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Page 8 of 12 Tagliari et al. Vessel Plus 2020;4:16 I http://dx.doi.org/10.20517/2574-1209.2020.05

Figure 4. Transcatheter aortic valve implantation concomitant with patent foramen ovale closure in a 70-year-old female patient with
severe symptomatic aortic stenosis (the first 2 images) and patent foramen ovale with atrial septal aneurysm. The patient had a previous
history of stroke and Heyde syndrome (induced Von Willebrand disease, lower gastrointestinal bleeding, and anemia). A transfemoral
26-mm balloon-expandable Edwards SAPIEN 3 valve was implanted, followed by patent foramen ovale closure using a 30-mm
patent foramen ovale occluder

Considering that PFO closure is safe, technically simple, effective, and can be carried out by a single
[67]
surgeon in less than 15 min, Taramasso et al. believe that this intervention may be justified, especially
in the presence of anatomical characteristics such as atrial septal aneurysm, Eustachian valve and Chiari
network, or in the presence of a large spontaneous shunt.

[68]
In terms of a combined PFO/ASD and TAVI procedure, Pasic et al. reported, in 2011, the first case of
[63]
TAVI simultaneous with an ASD transcatheter closure. Later, in 2014, Khattab et al. reported the results
of 10 TAVI procedures combined with other structural heart interventions. PFO closure was performed
using a 25-mm Amplatzer PFO Occluder in two patients, while ASD closure was performed using a 24-mm
Amplatzer Septal Occluder in one patient. No residual shunts or thrombi were seen after the procedure.
The authors pointed out the feasibility of the combined approach, but also stressed that high-volume
centers, with experienced surgeons, are needed to obtain proper results.

When a concomitant approach is performed, the strategy is similar as with LAAO, starting with TAVI
[Figure 4].

COST-EFFECTIVENESS ANALYSES
Despite the fact that a precise definition of the best timing for treating concurrent comorbidities in patients
undergoing TAVI remains unknown, a common additional factor to take into account in the decision-
making process is the local reimbursement policies. Although TAVI procedural costs exceed those of
surgical aortic valve replacement, many cost-effectiveness analyses have shown that a shorter length of