In Battles You Easily Win, the Choice of Weapon is Secondary

The series of percutaneous closure of a patent foramen ovale (PFO) presented by the German institution represents one of the largest experiences worldwide.1 It is only natural that these pioneers of the Cardia device then moved on to its next generation, the Intrasept device. Curiosity obviously made them use as a comparator what they considered the best device other than their own. This is how the Amplatzer PFO occluder came into play.

It is regrettable that in spite of their gargantuan experience with PFO patients, the authors missed the chance to throw in what really matters. Rather than obediently stating that they only treated patients with all other possible causes of systemic emboli excluded, they should have confessed to what is insidiously going on in experienced centers: the PFO is identified as a potential cause of stroke, myocardial infarction or other systemic embolism, irrespective of the presence of alternative causes. The word “cryptogenic stroke” is a misnomer in the presence of a PFO, the latter being as plausible an etiology as any other, and the easiest to eliminate, for that matter.

The results presented contradict our group’s earlier report of the Amplatzer’s supremacy.2 Almost a decade ago, we acquired experience using the few available devices for percutaneous PFO closure, among them, the Cardia device. When the Amplatzer PFO occluder hit the market, we felt like a family that, after having hitherto driven to church on Sunday on a variety of tractors, was now graced with a normal car for that purpose. When it became obvious that the Amplatzer PFO occluder not only made the trip (implantation) easier and more pleasant, but also had superior long-term results, it was the end of the tractors.

Currently in our country, at least 12 different device lines are available to close PFOs. An arbitrary ranking has ensued based on extensive experience with a few of them, and some experience with most. At the top, there are 2 cars: the Amplatzer PFO occluder and its carbon copy, the Occlutech PFO occluder. Then follow the tractors, with only subtle differences among them, in the order of the Solysafe occluder, the Intrasept, the Premere, the Biostar, the Helex, and so forth.

These new data corroborate this to a great extent. The best outcome was again achieved with the Amplatzer PFO occluder, except that the superior long-term closure rate we have found fell short of being detected by Spies and colleagues. This is likely because a mixture of transthoracic and transesophageal echocardiograms done by referring physicians cannot possibly be discriminative.

The high rate of atrial fibrillation with the Amplatzer PFO occluder (10%) comes as a surprise, as we see this problem in less than 1% of our patients. Atrial fibrillation after PFO closure is primarily dependent on the age of the patient, and so far we have only seen it in elderly patients possibly already at the brink of atrial fibrillation before receiving an implant.

There are many means to go to church on Sunday. It does not matter so much what you use, just go to church on Sunday.
 
J INVASIVE CARDIOL 2008;20: 448