Patent foramen ovale closure without echocardiographic control: use of "standby" intracardiac ultrasound.
OBJECTIVE
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.
Hildick-Smith
David
D
Sussex Cardiac Centre, Brighton and Sussex University Hospital NHS Trust, Brighton, United Kingdom. David.Hildick-Smith@BSUH.nhs.uk
Behan
Miles
M
Haworth
Peter
P
Rana
Bushra
B
Thomas
Martyn
M
D000328:Adult; D006328:Cardiac Catheterization / Q000191:economics / Q000295:instrumentation; D003287:Contrast Media; D003362:Cost-Benefit Analysis; D017548:Echocardiography, Transesophageal / Q000191:economics; D004739:England; D004867:Equipment Design; D005260:Female; D005471:Fluoroscopy; D054092:Foramen Ovale, Patent / Q000000981:diagnostic imaging / Q000191:economics / Q000628:therapy*; D017721:Hospital Costs; D006801:Humans; D008297:Male; D008875:Middle Aged; D015641:Radiography, Interventional / Q000191:economics; D016896:Treatment Outcome; D018084:Ultrasonography, Interventional / Q000191:economics; D019564:Unnecessary Procedures / Q000191:economics
D003287:Contrast Media