A 35-year-old female patient with a history of cerebral embolization two years ago visited our hospital to evaluate the cause of thromboembolism. Physical examination revealed no abnormal murmur or irregular beat on heart sound. Transthorasic echocardiography (TTE) and transesophageal echocardiography (TEE) demonstrated no abnormal shunt flow, so we examine the contrast bubble test. TEE with agitated saline contrast injection demonstrated complete opacification of the left-atrial chamber by bubbles entering the right-atrial chamber (Figure 1). This finding was consistent with a patent foramen ovale (PFO).

Transcatheter closure of PFO using 25 mm Amplatzer PFO Occluder device was performed under general anesthesia. Access in right femoral vein was obtained. Initially, we tried guidewire passage through PFO from right atrium (RA) to the left atrium, but failed. Thus, we performed septal puncture. Under the guidance of fluoroscopy and TEE, the distance of septal puncture needle and upper margin of PFO measure by TEE was 11.9 mm (Figure 2). And thus 25 mm sized Amplatzer PFO Occluder device was selected. The 10 Fr. delivery sheath containing Amplatzer PFO Occluder was passed over the guidewire and introduced into the left atrium

When good positioning of the Amplatzer PFO Occluder confirmed with angiogram, the catheter was retracted further. After final position of the device was confirmed by additional angiogram, the PFO Occluder was released (Figure 3). After the successful deployment of the PFO device, final angiogram revealed good positioning of the device and TEE revealed successful implantation of PFO Occluder without shunt flow (Figure 4). On the following day, follow-up TTE revealed stable positioning of the device without residual shunt flow. The patient was discharged without any complications on the third hospital day.

The persistence of a PFO into adulthood is a common finding, and is not harmful in the majority of cases. Nonetheless, some PFOs are capable of clinically important right-to-left shunting under certain hemodynamic conditions. Transcatheter closure of PFO with Amplatzer PFO Occluder devices is a safe and effective therapy for patients with previous cerebral embolism. Percutaneous closure is associated with a high success rate, low incidence of hospital complications, and freedom from cerebral ischemic events.