Should You Undergo a Second PFO Closure?
You should not pursue a second PFO closure procedure at this time, as your TEE shows no residual cardiac shunt and your TCD findings most likely represent physiological pulmonary shunting or recirculated bubbles rather than a clinically significant cardiac defect. 1
Understanding Your Current Diagnostic Results
Your imaging tells a clear story that argues against repeat closure:
TEE remains the gold-standard test for detecting residual PFO and provides the highest sensitivity for identifying true cardiac shunts. 1 Your TEE showed no passage across the device, even when the device and atrial septal aneurysm were filled with contrast during Valsalva maneuver. 1
When TEE shows no contrast passage but TCD detects microbubbles (as in your case with 5-10 at rest and 15-20 with Valsalva), this most likely represents physiological pulmonary shunt or recirculated bubbles rather than a clinically significant residual cardiac shunt. 1 The fact that bubbles appeared "at the end of the Valsalva release phase" is the key diagnostic clue here.
True cardiac shunts produce microbubbles in the left atrium within the first cardiac cycles after appearance in the right atrium; bubbles that appear later (at the end of Valsalva release) are characteristic of recirculated bubbles. 1 This timing pattern matches your description perfectly.
Why the Stroke Risk Data Don't Apply to You
The 4-5 times higher stroke risk and 36% cumulative 20-year risk you cite apply to a fundamentally different patient population:
Recurrence-risk studies pertain to patients with unclosed PFOs or those with residual shunts confirmed by TEE; they do not apply to cases where TEE shows no residual flow. 1 You are extrapolating data from patients with documented residual cardiac shunts to your situation where no cardiac shunt exists on the most sensitive test available.
BMJ guidelines recommend PFO closure only in patients with cryptogenic stroke AND a PFO demonstrably present on TEE. 2 Closure based solely on a positive TCD when TEE is negative is not supported by the evidence. 1
The Real Risks of a Second Procedure
Pursuing repeat closure exposes you to concrete procedural risks for uncertain (likely zero) benefit:
Repeat percutaneous closure carries real adverse-event risks, including device-related complications, new-onset atrial fibrillation, vascular injury, and the possibility of perforation or erosion when multiple devices are placed. 1 These are not theoretical—they occur in real patients.
Device-related atrial fibrillation occurred in recent trials of even first-time PFO closure. 2 Adding a second device increases these risks further.
If You Still Have Doubts: Additional Diagnostic Options
Before considering any intervention, you could pursue further diagnostic clarification:
A repeat TEE performed with a protocol specifically targeting pulmonary shunt detection can help differentiate residual cardiac flow from pulmonary sources. 1 This would definitively answer whether you have a cardiac versus pulmonary source of bubbles.
If a pulmonary arteriovenous malformation is suspected, contrast-enhanced chest CT or pulmonary angiography should be considered. 1 This would identify any pulmonary shunts that might explain your TCD findings.
Intracardiac echocardiography (ICE) may identify very small shunts invisible on TEE, but there is no evidence that such minute shunts increase stroke risk, and ICE itself entails procedural risk. 1 Even if ICE found something, it wouldn't change your management because microscopic shunts don't cause strokes.
Regarding Physical Activity and Weightlifting
Your provider's restriction on weightlifting is overly conservative given your imaging results:
Resistance training is permissible when performed with moderate loads (approximately 50-70% of 1-RM) and continuous breathing, avoiding maximal lifts that require a Valsalva maneuver. 1 You can return to weightlifting with these modifications.
Aerobic activities (swimming without prolonged apnea, cycling, team sports) are safe and unrestricted. 1
Cardiovascular exercise can be performed without limitation. 1
The key is avoiding maximal Valsalva maneuvers (like maximal bench press attempts), but moderate resistance training with proper breathing technique is safe. 1
Your Ongoing Medical Management
Current BMJ guidelines strongly advise continuation of antiplatelet therapy after successful PFO closure. 1 This is your most important stroke prevention strategy now.
Continue avoiding constipation (which causes Valsalva during straining) as your provider recommended. 1
Common Pitfalls to Avoid
Physiologic pulmonary shunting is present in normal individuals and should not be misinterpreted as residual cardiac shunt. 1 This is likely what you have.
A negative TEE should not be disregarded; it remains the most sensitive and specific test for residual PFO. 1 Your negative TEE is the most important piece of data you have.
PFO closure is indicated only for specific clinical scenarios and is not universally beneficial for all patients with a PFO. 1 More intervention is not always better.
The Bottom Line
A second closure should be contemplated only when objective evidence of a significant residual shunt is demonstrated on TEE, after weighing the procedural risks against the uncertain benefit. 1 You do not meet this criterion. Your TEE is negative, your device is well-positioned without thrombus, and your TCD findings are consistent with normal physiological phenomena rather than pathological cardiac shunting. You can safely return to modified resistance training while continuing antiplatelet therapy.