(Hellenic Journal of Cardiology) HJC • 155 Hellenic J Cardiol 2012; 53: 155-159 Case Report Case Report Manuscript received: March 17, 2010; Accepted: May 15, 2010. Address: Petros Dardas Department of Cardiology St. Luke’s Hospital, 552 36 Panorama Thessaloniki, Greece e-mail: pdardas@otenet.gr Key words: Atrial septal defect, patent foramen ovale, percutaneous closure, Amplatzer device, cryptogenic stroke. Cryptogenic Stroke After Percutaneous Closure of an Atrial Septal Defect Petros s. DarDas 1 , Vlasis NiNios 1 , Nikos Mezilis 1 , efstratios k. theofilogiaNNakos 1 , DiMitris tsikaDeris 1 , Vassilis thaNoPoulos 2 1 Department of Cardiology, St. Luke’s Hospital, Thessaloniki, 2 Department of Cardiology, Agia Sofia’s Children’s Hospital, Athens, Greece We present the case of a patient who underwent a percutaneous secundum atrial septal defect (ASD II) clo- sure with an undersized septal occluder device. One week and one month later she experienced two tran- sient ischemic attacks. Three-dimensional transesophageal echocardiography (TEE) revealed a residual pat- ent foramen ovale (PFO) with a positive Valsalva bubble test. She underwent a second procedure under the 3D TEE guidance and the PFO was successfully closed percutaneously using a PFO occluder device that was attached to the ASD device. Accurate ASD and PFO morphology assessment and appropriate device se- lection are the key factors in the success of percutaneous closure. 3D TEE is an innovative diagnostic tech- nique, providing a complete description of the cardiac defect and improving spatial orientation. Real-time 3D TEE is the appropriate guidance for successful and accurate positioning of the device. T he incidence of percutaneous clo- sure of a secundum atrial septal defect (ASD) and patent foramen ovale (PFO), which has become an estab- lished therapy, is constantly increasing. 1 Transcatheter ASD closure is a safe and effective treatment modality with excellent long-term success rates, 2 provided that the defect is appropriate for percutaneous clo- sure and the device is deployed successfully. It is well known that patients who have suffered a cryptogenic stroke, which has been associated with PFO, are at risk of recurrent stroke, despite being on medi- cal treatment. 3-6 The incidence of recur- rence of the stroke in these patients varies from 0-15% per year. 7-10 This risk is par- ticularly increased in patients who have a combination of PFO and atrial septal an- eurysm. 5,11,12 The likeliest mechanism of stroke in these patients is paradoxical em- bolization through the PFO. 13 It appears that percutaneous closure of the PFO is at least as effective as medical treatment in preventing the recurrence of stroke. More- over, closure appears to be more effective than medical treatment in patients who have suffered more than one event. 14 Amplatzer devices, specifically the Am- platzer Septal Occluder ® and Amplatzer PFO Occluder ® (AGA, Medical Corpo- ration, Golden Valley MN, USA), have been granted FDA approval for percutane- ous closure of ASD and PFO, respectively. At the moment these devices are the most commonly used devices for percutaneous closure of ASDs. 15 The results of percuta- neous closure with these particular devices are quite encouraging. 16,17 We present the case of a 34-year-old woman who experienced two transient ischemic attacks (TIA) one week and one month after a percutaneous ASD closure, as the result of a residual PFO. Case presentation A 34-year-old woman underwent uncom-