Patent foramen ovale closure without echocardiographic control: use of "standby" intracardiac ultrasound.

OBJECTIVES: Our aim was to develop a "standby intracardiac echocardiography" approach to patent foramen ovale (PFO) closures where intracardiac echocardiography (ICE) is only utilized where there are adverse features.

BACKGROUND: Percutaneous closure of PFO is usually aided by transesophageal echocardiography or ICE. This may be unnecessary where anatomical features are straightforward.

METHODS: Patients were excluded from standby ICE if they had adverse anatomical features on their diagnostic transoesophageal echocardiogram, a device other than Amplatzer (AGA Medical, Plymouth, Minnesota), STARflex (NMT Medical, Boston, Massachusetts), or BioSTAR (NMT Medical) were to be used, or they were in a clinical trial demanding ICE/transesophageal echocardiography. Procedurally, defect diameter >15 mm on balloon sizing and tunnel length >12 mm warranted ICE guidance.

RESULTS: Between April 2006 and October 2007, 124 patients underwent PFO closure. Fifty-four were excluded from standby ICE due to trial protocols (n = 22), hybrid atrial septal defect/PFO (n = 6), additional defect (n = 4), exuberant aneurysm (n = 3), or other device (n = 19, all HELEX, Gore Medical, Flagstaff, Arizona). The remaining 70 patients were age 38.1 +/- 6.4 years, 49% men. Primary indication for PFO closure was stroke (n = 46, 65%), transient ischemic attack (n = 22, 31%), or decompression illness (n = 2, 3%). Sixty-four (91%) underwent contrast fluoroscopic PFO closure alone. Six patients (9%) converted to ICE-controlled closure: PFO sized to >15 mm (n = 2); difficulties crossing PFO (n = 2), or long tunnel requiring transseptal puncture (n = 2). All 70 patients had procedural success without significant complications. Procedure duration and cost favored standby ICE.

CONCLUSIONS: PFO closure can, in the majority of cases, be performed safely using contrast media and fluoroscopy alone. Standby ICE facilitates closure in the remaining patients during the index procedure.