Transcatheter Coil Occlusion of Residual Shunt in a Patient With Recurrent Cryptogenic Stroke After PFO Percutaneous Closure Andrea Donti, MD, Alessandro Giardini, * MD, Roberto Formigari, MD, Gabriele Bronzetti, MD, Daniela Prandstraller, Marco Bonvicini, MD, and Fernando M. Picchio, MD A significant association has been suggested between a residual shunt and the risk of cerebral ischemic recurrences after transcatheter patent foramen ovale (PFO) closure. We report the use of a detachable coil to treat a residual shunt in a patient who had a recurrent cerebral ischemic event after transcatheter closure of a PFO. Catheter Cardio- vasc Interv 2004;61:415– 417. © 2004 Wiley-Liss, Inc. Key words: cardiac catheterization; transesophageal echocardiography; interatrial sep- tum; residual shunt INTRODUCTION A strong association between cryptogenic stroke in young adults and the presence of a patent foramen ovale (PFO) has been shown by retrospective [1,2] and pro- spective studies [3,4]. Transcatheter closure significantly reduces the risk of recurrent events in these patients [5–7]. However, no randomized prospective trial has been completed so far, clearly showing that PFO closure in such patients is better than continued medical therapy. However, some authors have shown a significant associ- ation between a residual shunt after transcatheter PFO closure and the risk of recurrent cerebral ischemic events [5,6]. Occasionally, a second device has been implanted in patients with a significant residual shunt [5,7]. We report the case of a patient who had a recurrent cerebral ischemic event 13 months after transcatheter PFO clo- sure and received a detachable coil to treat a residual shunt. CASE REPORT A 42-year-old male underwent transcatheter PFO clo- sure at our institution for cryptogenic stroke: a 33 mm CardioSeal Starflex (MNT Medical, Boston, MA) device was successfully implanted. Transesophageal echocardi- ography performed at the end of the implantation proce- dure and at 6 months from closure revealed a small left-to-right shunt at color Doppler and a moderate resid- ual right-to-left shunt across the interatrial septum after intravenous saline injection. Our policy at that time was to continue lifelong aspirin therapy in patients with a residual shunt. At 13 months from closure, while still receiving 100 mg aspirin daily, the patient experienced a recurrent cerebral embolic event with magnetic reso- nance confirmation of a new cerebral ischemic lesion. After the recurrent event, the patient underwent TEE with intravenous saline injection that confirmed the mod- erate residual shunt and excluded any thrombus associ- ated with the device. The patient was started on ticlopidin 250 mg b.i.d. on top of aspirin and was scheduled to receive a second device. Intraprocedural TEE and right atrial angiography confirmed the presence of a small residual shunt between the superior edges of the previ- ously implanted device and the interatrial septum (diam- eter, 2 mm; Fig. 1). The channel responsible for the residual shunting was small and, at least partially, run- ning between the arms of the CardioSeal device and the interatrial septum, so that crossing the residual defect with a large sheath and a stiff dilator and deploying a second device would have been troublesome. Therefore, a 6.5 mm patent ductus arteriosus (PDA) detachable coil (Cook, Bloomington, IN) was preferred. The implantation procedure was performed under gen- eral anesthesia with TEE and fluoroscopic guidance. Venous access was gained from the right femoral vein. A Pediatric Cardiology and Adult Congenital Unit, University of Bologna, Bologna, Italy *Correspondence to: Dr. Alessandro Giardini, Pediatric Cardiology and Adult Congenital Unit, University of Bologna, Policlinico S. Orsola-Malpighi, Via Massarenti 9, 40138, Bologna, Italy. E-mail: alessandro5574@iol.it Received 12 March 2003; Revision accepted 25 October 2003 DOI 10.1002/ccd.10770 Published online in Wiley InterScience (www.interscience.wiley.com). Catheterization and Cardiovascular Interventions 61:415– 417 (2004) © 2004 Wiley-Liss, Inc.