Tough Calls: Case 8

PFO with nickel allergy

Imagine how you would work through each case. What equipment would you select and what would you do first? After having a go at it, see what our panel would do in the same situation. This exercise highlights the many possible approaches to a difficult problem. By seeing what others would do after thinking it through yourself, you will gain an understanding of the spectrum of approaches to a problem. 

56 year old female with below knee DVT and two small cortical strokes. PFO and ASA. Previous history of mountain sickness. History of severe nickel allergy documented by dermatology. How would you proceed?

Expert Approaches

Hover over an experts image to view their approach.

  • Close defect with Gore (likely 25mm) Cardioform septal occluder

Dr. Ryan Callahan
MD, FSCAI
 

Boston Children's Hospital

Division of Invasive Cardiology

Assistant Professor of Pediatrics, Harvard Medical School 

  • Discuss with patient and use Gore device

  • Alternatively would consider minimally invasive stitch of the PFO

  • Possible steroid course afterwards

Dr. Harsimran SIngh
MD, MSc
 

Director, Adult Congenital Heart Disease,

Director, Cardiovascular Disease Fellowship, Weill Cornell Medicine

  • Thorough assessment of current DVT and treatment as required/appropriate. Proceed with systemic anticoagulation and consideration for device occlusion of the PFO with a Gore SeptalOccluder to minimize nitinol exposure, but still proceed in spite of nickel dermatitis/allergy

Dr. Matt Crystal
MD, FACC, FSCAI

New York-Presbyterian & Morgan Stanley Children's Hospital

Assistant Professor of Pediatrics, Columbia University Medical Centre
Associate Director, Pediatric Cardiac Catheterization Cardiology

  • I would not be too concerned about this–how did dermatology determine that she was allergic?

    • Prick test or other??

    • Journal of Invasive Cardiology 2015 Verma DR, et.al.

  • For the procedure-Tandem femoral vein sheath with Intracardiac echo imaging for guidance

  • Cross the defect utilizing a multipurpose catheter, 0.035” exchange length wire in the pulmonary vein and place a 30 mm GORE septal occluder [GSO] for effective closure of the PFO

Dr. Allison Calbalka
MD, FSCAI
 

Professor of Pediatrics, Mayo Clinic College of Medicine

Consultant, Pediatric Cardiology 

Director, Congenital Cardiac Laboratory

Mayo Clinic, Rochester, Minnesota

  • Informed consent about Nickel allergy syndrome and use Gore or stitch

Dr. Zahid Amin
MD, FSCAI, FAHA, FAAP

William B. Strong Chair and Professor and Section Chief

Division of Pediatric Cardiology 
Congenital and Structural Heart Disease
Children’s Hospital of Georgia, Augusta University