Patent foramen ovale Most patients with a PFO are asymptomatic and do not require any specific treatment. However, those who develop a stroke require further workup to identify the etiology. In those where a comprehensive evaluation is performed and an obvious etiology is not identified, they are defined as having a cryptogenic stroke. The mechanism for stroke is such individuals is likely embolic due to paradoxical emboli, a left<unk>  appendage clot, a clot on the inter-atrial septum, or within the PFO tunnel. PFO closure The Amplatzer<unk>  Occluder is a device specifically designed to close an<unk>  Until recently, patients with PFO and cryptogenic stroke were treated with antiplatelet therapy only. Previous studies did not identify a clear benefit of PFO closure over antiplatelet therapy in reducing recurrent ischemic stroke. However, based on new evidence and systematic review in the field, percutaneous PFO closure in addition to antiplatelet therapy is suggested for all who meet all the following criteria: * Age ≤ 60 years at onset of first stroke, * Embolic-appearing cryptogenic ischemic stroke (i.e., no evident source of stroke despite a comprehensive evaluation), and * PFO with a right-to-left interatrial shunt<unk> ed by bubble study (echocardiogram) A variety of PFO closure devices may be implanted via catheter-based procedures. Amplatzer PFO Occluder in heart Medical therapy Based on the most up to date evidence, PFO closure is more effective at reducing recurrent ischemic stroke when compared to medical therapy. In most of these studies, antiplatelet and anticoagulation were combined in the medical therapy arm. Although there is limited data on the effectiveness of anticoagulation in reducing stroke in this population, it is hypothesized that based on the embolic mechanism, that anticoagulation should be superior to antiplatelet therapy at reducing risk of recurrent stroke. A recent review of the literature supports this hypothesis recommending anticoagulation over the use of antiplatelet therapy in patients with PFO and cryptogenic stroke. However, more evidence is required comparing of PFO closure with anticoagulation or anticoagulation with antiplatelet therapy.<unk>  Once someone is found to have an<unk> , a determination of whether it should be corrected is typically made. If the<unk>  is causing the right ventricle to enlarge a secundum<unk>  should generally be closed. If the<unk>  is not causing problems the<unk>  may simply be checked every two or three years. Methods of closure of an<unk>  include surgical closure and percutaneous closure. Evaluation prior to correction Prior to correction of an<unk> , an evaluation is made of the severity of the individual's pulmonary hypertension (if present at all) and whether it is reversible (closure of an<unk>  may be recommended for prevention purposes, to avoid such a complication in the first place. Pulmonary hypertension is not always present in adults who are diagnosed with an<unk>  in adulthood). If pulmonary hypertension is present, the evaluation may include a right heart catheterization. This involves placing a catheter in the venous system of the heart and measuring pressures and oxygen saturations in the superior vena cava, inferior vena cava, right atrium, right ventricle, and pulmonary artery, and in the wedge position. Individuals with a pulmonary vascular resistance (PVR) less than 7 wood units show regression of symptoms (including NYHA functional class). However, individuals with a PVR greater than 15 wood units have increased mortality associated with closure of the<unk> . If the pulmonary arterial pressure is more than two-thirds of the systemic systolic pressure, a net left-to-right shunt should occur at least 1.5:1 or evidence of reversibility of the shunt when given pulmonary artery vasodilators prior to surgery. (If Eisenmenger's physiology has set in, the right-to-left shunt must be shown to be reversible with pulmonary artery vasodilators prior to surgery.) Surgical mortality due to closure of an<unk>  is lowest when the procedure is performed prior to the development of significant pulmonary hypertension. The lowest mortality rates are achieved in individuals with a pulmonary artery systolic pressure less than 40 mmHg. If Eisenmenger's syndrome has occurred, a significant risk of mortality exists regardless of the method of closure of the<unk> . In individuals who have developed Eisenmenger's syndrome, the pressure in the right ventricle has raised high enough to reverse the shunt in the<unk>  If the<unk>  is then closed, the afterload that the right ventricle has to act against has suddenly increased. This may cause immediate right ventricular failure, since it may not be able to pump the blood against the pulmonary hypertension. Surgical closure Illustration depicting surgical patch closure of<unk>  Surgical closure of an<unk>  involves opening up at least one atrium and closing the<unk>  with a patch under direct visualization. Catheter procedure Illustration depicting surgical device closure of<unk>  Percutaneous device closure involves the passage of a catheter into the heart through the femoral vein guided by fluoroscopy and echocardiography. An example of a percutaneous device is a device which has discs that can expand to a variety of diameters at the end of the catheter. The catheter is placed in the right femoral vein and guided into the right atrium. The catheter is guided through the<unk><unk>  wall and one disc (left<unk>  is opened and pulled into place. Once this occurs, the other disc (right<unk>  is opened in place and the device is inserted into the<unk>  wall. This type of PFO closure is more effective than drug or other medical therapies for decreasing the risk of future thromboembolism. The most common adverse effect of PFO device closure is new-onset<unk>  fibrillation. Other complications, all rare, include device migration, erosion and embolization and device thrombosis or formation of an inflammatory mass with risk for recurrent ischemic stroke. Percutaneous closure of an<unk>  is currently only indicated for the closure of secundum<unk> s with a sufficient rim of tissue around the<unk><unk>  so that the closure device does not impinge upon the superior vena cava, inferior vena cava, or the tricuspid or mitral valves. The Amplatzer<unk>  Occluder (ASO) is commonly used to close<unk> s. The ASO consists of two self-expandable round discs connected to each other with a 4-mm waist, made up of 0.004– to 0.005-inch Nitinol wire mesh filled with Dacron fabric. Implantation of the device is relatively easy. The prevalence of residual<unk>  is low. The disadvantages are a thick profile of the device and concern related to a large amount of nitinol (a nickel-titanium compound) in the device and consequent potential for nickel toxicity. Percutaneous closure is the method of choice in most centres. Studies evaluating percutaneous<unk>  closure among pediatric and adult population show that this is relatively safer procedure and has better outcomes with increasing hospital volume.
Atrial septal defect
Atrioventricular septal defect
Heart septal defect
Ventricular septal defect
Aortopulmonary septal defect
Tricuspid atresia
Persistent truncus arteriosus
Double inlet left ventricle