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?
Hover over an experts image to view their approach.
Close defect with Gore (likely 25mm) Cardioform septal occluder
Dr. Ryan Callahan
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
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
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