Predictors of Residual Right-to-Left Shunt After Percutaneous Suture-Mediated Patent Fossa Ovalis Closure

Transcatheter PFO closure for cryptogenic stroke: current approaches and future considerations

Patent Foramen Ovale (PFO) is a common congenital atrial septal defect present in 20%-35% of the general population. Although generally considered a benign anatomic variant, a PFO may facilitate passage of a thrombus from the venous to arterial circulation, thereby resulting in cryptogenic stroke or systemic embolization. A PFO is detected in nearly one half of patients presenting with cryptogenic stroke and often considered the most likely etiology when other causes have been excluded. In this review, we discuss the contemporary role of transcatheter closure of PFO in the treatment of cryptogenic stroke, including devices currently available for commercial use in the United States (Amplatzer PFOTM Occluder and GoreTM Cardioform Septal Occluder) and a novel suture-mediated device (NobleStitchTM EL) under clinical investigation. To provide the best care for cryptogenic stroke patients, practitioners should be familiar with the indications for PFO closure and corresponding treatment options.

Atrial function after percutaneous occluder device and suture-mediated patent fossa ovalis closure

Aims

Suture-mediated patent fossa ovalis (PFO) closure is a recent technique, achieving closure by means of a simple suture. The differences between traditional occluders and suture might have different impacts on atrial function. The aim of this study was to evaluate atrial function after PFO closure by direct suture and traditional occluders.

Methods and results

We prospectively studied 40 patients, 20 undergoing PFO closure by occluder and 20 by suture. Trans-thoracic echocardiography was carried out the day before and 1 year after the procedure. Left atrial (LA) and right atrial (RA) function was evaluated by using speckle-tracking analysis assessing the strain values of the reservoir (st-RES), conduit (st-CD), and contraction phase (st-CT). Compared with values baseline PFO closure, at 1-year follow-up, patients with occluder implantation had significantly worse indices of LA and RA reservoir (LA st-RES P < 0.001; RA st-RES P < 0.001), conduit (LA st-CD P < 0.001; RA st-CD P < 0.001), and contraction function (LA st-CT P < 0.05; RA st-CT P < 0.05). In patients with suture-mediated PFO closure, no significant differences were observed in the same indices of reservoir (LA st-RES P = 0.848; RA st-RES P = 0.183), conduit (LA st-CD P = 0.156; RA st-CD P = 0.419), and contraction function (LA st-CT P = 0.193; RA st-CT P = 0.375).

Conclusion

Suture-mediated PFO closure does not alter atrial function. Conversely, PFO closure by metallic occluders is associated with a deterioration of atrial function. This detrimental effect on atrial function could favour the development of atrial arrhythmias.

Percutaneous suture-based patent foramen ovale closure: A state-of-the-art review

Percutaneous closure of a patent foramen ovale (PFO), a common variation of interatrial septum anatomy, is a commonly performed procedure in the catheterization laboratory to reduce the risk of recurrent stroke in selected patients and to treat other PFO-related syndromes. In the last twenty years, disc-based devices have represented the armamentarium of the interventional cardiologist; recently, suture-based devices have become an attractive alternative, despite limited data regarding their long-term performance. The present review gives an overview of the current evidence regarding suture-based PFO closure, the device's characteristics, the echocardiographic evaluation of the PFO anatomy, and recommendations for patient selection. A detailed procedural guide is then provided, and potential complications and future developments in the field are discussed.

Effects of morphological characteristics of patent foramen ovale by transesophageal echocardiography on minimalist transcatheter closure in southern China

OBJECTIVES

Transcatheter closure has become one of the main treatment methods for patent foramen ovale (PFO). However, the population in southern China is generally thin and the size of PFO is small, so the application of minimalist surgery is challenging. This study aimed to analyze the morphological characteristics of PFOs in southern China by transesophageal echocardiography (TEE), and to explore the influence on minimalist transcatheter closure.

METHODS

About 110 patients with PFO closure in our hospital were selected. All cases were examined by TEE including the PFO size, length, septum secundum thickness, color characteristic and surrounding structures, and morphologically classified. During the operation, the procedure time, number of times for the guidewire attempting to pass the interatrial septum and the success rate of simply using J guidewire to cross the interatrial septum were recorded.

RESULTS

About 110 cases of PFO were classified into two categories and four subtypes, including 55 cases with Uniform Channel Type (UCT, 50.0%), 16 cases with Irregular Channel Type (ICT, 14.6%), 15 cases with Right Funnel Type (RFT, 13.6%), and 24 cases with Left Funnel Type (LFT, 21.8%). According to the complexity of the procedure, they were divided into simple procedure (n = 73) and complex procedure (n = 37). Multivariate logistic regression showed that the anatomical types of PFO, the tunnel entrance size, and the tunnel entrance size <2 mm were independent factors affecting the complexity of procedure [OR = 2.819, 95% CI (1.124, 7.066), p = .027; OR = .027, 95% CI (.004, .208), p = .001; OR = 4.715, 95% CI (1.028, 21.619), p = .046]. With ICT and LFT groups, the procedure duration was relatively long (p < .001), number of times for the guidewire attempting to pass the interatrial septum was significantly increased (p < .001), and the success rate of simply using J guidewire to cross the interatrial septum was relatively low (p < .001).

CONCLUSIONS

The PFO size in southern China was relatively small and characterized by large tunnel tension. It was concluded that TEE could clearly show the morphological characteristics of PFO, which could provide guidance for making more reasonable surgical plans in clinical practice, shorten the procedure time and improve the success rate of PFO closure.

A new echocardiographic index to select patients for PFO suture-mediated percutaneous closure

OBJECTIVES

To identify a simple echocardiographic predictor of procedural success to select patient for percutaneous suture-mediated patent fossa ovalis (PFO) closure.

BACKGROUND

Percutaneous suture-mediated PFO closure has been shown as a safe and advantageous alternative to device-based PFO closure, yet its overall success is slightly lower in unselected patients.

METHODS

Preprocedural transesophageal echocardiogram (TEE) of 302 patients (113 men, 45 ± 12 years) who underwent percutaneous suture-mediated PFO closure were reviewed.

RESULTS

At echocardiographic follow-up (3-6 months), residual right-to-left shunt (RLS) ≥2 was found in 60 (19.9%) patients. At multivariable analysis, only two anatomical variables measured at preprocedural TEE were found as independent predictors of residual RLS ≥ 2 at follow-up: PFO maximum width (odds ratio [OR] 1.89, 95% confidence interval [CI] 1.16-3.40, p = 0.02) and PFO minimal septa overlapping (OR 0.58, 95% CI 0.35-0.88, p = 0.02). An index based on the ratio of PFO maximum width to PFO minimum septal overlapping (W/SO) proved to be the most powerful predictor of RLS ≥ 2 at follow-up (OR 48.1, 95% CI 9.3-352.2, p < 0.01). The ROC curve for the W/SO ratio was found to have an AUC of 0.84 (95% CI 0.75-0.93) and a cut-off value of 0.61 yielding a sensitivity of 80% and specificity of 78% with a negative predictive value of 94%. A decision tree methodology's AUC was 0.75 (95% CI 0.67-0.83).

CONCLUSIONS

The results of this study indicate that the ratio between the maximum amplitude of the PFO and the minimum overlap of the septa is the best predictive index of a favorable result by using one stitch only.

Noblestitch® system for PFO closure: A novel but judicious alternative to traditional devices—A case report

Background

Percutaneous suture-mediated patent foramen ovale (PFO) closure has recently been used with the aim of avoiding double-disc nitinol device implantation. This novel technique has been carried out successfully in several centers offering PFO closure with an effective closure rate comparable to conventional double-disc devices.

Case summary

A 50-year-old man, a pentathlon athlete, suffering from a previous left-sided ischemic stroke, underwent percutaneous closure of a permanent right-to-left shunt via PFO with a large fenestrated septum primum aneurysm at another institution. The NobleStitch® system was successfully implanted using local anesthesia and under angiographic-fluoroscopic monitoring. He was discharged home on aspirin 100 mg daily with a moderate residual shunt on contrast transthoracic echocardiography (cTTE) that persisted unaltered at subsequent controls. After 7 months, unable to resume sporting activity because of physical discomfort and dyspnea on exertion, the patient asked for a second opinion at our Heart and Brain clinic. Two-dimensional (2D) TTE showed septum primum laceration next to a radiopaque polypropylene knot with a moderate bidirectional shunt located at the fenestrated septum primum far from the PFO site. A catheter-based closure of the septal defect was therefore planned under local anesthesia and rotational intracardiac echo monitoring. An equally sized discs 28.5 mm × 28.5 mm Flex II UNI occluder (Occlutech GmbH, Jena, Germany) was successfully implanted across the atrial septal defect without complications. The patient was discharged in good clinical conditions; dual antiplatelet therapy (aspirin 100 mg/daily and clopidogrel 75 mg/daily) was recommended for 2 months and then single antiplatelet therapy (aspirin100 mg/daily) up to 6 months. Abolition of the residual shunt was confirmed at 1- and 6-month follow-up by contrast transcranial Doppler and 2D color Doppler cTTE.

Discussion

Closing a PFO with a suture-base system, without leaving a device implant behind, may be a cutting-edge technology and potential alternative to traditional devices. Nevertheless, meticulous selection of the PFO anatomies by 2D TEE is key to a successful closure procedure in order to avoid complications that must be managed again with a second percutaneous procedure or by surgery.

Three-dimensional Transesophageal Echocardiography for Transcatheter Patent Foramen Ovale Closure: Standardizing Anatomic Nomenclature and Novel Sizing Concepts

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Terminology for PFO tunnel sizing remains unstandardized.

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Device size selection for transcatheter PFO closure is highly variable.

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Tunnel width measurements may be a better descriptor of PFO size.

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Wire sizing may be a useful technique for assessment of PFO dimensions.

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PFO sizing strategies based on tunnel width need to be better studied.

The evolving role of echocardiography in the assessment of patent foramen ovale in patients with left-side thromboembolism

Patent foramen ovale (PFO) is the most common congenital cardiac abnormality found approximately in 25% of the adult population The pathophysiological role of paradoxical embolization through the PFO in ischemic stroke is well established. "Self-expanding double disk" and, more recently, suture-based "deviceless" systems are used for PFO closure in the setting of secondary prevention after ischemic stroke likely related to paradoxical embolization. Ultrasound plays a significant role in PFO assessment, indication to treatment, intra-procedural guidance, and follow-up for those undergoing PFO closure. Three different techniques are frequently used for these purposes: transesophageal echocardiography, transthoracic echocardiogram, and transcranial Doppler. In this review, advantages and limits of these techniques are discussed in detail to improve our skills in detection and treatment of this important condition by using ultrasound.