Tough Calls: Case 1

The Super Floppy Aneurysmal Septum For PFO Closure

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. 

89 year old gentleman, right lower lobectomy, hypoxia not responding to oxygen therapy or BiPaPDiagnosis: platypnoeaorthodeoxia 

Expert Approaches

Hover over an experts image to view their approach.

•Need 3D assessment – either with pre-procedure CTA or intra-procedure TEE

•Balloon size

•Probably use 35 mm Amplazter PFO Occcluder

•Goal: Reduce R to L shunting so no longer hypoxic – do not have to eliminate all shunting.

Dr.John Carroll
Professor of Medicine, University of Colorado Denver
Director of Interventional Cardiology

I would use an Amplatzer PFO device with a large RA desk, 35mm to prevent embolization to the LA.

Dr. Ziyad Hijazi
Professor of Pediatrics & Medicine, Weill Cornell Medicine
Chair, Department of Pediatrics and Director, Sidra Cardiac Program


Right heart catheterization with balloon test occlusion/sizing of the PFO/ASD. Consideration for PFO device (Amplatzer PFO device versus Gore Cardioform Septal Occluder) versus Amplatzer Septal Occluder depending on findings on ICE and balloon sizing/approximation of the tunnel if present. Very redundant appearing foramen flap may be better with ASO or larger Amplatzer PFO device.

Dr. Matthew Crystal
New York-Presbyterian & Morgan Stanley Children's Hospital
Assistant Professor of Pediatrics, Columbia University Medical Centre

I would balloon size this PFO, even though I almost never do that. I suspect it will stretch quite a bit, given the septal mobility on echo.  Would anticipate closing with an Amplatzer Septal Occluder (for its “self-centering”) that is the diameter of the sized PFO +0-2 mm.  The proximity to the aorta doesn’t concern me too much for erosion; I think it would straddle the root well.

Dr. Nathan Taggart

Pediatric Interventional Cardiologist 
Assistant Professor of Pediatrics
Mayo Clinic 


8f sheath

Cross with MP catheter and deliver Amplatzer extrastiff to LUPV

Balloon size using 34mm Amplatzer sizing balloon 

Aim to deploy 35mm Amplatzer PFO occluder.

Need to ensure stable prior to release- ideally, disks would splay on aortic ridge

I think PFO occluder likely to work better than ASO. 

I would be wary regarding using a Gore device in this case (stability). 

Dr. William Wilson
Consultant Cardiologist at Royal Melbourne Hospital