An asymptomatic 50-year-old Caucasian woman was referred to our echocardiography laboratory to monitor a Biostar septal occluder device inserted six months before in order to close a patent foramen ovale.

On transthoracic echocardiography no residual shunt was observed but the device was not identifiable (Figure 1A); after injection of agitated saline solution in a vein of the right arm and the Valsalva maneuver, a remarkable paradoxical right-to-left shunt appeared (Figure 1B, video clip 1). The estimated systolic artery pressure was 25mmHg.

Figure 1.

(A) Transthoracic echocardiography; (B) contrast echocardiography; (C) 3D real-time transesophageal echocardiography; (D) 3D off-line reconstruction of the PFO; (E and F) cardioscopy.

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To better understand the pathophysiology of the shunt 3D real-time transesophageal echocardiography was performed. The septal occluder was not found on the interatrial septum (Figure 1C). A small interatrial defect was identified close to the foramen ovale (Figure 1D, video clip 2) with a trivial left-to-right shunt (Qp/Qs 1.1) in baseline conditions; the agitated saline contrast test after the Valsalva maneuver was markedly positive. Given the suspicion of distal embolization of the device, cardioscopy was performed: the Biostar was found in the left pulmonary artery (Figure 1E and F, video clips 3 and 4), without hemodynamic effects (mean pulmonary artery pressure 18mmHg).

In accordance with the clinical and instrumental findings, the patient was enrolled for long-term follow-up, with regular clinical and echocardiographic monitoring in order to prevent complications.