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LATE LEFTATRIAL THROMBOSIS OFAN AMPLATZER PATENT FORAMEN OVALE OCCLUDER MAY BE THE RESULT OF KOUNIS HYPERSENSITIVITYASSOCIATED SYNDROME To the Editor: In the very interesting report by Klotz and colleagues published in this Journal, a patient with a patent foramen ovale that was successfully occluded with an Amplatzer occluder had a large thrombosis develop on the atrial disk of the device 33 months after the initial implantation. Although Klotz and colleagues did not refer to the etiology of thrombus formation, several such causes have been reported, including incorrect device placement, device size, device instability, anticoagulation, and antiplatelet therapy monitoring. The Amplatzer closure device is made from nitinol, which is a nickeltitanium alloy. Nickel allergy is quite common, and in a recent report the overall prevalence was found to be 24.6%. Titanium hypersensitivity, although low, has been seen in dental procedures and induces implant failure. The described patient received also aspirin and warfarin on several occasions, both of which are wellknown antigenic compounds. It is known that mast cells bring, on their surface, 500,000 to 1 million IgE molecules, and to degranulate they need 2000 of these molecules, which is a critical number, to make 1000

Late left Atrial Thrombosis of an Amplatzer patent foramen ovale occluder may be the result of Kounis hypersensitivity-associated syndrome