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Updated: Jun 10, 2025
Echocardiographic Evaluation of Atrial Communications before Transcatheter Closure
Published on: February 8, 2022
Occlusion of functional high-volume intra-atrial shunts in older patients after embolic stroke of undetermined source
Helene Schrader1,2, Leif-Hendrik Boldt1,2,3, Abdul S Parwani1,2,3
1Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Berlin, Germany.
Insights
Percutaneous closure of intra-atrial shunts is safe and effective for preventing stroke in patients over 50. Outcomes remain favorable regardless of shunt size, offering a reliable secondary prevention strategy.
Area of Science:
- Cardiology
- Neurology
- Interventional Cardiology
Background:
- Intra-atrial shunts increase the risk of embolic stroke of undetermined source (ESUS).
- Percutaneous occluder implantation is a recommended secondary prevention for younger patients with ESUS.
- The study evaluates outcomes in older patients undergoing shunt occlusion, focusing on high-volume shunting impact.
Purpose of the Study:
- Compare outcomes after percutaneous shunt occlusion between younger and older patients with presumed paradoxical embolism.
- Evaluate the impact of high-volume shunting on outcomes in elderly patients undergoing shunt occlusion.
Main Methods:
- Retrospective, single-center observational study of 187 patients undergoing percutaneous PFO or ASD occlusion (2013-2023).
- Patients were stratified into younger (≤50 years) and older (>50 years) groups.
- Comparison of high-volume (≥10mm or ≥20 bubbles) versus low-volume shunts in the elderly cohort.
Main Results:
- Older patients had more cardiovascular risk factors; shunt characteristics were similar between age groups.
- No significant differences in procedural or intrahospital complications were observed.
- Low 6-month event rates: 1.6% in younger vs. 3.8% in older patients (p=0.817). No significant difference in outcomes for high-volume vs. low-volume shunts in the elderly.
Conclusions:
- Percutaneous closure of intra-atrial shunts is safe and effective for secondary prevention of cryptogenic embolism in patients over 50.
- The beneficial outcome is independent of high-volume shunting prior to implantation.
- Shunt occlusion provides a viable secondary prevention strategy for cryptogenic embolism in the elderly.
Background:
Intra-atrial shunts are associated with an elevated risk of embolic stroke of undetermined source (ESUS). Percutaneous occluder implantation is recommended as secondary prevention in younger patients. This study aims to compare the outcome after shunt occlusion between younger and older patients with a history of presumed paradox embolism and to evaluate the impact of high-volume shunting in an elderly population.
Methods:
We conducted a single-center, retrospective, observational study, involving 187 patients who underwent interventional percutaneous PFO or ASD occlusion at our center between 2013 and 2023.
Results:
The mean age of participants was 51.8 ± 11.8 years, with 76 patients aged ≤50 years and 111 patients aged >50 years. Older patients presented more cardiovascular risk factors. The presence of atrial septum aneurysm or large shunting was evenly distributed (ASA 26.3% vs. 28.8%, p = 0.833, mean shunt defect size 6.67 vs. 7.23 mm, p = 0.151). There were no significant differences in procedural or intrahospital complications. The event rate during the 6-month follow-up was low. Recurrence of arterial embolism occurred in 1.6% of the younger and 3.8% of the older patients (p = 0.817). Comparison of high-volume shunts (defect size ≥10 mm or passage ≥20 bubbles during bubble study) with low-volume shunts in this elderly cohort with a mean age ≥50 years showed no significant difference in outcomes. There was a statistically non-significant trend toward a higher rate of residual shunt at the end of the procedure in the high-volume shunt group (2.9% vs. 9.8%, p = 0.0894). This difference was not observed at the 6-month follow-up anymore (14.5 vs. 12.1%, p = 0.628). Two unsuccessful implantation attempts were reported in the high-volume shunt group, while none were observed in the low-volume shunt group (p = 0.372). No intervention-related deaths occurred in this patient cohort during follow-up.
Conclusion:
Occlusion of relevant, intra-atrial shunting is a safe and effective option for secondary prevention of cryptogenic embolism in patients over 50 years of age. The beneficial outcome was irrespective of a high-volume shunting before implantation.
