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Persistent foramen ovale (PFO) is a congenital heart disease which represents 80% of atrial septal defects. It is a remnant of fetal circulation that functions in postnatal conditions as a transient interatrial right‑to‑‑left shunt of variable magnitude. Persistent foramen ovale may be implicated in the pathogenesis of several medical conditions, such as cryptogenic stroke, cryptogenic left circulation thromboembolism, migraine syndromes, and decompression sickness. The most frequent indication for PFO closure remains PFO‑associated left circulation thromboembolism. In select patients, PFO closure reduces stroke recurrence in comparison with medical therapy after more than 3 years of follow‑up on average, especially in patients with a high risk of recurrence. While in PFO‑associated left circulation embolism, there is now conclusive evidence on the growing benefit of PFO closure in long‑term follow‑up, in many other clinical conditions, the degree of certainty of the results is deceiving. In this paper, we will review the benefits and risks that one can expect in the long term after percutaneous PFO closure in various clinical scenarios in order to facilitate therapeutic decision making.

Background: Arteriovenous fistula (AVF) for haemodialysis (HD) induces a volume/pressure overload which impairs bi-ventricular function and increases systolic pulmonary arterial pressure (PAPS) and left ventricular mass (LVM). In the presence of high blood flow (Qa) AVF (> 1.5 L/min/1.73 m 2 ) and cardio-pulmonary recirculation (>20%), high-output congestive heart failure (CHF) may occur and AVF flow reduction is recommended. Proximal Radial Artery Ligation (PRAL) is an effective technique for distal radio-cephalic (RC) AVF flow reduction., Methods: we evaluated six HD and four transplant patients with high-flow RC AVF and symptoms of CHF who underwent PRAL. We compared echocardiographic (ECHO) findings before (T0) and 1 and 6 months (T1,T6) after PRAL. Preoperative ECHO was performed before (T0b) and after AVF anastomosis manual compression (T0c)., Results: At T1 AVF flow reduction rate was 58.4% ± 13% and 80% of patients reported improved CHF symptoms. ECHO data showed an improvement of tricuspid annular plane systolic excursion (TAPSE) at T1 (p = 0.03) and a reduction of PAPS at T6 (p = 0.04). TAPSE improved after AVF anastomosis compression during preoperative ECHO (p = 0.03). Delta of TAPSE at the dynamic manoeuvre at T0 directly correlated with early (1 month after PRAL, p = 0.01) and late (6 months after PRAL, p = 0.04) deltas of TAPSE., Conclusions: AVF flow reduction after PRAL induces immediate regression of CHF symptoms, early improvement of TAPSE and late improvement of PAPS, suggesting a prevalent right sections involvement in CHF. Preoperative TAPSE modification after AVF anastomosis compression could represent a useful evaluation tool to determine which patients would benefit of PRAL.