Wish you were (not) here : a patent foramen ovale closure device embolization

A 59-year-old asymptomatic man, with a history of previous transient ischaemic attack and patent foramen ovale (PFO) closure with an Amplatzer 24-mm atrial septal defect occluder device (Abbott Vascular; Abbott Park, IL, USA), performed in another centre 15 months before, was admitted to our hospital for a routine echocardiographic follow-up. Transthoracic echocardiogram showed the absence of the occluder device in the interatrial septum and a huge septal aneurysm with moderate right-to-left shunt detected after saline injection during Valsalva manoeuvre (Figure ​Figure11, Supplementary material online, Videos S1 and S2). Subsequently, the patient underwent computed tomography angiography of the thoracoabdominal aorta, which confirmed the migration of the device in the aortic arch (Figure ​Figure22). Considering the high risk of complications due to percutaneous management, the patient was scheduled for a surgical retrieval of the device. Patent foramen ovale closure device embolization is rare and typically occurs early after deployment. Common sites of migration are cardiac chambers, pulmonary artery, aortic arch, descending and abdominal aorta. Reported anatomical predisposing factors are an atrial septal aneurysm, a thick septum secundum (>10 mm) or a long tunnel.1 In our case, we believe that an undersized device together with the large atrial septal aneurysm was the possible mechanism for the failure of the PFO repair. Larger devices are usually indicated in cases of atrial septal aneurysm in order to cover the entire redundant septum. We can suppose the embolization occurred early, but we don’t have any previous echocardiographic images available for comparison. A successfully placed PFO closure device straddles the thick muscular septum secundum with its two disks and is subsequently covered up and stabilized by endothelial tissue, so the long-term dislodgement is uncommon.2 Given the inability of these devices to retract and compress, as they would when initially implanted,3 to allow the passage into a vascular sheath, often an open-heart surgical approach is recommended.