Abstract | April 4, 2022

Persistent chest pain post PFO closure with an Amplatzer occluder

Presenting Author: Mohammed Afraz Pasha, MBBS, MD, Internal Medicine Resident PGY2, Department of Internal Medicine, North Alabama Medical Center, Florence, Alabama

Coauthors: Sangeetha Isaac, MD, Internal Medicine, PGY2, North Alabama Medical Center, Florence, AL; Zubair Khan, MD, Interventional Cardiologist, Department of Cardiovascular Disease, North Alabama Medical Center, Florence, AL.

Learning Objectives

  1. The Risk of Paradoxical Embolism (RoPE) score helps in determining the possibility of cryptogenic stroke secondary to paradoxical embolism through the PFO and the recurrence rate;
  2. Late onset chest pain in patients with an Amplatzer occluder device must be evaluated with echocardiography, to rule out device erosion into the pericardial space or aorta which is rare and occurs in 0.3% cases.

Introduction: Patent foramen ovale (PFO) closure is recommended in cases of recurrent cryptogenic stroke presumed to be secondary to paradoxical embolism. Though randomized controlled trials comparing surgical and percutaneous closure are lacking, percutaneous PFO closure is known to have a higher success rate and lower incidence of complications. Amplatzer device is associated with short term complications such as peri-procedure arrhythmia, residual shunt, device related thrombosis and cardiac perforation within 4 to 6 weeks of implantation. While chest pain within 6 weeks of procedure is well known, studies demonstrating late onset chest pain are limited. Persistent chest pain is associated with device erosion and occult interatrial hemopericardium which requires surgical explantation

Case report: A 48-years-old Caucasian male presented with recurrent left sided positional chest pain for three months. His past medical history was significant for cryptogenic cerebrovascular accident, hypertension, end stage renal disease on hemodialysis, factor V deficiency with history of deep vein thrombosis and pulmonary embolism. Six months prior, he underwent an Amplatzer closure device placement for PFO, at an outside facility after an unremarkable exercise stress test. Medications included apixaban, aspirin, nifedipine and labetalol. Presenting ECG and troponin-I were unremarkable, similar to two prior presentations to the emergency room when he was reassured and discharged with outpatient cardiology follow-up when no additional work up was performed. Lung perfusion scan was normal. Echocardiogram showed a well-seated Amplatzer device in the interatrial septum with preserved biventricular size and function. Both the atria were normal in size without any evidence of pericardial effusion or valvular heart disease.

Final diagnosis: Patient’s chest discomfort was deemed to be of non-ischemic nature and secondary to the Amplatzer PFO closure device.

Outcome: With spontaneous resolution of chest pain, he was discharged and planned for periodic outpatient Amplatzer device surveillance. With the incidence of Amplatzer device erosion into the pericardial space or aorta being 0.3%, persistent chest pain occurring in patients with an Amplatzer device must be evaluated with a transthoracic echocardiogram to rule out device erosion which can occur several months after the procedure.