Cardiac tamponade following aortic root erosion by an Amplatzer PFO-Occluder in a 41-year-old woman: Only a matter of sizing?

A 41-year-old woman who had suffered an acute stroke underwent closure of a persistent patent foramen ovale (PFO) two months later. Eleven months after PFO closure the patient was hospitalized with signs of cardiogenic shock due to cardiac tamponade. Imaging studies showed a correct position of the left occluder disc, whereas the right atrial disc was in direct contact with the aortic root. At day 6, the patient underwent surgery via a minimally invasive route under cardiopulmonary bypass. The left atrial disc of the occluder was in a correct position. A too big right atrial disc together with a sharp angle misalignment toward the right atrial wall led to an erosion of the right atrial wall and of the wall of the aortic root. The occluder was explanted and the PFO closed by direct suture. Given the increasing number of procedures performed, serious and potentially life-threatening complications – even if rare – deserve special attention. Even though device oversizing was the most likely factor causing the erosion, other factors may play a role, as the patient used whole-body vibration starting three months before the incident. This could explain why the event happened as late as 11 months after the initial PFO closure. <Learning objective: Recent trials have shown that patent foramen ovale (PFO) closure reduces the risk of recurrent stroke after an initial event of cryptogenic stroke in patients younger than 60 years. If PFO closure is performed more frequently, even rare complications have to be considered. Device-induced erosion of adjacent cardiac structures remains a possible short- or long-term complication after PFO closure. This is an unlikely (0.018%) but potentially life-threatening event. An oversized and misaligned device is the central mechanism.>