We report a patient with infectious complication of patent foramen ovale (PFO) closure device two years after implantation, leading to septic embolic stroke with hemorrhagic conversion. We also describe the challenges in management of the case, particularly in deciding the timing for safe anticoagulation for cardiac surgery. 

PFO closure is an emerging secondary stroke prevention strategy for cryptogenic stroke in patients less than 60 years old. Patent foramen ovale (PFO) closure device infection is extremely rare, only one case (0.2%) was reported in the long term follow up study of RESPECT trial.

Case report of recurrent stroke from PFO closure device infection as a late complication. Literature review for infection of PFO closure device; safety and timing of anticoagulation after infective endocarditis related embolic stroke.

A 39 years old woman who underwent PFO closure for cryptogenic stroke 2 years prior to presentation had sudden onset expressive aphasia and right sided weakness consistent with recurrent stroke. Further investigation revealed a left frontal infarct with hemorrhagic conversion. Initial transthoracic echocardiogram (TTE) was normal but transesophageal echocardiogram showed two cystic masses attached to the PFO closure device. Blood culture grew methicillin sensitive staphylococcus aureus. She suffered from symptomatic hemorrhagic conversion of left frontal infarct with cerebral herniation, requiring hemicraniectomy. She was treated with intravenous antibiotics. Open resection of the infected PFO closure device was performed 3 weeks post hemicraniectomy. She made good recovery and was discharged home with minimal neurological deficits. She showed excellent recovery during follow up visit, with only mild persistent aphasia on examination.

PFO closure device infection is extremely rare. A low index of suspicion is required to identify this potentially life-threatening condition. Prompt evaluation with transesophageal echocardiogram, intravenous antibiotic treatment and definitive surgical intervention may be life-saving.