A 61 year old man presented with a cryptogenic cerebrovascular insult. Transoesophageal echocardiography (A) showed a patent foramen ovale (thin arrow). Agitated Haemaccel (polygeline, Hoechst Marrion Roussel, Middlesex, UK) was injected intravenously as a 2 ml bolus and flushed with 10 ml of saline 0.9%. During Valsalva manoeuvre, a right to left shunt was demonstrated through the patent foramen ovale of the interatrial septum (B). A buttoned occluder was placed successfully during cardiac catheterisation. Echocardiography was not used during the procedures. Transoesophageal echocardiography the next day demonstrated a good position of the occluder (arrow) and counter occluder (arrowhead) (C) without and (D) with right atrial contrast filling. (AS, atrial septum; LA, left atrium; RA, right atrium.)

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