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Patent Foramen Ovale Closure Without Echocardiographic Control: Use of "Standby" Intracardiac Ultrasound

David Hildick-Smith, MD, MRCP^_*,_*, Miles Behan, DM, MRCP^_*, Peter Haworth, MRCP^_*, Bushra Rana, MRCP, Martyn Thomas, MD, FRCP

^_* Sussex Cardiac Centre, Brighton and Sussex University Hospital NHS Trust, Brighton, United Kingdom
Department of Cardiology, King's College Hospital NHS Foundation Trust, London, United Kingdom.

^_* Reprint requests and correspondence: Dr. David Hildick-Smith, Sussex Cardiac Centre, Brighton and Sussex University Hospitals NHS Trust, Brighton, United Kingdom, BN2 5BE. (Email: David.Hildick-Smith{at}BSUH.nhs.uk).

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.

Key Words: patent foramen ovale closure • intracardiac echocardiography • percutaneous closure

Abbreviations and Acronyms   ASD = atrial septal defect   ICE = intracardiac echocardiography   PFO = patent foramen ovale   TOE = transesophageal echocardiography

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