Manuscript
Severe hypoxemia secondary to COVID-19 pneumonia is a significant
contributor to morbidity and mortality.1 Patent
foramen ovales (PFOs) can exacerbate hypoxemia through an intracardiac
shunt, slowing recovery and worsening outcomes.2-4Additionally, cryptogenic stroke is a complication commonly associated
with PFOs, however, current guidelines do not address PFO management in
COVID-19 patients who suffer from recurrent paradoxical emboli,
especially in the setting of COVID-19 pneumonia, increased right-sided
pressures, and hypercoagulable state.3, 4 This is
significant considering approximately 25% - 34% of the population
suffer from a congenital PFO.3, 5 Interestingly, a
recent cross-sectional study (n=75) of patients under mechanical
ventilation secondary to COVID-19 pneumonia found a prevalence of PFOs
in 15% of their patients.6 While most patients with a
PFO do not require surgical intervention, selected patients may strongly
benefit from PFO closure to prevent recurrent cryptogenic
strokes.7 This report describes a challenging case of
an unvaccinated patient with recurrent strokes and refractory hypoxemia
secondary to COVID-19 pneumonia. The patient was subsequently found to
have a PFO and underwent a PFO closure using NobleStitch EL
(Heartstitch, Fountain Valley, CA).
FDA approved in 2019, NobleStitch enables a deviceless method of PFO
closure 8, 9 Using percutaneous access, NobleStitch
approximates the septum primum and the septum secundum using two
polypropylene sutures and a single polypropylene knot, thereby avoiding
the risks associated with septal occluders, such as infection,
anticoagulant use, arrhythmias, device erosion/dislodgment, and hindered
left atrial access.8, 9 Initial registry data (n=192)
has demonstrated that NobleStitch is a safe and effective method of PFO
closure, revealing complete resolution of the right-to-left shunt in
75% and a grade 1 residual right-to-left shunt in
14%.9 Although recent studies have begun to refine
the inclusion criteria for this procedure to improve postprocedural
residual shunting, long term outcomes of this device will be better
further understood with the completion of the prospective multicenter
clinical trial slated to conclude in 2026.10-12