Transcatheter Closure of PFO and ASD: Multimodality Imaging for Patient Selection and Perioperative Guidance

Same-day discharge after percutaneous closure of persistent foramen ovale using intracardiac echocardiography and the Gore Septal Occluder

Aim

Periprocedural and postinterventional care of patients undergoing closure of patent foramen ovale (PFO) varies significantly across care providers. Same-day discharge (SDD) after transcatheter interventions is an evolving concept. This study aimed to assess the same-day discharge rate and incidence of complications in patients undergoing PFO closure with intracardiac echocardiography (ICE) using the Gore®Cardioform Septal Occluder (GSO) device. The secondary aim was to analyse the efficacy of femoral vein closure with Perclose ProGlide.

Methods

Patients who underwent PFO closure with the GSO device at a university hospital in Stockholm, Sweden, were retrospectively included between March 1, 2017, and June 30, 2020, all with cryptogenic stroke as the indication for the procedure. All patients underwent PFO closure with conscious sedation and local anaesthesia. The indication for all patients was a cryptogenic stroke. Periprocedural imaging was performed using ICE and fluoroscopy in all patients. Patient characteristics and periprocedural data were collected from patient charts. Patients were kept on bed rest for 4-6 h post-intervention. Transthoracic echocardiography and clinical examination, including groin status, were performed before discharge. No clinical routine follow-up was performed the day following the intervention. Clinical follow-up was done by phone call two weeks after the procedure, and echocardiographic follow-up was done after 12 months. Data were analysed using linear and logistic regression models.

Results

In total, 262 patients were included, of which 246 (94%) had SDD. 166 patients (63%) received the ProGlide™ system for femoral vein access closure. Post-procedural arrhythmias occurred in 17 (6%) patients, and vascular complications in 9 patients (3%). The overall closure rate at follow-up was 98.5%. 25 out of 264 patients (9.5%) had to be readmitted within the first eight weeks after PFO closure, 16 due to atrial fibrillation warranting electric cardioversion, one due to an arteriovenous fistula that was operated, four due to chest pain/pain at the access site, and four patients developed fever. There was no difference in SDD among patients who received ProGlide™ vs. patients who did not receive ProGlide™.

Conclusion

SDD appears safe after transcatheter PFO closure with the GSO device with high procedural success rates. Low rates of complications and readmissions make the intervention suitable for this patient-friendly and cost-effective concept.

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.

In Vivo Contrast Imaging of Rat Heart with Carbon Dioxide Foam

Widely used classical angiography with the use of iodine contrast agents is highly problematic, particularly in patients with diabetes mellitus, cardiac and pulmonary diseases, or degree III or IV renal insufficiency. Some patients may be susceptible to allergic reaction to the iodine contrast substance. The intravenous injection of a bolus of CO₂ (negative contrast) is an alternative method, which is, however, currently only used for imaging blood vessels of the lower limbs. The aim of our project was to design and test on an animal model a methodology for injecting the CO₂ foam which would minimize the possibility of embolization of the brain tissue and heart infarction, leading to their damage. This is important research for the further promotion of the use of CO₂, which is increasingly important for endovascular diagnosis and treatment, because carbon-dioxide-related complications are extremely rare. CO₂ foam was prepared by the rapid mixing in a 2:1 ratio of CO₂ and fetal bovine serum (FBS)-enriched Dulbecco's Modified Eagle Medium (DMEM). Freshly prepared CO₂ foam was administered into the catheterized rat tail vein or cannulated rat abdominal aorta and inferior vena cava (IVC). CO₂ foam was compared with commercially available microbubbles (lipid shell/gas core). The rat heart in its parasternal long axis was imaged in B-Mode and Non-linear Contrast Mode before/during and after the contrast administration. Samples of the brain, heart and lungs were collected and subjected to histological examination. The non-linear contrast imaging method enables the imaging of micron-sized gas microbubbles inside a rat heart. The significantly shorter lifetime of the prepared CO₂ foam is a benefit for avoiding the local ischemia of tissues.