{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,5]],"date-time":"2026-06-05T04:26:39Z","timestamp":1780633599580,"version":"3.54.1"},"reference-count":13,"publisher":"Oxford University Press (OUP)","issue":"11","license":[{"start":{"date-parts":[[2023,9,27]],"date-time":"2023-09-27T00:00:00Z","timestamp":1695772800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2023,11,2]]},"abstract":"<jats:title>Abstract<\/jats:title>\n               <jats:sec>\n                  <jats:title>Background<\/jats:title>\n                  <jats:p>Percutaneous closure is nowadays still deemed challenging in patent forame ovale (PFO) associated to multi-fenestrated atrial septal aneurysm (ASA). This anatomic arrangement is still considered a significant risk factor for recurrence of paradoxical embolism. Theoretically, transcatheter approach could be theoretically even more complex in the case of dextrocardia and visceral situs inversus.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Case summary<\/jats:title>\n                  <jats:p>A 59-year-old man with history of migraine with aura and multiple cryptogenic strokes was referred for percutaneous closure of a PFO with associated ASA. He had been previously submitted to repeat attempt of percutaneous closure with not self-centering and self-centering devices that failed due to unfavorable anatomic characteristics (dextrocardia with situs viscerum inversus, huge ASA, multiple fenestrations, large PFO). Based on this \u201ccomplex\u201d anatomy, a sequential 2-step interventional approach aiming to reduce size and mobility of the atrial septal aneurysm with a suture-based approach (Noblestich\u2122 EL, HeartStitch, Fountain Valley, CA, USA) and to close any eventual accessory fenestrations with a not self-centering occluding device was planned. At the end of the procedure, the ASA completely disappeared and no residual shunt was imaged at TEE bubble test.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Discussion<\/jats:title>\n                  <jats:p>We describe a very rare case of symptomatic ASA-PFO in dextrocardia with situs viscerum inversus as well as an innovative approach to treat such complex anatomic setting by using the suture-based closure of a PFO to reduce size and mobility of an ASA in order to deploy dedicated not-self-centering occluding devices.<\/jats:p>\n               <\/jats:sec>","DOI":"10.1093\/ehjcr\/ytad467","type":"journal-article","created":{"date-parts":[[2023,9,27]],"date-time":"2023-09-27T22:38:50Z","timestamp":1695854330000},"source":"Crossref","is-referenced-by-count":4,"title":["Percutaneous closure of \u2018complex\u2019 multi-fenestrated atrial septal aneurysm in visceral situs inversus using a multi-device approach: a case report"],"prefix":"10.1093","volume":"7","author":[{"given":"Silvia","family":"Scalera","sequence":"first","affiliation":[{"name":"Pediatric Cardiology and GUCH Unit, Heart Hospital \u2018G. Pasquinucci\u2019, National Research Council-Tuscany Foundation \u2018G. Monasterio\u2019 , Via Aurelia Sud, Massa 54100 , Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alessandra","family":"Pizzuto","sequence":"additional","affiliation":[{"name":"Pediatric Cardiology and GUCH Unit, Heart Hospital \u2018G. Pasquinucci\u2019, National Research Council-Tuscany Foundation \u2018G. Monasterio\u2019 , Via Aurelia Sud, Massa 54100 , Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Pietro","family":"Marchese","sequence":"additional","affiliation":[{"name":"Pediatric Cardiology and GUCH Unit, Heart Hospital \u2018G. Pasquinucci\u2019, National Research Council-Tuscany Foundation \u2018G. Monasterio\u2019 , Via Aurelia Sud, Massa 54100 , Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6342-7843","authenticated-orcid":false,"given":"Giuseppe","family":"Santoro","sequence":"additional","affiliation":[{"name":"Pediatric Cardiology and GUCH Unit, Heart Hospital \u2018G. Pasquinucci\u2019, National Research Council-Tuscany Foundation \u2018G. Monasterio\u2019 , Via Aurelia Sud, Massa 54100 , Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2023,9,27]]},"reference":[{"key":"2023110716545341400_ytad467-B1","doi-asserted-by":"crossref","first-page":"1638","DOI":"10.1093\/eurheartj\/ehy121","article-title":"Patent foramen ovale closure vs medical therapy for cryptogenic stroke: a meta-analysis of randomized controlled trials","volume":"39","author":"Ahmad","year":"2018","journal-title":"Eur Heart J"},{"key":"2023110716545341400_ytad467-B2","doi-asserted-by":"crossref","first-page":"k2515","DOI":"10.1136\/bmj.k2515","article-title":"Patent foramen ovale closure, antiplatelet therapy or anticoagulation therapy alone for management of cryptogenic stroke? A clinical practice guideline","volume":"362","author":"Kuijpers","year":"2018","journal-title":"BMJ"},{"key":"2023110716545341400_ytad467-B3","doi-asserted-by":"crossref","first-page":"10","DOI":"10.1097\/WCO.0000000000000782","article-title":"Patent foramen ovale and stroke: current evidence and treatment options","volume":"33","author":"Favilli","year":"2020","journal-title":"Curr Opin Neurol"},{"key":"2023110716545341400_ytad467-B4","doi-asserted-by":"crossref","first-page":"47","DOI":"10.1016\/j.ijcard.2018.10.053","article-title":"Patent foramen ovale with complex anatomy: comparison of two different devices (Amplatzer Septal Occluder device and Amplatzer PFO Occluder device 30\/35)","volume":"279","author":"Giordano","year":"2019","journal-title":"Int J Cardiol"},{"key":"2023110716545341400_ytad467-B5","doi-asserted-by":"crossref","first-page":"49","DOI":"10.2459\/JCM.0000000000001239","article-title":"Transcatheter closure of fenestrated atrial septal aneurysm: feasibility and long-term results","volume":"32","author":"Mahmoud","year":"2022","journal-title":"J Cardiovasc Med (Hagerstown)"},{"key":"2023110716545341400_ytad467-B6","doi-asserted-by":"crossref","first-page":"811","DOI":"10.1016\/j.echo.2019.03.021","article-title":"Identification of high-risk patent foramen ovale associated with cryptogenic stroke: development of a scoring system","volume":"32","author":"Nakayama","year":"2019","journal-title":"J Am Soc Echocardiogr"},{"key":"2023110716545341400_ytad467-B7","doi-asserted-by":"crossref","first-page":"168","DOI":"10.2459\/JCM.0b013e328353809d","article-title":"Percutaneous closure of patent foramen ovale in a patient with situs viscerum inversus","volume":"14","author":"Mega","year":"2013","journal-title":"J Cardiovasc Med (Hagerstown)"},{"key":"2023110716545341400_ytad467-B8","doi-asserted-by":"crossref","first-page":"2437","DOI":"10.2147\/IJGM.S295444","article-title":"Situs inversus totalis: a clinical review","volume":"15","author":"Eitler","year":"2022","journal-title":"Int J Gen Med"},{"key":"2023110716545341400_ytad467-B9","doi-asserted-by":"crossref","first-page":"252","DOI":"10.1111\/j.1747-0803.2009.00302.x","article-title":"Percutaneous PFO closure with Amplatzer PFO Occluder: predictors of residual shunts at 6 months follow-up","volume":"4","author":"Greutmann","year":"2009","journal-title":"Congenit Heart Dis"},{"key":"2023110716545341400_ytad467-B10","doi-asserted-by":"crossref","first-page":"104860","DOI":"10.1016\/j.jstrokecerebrovasdis.2020.104860","article-title":"Recurrent cerebrovascular events in patients after percutaneous closure of patent foramen ovale","volume":"29","author":"Karagianni","year":"2020","journal-title":"J Stroke Cerebrovasc Dis"},{"key":"2023110716545341400_ytad467-B11","doi-asserted-by":"crossref","first-page":"619","DOI":"10.1212\/WNL.0b013e3182a08d59","article-title":"An index to identify stroke-related vs incidental patent foramen ovale in cryptogenic stroke","volume":"81","author":"Kent","year":"2013","journal-title":"Neurology"},{"key":"2023110716545341400_ytad467-B12","doi-asserted-by":"crossref","first-page":"2277","DOI":"10.1001\/jama.2021.20956","article-title":"Heterogeneity of treatment effects in an analysis of pooled individual patient data from randomized trials of device closure of patent foramen ovale after stroke","volume":"326","author":"Kent","year":"2021","journal-title":"JAMA"},{"key":"2023110716545341400_ytad467-B13","first-page":"487","article-title":"Cryptogenic stroke and patent foramen ovale risk assessment","volume":"6","author":"Melkumova","year":"2017","journal-title":"Interv Cardiol Clin"}],"container-title":["European Heart Journal - 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