO) closure. Percutaneous PFO closure is an increasingly com- mon treatment for prevention of paradoxical embolism and is typically performed by passing the device through the defect tunnel itself. The transseptal technique, in which the septum primum is punctured to create a hole through which the device is passed, has been proposed for patients with long-tunnel PFO. From May 2001 to December 2003, 120 patients underwent PFO closure at our institution and were included in this analysis. Defect closure was assessed by transesophageal echocardiography (TEE) with bubble study. Clinical follow-up data were obtained by clinic visits or standardized telephone interviews. Device closure was successfully completed in all patients, with 12 (10%) undergoing transseptal closure and 108 (90%) undergoing tunnel closure. Immediately following the procedure, complete closure occurred in 6 of 12 (50%) of the transseptal group and 88 of 108 (81.5%) of the tunnel group (P = 0.0120). Of the 89 patients (74.2%) who returned for 6-month TEE, complete closure was demonstrated in 4 out of 10 (40%) of the transseptal group and 58 out of 79 (73.4%) of the tunnel group (P = 0.0303). There have been four transient ischemic attacks during a mean follow-up of 11 months. The transseptal technique of PFO closure results in a higher proportion of patients with persistent interatrial shunting when compared with the tunnel tech- nique. Whether this is due to a difference in technique, device, or patient anatomy is unclear. ' 2005 Wiley-Liss, Inc. Key words: patent foramen ovale closure; transseptal puncture; transesophageal echocardiography; heart septal defects; paradoxical embolism INTRODUCTION Patent foramen ovale (PFO) is an increasingly rec- ognized cause of paradoxical embolism, resulting in stroke, transient ischemic attack (TIA), embolic myo- cardial infarction (MI), and peripheral embolism. Post- mortem examination reveals PFO in approximately 27% of the general population [1]. This prevalence is even higher in patients with cryptogenic stroke [2]. This evidence, along with several reports of echocar- diographically visualized thrombus within the PFO itself [3,4], has led to the currently presumed link between PFO and paradoxical embolism. As evidence of this link emerges, the need for effective prevention of recurrent embolic events has grown. Prior to the development of percutaneous techniques for PFO closure, patients with PFO and paradoxical embolism were treated with medication (anticoagula- tion or antiplatelet therapy) or surgical closure. However, data from the PFO in the Cryptogenic Stroke Study (PICSS) subset of the Warfarin-Aspirin Recurrent Stroke Study (WARSS) study indicates that patients with cryptogenic stroke and PFO have a Minneapolis Heart Institute Foundation, Minneapolis, Minnesota Abstract presented at the American Heart Association Scientific Sessions in Orlando, Florida, on 10 November 2003. *Correspondence to: Dr. Kevin M. Harris, Minneapolis Heart Insti- tute Foundation, 920 East 28th Street, Suite 300, Minneapolis, MN 55407. E-mail: kharris@mplsheart.com Received 27 May 2004; Revision accepted 7 February 2005 DOI 10.1002/ccd.20377 Published online 4 May 2005 in Wiley InterScience (www.interscience. wiley.com). ' 2005 Wiley-Liss, Inc. Catheterization and Cardiovascular Interventions 65:295–300 (2005)