Evaluating Percutaneous Repair Of The Atrial Septum With A Novel PFO Occluder: The PROTEA-PFO OUS Study

Prior treatment

• Myocardial Infarction (MI) or unstable angina within the previous 180 days.
• Active endocarditis or other infection that may preclude implantation of the investigational device.
• Known hypercoagulable state that would require full anticoagulation. Minimum testing to include lupus anticoagulant, anticardiolipin antibodies, beta-2-glycoprotein, homocysteine.
• Any disorder in the investigator's opinion that could interfere with compliance of safety evaluation or require premature discontinuation of antiplatelet regime post-implantation, as well as any severe concurrent illness that would limit life expectancy (e.g., malignancies).
• Currently an active subject in an investigational drug or device study that could confound the results of this study.
• Any prior percutaneous cardiovascular intervention for AF ablation.

Other illness

• Other identifiable causes of stroke, including but not limited to aortic arch plaques (protruding \>4 mm into the lumen), large artery atherosclerotic disease proximal to the territory of the index stroke, an established cardioembolic source, small-vessel occlusive disease, or arterial dissection, presence of left atrial appendage thrombus.
• Other arteriopathy of the intracranial or extracranial vessels with \>50% stenosis proximal to the territory of the index stroke.
• History of atrial tachycardia, atrial fibrillation or flutter, AV block, or ventricular arrhythmia requiring antiarrhythmic medication, pacemaker, or AICD.
• Severe liver disease (e.g., documented cirrhosis or active hepatitis).
• Severe lung insufficiency (e.g., need for supplemental oxygen or chronic steroid medications).
• Uncontrolled hypertension, defined as sustained elevated blood pressure \>140/90 mm Hg.
• Severe pulmonary artery hypertension, defined as pulmonary systolic pressure of \>50mmHg.
• Increased bleeding risk such as severe liver failure, active peptic ulcer, proliferative diabetic retinopathy, history of severe bleeding (e.g.: gastrointestinal bleeding, macroscopic hematuria, intraocular bleeding, intracranial or cerebral hemorrhage), or other history of bleeding or coagulopathy.
• Subjects not able to discontinue anticoagulation for indications other than then index stroke.
• Any significant valve dysfunction that contraindicates PFO closure or increased pulmonary vascular resistance/severe pulmonary hypertension.
• Known nickel allergy that, in the opinion of the investigator, poses a safety risk with regards to participation in the trial.

Lab values

• Left ventricular dilated cardiomyopathy with LVEF \<35%.
• Severe renal failure ( Stage 4 CKD, eGFR \<30) or patient requiring dialysis.
• Uncontrolled hyperglycemia, defined as HbA1c value \>8% (IFCC: \>64 mmol/mol).

Age

• Life expectancy \< 2 years.

Other

• Intracardiac thrombus or tumor.
• Left ventricular aneurysm or akinesis.
• Moderate to severe mitral valve stenosis or severe mitral regurgitation.
• Aortic valve stenosis (mean gradient \>20 mmHg) or severe regurgitation.
• Any valve vegetation or Lambl's excrescence of any left-sided valve.
• Another source of right-to-left shunts identified at baseline, including an atrial septal defect and/or fenestrated septum and pulmonary arteriovenous malformation.
• Subjects contraindicated for aspirin or clopidogrel.
• Contraindication for transesophageal echocardiography (TEE) or intracardiac echocardiography (ICE).

• Patient must be ≥ 18 and ≤ 65 years of age
• Diagnosis of PFO, defined as visualization of microbubbles per TEE in the left atrium within three cardiac cycles from the right atrial opacification demonstrating right-to-left shunting at rest and/or during Valsalva release.
• Ischemic stroke, defined as acute focal neurological deficit, presumed to be due to focal ischemia and confirmed by MRI or CT to have a neuroanatomically relevant cerebral infarct.
• Modified Rankin score (mRS) ≤ 3.
• Appropriate PFO anatomy for implantation of the investigational device as evaluated and determined by independent committee.
• Patient is willing and capable of providing informed consent.
• Prior to index procedure (7-day window), persons of childbearing potential must have a negative pregnancy test.