Author + information
- Bernhard Meier, MD⁎ ()
- ↵⁎University Hospital Bern, Cardiology, Swiss Cardiovascular Center Bern, Freiburgstrasse, 3010 Bern, Switzerland
I thank Dr. Newton and colleagues for their interest in the paper of Hildick-Smith et al. (1) and my commentary (2). Obviously, neither the paper nor my commentary have convinced Dr. Newton and colleagues. Their letter will be appreciated by colleagues looking for reasons to stick to their habits of using intracardiac echocardiography (ICE) guidance during closure of the patent foramen ovale (PFO).
The inferior rim of a PFO is invariably at least 3 cm long and never a problem. I agree that tiny atrial septal defects in the flimsy central part of the septum primum are detectable by ICE and not by fluoroscopy. Yet they are very easily overlooked even with ICE, and they lack clinical significance. Paradoxical embolism through such a defect is highly unlikely as they are way off the inflow current of the inferior vena cava.
The thrombus ICE may find on a closure device exiting the carrier sheath may well be the consequence of using ICE in the first place. If a PFO closure is done swiftly, with less than a minute between inserting the device into the carrier sheath and having it placed properly, there is no risk (no time) for thrombus formation. If, however, the catheters are left unattended to concentrate on ultrasound pictures for several minutes, a thrombus may form in the sheath. It will then be pushed out by the exiting device to which it may remain attached.
ICE gives little additional information about the position of the device beyond what is seen with the proper fluoroscopic view using a small amount of contrast medium. It is unlikely that crucial information can be gathered from ICE in more than a fraction of a percent of cases. This hardly makes it worthwhile in the other >99% of patients.
After having closed more than 1,000 PFOs, I have not yet encountered the indication to close a PFO in a woman in early pregnancy. If I do, ultrasound guidance will be my choice.
Is it not trivial math that if 1 groin puncture requires a certain amount of time and engenders a certain amount of discomfort and complications, 2 groin punctures will double that?
- American College of Cardiology Foundation
- Hildick-Smith D.,
- Behan M.W.,
- Haworth P.,
- Rana B.S.,
- Thomas M.R.
- Meier B.