Patent foramen ovale closure in a patient with extensive lipomatous hypertrophy of the septum secundum: A case report

Lipomatous hypertrophy of the septum secundum (LHSS) is a benign disorder characterized by the accumulation of fat in the interatrial septum, presenting with an hourglass appearance that spares the fossa ovalis on echocardiography. Typically asymptomatic, LHSS is often incidentally detected through two-dimensional transthoracic echocardiography/transesophageal echocardiography, computed tomography, and cardiac magnetic resonance imaging. It primarily affects elderly and obese individuals, with a higher prevalence among females, and may cause atrial arrhythmias, syncope, and heart failure. Transcatheter closure of patent foramen ovale (PFO) associated with LHSS has traditionally posed challenges due to the lack of specifically designed devices and the risk of suboptimal results. Our case report details the off-label implantation of a flexible atrial septal defect closure device for a PFO closure in an elderly patient presenting with an embolic stroke of undetermined source, severe kyphosis, platypnea-orthodeoxia syndrome, and a large LHSS. In addition, strategies adopted to enhance the success of percutaneous closure are discussed.