A rocking motion of a patent foramen ovale device.

A 58-year-old man, who experienced recurrent strokes while on aspirin therapy, was admitted for further evaluation. The patient’s electrocardiogram showed normal sinus rhythm, and transthoracic echocardiography revealed normal cardiac functions with mild tricuspid regurgitation and a floppy interatrial septum. Transesophageal echocardiography (TEE) revealed a patent foramen ovale (PFO) with an atrial septal aneurysm (Fig. 1, Video 1). Therefore, a PFO closure was planned.

Figure 1

(a) TEE image of the PFO device. (b) TEE image of the large atrial septal aneurysm. The arrow indicates that the atrial septal aneurysm has large amplitude movements bulging to the left atrium

With the patient under general anesthesia, a 25-mm Amplatzer PFO Occluder (St. Jude Medical, Plymouth, MN, USA) was placed at the correct position and subsequently released after the final assessment of both TEE and fluoroscopy. However, after deployment, fluoroscopy revealed that the PFO Occluder had a rocking motion (Video 2). The motion was synchronized with breathing, possibly attributing it to the cardiac chamber expansion and increased cardiac preload during inspiration as the underlying mechanisms. It is hypothesized that the rocking motion could be exaggerated by increased preload, owing to colloid infusion before venous puncture. The patient was then conservatively followed. On the second day, control fluoroscopy showed that the device was in a steady position (Video 3).

Larger PFOs may be closed using atrial septal defect (ASD) devices, especially in the presence of a large atrial septal aneurysm (1). This recommendation seems to be convenient because the larger volume of the interdiskal connection of the ASD device would not allow the aneurysm to cause any rocking motion. However, further prospective study is needed to clarify this issue.

Video 1

TEE showing the PFO device with the atrial septal aneurysm.

Video 2

Fluoroscopy revealing that the PFO device has a rocking motion along with the atrial septal aneurysm.

Video 3

Control fluoroscopy showing that the PFO device is in a steady position.