Atrial septal defects (ASDs) are common congenital heart defects that can be corrected with the placement of minimally invasive occlusion devices. There is a very small risk of perioperative infection associated with these devices following placement. Late endocarditis involving occlusion devices is an exceedingly rare complication of percutaneous occlusion devices. Here we present the case of a female in her 30s who presented with neurologic symptoms typical of her multiple sclerosis flares, but was found to be secondary to late infective endocarditis of an ASD occlusion device requiring surgical excision.

A retrospective analysis was conducted on the neuroimaging features of white matter lesions related to patent foramen ovale and clinical characteristics (age, sex, history of hypertension and diabetes, etc.) of patients who underwent patent foramen ovale closure surgery at Fuwai Hospital, Chinese Academy of Medical Sciences, from February 2021 to June 2025. All patients were confirmed to have right-to-left shunt by contrast-enhanced transthoracic echocardiography and completed brain MRI examination. According to the results of contrast-enhanced transthoracic echocardiography, patients were divided into 2 groups (large-shunt group and non-large-shunt group). The distribution characteristics of white matter lesions were investigated from multiple dimensions, including anterior/posterior circulation, left/right hemisphere, and single/multiple lesions. A total of 118 patients were screened, among whom 100 with complete clinical data were included in the study. The age was (45.4±9.9) years. There were 62(62%) cases in the large-shunt group and 38(38%) cases in the non-large-shunt group. No statistically significant differences were found between the 2 groups in terms of age, gender, or history of hypertension, diabetes, stroke or transient ischemic attack (TIA). The proportion of multiple white matter lesions in the large-shunt group was significantly different [59.7%(37/62) vs 39.5%(15/38), P=0.049], as was the proportion of bilateral hemispheric distribution [62.9%(39/62) vs 42.1%(16/38), P=0.042]. The proportion of lesions distributed in the right hemisphere was higher [66.1%(41/62) vs 47.4%(18/38)], but the difference did not reach statistical significance (P=0.064). Among patients with a history of stroke or TIA, the proportions of multiple, bilateral, and involvement of both anterior and posterior circulation white matter lesions were significantly higher than those without such histor[66.1%(39/59) vs 31.7%(13/41), 67.8%(40/59) vs 36.6%(15/41), 62.7%(37/59) vs 26.8%(11/41), all P<0.01]. No statistically significant difference in white matter lesions distribution was observed between patients with and without a history of migraine. Patients with patent foramen ovale and a large right-to-left shunt are more likely to present with bilateral and multiple cerebral white matter lesions on brain MRI, and these white matter lesions are more prone to occur in the right hemisphere.

Pulmonary arterial hypertension (PAH) complicates a clinically important subset of adult congenital heart disease (ACHD) and contributes to substantial morbidity and premature mortality. This narrative review synthesizes direct and indirect evidence within a second-hit conceptual framework for ACHD-associated PAH. In this framework, baseline pulmonary vascular susceptibility interacts over time with sustained hemodynamic or hypoxemic exposure and with superimposed biological or clinical stressors. SOX17 has the clearest direct genetic association with ACHD-PAH, whereas evidence involving BMPR2-related metabolic, inflammatory, and proliferative pathways is derived predominantly from heritable PAH, broader PAH populations, and experimental models. Experimental and computational studies also suggest that disturbed flow and mechanobiological signaling may contribute to endothelial dysfunction and endothelial-to-mesenchymal transition, although these mechanisms have not been established as a causal sequence in longitudinal ACHD cohorts. Four-dimensional flow magnetic resonance imaging and cardiopulmonary exercise testing may characterize abnormal flow patterns and impaired pulmonary vascular reserve in research settings, but neither is validated for screening patients with borderline ACHD hemodynamics or for selecting therapy. Evidence supporting treat-and-repair remains observational and defect-specific, with the most developed adult data derived from carefully selected patients with atrial septal defects; these findings should not be extrapolated directly to ventricular septal defects, patent ductus arteriosus, or complex congenital heart disease. Fontan physiology is considered separately as a low-flow, low-reserve pulmonary vascular state rather than as classical high-pressure PAH. The principal contribution of this review is to organize heterogeneous evidence according to its directness, distinguish established clinical practice from investigational approaches, and identify priorities for prospective validation. The second-hit framework should therefore be interpreted as a hypothesis-generating conceptual synthesis rather than as a validated diagnostic or therapeutic algorithm.

Atrial septal defect (ASD) is considered a benign condition and is usually closed electively in pre-school age. Early symptomatic presentation is uncommon and often associated with comorbidities such as chronic lung disease and recurrent respiratory infections. Although pulmonary hypertension is rare in ASD, infants with large defects may develop respiratory symptoms and failure to thrive even in its absence. In such conditions earlier intervention may be considered, particularly in those with right heart volume overload or growth impairment. However, limited evidence suggests potential benefit from early intervention, especially in infants with bronchopulmonary dysplasia. This study aims to systematically review the literature and perform a pooled analysis of clinical and hemodynamic characteristics of children undergoing early ASD closure (weight < 15 kg or age < 2 years). Additionally, it evaluates the safety and efficacy of both surgical and transcatheter closure in this population.

Paradoxical embolism through an atrial septal defect (ASD) is a rare but important cause of acute coronary syndrome (ACS) in patients without conventional cardiovascular risk factors. We report the case of a 40-year-old male with no history of hypertension, diabetes, smoking, dyslipidemia, or family history of premature coronary artery disease who presented with acute chest pain and ischemic electrocardiographic changes. Basic thrombophilia profile screening was nonaffirmative. Troponin-T testing using a point-of-care and quantitative assay was positive. Coronary angiography revealed angiographically normal epicardial coronary arteries. Transthoracic and transoesophageal echocardiography demonstrated a large ostium secundum ASD measuring 22 mm × 24 mm, with a prominent Eustachian valve and significant right-to-left shunting on contrast study, accentuated during the Valsalva maneuver. The patient underwent successful transcatheter ASD closure with complete abolition of shunting. This case highlights paradoxical coronary embolism as a potential mechanism of ACS in young, low-risk individuals and underscores the importance of evaluating intracardiac shunts in patients presenting with ACS and nonobstructive coronaries.

Transcatheter device closure is the preferred treatment for secundum atrial septal defect (ASD) in young adults with suitable anatomy. In this population, routine coronary angiography is generally not recommended in the absence of ischemic symptoms or conventional cardiovascular risk factors. However, coronary imaging is selectively performed during ASD intervention to delineate anomalous coronary anatomy at risk of device-related compression, and emerging evidence indicates that clinically significant coronary artery disease may occasionally coexist silently in younger adults. We report the case of a 28-year-old asymptomatic woman undergoing transcatheter closure of a large secundum ASD with deficient rims, in whom coronary angiography performed during invasive catheterization unexpectedly revealed critical left main coronary artery stenosis. Intravascular ultrasound (IVUS) confirmed severe luminal compromise, and successful IVUS-guided left main coronary stenting was performed, followed by device-assisted ASD closure in the same procedural session. Retrospective clinical assessment revealed a history of premature sudden cardiac death in a first-degree relative. This case illustrates the potential for occult yet prognostically significant coronary artery disease in young adults undergoing congenital heart interventions and supports a selective, individualized, and context-driven approach to coronary evaluation, consistent with contemporary adult congenital heart disease guidelines.

Patent foramen ovale (PFO) is closely associated with migraine. However, the mechanism remains unclear. Surface-based morphometry (SBM) and voxel-based morphometry (VBM) were widely used to study microstructural changes in the brain. We aimed to use SBM and VBM to investigate microstructural changes in the brain in migraineurs with PFO. A total of 20 migraineurs were enrolled in the PFO group, and 20 TCD-negative migraineurs, matched by gender and similar age, were included in the control group. All patients underwent brain MRI. 3D-T1-WI imaging was used to reconstruct and post-process for VBM and SBM analysis. There were no significant differences in their baseline clinical characteristics. VBM results showed that white matter (WM) volumes decreased in six relevant brain regions in the PFO group: cerebellar vermis VIII, right caudate, left superior temporal gyrus, left fusiform, left posterior cingulate gyrus, and left postcentral gyrus (P < .05 or P < .01). Also, the gray matter (GM) volumes of the bilateral hippocampus were significantly decreased in the PFO group (P < .01). Furthermore, SBM results showed that the cortex of the right superior frontal gyrus was thicker, the sulcus of the right rostral middle frontal gyrus was deeper, and the fractal dimension of the left superior parietal gyrus was more complex in the PFO group, but these results couldn't pass FDR correction (P > .05). This cross-sectional study demonstrates that migraine patients with PFO exhibit focal gray and white matter volume reductions in multiple pain, cognition, and emotion-related brain regions. These structural alterations may represent important neural substrates underlying PFO-related migraine.

Patent foramen ovale (PFO) is a common congenital cardiac anomaly, generally responsible for cryptogenic stroke. Still, it can cause severe positional hypoxia via a right-to-left shunt if associated with anatomic distortion of the interatrial septum. A man in his 90s with a known atrial septal defect (pulmonary blood flow/systemic blood flow (Qp/Qs) ratio of 0.85) and ascending aortic aneurysm presented with sudden worsening of chronic exertional dyspnoea and had profound hypoxia, requiring bilevel positive airway pressure. Workup was negative for pulmonary embolism with an unremarkable prior transthoracic echocardiogram (TTE). During hospitalisation, he was found to have worsening hypoxia in the upright position, which improved in the supine and right lateral decubitus positions. A repeat TTE with agitated saline was performed, which showed a PFO with a large right-to-left shunt, confirmed by transoesophageal echocardiogram (TEE), along with a severe atrial septum aneurysm on TEE. Percutaneous PFO closure with a 37 mm Gore occluder resulted in immediate resolution of hypoxaemia and clinical improvement.