case_images: PMC11249728_01
case_images: (A,B) Six-months 2D TEE color Doppler in the short view after the first percutaneous PFO closure procedure. The large equally sized double-disc UNI 33/33 mm device (red asterisk), is not parallel to the interatrial septum, with two discs diverging on one side (white arrows) and on the other side not capturing the aortic muscular rim (yellow arrow); the device is partially protruding in the right atrium with inappropriate orientation. (C,D) 3D TEE color Doppler showing a 4 mm x 7 mm ASA fenestration (septal defect) far from the UNI device.
case_images: fcvm-11-1367515-g001.jpg
case_images: PMC11249728_01_fcvm-11-1367515-g001.jpg
case_images: F1
case_images: At 6 months follow-up, 2D/3D transesophageal echocardiography (TEE) color Doppler showed incorrect orientation of the device, not parallel to the interatrial septum, with the two discs not capturing the aortic muscular rim and partially protruding in the right atrium (Figures 1A,B); furthermore, a 4 mm x 7 mm ASA fenestration (septal defect) far from the UNI device was also identified (Figures 1C,D), with a residual bidirectional shunt that persisted unaltered on subsequent controls. She finally decided to attend our Heart and Brain Clinic a year later for a second opinion; after evaluation, our multidisciplinary heart team decided to offer a percutaneous redo intervention due to deteriorating clinical conditions and the persistent significant residual shunt, which was confirmed by contrast 2D TTE (Supplementary Figure S1).
case_images: Long-axis four-chamber plane intraprocedural rotational intracardiac echocardiography by Ultra ICE (mechanical 9F/9 MHz 360  scan probe) procedural steps. The guidewire (yellow arrowhead) is across the residual septal defect (orange arrow) apart from the previously implanted device (light blue asterisk) (A). Successful implantation steps of the Flex II PFO 16/18-mm device (white arrows) (B,C). Contrast-enhanced Ultra ICE image confirming the abolition of the residual shunt (D). LA, left atrium; RA, right atrium; RUPV, right upper pulmonary vein. Red asterisk, the Ultra ICE-9F-9 MHz catheter located at the center of the image.
case_images: fcvm-11-1367515-g002.jpg
case_images: PMC11249728_01_fcvm-11-1367515-g002.jpg
case_images: F2
case_images: After a meticulous "push-and-pull" maneuver, the device was successfully released, and fluoroscopic and rotational intracardiac ultrasound guidance imaging showed the two devices in profile without interferences or malapposition/dislocations between them (Figures 2,3). Follow-up with 2D TTE color Doppler and contrast transcranial Doppler (cTCD) at 6 and 12 months confirmed the correct position and good interaction between the two devices, without any residual shunt (Figure 4, Supplementary Figure S2).
case_images: Two-year follow-up 2D TTE color Doppler in the apical four-chamber view showing the correct interaction between the UNI 33/33-mm device (light blue asterisk) and the Figulla Flex II 16/18-mm device (red asterisk) (A); contrast 2D TTE confirming abolition of the residual shunt at baseline (B) and after the Valsalva maneuver (C).
case_images: fcvm-11-1367515-g004.jpg
case_images: PMC11249728_01_fcvm-11-1367515-g004.jpg
case_images: F4
case_images: Follow-up with 2D TTE color Doppler and contrast transcranial Doppler (cTCD) at 6 and 12 months confirmed the correct position and good interaction between the two devices, without any residual shunt (Figure 4, Supplementary Figure S2).