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This thesis reports the efficacy and safety of different devices in percutaneous patent foramen ovale- (PFO) and atrial septal defect (ASD) closure during long-term follow-up. A PFO is a tunnel-like opening between the left- and right atrium. During Valsalva-like maneuvers, such as coughing, a right-to-left shunt (RLS) can occur, creating the possibility for a peripheral embolus to access the systemic circulation resulting in a stroke. Percutaneous PFO closure has proven to be safe and effective for several devices during long-term follow-up, whereas other devices have been taken off market because they proved to be ineffective and less safe. Migraine is a common neurological disease with an immense disability burden. Patients with migraine with aura (MA) are known to have a higher risk for strokes. This seems to be related to the presence of a PFO, especially in combination with an atrial septal aneurysm (ASA). An ASD is a congenital defect of the atrial septum. A left-to-right shunt (LRS) is present in these patients due to the higher left atrial pressure compared to the right atrial pressure. An LRS causes right ventricle pressure- and/or volume overload. Percutaneous ASD closure is safe and effective in these patients using different devices. Image guiding during these procedures is essential. Transesophageal echocardiography (TEE) is the gold standard for these procedures, but has some important downsides such as general anesthesia, inconvenience of the patient and possible complications. Micro-TEE has proven to be safe and effective during these procedures as well, but less downsides. An important downside however is that micro-TEE does not have three-dimensional view possibilities. The aims of this thesis were to study the safety and efficacy for different devices in percutaneous ASD- and PFO closure during long-term follow-up. Further, comparing TEE and micro-TEE guiding during these procedures. Also, to study the association between migraine, presence of a PFO and septal anatomy.

This thesis reports on the application of several new devices for percutaneous treatment of structural heart disease. A patent foramen ovale (PFO) is a tunnellike communication between the right and the left atrium and has been associated with the occurrence of cryptogenic stroke. PFO closure has proven its efficacy in preventing recurrent TIA or stroke. An atrial septal defect (ASD) occurs when a part of the interatrial septum is missing and is characterized by a left-to-right shunt, resulting in volume overload of the right heart. Percutaneous closure has become common practice. New devices for PFO and ASD closure are being constructed to facilitate the procedure and to lower the complication rate. Mitral valve regurgitation (MR) is an important clinical issue. Less invasive transcatheter techniques are proposed as an alternative treatment option in highsurgical- risk patients. The aims of this thesis were to study the safety and the efficacy if this new devices and techniques. The general discussion describes the different treatment options for PFO, ASD, and MR. We provide an overview of the literature with implementation of our study results, highlighting new techniques with recommendations for further investigation.