Abstract 4345985: PFO-Closure Induced Myopericarditis

Case Description: A 43-year-old female with a history of cryptogenic stroke and a large aneurysmal patent foramen ovale (PFO) underwent successful intra-cardiac echocardiography (ICE)-guided closure with a 30 mm GORE® CARDIOFORM Septal Occluder (Figure 1). Immediately post-procedure, she reported left-sided substernal chest pain. A STAT transthoracic echocardiogram (TTE) showed no pericardial effusion, no new wall motion abnormalities, and correct device positioning. She was discharged on aspirin and clopidogrel. The following day, she returned to the emergency department with persistent sharp, pleuritic, and positional chest pain, associated with dyspnea and unrelieved by acetaminophen or ibuprofen. Subsequent workup revealed leukocytosis, elevated inflammatory markers and troponin levels, diffuse concave ST-segment elevations on ECG (Figure 2), and a trace pericardial effusion on both computed tomography angiography (CTA) and TTE (Figure 3)—findings concerning for myopericarditis. She was treated with colchicine and ibuprofen, leading to rapid symptom improvement and discharge. Follow-up cardiac magnetic resonance imaging (MRI) three months later showed no residual inflammation. Discussion: Myopericarditis refers to concurrent inflammation of the pericardium and myocardium, most commonly caused by viral infections but occasionally triggered by cardiac interventions. Though rare, pericarditis and myocarditis have been reported following intracardiac device implantation, including PFO closure. One proposed mechanism involves a type IV hypersensitivity reaction to nickel, a component of nitinol used in many closure devices. The GORE® CARDIOFORM Septal Occluder, while containing nitinol, is encapsulated in expanded polytetrafluoroethylene (ePTFE), which may reduce direct nickel exposure compared to devices like the AMPLATZER™ PFO Occluder. However, no significant difference in the incidence of hypersensitivity reactions between devices has been established. Nickel skin testing has been suggested in select cases but is not validated for predicting systemic or device-related reactions. Even in patients with known nickel sensitivity, the clinical relevance remains uncertain, as the pre-test probability of device-related reaction is low, and no nickel-free alternatives currently exist. As such, the potential risk of hypersensitivity must be weighed against the proven benefit of PFO closure in reducing the risk of recurrent stroke in select patients.