1. “PFO Closure: anatomical variants and implications for choice of procedure, success rates and complications” LM Shapiro. Papworth Hospital, Cambridge

2. NO CONFLICT OF INTEREST TO DECLARE

3. “PFO Closure: What are we trying to achieve LM Shapiro

4. “PFO Closure: What are we trying to achieve complete closure LM Shapiro

5. Basic anatomy

6. ASSESSMENT OF PFO Characterisation Tunnel length / height / width Flap separation / adhesion – RA/LA edge, body Flap retraction – spontaneous / potential Tunnel openings “PFD (patent foramen defect)”– ASD structurally merged with PFO or PFO with functional ASD

7. Incomplete PFO closure

8. Residual flow (AGA device)

9. Papworth Hospital 2005 to 2008 241 consecutive pfo closures (271 devices) No late complication

10. 3 balloon morphologies. SHORTTUNNEL LONGTUNNEL ? SHORT TUNNEL ? LONG TUNNEL

11. Typical PFO – LA edge tunnel height and width flap separation with wire

12. Partial Split-level PFO. Apposition at RA edge only. fixed tunnel 1cm. LA edge tethered into LA

14. Narrow partial fixed split, long tunnel, narrow RA opening Shortest tunnel segment 12.5mm PosterosuperiorAnterosuperior

15. Spontaneous flap retraction

16. Papworth Hospital Conclusion No one device fits all defects Complete closure is necessary for stroke prevention Echo Pfo characteristics determine appropriate device

17. Papworth Hospital Conclusion No one device fits all defects Complete closure is necessary for stroke prevention Echo Pfo characteristics determine appropriate device

18. Typical PFO – tunnel height or flap separation

19. Typical PFO – LA edge tunnel width with wire

20. Long tunnel, partial fixed split, narrow flap separation

21. Septal bounce Flap retraction

22. Flap attachment Flap attachment point, marked by small indent of LA wall

23. Partial Split-level PFO. Apposition at RA edge only. fixed tunnel 1cm. LA edge tethered into LA, may not retract device traction to shorten tunnel much

24. 5mm distance disk to disk including disk thickness Approx 3mm waist