Figura 1.

Figura 2.

The case presented is that of a 32-year-old man who suffered a vertebrobasilar ictus, with a positive shunt study on transcranial Doppler, prompting further workup with transesophageal echocardiography (TEE). TEE showed a patent foramen ovale (PFO) with spontaneous shunting (Figure 1a) and an adjacent 4-5-mm ostium secundum atrial septal defect (ASD) in the posterosuperior aspect of the fossa ovalis (Figure 1b). This type of multi-fenestrated septum requires a tailored procedural approach. The use of more than one closure device has been well described, particularly for large or spatially separated defects. An alternative strategy is the implantation of a single device capable of closing all defects simultaneously.

In this case, a combined approach was preferred, using an 18-mm AmplatzerTM occluder device (Abbott) for ASD closure (Figures 2a–2b, yellow arrow) and a NobleStitchTM EL non-resorbable implantable suture (HeartStitch) for PFO closure, with minimal residual shunting. Given the anatomical complexity of the case, the procedure was performed under TEE guidance. The occluder device was confirmed in correct position (Figures 2a–2b, yellow arrow), adjacent to the suture repair site (Figures 2a–2b, red arrow). The use of the NobleStitchTM system for PFO closure in cases with favorable anatomical characteristics has emerged as an alternative to conventional double-disk devices. This approach minimizes the amount of intracardiac implanted material, thereby reducing the risks of device dislodgement, erosion, and thrombosis in select patients.

1. Ferreira LC, Ferre GF, Lezcano JS, Ramón ML. Transcatheter closure of multiperforated atrial septal defect. REC Interv Cardiol. 2025 May 5;7(3):164-168. doi: 10.24875/RECICE.M25000510. PMID: 40933013; PMCID: PMC12418242.

2. Masseli J, Bertog S, Stanczak L, et al. Transcatheter closure of multiple interatrial communications. Catheter Cardiovasc Interv. 2013 Apr;81(5):825-36. doi: 10.1002/ccd.24329. Epub 2012 Aug 20. PMID: 22907918.

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Patent foramen ovale and atrial septal defect: hybrid percutaneous approach

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