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Tagliari et al. Vessel Plus 2020;4:16 I http://dx.doi.org/10.20517/2574-1209.2020.05 Page 7 of 12

Figure 3. Transcatheter aortic valve implantation simultaneous with left atrial appendage occlusion in a 73-year-old female patient
with severe symptomatic aortic stenosis (the first image) and persistent atrial fibrillation. The patient had a previous history of anemia
and lower gastrointestinal bleeding associated with anticoagulation use. The procedure was started by a transfemoral implantation
of a 27-mm self-expanding Portico valve. After transcatheter aortic valve implantation, the left atrial appendage was angiographically
measured, and an left atrial appendage occlusion occluder was implanted (Amplatzer Amulet Occluder 28 mm)

In terms of potential risks, combined procedures require an additional venous access and a transseptal
puncture, increasing procedural time and the contrast volume used. Despite this, no impact on
periprocedural morbidity and mortality of LAAO combined with TAVI has been observed [55,63] .

Based on these data, the best candidates for LAAO concomitant with TAVI seem to be those with chronic
AF and established contraindications to anticoagulation, or those with high risk of bleeding. When a
concomitant approach is chosen, usually LAAO is addressed after TAVI [Figure 3].

ATRIAL SEPTAL DEFECT AND PATENT FORAMEN OVALE CLOSURE
Patent foramen ovale (PFO) and atrial septal defect (ASD) are defects of the interatrial septum. Normally,
after birth, the elevation in left atrial pressure forces the septum primum and septum secundum together,
[64]
collapsing the space between them. In approximately 20% of the population, however, a PFO persists ,
and it becomes a possible conduit for thrombi, air, or vasoactive peptides.

Percutaneous PFO and ASD closure are feasible and effective in reducing paradoxical embolism and
preventing secondary stroke, as demonstrated by the extended follow-up of the RESPECT trial (Randomized
Evaluation of Recurrent Stroke Comparing PFO Closure to Established Current Standard of Care
Treatment) and the CLOSE trial (PFO Closure or Anticoagulants Versus Antiplatelet Therapy to Prevent
Stroke Recurrence). In the former, PFO closure significantly reduced ischemic recurrence when compared
to medical therapy, with a number needed to treat (NNT) of 45 (HR = 0.55, 95%CI: 0.31-0.999; NNT 45),
while in the CLOSE trial, NNT was only 17 (HR = 0.03, 95%CI: 0-0.26) [65,66] .