Transthoracic echocardiography guidance during percutaneous closure of patent foramen ovale

Background: Percutaneous closure of patent foramen ovale (PFO) has been increasingly performed for several indications; mostly due to cryptogenic stroke. In this study we aimed to evaluate the safety and efficacy of transthoracic echocardiographic (TTE) guidance during percutaneous closure of PFO in using the Amplatzer and Occlutech Figulla PFO occluder devices. Methods: Between October 2005 and March 2011, 139 patients (74 male, mean age: 40.4 ± 10.3) underwent transcatheter PFO closure. In all patients transesophageal echocardiography performed subsequently to diagnose, assess the size and evaluate for suitability of the defect for percutaneous closure. During the procedure fluoroscopy and TTE were used for guidance. Results: Among 139 patients, Amplatzer PFO occluder was used in 74 patients and in 65 of them Occlutech Figulla device was selected for occlusion. The indications for PFO closure were ischemic stroke in 98 (70.5%), recurrent transient ischemic attacks (TIA) in 40 (28.7%), peripheral embolism in 1 (0.8%) of the patients. In all patients, percutaneous intervention was performed successfully under TTE guidance. There have been no neurologic (recurrent strokes or TIAs) and cardiovascular complications during the immediate and long‐term follow‐up period (2–67 months, median 29). There was significant difference between the mean fluoroscopic time from the beginning which is 8.6 ± 3.4 min in the former versus 3.4 ± 1.9 min in the latter (P < 0.05). Conclusion: Our study confirms the efficacy and safety of TTE guidance during percutaneous closure of PFO, which shortens the procedural time and obviates the need for general anesthesia or endotracheal intubation. (Echocardiography 2011;28:1074‐1080)     

Overcoming a stubborn patent foramen ovale

Transesophageal echocardiography (TEE) with agitated saline contrast (“bubble study”) is the gold standard for detection of patent foramen ovale (PFO). Standard provocative maneuvers help facilitate right-to-left shunting necessary for diagnosing PFO but may be difficult to implement during TEE. Hypovolemia related to preprocedural fasting may challenge detection of PFO in TEE, and additional optimization measures such as fluid replenishment with passive leg raise (PLR) can enhance PFO detection. We present a 57-year-old male with history of cryptogenic stroke and stubborn PFO which during TEE bubble study responded only to ample fluid replenishment with PLR following a period of prolonged preprocedural fasting.     

Inter- and intra-observer variability in detection of patent foramen ovale with contrast echocardiography

Patent foramen ovale is detected in-vivo using the techniqueof contrast echocardiography. A positive test depends on theability of an observer to recognise micro-bubbles passing fromthe right to the left heart, and to differentiate them frombackground noise and/or chordae tendinae. To assess the inter- and intra-observer variability of thistechnique four observers reviewed independently, and on twoseparate occasions, 100 consecutive contrast studies storedon video tape. The proportions of agreement (95% CI) for each separate observeron the two occasions for the presence of patent foramen ovalewere 0.91 (0.76–0.98), 0.88 (0.73–0.92), 0.80 (0.63–0.92)and 0.78 (0.60–0.91), and for its absence were 0.96 (0.88–0.99),0.95 (0.87–0.99), 0.90 (0.81–0.96) and 0.91 (0.82–0.96),respectively. The proportions of agreement (95% CI) betweenall observers on the first viewing were 0.78 (0.72–0.84)for the presence and 0.91 (0.87–0.93) for the absenceof patent foramen ovale. For the second viewing these were 0.81(0.75–0.86) and 0.91 (0.88–0.94), respectively (P= NS, Chi-squared test). These results indicate that contrast echocardiography is subjectto clinically acceptable inter- and intra-observer variability.     

Enhanced detection of patent foramen ovale by systematic transthoracic saline contrast echocardiography

Objective

We aimed to evaluate the effectiveness of transthoracic saline contrast echocardiography (TSCE) in detecting patent foramen ovale (PFO).

Background

Transesophageal echocardiography (TEE) is semi-invasive and not ideal for PFO screening.

Methods

112 patients (48 males, 46 ± 14 years) with suspected PFO received intravenous agitated-saline contrast at rest and stress (strain and release phases of Valsalva maneuver and coughing). The presence of interatrial shunting was defined as > 5 bubbles appearing in the left heart within 3 cardiac cycles. The stage of the maneuver at which interatrial shunting occurred was recorded. The TSCE findings were validated by TEE.

Results

TEE identified PFO in 45% of patients. The sensitivities of TSCE in detecting PFO at rest, during strain and release of Valsalva maneuver, and coughing were 12.0%, 38.0%, 80.0% and 94.0% respectively (each p < 0.05 when compared to previous stage). Specificities were similar and > 95% for all stages. Moreover, the release phase of the maneuver improved the diagnostic accuracy [defined as (number of true positives + true negatives) divided by total in sample] with incremental value over the preceding strain phase (89.2 vs. 70.5%, p < 0.001).

Conclusions

Patent foramen ovale can be identified confidently with proper conduct of the Valsalva maneuver during the transthoracic saline contrast echocardiography.     

Protocol for optimal detection and exclusion of a patent foramen ovale using transthoracic echocardiography with agitated saline microbubbles

Agitated saline bubble studies in conjunction with echocardiography, in particular transesophageal echocardiography, are currently the principal means in the diagnosis of patent foramen ovale (PFO). We describe techniques and guidelines for the detection and exclusion of a PFO. The potential for misinterpretation of these bubble studies exists and therefore, several false positive and false negative scenarios are illustrated and discussed.     

Role of real-time three-dimensional transoesophageal echocardiography for guiding transcatheter patent foramen ovale closure

Patent foramen ovale (PFO) is a relatively common congenitalcondition which has been implicated in cryptogenic stroke asa result of paradoxical thromboembolism by right-to-left shunting.Many studies have demonstrated that transcatheter PFO closuresignificantly reduced the incidence of recurrent strokes ina small group of high-risk patients with PFO and atrial septalaneurysm compared with antithrombotic drugs. Two-dimensionaltransoesophageal echocardiography (2D TEE) has become the electiontechnique for guiding patent foramen ovale closure. Real-timeThree-dimensional transoesophageal echocardiography (3D TEE)may be potentially superior to 2D TEE in the accurate assessmentof the morphology and efficacy of transcatheter closure devicesbecause of a better spacial orientation.     

Harmonic imaging improves sensitivity at the expense of specificity in the detection of patent foramen ovale

Contrast echocardiography using agitated saline is widely employed to detect right to left shunt in patients with suspected patent foramen ovale (PFO). The sensitivity of fundamental transthoracic echocardiography (FTTE) is often limited by poor far-field resolution. The purpose of this study was to evaluate the test characteristics of harmonic imaging during transthoracic echocardiography (HTTE) for the detection of PFO. METHODS: Sixty-four patients referred for transesophageal echo (TEE) for clinical indications underwent FTTE and HTTE during saline contrast injections. RESULTS: TEE identified nine PFOs. For FTTE, the sensitivity was 78% and the specificity was 100%. For HTTE, the sensitivity was 100% and the specificity was 82%. All ten false positives with HTTE occurred after five cardiac cycles, suggesting transpulmonary transit of the bubbles. CONCLUSION: In the detection of PFO, HTTE improves sensitivity at the expense of specificity, particularly if the timing of contrast appearance in the left heart is ignored.     

Transesophageal echocardiography-guided versus fluoroscopy-guided patent foramen ovale closure: A single center registry

Background

Percutaneous closure of patent foramen ovale (PFO) is conventionally performed under continuous transesophageal echocardiographic (TEE) guidance. We aimed to evaluate whether a simplified procedural approach, including pure fluoroscopy-guidance and final TEE control, as well as an aimed ‘next-day-discharge’ is comparable with the conventional TEE-guided procedure in terms of periprocedural and intermediate-term outcomes.

Methods

All patients who underwent a PFO closure at our center between 2010 and 2022 were retrospectively included. Prior to June 2019 cases were performed with continuous TEE guidance (TEE-guided group). Since June 2019, only pure fluoroscopy-guided PFO closures have been performed with TEE insertion and control just prior to device release (fluoroscopy-guided group). We analyzed procedural aspects, as well as long term clinical and echocardiographic outcomes.

Results

In total 291 patients were included in the analysis: 197 in the TEE-guided group and 94 in the fluoroscopy-guided group. Fluoroscopy-guided procedures were markedly shorter (48 ± 20 min vs. 25 ± 9 min; p < .01). There was no difference in procedural complications, including death, major bleeding, device dislodgement, stroke or clinically relevant peripheral embolization between the two groups (.5% vs. 0%; p = .99). Hospital stay was also shorter with the simplified approach (2.5 ± 1.6 vs. 3.5 ± 1.2 days; p < .01), allowing 85% same-day discharges during the last 12 months of observation period. At 6 ± 3 months echocardiographic follow-up a residual leakage was described in 8% of the TEE-guided cases and 2% of the fluoroscopy-guided cases (p = .08).

Conclusion

While a complete TEE-free PFO closure might have potential procedural risks, our approach of pure fluoroscopy-guided with a brisk final TEE check seems to be advantageous in terms of procedural aspects with no sign of any acute or intermediate-term hazard and it could offer an equitable compromise between the two worlds: a complete TEE procedure and a procedure without any TEE.     

Comparison of transthoracic echocardiography using second harmonic imaging, transcranial Doppler and transesophageal echocardiography for the detection of patent foramen ovale in stroke patients.

AIMS: The comparison of three imaging methods to determine which is the most accurate and reliable for the detection of right-to-left shunt. METHODS AND RESULTS: One hundred and seven patients who were hospitalized for stroke underwent: a transthoracic echocardiography (TTE) using second harmonic, a transcranial Doppler (TCD) and a transesophageal echocardiography (TEE) from August 2003 to April 2004. All studies were recorded on a videotape and were studied by a physician blinded to the study. With TTE and TEE, we found 44 (41%) patent foramen ovales. All contrast tests were positive with TCD for these 44 patients. For two patients, the contrast test was positive only with TTE and TCD. We found four false negative contrast tests with TTE. Among the 63 patients who had a negative contrast test with TEE and TTE, the results were the same with TCD for 59 of them; we were not able to determine a cause for the four positive tests. CONCLUSION: This study confirms that transesophageal echocardiography has limitations in the diagnosis of patent foramen ovale. In this study, the negative predictive value of transcranial Doppler was excellent. Therefore, this examination is able to exclude a patent foramen ovale with a high level of confidence.     

Asymptomatic significant patent foramen ovale: Giving patent foramen ovale management back to the cardiologist

Percutaneous closure of patent foramen ovale (PFO) is still a much debated issue. Although many questions remain open, patients are finding out about PFO management and are beginning to ask for the most rapid and complete solution to their potential problems in spite of the warnings from the medical profession about off‐label indications for transcatheter closure. As a result, asymptomatic patients with PFO are coming into medical offices to be assured about stroke risk or treated for any degree of migraine. The cardiologist should be the preferred interlocutor in asymptomatic significant PFO: he is competent in assessing the associated anatomical and functional risk factors, and he is the only specialist who can evaluate on the basis of the anatomo‐functional picture the potential risk of paradoxical embolism and discuss with patients eventual off‐label indications to closure. © 2008 Wiley‐Liss, Inc.     

Real time/three-dimensional transthoracic echocardiographic visualization of the valve of foramen ovale

We describe an adult patient in whom the valve of foramen ovale and its opening and closing movements were well visualized by live/real time three-dimensional transthoracic echocardiography.     

Sustained long‐term benefit of patent foramen ovale closure on migraine

Objectives : This single‐center, observational, prospective study evaluated the impact of patent foramen ovale (PFO) closure on migraine attacks over time. Background : PFO closure may reduce the frequency and severity of migraine headaches in patients with significant right‐to‐left shunts. Methods : Between May 2000 and September 2009, 305 consecutive patients (mean age, 43 ± 12 years; 54.5% women) with a prior embolic cerebrovascular event underwent PFO closure with the Amplatzer PFO occluder for recurrence prevention. All patients had right‐to‐left shunts; the shunts were associated with migraine symptoms in 77 (25%), either alone (n = 64, 83%) or with aura (n = 13, 17%). Septal aneurysm was present in 15 (19.5%) migraine patients, and 43 (56%) had a previous transient brain ischemic attack. All migraine patients had a computed tomography scan or magnetic resonance imaging, indicating a previous brain ischemic lesion. All 305 patients underwent transthoracic echocardiography with clinical follow‐up at 24 hr, at 3, 6, and 12 months, and then yearly. Results : An acute migraine attack occurred 24–48 hr after PFO closure in 28 (36.4%) of 77 patients. There was a significant reduction (>50%) in the number and intensity of attacks in 46 (60.5%) of 77 patients at the 3‐month follow‐up. At the 12‐month follow‐up, migraine had ceased in 23 (46%) patients, and 20 (40%) had a reduction in the migraine recurrence rate and disabling symptoms. These results were maintained at follow‐up (mean, 28 ± 27 months). There was overall improvement in migraine in 89% of the treated patients. Conclusions : Percutaneous PFO closure in migraineurs may provide beneficial mid‐term and long‐term results, with significant reduction in the intensity and frequency of headache symptoms. © 2010 Wiley‐Liss, Inc.     

老年卵圆孔未闭患者经胸超声心动图特点及临床分析

目的对老年卵圆孔未闭(PFO)患者经胸超声心动图特点及临床分析。方法回顾性分析8例老年PFO患者的临床特点;并通过彩色多普勒超声诊断仪检测老年PFO患者的经胸超声心动图特点及心脏的变化。结果老年PFO患者多有不同程度的心功能不全表现,多伴有心房颤动、左右心房及左心室的扩大及肺动脉压增高、左心室射血分数减低。4例治疗后病情好转,PFO消失或显示不清。彩色多普勒血流频谱显示,8例PFO患者血液分流方向均为左向右分流,3例病情最重时出现双向分流。PFO大小均在3～4 mm。4例患者住院期间并发重度肺部感染死亡,4例仍健在,继续接受治疗。结论老年PFO患者有其独特的特征,多伴有心功能不全、心房颤动、心腔扩大、肺动脉高压等,PFO血液分流方向多为左向右分流,病情严重时出现双向分流,预后较差。     

Transesophageal echocardiography through nasal way as a guide to percutaneous closure of patent foramen ovale

Percutaneous device closure of patent foramen ovale (PFO) has become an effective and safe alternative to medical or surgery treatment. Transesophageal echocardiography (TEE), as commonly used to guide this procedure, has the limitation to require general anesthesia. Recently, intracardiac echocardiography (ICE) with AcuNav probe was used to guide percutaneous PFO closure. We report a 42 year-old man with two previous cryptogenetic strokes in whom both diagnosis and guidance of PFO closure were performed by means of TEE using the AcuNav catheter introduced through nasal way (TEENW). This technique, that does not require general anesthesia, provided adequate and complete view of the Amplatzer procedure. TEENW might offer a feasible and equivalent echocardiographic alternative either to standard TEE or ICE as a guide to percutaneous PFO closure.     

Anatomy of the patent foramen ovale for the interventionalist

Background: Patent foramen ovale (PFO) is an interatrial communication whose management is controversial. Several manufacturers have submitted protocols for Food and Drug Administration (FDA) approval of their PFO closure device. The purpose of this study was to define anatomy relevant to percutaneous PFO closure, validate the clinical observation that most PFOs contain little tissue rim at the aorta, comment on proposed closure guidelines, and to discuss approaches to PFO closure. Methods: From the Mayo Clinic Tissue Registry, five normal hearts with PFO were selected from each sex from the first 10 decades of life (n = 100). Measurements (mm) included PFO length, diameter, and distance from FO‐superior vena cava (SVC) and FO‐aortic annulus (AoAn). Patient age, weight, and height were obtained from autopsy reports, and body surface area (BSA) was calculated. Results: PFO length and diameter increased with age (P = 0.029 and 0.001, respectively), and FO‐SVC and FO‐AoAn increased with BSA (P ≤ 0.0001 and 0.006, respectively). PFO diameter was larger in women than men (P = 0.028). Using current sizing guidelines, 66% (CI = 56–75%) of the 100patients would have been excluded from device closure, and only 31% could have received the smallest (18 mm) device. Conclusions: Our results suggest that the proposed device closure guidelines may result in inappropriate device sizing. In addition to excluding suitable candidates, strict application of the guidelines could also result in incomplete closure or device embolization. Suggestions for modification of the guidelines and options for device closure are discussed. © 2009 Wiley‐Liss, Inc.