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FIGURE 15.13 (A) Fluoroscopy of an intracardiac echocardiography (ICE) imaging catheter on the left side of the image with a 5F MP1
catheter engaged into the foramen ovale (asterisk), filling it with contrast medium and the contrast medium is seen spilling back (arrows) into the
right atrium (RA) without any entering the left atrium (LA), suggesting a sealed foramen ovale pouch. (B) An intracardiac echocardiography
image of the interatrial septum during agitated saline contrast medium injection under Valsalva release, showing a stream of bubbles (arrows)
crossing from the right atrium (RA) to the left atrium (LA), confirming the presence of a PFO despite a negative radiographic contrast medium
injection as seen in (A). (C) Once the 5F MP1 catheter was slightly withdrawn, rotated counterclockwise and readvanced into the PFO (asterisk),
angiographic contrast medium flowed fully into the left atrium (LA) indicated by arrows. ICE, intracardiac echocardiography; RA, right atrium.
VII. SAFETY, TECHNICAL ASPECTS TO PFO CLOSURE, AND FUTURE OUTLOOK
UNUSUAL CASES: TIPS AND TRICKS 199
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After closing the PFO with a 25 mm Gore Cardioform Septal Occluder, a repeat agitated saline contrast medium
injection was performed to confirm closure. Surprisingly, there was a significant persistent right-to-left shunt.
Repeated agitated saline contrast medium injections, with adjustment of the ICE catheter to interrogate the pulmo-
nary veins, revealed agitated saline bubbles in the right inferior pulmonary vein, suggesting a transpulmonary shunt
in addition to the PFO that was just closed. An angiogram performed into the right main pulmonary artery revealed
an area in the periphery that appeared to be an arteriovenous malformation (AVM). A 5F Judkins Right (JR) 4 cath-
eter was positioned just before the area and selective angiography was performed showing a large AVM
(Fig. 15.12B), which was subsequently reconstructed in 3 dimensions by computed tomography (Fig. 15.12C). The
patient later underwent occlusion of this AVM to ensure all routes for paradoxical emboli were sealed. In this
case, the PFO was probably an “innocent bystander” since the flow through the pulmonary AVM was much greater;
but that was only discovered after the PFO was closed because there was such a large residual shunt [29]. During the
case, it is helpful to meticulously reassess all imaging data both preoperatively and intraoperatively when there are
difficulties in closing the PFO.
In Case #4, a 66-year-old man suffered a st roke and the subsequent workup revealed no obvious cause of stroke,
but there was a small PFO with early shunting of a gitated saline contrast at rest on TEE. The patient was brought
for PFO closure, but the J-tipped wire would not cross the septum, despite appearing to slide under the septum
secundum. As noted previously, we used the technique of engaging the sept um with the 5F MP 1 catheter and
performing contrast medium injections, and we could delineate what appeared to be a sealed foramen ovale
(Fig. 15.13A). However, based on the MRI-proven stroke as we ll as agitated saline contrast seen c rossing the
septum on the TEE, we performed an agitated saline contrast medium injection from the femoral sheath. As shown
in the ICE image in Fig. 15.13B, there was a string of dense bubbles crossing the septum after release of the Valsalva
maneuver. Given this finding, we concluded that either there was another opening in the septum or perhaps a pul-
monary AVM was the cause of the right-to-left shunt. The catheter was withdrawn slightly and with counterclock-
wise rotation, t he catheter was readvanced to perform a contrast medium injection which now showed
free-flowing contrast into t he left atrium (Fig. 15.13C). At this point, a straight wire was used to cross the PFO
and bring the MP1 catheter into the left atrium, and the remainder of the procedure was completed without dif-
ficulty. We concluded that the initial catheter position was in a blind pouch of the partially closed PFO, but was not
directed toward the actual opening into the left atrium.
Although the PFO closure procedure is usually straightforward, anatomic variations, inconsistent imaging, and
small, tunnel-like PFOs can make it more challenging. It is important to review all preoperative cardiac imaging and
complement it with intraoperative imaging, including a full ICE interrogation of the interatrial septum and agitated
saline contrast study at the beginning of the procedure. If there is difficulty crossing the septum, a series of attempts
using ICE-guidance, including a soft straight tipped wire or the catheter alone, can often overcome the obstacle of a
small PFO. If not, hand injections of angiographic contrast medium can provide critical additional information about
the location and geometry of the PFO, to allow adjustments and permit crossing into the left atrium. Finally, using a
sizing balloon can confirm the PFO size and provide guidance in choosing the appropriate occluder size.
References
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July 2010;3(7):749e60. https://doi.org/10.1016/j.jcmg.2010.01.007.
[2] de Hemptinne Q, Horlick EM, Osten MD, et al. Initial clinical experience with the GORE CARDIOFORM ASD occluder for transcatheter atrial
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[3] Davison P, Clift PF, Steeds R. The role of echocardiography in diagnosis, monitoring closure and post-procedural assessment of patent fora-
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[4] Mojadidi M, Tobis, J, Mahmoud L, et al. Transesophageal echocardiography for the detection of patent foramen ovale. J Am Soc Echocardiogr,
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tial causes, and management. Tex Heart Inst J 2013;40(4):439e44.
[7] Bartel T, Konorza T, Arjumand J, et al. Intracardiac echocardiography is superior to conventional monitoring for guiding device closure of
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[8] Reynolds HR, Spevack DM, Shah A, et al. Comparison of image quality between a narrow caliber transesophageal echocardiographic probe
and the standard size probe during intraoperative evaluation. J Am Soc Echocardiogr October 2004;17(10):1050e2.
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(Auckl) 2015;8:231e9. https://doi.org/10.2147/MDER.S49567.
VII. SAFETY, TECHNICAL ASPECTS TO PFO CLOSURE, AND FUTURE OUTLOOK
15. HOW I DO IT: ICE-GUIDED TECHNIQUE FOR PERCUTANEOUS PFO CLOSURE200
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[10] Newton JD, Mitchell AR, Wilson N, et al. Intracardiac echocardiography for patent foramen ovale closure: justification of routine use. JACC
Cardiovasc Interv April 2009;2(4):369. https://doi.org/10.1016/j.jcin.2009.02.005.
[11] Alqahtani F, Bhirud A, Aljohani S, et al. Intracardiac versus transesophageal echocardiography to guide transcatheter closure of interatrial
communications: nationwide trend and comparative analysis. J Interv Cardiol 2017;30(3):234e41. https://doi.org/10.1111/joic.12382.
[12] Hara H, Virmani R, Ladich E, et al. Patent foramen ovale: current pathology, pathophysiology, and clinical status. J Am Coll Cardiol
November 1 , 2005;46(9):1768e76.
[13] Silvestry FE, Cohen MS, Armsby L, et al. Guidelines for the echocardiographic assessment of atrial septal defect and patent foramen ovale:
from the American society of echocardiography and society for cardiac angiography and interventions. J Am Soc Echocardiogr August 2015;
28(8):910e58. https://doi.org/10.1016/j.echo.2015.05.015.
[14] Sakagianni K, Evrenoglou D, Mytas D, et al. Platypnea-orthodeoxia syndrome related to right hemidiaphragmatic elevation and a ’stretched’
patent foramen ovale. BMJ Case Rep December 10, 2012;2012. https://doi.org/10.1136/bcr-2012-007735. pii: bcr-2012-007735.
[15] Tobis J, Narasimha D, Abudayyeh I. Patent foramen ovlae closure for hypoxemia. Interv Cardiol Clin 2017;6(4):547e54. https://doi.org/10.
1016/j.iccl.2017.05.003.
[16] Enriquez A, Saenz LC, Rosso R, et al. Use of intracardiac echocardiography in interventional cardiology; working with the anatomy rather
than fighting it. Circulation 2018;137:2278e94. https://doi.org/10.1161/circulationaha.117.031343.
[17] Jez J, Starek Z, Lehar L, et al. Complex electrophysiology intervention in a patient with an inferior vena cava filter. Cor Vasa October 2015;
57(5):e341e6.
[18] Bartel T, Mu
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ller S, Biviano A, et al. Why is intracardiac echocardiography helpful? Benefits, costs, and how to learn. Eur Heart J 2014;35(2):
69e76. https://doi.org/10.1093/eurheartj/eht411.
[19] Hijazi Z, Shivkumar K, Sahn D. Intracardiac echocardiography during interventional and electrophysiological cardiac catheterization. Cir-
culation 2009;119:587e96. https://doi.org/10.1161/circulationaha.107.753046.
[20] Rigatelli G, Pedon L, Zecchel R, et al. Long-term outcomes and complications of intracardiac echocardiography-assisted patent foramen ovale
closure in 1,000 consecutive patients. J Interv Cardiol 2016;29:530e8. https://doi.org/10.1111/joic.12325.
[21] Kim S, Hijazi Z, Lang R, et al. The use of intracardiac echocardiography and other intracardiac imaging tools to guide noncoronary cardiac
interventions. J Am Coll Cardiol June 9, 2009;53(23):2117e28. https://doi.org/10.1016/j.jacc.2009.01.071.
[22] George JC, Varghese V, Mogtader A. Intracardiac echocardiography; evolving use in interventional cardiology. J Ultrasound Med 2014;33:
387e95. https://doi.org/10.7863/ultra.33.3.387.
[23] Bartel T, Mu
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ller S. Device closure of interatrial communications: peri-interventional echocardiographic assessment. Eur Heart J Cardiovasc
Imaging July 1 , 2013;14(7):618e24. https://doi.org/10.1093/ehjci/jet048.
[24] Abaci A, Unlu S, Alsancak Y, et al. Short and long term complications of device closure of atrial septal defect and patent foramen ovale: Meta-
analysis of 28,142 patients from 203 studies. Cardiovasc Intervent 2013;82:1123e38. https://doi.org/10.1002/ccd.24875. https://doi.org/10.
1002/ccd.24875.
[25] Marriott K, Manins V, Forshaw A, Wright J, Pascoe R. Detection of right-to-left atrial communication using agitated saline contrast imaging:
experience with 1162 patients and recommendations for echocardiography. J Am Soc Echocardiogr 2013;26:96e102.
[26] Rodrigues AC, Picard MH, Carbone A, Arruda AL, Flores T, Klohn J, Furtado M, Lira-filho EB, Cerri GG, Andrade JL. Importance of
adequately performed Valsalva maneuver to detect patent foramen ovale during transesophageal echocardiography. J Am Soc Echocardiogr
2013;26:1337e43.
[27] Yamashita E, Murata T, Goto E, Fujiwara T, Sasaki T, Minami K, Nakamura K, Kumagai K, Naito S, Kario K, Oshima S. Inferior vena cava
compression as a novel maneuver to detect patent foramen ovale: a transesophageal echocardiographic study. J Am Soc Echocardiogr
2017;30:292e9.
[28] Gevorgyan R, Perlowski A, Shenoda M, Mojadidi MK, Agrawal H, Tobis JM. Sensitivity or brachial versus femoral vein injection of agitated
saline to detect right-to-left shunts with transcranial Doppler. Cathet Cardiovasc Interv 2014;15:992e6.
[29] Galea R, Wustmann K, Meier B, Ra
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ber L. Right-to-left shunt in cryptogenic cerebrovascular event: fleas and lice. Eur Heart J. 2019 Mar 20.
https://doi.org/10.1093/eurheartj/ehz161. pii: ehz161.
VII. SAFETY, TECHNICAL ASPECTS TO PFO CLOSURE, AND FUTURE OUTLOOK
REFERENCES 201
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CHAPTER
16
How I Do It: Fluoroscopy-Guided Technique for
Percutaneous PFO Closure
Bernhard Meier
1
, Fabian Nietlispach
2
1
University Hospital Bern, Bern, Switzerland;
2
Cardiovascular Center Zurich, Hirslanden Klinik im Park,
Zurich, Switzerland
OUTLINE
Introduction 203
Preliminary Exams and Device Selection 204
Passing the PFO 206
Introducing the Delivery Sheath 209
Device Deployment 210
Second Occluder for Residual Shunt at Follow-Up 215
Conclusion 215
Supplementary Materials 216
Conflicts of interest 216
References 216
INTRODUCTION
For over 2 decades, the authors have practiced catheter-based patent foramen ovale (PFO) closure for more than
8000 patients in a frugal way (i.e., guided by fluoroscopy only), with a high success rate and without any significant
in-hospital complications [1]. The world’s first dedicated PFO occluder (Amplatzer PFO Occluder) was clinically
introduced by one of the authors (BM) together with Kurt Amplatz in 1997 [2,3]. It is the only device in interventional
cardiology, together with the Inoue balloon for mitral valvuloplasty, that has been used in its initial design without
significant mo difications for decades. Later, other derivatives of the Amplatzer PFO Occluder, from the original and
other manufacturers, were used by the authors. The reasons not to use echocardiographic guidance are listed in Ta-
ble 16.1 [4]. The most compelling one may be patient comfort, followed by avoiding unnecessary irradiation of an
echocardiographer (Table 16.2 [4]) and risk (albeit small), logistical inconvenience, and cost of (intracardiac) echo-
cardiographic guidance. Intracardiac echocardiography-guided technique for percutaneous PFO closure is
described in Chapter 15. Although commonly used in clinical practice, imperative reasons for using echocardio-
graphic guidance have not occurred in the authors’ extensive practice. They would be: a situation not manageable
by fluoroscopy with contrast medium injection, a strict contraindication to radiation in early pregnancy, or a contra-
indication to using any contrast medium because of severely impaired kidney function (e.g., glomerular filtration
rate <15 mL/min) in patients not yet on dialysis. In patients with a preprocedural diagnostic transesophageal echo-
cardiography (TEE), fluoroscopy-guided PFO closure can be accomplished with as little as 5 mL of contrast medium
for documenting the final result and even that can potentially be omitted.
The procedure generally takes only minutes, unless it is combined with other diagnostic or therapeutic interven-
tions [5]. Having been shown the place to press, the fully awake patient can personally hold the groin after removal
of the venous sheath, just like holding the elbow after donating blood, and walk out of the catheterization laboratory.
203
PFO Closure for Stroke, Myocardial Infarction, Peripheral Embolism, Migraine, and Hypoxemia
Copyright © 2020 Elsevier Inc. All rights reserved.https://doi.org/10.1016/B978-0-12-816966-7.00016-6
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The pressure in the femoral vein while supine is about 10 mmHg, insufficient to infiltrate tissue and cause a
hematoma. That is why the skin suture applied by some operators at the end of the procedure (referred to as
figure-of-eight stitch) remotely (indirectly) closes the venous hole. Getting up, the pressure at the venous puncture
site remains nonpulsatile but increases to about 75 mmHg (weight of a vertical blood column of about 100 cm
from the tip of the head to the groin). The patient can manage this by increasing the firmness of finger pressure while
getting up. Hospital discharge generally occurs a few hours later with no physical restrictions imposed. Even sports
(e.g., diving) are allowed the same day. Predischarge transthoracic echocardiography (TTE), demonstrating the device
in place and excluding pericardial effusion or significant thrombus on the device, only takes 5 minutes and patients
often like to take home a picture showing the device in their heart. In practice, a predischarge TTE never shows any-
thing that needs attention and can thus be regarded as optional. The follow-up medication is low dose acetylsalicylic
acid every day for 2e5 months, without preloading or a loading dose. Typically, 75 mg of clopidogrel is also recom-
mended without preloading or a loading dose for 1 month. Prasugrel or ticagrelor are alternatives. Patients taking
oral anticoagulation do not need to pause the medication for the procedure, but anticoagulation is not continued after
the intervention, unless prescribed for a reason not addressed by PFO closure. In that case, additional antiplatelets are
not required. A follow-up TEE (in some centers just a TTE or transcranial Doppler exam) after 3e6 months, at least
1 month after stopping antiplatelets, is the only routine follow-up control recommended and generally closes the PFO
chapter for the patient. The procedure is summarized in Table 16.3 in its principal steps [3,6].
PRELIMINARY EXAMS AND DEVICE SELECTION
Ideally, there is a prior TEE examination to review (Fig. 16.1). The date is not important. A bubble test hopefully
clearly delineates contrast passage across the PFO. An unequivocal Doppler shunt through the PFO obviates the
need for a bubble study. This virtually guarantees the successful placement of a device and also provides all the
information required for device selection (Figs. 16.2 and 16.3). The rate of complete closure is better with smaller
devices as they hug the septum more snugly. Larger devices are selected for a reason as depicted in Fig. 16.2.They
cannot embolize or partially unhinge off the septum secundum (meaning that the cranial part of the right disc slips
into the PFO canal). Yet, they are often pulled away from the atrial septum in their periphery by convex parts of the
atrial wall or simply by the concavity of the atria. This compromises the complete closure rate. The standard
TABLE 16.1 Reasons for Not Using Echocardiographic Guidance.
• No significant benefit, success rate already close to 100%
• Transthoracic echocardiography poorly showing PFO in most adults
• Small risk for complications of transesophageal echocardiographic guidance
• Need for general anesthesia or intubation with transesophageal echocardiography
- If only moderate sedation used, risk of tube discomfort and bronchial aspiration in
supine position
• Radiation for echocardiographer (3 to 10 higher than radiation for operator) [4]
• Need for second venous access, complications, and cost in case of intracardiac
echocardiography
• Distraction by echocardiography from what is essential in fluoroscopy
• Longer procedure with increased risk for clots in or on sheath or other gear
TABLE 16.2 Radiation Exposure (mSv) of Transesophageal Echocardiographer and
Interventional Cardiologist During PFO Closure [4].
Echocardiographer Interventional Cardiologist
Head 5.9 2.1
Arm 18.7 2.8
Hand 20.7 7.0
Foot 17.9 1.8
P < .05 for comparisons at all measured sites.
16. HOW I DO IT: FLUOROSCOPY-GUIDED TECHNIQUE FOR PERCUTANEOUS PFO CLOSURE204
VII. SAFETY, TECHNICAL ASPECTS TO PFO CLOSURE, AND FUTURE OUTLOOK
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Amplatzer PFO Occluder 25 (right disc 25 mm/l eft disc 18 mm) will be chosen in about 80% of cases according to
the criteria in Fig. 16.2 and Fig. 16.3; an Amplatzer PFO Occluder 35 (35/25 mm) or alternatively an Amplatzer
Cribriform Occluder 30 (30/30 mm) or (rarely) 35 (35/35 mm) is used in about 20%. An Amplatzer Cribriform
Occluder 40 (40/40 mm) will only be required if an additional small ASD in the septum primum, quite distant
to the PFO, needs to be covered simultaneously. Cribriform devices with 2 identical size discs are suboptimal
for PFO closure.
Kurt Amplatz deliberately designed the PFO occluders to be asymmetrical and reserved the larger disc for the
right side. The anatomy of the PFO, with the septum primum overlying the septum secundum on its left side, ren-
ders partial or total embolization of the left disc to the right atrium practically impossible. A small left disc will reli-
ably shut the valve, like a door ajar that is pulled closed by an umbrella stuck through it, then opened, and pulled
back. However, the right disc may slip off the septum secundum, particularly if the latter is thick (also called lipo-
matous) and round or triangular like a cone or a wedge, and a mobile or even aneurysmal septum primum allows for
extensive device tilting during the heart cycle (Fig. 16.4, Video 16.1, Video 16.2 ). Larger discs carry a higher risk of
free wall erosion because small discs do not reach the free wall. Only the right side really demands larger discs.
Anatomically, an asymmetric device makes sense. As an exception, a narrow long tunnel or tiny hole may permit
a smaller right disc, even in the presence of an atrial septal aneurysm or thick septum secundum (Fig. 16.3).
TABLE 16.3 Frugal PFO Closure.
• 0e1 night at hospital
• Antibiotics (oral cephalosporin), 2 or 3 doses, first before, second at discharge (outpatient), third next
morning (inpatient)
• No echocardiographic guidance
• Heparin bolus 5000 U before puncture
• Local groin anesthesia
• Access: right femoral vein
• 0.035
00
regular U-tip guidewire, exchange length not required
• Multipurpose or right Judkins catheter to pass defect if wire fails to pass spontaneously
• 9 French single 45 degrees curve 60e80 cm TorqVue sheath (10 F for 40/40 mm Cribriform Occluder
or other brands)
• Right atrial contrast medium injections for position control (left anterior oblique view without any
overlap of discs)
• Unrestricted physical activity after a few hours
• Acetylsalicylic acid 100 mg for 2e5 months, starting after procedure without loading
• (Clopidogrel 75 mg for 1 month, starting after procedure without loading)
• Instruction for prophylaxis against endocarditis for 2e6 months
• Transesophageal echocardiography (less ideally transthoracic echocardiography or transcranial
Doppler exam) at about 3e6 months (1 month after stopping platelet inhibitors)
FIGURE 16.1 Diagnosis of PFO by Transesophageal Echocardiography (TEE). TEE proving a PFO by a spontaneous left-to-right Doppler
shunt (arrow, left panel). Although not additionally required in that case, the PFO was also demonstrated by a right-to-left bubble shunt at the end
of a sustained Valsalva maneuver (arrow, right panel). LA, left atrium; RA, right atrium; SP, septum primum; SS, septum secundum.
VII. SAFETY, TECHNICAL ASPECTS TO PFO CLOSURE, AND FUTURE OUTLOOK
PRELIMINARY EXAMS AND DEVICE SELECTION 205
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In the absence of a prior TEE, a TTE with bubble study may suffice to confirm the presence of a PFO (Fig. 16.5,
Video 16.3) (Chapters 2 and 3). To select the a ppropriate occluder device, it is prudent to assess the PFO character-
istics (flimsiness and mobility of the septum primum and thickness of the septum secundum) angiographically
before or after crossing it with a guidewire (Fig. 16.6, Video 16.4).
PASSING THE PFO
Intravenous heparin (5000 units) can be administered at the beginning of the procedure simultaneously with local
groin anesthesia. The entire procedure may take just 5 minutes, so early heparin injection intuitively makes sense but
assessing an activated clotting time does not. After puncturing the femoral vein through a w5 mm skin cut, a regular
0.035
00
U-tip guidewire is advanced up and through the right atrium. In about half of cases, the PFO will be passed
with the first or just a few such approaches (Video 16.5) because the opening is situated in the direction of the inferior
Normal
- No thick SS
- No ASA
PFO 25 (25/18 mm)
(about 80% of cases)
ASA
PFO 35 (35/25 mm)
or
Cribriform 30 (30/30 mm)
Exception:
Long tunnel, remote ASA, or small PFO:
PFO 25 (25/18 mm)
Thick (lipomatous) SS
ASA
+
Thick (lipomatous) SS
PFO 35 (35/25 mm)
or
Cribriform 35 (35/35 mm)
SS
SP
Amplatzer Device
SS
SP
SS
SP
SS
SP
PFO Characteristics
ASA: atrial septal aneurysm, SP: septum primum, SS: septum secundum
FIGURE 16.2 Device Selection Criteria. The length of the tunnel and the maximum opening gap of the PFO are of practically no importance
for Amplatzer device types, except that narrow long tunnels and small holes render difficult features of the septum primum, such as redundancy
called atrial septal aneurysm (ASA), and of the septum secundum (SS), such as thickness or round or cone shape, less important (Figure 16.3).
FIGURE 16.3 Narrow long tunnel and remote and localized atrial septal aneurysm (ASA). A long tunnel or a small hole stabilize the device
and render unhinging of the cranial right disc off the septum secundum (SS) into the PFO tunnel less likely and allow the selection of a standard
25/18 mm PFO Occluder (yielding the highest complete closure rate) even in the presence of a thick SS (not the case in the example depicted) and
an ASA. This particular ASA is remote and localized. This forfeits the need for a larger device because the ASA is too distant to allow the standard
PFO Occluder 25 device to pivot into its cavity.
VII. SAFETY, TECHNICAL ASPECTS TO PFO CLOSURE, AND FUTURE OUTLOOK
16. HOW I DO IT: FLUOROSCOPY-GUIDED TECHNIQUE FOR PERCUTANEOUS PFO CLOSURE206
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vena cava continuation. This is why it is an easy target for clots. PFO passage is recognized when the wire crosses the
heart silhouette toward the 2 o’clock position in the posteroanterior view and shows a straight course in the lateral
view. If the bare wire fails to pass, a multipurpose catheter (or right Judkins catheter if a diagnostic coronary angio-
gram is part of the intervention) is used without a sheath to point the wire in different directions by rotating the
catheter tip at a level just above the hepatic vein. The U-tip wire is intentionally sele cted to pass through the PFO
slit and avoid small holes in the septum primum that may occasionally be associated with atrial septal aneu rysms.
Straightening of the guidewire may increase the chance of passing a small PFO. This can be achieved by stroking
the back of the U-bend toward the wire tip with the thumbnail or a needle until it is straightened. This action is
reversible in case the U-tip is needed again. The next step would be to attempt passage with the cathet er itself, typi-
cally, by engaging the PFO entry and advancing the catheter with a slight counterclockwise rotation.
After passing with a wire or a catheter, on occasion the right upper pulmonary vein ending right above the PFO
may be entered (Video 16.6). The path out of the cardiac silhouette but toward the right side of the patient, rather
than the left side where the left atrium is, should be recognized as accomplished passing through the PFO rather
than just pulling back the guidewire. A left or lateral projection is optimal for that.
SS
SS
ASA
ASA
ASA
RA
RA
RA
LA
LA
LA
PM
SS
RA
LA
RA
LA
SS
SS
FIGURE 16.4 Atrial Septal Aneurysm (ASA) and Device Selection. An ASA of the septum primum (SP) allows for marked tilting of the PFO
Occluder during the cardiac cycle (top panels, Video 16.1, Video 16.2) with the risk of unhinging of the cranial right atrial disc portion off the
septum secundum (SS). The top panels show a case (Video 16.1) where, despite the use of a larger device (30/30 mm Cribriform Occluder), the
occluder is only sitting perfectly (left panel) while the ASA is not protruding into the left atrium (LA) but almost unhinges while the ASA is
protruding into the LA (right panel). The bottom panel shows a similar case (Video 16.2) in a patient with pacemaker electrodes (PM) in the right
atrium (RA) where the right disc of the incorrectly selected standard 25/18 mm PFO Occluder (right disc too small for the situation) unhinged to
wind up in the PFO canal with a significant residual shunt through the original PFO channel (arrow). The bottom center panel depicts this sit-
uation and the bottom right panel depicts the normal situation with transesophageal echocardiography looked at in the projection used for
angiography. The chance of complete closure in such a situation is still about 50% secondary to local endocardial abrasion and subsequent
neoendocardialization. The risk of device embolization is minimal (insert bottom right) as the right disc is larger than the PFO slit (like a button not
yet halfway through a button hole) and the connector gets stuck at the SS.
VII. SAFETY, TECHNICAL ASPECTS TO PFO CLOSURE, AND FUTURE OUTLOOK
PASSING THE PFO 207
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Difficult PFOs may need to be approached after an assessment with contrast medium (angiogram usually in a left
anterior oblique view) to unravel their anatomy for passage (Fig. 16.6, Fig. 16.7, Video 16.4, Video 16.7).
Sizing balloon measurement is never required for PFO closure. The quantified maximal opening is not instru-
mental as the septum primum is pulled against the septum secundum by the device. The length of the tunnel in
millimeters, evident from the parallel segment of a sizing balloon waist, was only of importance when intratunnel
or fusion devices were utilized; they are no longer in use. Even a soft gauging balloon used at low pressure carries
Right
Atrium
Right
Ventricle
Left
Ventricle
Left
Atrium
ASA
PFO
Shunt
ASA
PFO
SS
SS
FIGURE 16.5 Transthoracic Echocardiography (TTE) with Bubble Test Diagnostic for a PFO. The atrial septal aneurysm (ASA), well visible
even with TTE, already hints at a PFO, because atrial flimsiness and mobility beget PFO by preventing closure after birth. The arrow shows
bubbles crossing from the right atrium into the left atrium and from there into the left ventricle. The top insert shows the situation after placing a
30/30 mm Cribriform Occluder (standard 25/18 mm PFO Occluder not appropriate due to ASA) and the bottom insert shows the 6-month follow-
up three-dimensional transesophageal echocardiography documenting complete closure SS, septum secundum.
FIGURE 16.6 Angiographic Assessment of PFO Characteristics (Video 16.4). In this angiogram of the right atrium (RA) in a left anterior
oblique projection, all salient characteristics of a PFO can be seen. The shunt (arrow), the septum secundum (SS), the atrial septal aneurysm of the
septum primum (ASA), and the Eustachian valve (grouped arrows) are labeled.
VII. SAFETY, TECHNICAL ASPECTS TO PFO CLOSURE, AND FUTURE OUTLOOK
16. HOW I DO IT: FLUOROSCOPY-GUIDED TECHNIQUE FOR PERCUTANEOUS PFO CLOSURE208
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a small risk of tearing an overly thin septum primum and turning the PFO into an ASD which may then require a
different and larger closure device [7].
INTRODUCING THE DELIVERY SHEATH
During exchange for the delivery sheath, in case a diagnostic catheter has been used to place a regular length
guidewire in the left atrium, the proximal end of the guidewire maintained in the left atrium may disappear in
the catheter before the catheter is completely removed from the groin. Swiveling the catheter to overcome adhesion
friction may be sufficient to keep the guidewire put in place during the final catheter extraction. If that fails, a fluid-
filled syringe (or the contrast medium-filled power injector if the wire is kinked or sticky) is connected to the catheter
after the wire has disappeared. The part of the catheter still residing in the groin is slowly pulled out and secured
when exiting the skin while injecting forcefully to keep the wire in place. The delivery sheath is 20e40 cm shorter
than a catheter and can always be introduced over a regular length guidewire without having to pull the guidewire
tip out of the left atrium.
The delivery sheath can be introduced without predilatation over a regular 0.035
00
guidewire. Extra-stiff guide-
wires are not required. To get through the skin into the vein, continuous rotation (real screwing and not just half-
turns back and forth) is advised, ideally combined with short to and fro movements of the wire to avoid wire kinking
at the sheath tip. When reaching the right atrium over the guidewire, the sheath curve is directed toward the 2
o’clock position to effortlessly slide through the PFO.
If no prior TEE is available or questions about device selection persist, a selective angiogram can be performed
through the delivery sheath in a left anterior oblique or, less frequently, also in the posteroanterior projection
(Fig. 16.8, Video 16.7). For this, the dilator (in case of using a regular length guidewire, also the guidewire) is
removed once the sheath is deep within the left atrium. In the case of a regular length guidewire, the guidewire
is then reintroduced into the left atrium. The adjustable Y-connector that comes packe d with the delivery sheath
is connected. A general note of caution: always retract any catheter (or sheath) slightly before exiting its tip with
a wire in the thin-walled atria to avoid perforation in case the catheter tip should unintentionally be impinging
the wall. The sheath is withdrawn over the guidewire just proximal to the PFO for the angiogram and readvanced
FIGURE 16.7 Angiography Cases of PFO Which Were Difficulty to Pass. The angiograms (left anterior oblique views) show 3 PFOs that were
difficult to pass. The left one was passed by rotating the catheter tip clockwise, the center one by using a 0.014
00
coronary guidewire, and the right
one by using a straight 0.035
00
hydrophilic Terumo guidewire. All PFOs were successfully closed with standard Amplatzer 25 PFO Occluders
(inserts).
VII. SAFETY, TECHNICAL ASPECTS TO PFO CLOSURE, AND FUTURE OUTLOOK
INTRODUCING THE DELIVERY SHEATH 209
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