**Introduction / Hypothesis**
Patent foramen ovale (PFO) is a relatively common residual opening between the left and right atria in the heart. In the setting of cryptogenic stroke, the presence of a PFO poses a challenging clinical dilemma. Not only are these openings common in the general population, but their closure is not without procedural risk. Thiscase highlights one of numerous complications associated with PFO closure after a cryptogenic stroke.

**Methods**
A 57-year-old female was seen after aphasia. MRI brain revealed subacute thalamic infarcts.  Subsequent transthoracic echocardiogram (TTE) revealed patent foramen ovale (PFO) with large right to left shunting. She underwent PFO closure with no intraprocedural complications. That evening, she reported new chest fullness. She then became unresponsive and was found to be in PEA arrest after which CPR was started with ROSC after 1 minute. TTE revealed an enlarging pericardial effusion with tamponade physiology.

**Results**
The patient then underwent urgent pericardial drain placement with 250 ml sanguineous fluid drained. She was transferred to the ICU for further monitoring. Based on her clinical picture, it was felt the most likely cause of her significant pericardial effusion and PEA arrest was iatrogenic catheter puncture during her PFO closure. Her pericardial drain output progressively decreased, and on hospital day 2 her drain was pulled. She was discharged home with planned follow up.

**Conclusion**
PFOs are common, cited to be present in up to 1/3 of the general population. Though common, they have been associated with an increased risk of embolic stroke. Diagnosis is most frequently obtained through either TTE or TEE imaging with color doppler or agitated saline. Management of PFO after a cryptogenic stroke is debated given the high prevalence of this finding possibly representing a “bystander”, but studies have shown improved outcomes in patients who undergo PFO closure compared to antiplatelet therapy. Complications related to PFO closure include atrial fibrillation, device erosion/migration, device thrombosis, and pericardial injury resulting in pericardial effusion. Many of the post-device complications can be diagnosed with TTE. Clinicians must maintain a broad differential diagnosis in the evaluation of a patient presenting with new symptoms after PFO closure.



Don’t Go Breaking My Heart; Cardiac Arrest from Pericardial Effusion after PFO Closure