# Percutaneous closure of an ultra-long-tunnel-type patent foramen ovale: a rare case with multimodal imaging guidance

## TL;DR

A rare case of a very long patent foramen ovale was successfully treated using a modified technique guided by advanced imaging.

## Contribution

A modified trans-tunnel puncture technique is proposed for ultra-long tunnel PFO closure.

## Key findings

- A 37-mm ultra-long tunnel PFO was successfully treated with a modified trans-tunnel puncture technique.
- Follow-up imaging showed complete resolution of the shunt by June 2025.
- Multimodal imaging guidance was critical for successful intervention.

## Abstract

Patent foramen ovale (PFO) is a common congenital cardiac anomaly, and ultra-long tunnel PFO (> 20 mm) presents a significant interventional challenge despite routine standard closure. A 68-year-old female with recurrent headaches, chest pain history, and prior right coronary artery stenting was confirmed to have a 37-mm ultra-long tunnel PFO via transesophageal echocardiography (TEE) and digital subtraction angiography (DSA). After initial percutaneous closure failure, the patient was successfully treated with a modified trans-tunnel puncture technique and deployment of an Abbott 18/25 mm Amplatzer PFO Occluder. Follow-up showed gradual resolution of residual shunt, with no shunt detected by June 2025. The imaging-guided modified trans-tunnel puncture technique is an effective strategy for complex ultra-long tunnel PFOs.

The online version contains supplementary material available at 10.1186/s12872-026-05529-x.