PFO closure and PAVM

I recently underwent transcatheter PFO closure and experienced a great result in improved stamina and exercise tolerance.  I then started having chest pain with exercise, but I have admittedly been exercising a lot and it seems things might be irritated.  I have chest pain in my left chest followed by involuntary coughing.  I saw my cardiologist for a follow up.  The device appeared to be well-seated, but during the TTE with bubble study a large number of bubbles went through to the left heart on the 5th cardiac cycle.  They used to go through immediately.  Last year a different cardiologist and pulmonologist thought they heard a noisy PAVM (grade 4).  A pulmonary CTA was performed and showed nothing more that nonspecific pleuritic abnormalities.  I know it is possible to have microscopic PAVM.  It is likely too small to treat if I have one.  Do I need to follow up on this?  The chest pain and coughing are annoying, but tolerable.  I am not sure if there is value in investigating this further although I am a scuba diver and I have upcoming dental work.  Any thoughts on what I should do next if anything would be appreciated.  My ecg is normal with sinus tach.  I have possible svt's - still waiting to catch those on a monitor.

[Mukesh Garg, MD]

Bubbles seen in the left side of the heart after the 5th cardiac cycle can be from the natural passage of blood through the lung blood vessels and may not represent a residual shunt