The distance from the right parasternal third intercostal space to the puncture site was measured and marked before the procedure for catheter insertion d. This distance was also measured for the following insertion procedure for the super stiff guide wire and delivery sheath f, k. A 6Fr multi-purpose catheter b , guide wire c , and delivery sheath d were inserted through the PFO. RA, right atrium; LA, left atrium.
One day after the procedure, TTE and chest X-rays were performed to check for device position and any residual shunt or other peri-procedural complications. Electrocardiograms were checked for arrhythmia. The above examinations were performed by the same sonographer who participated in the procedures. Further annual clinical follow-up was scheduled for all patients. The main concern was whether new arrhythmia, recurrent stroke, aortic erosion, and other complications occurred.
Headache impact test-6 HIT-6 scores were used to evaluate migraine symptomatology and compare the pre- and post-procedural headache severities of patients with migraine [ 9 ]. If a new TIA or stroke was suspected, then a brain imaging examination was performed. For patients with palpitations, chest pain, or other symptoms, dynamic electrocardiogram examination needed to be performed.
Statistical analysis was performed using the SPSS Postoperative and preoperative HIT-6 scores were compared using paired t-test. There were 64 male patients and 68 female patients who participated.
Seventy-nine cases Fifty-seven The mean procedural time from percutaneous femoral vein puncture to the removal of the sheath was The mean hospitalization costs were The mean postoperative hospital stay was 1. The selection of the specific cardi-O-fix occluder was detailed in Table 1.
Finally, the mean sizes of the occlusion device were Among them, four 3. Considering migraine symptoms among the 57 patients with PFO, significant relief or resolution was reported by 42 The pre- and post-procedural HIT-6 scores for patients with migraine are shown in Table 2.
We repeated a procedure to upsize the first selected device in three patients. This device had initially failed to stabilize in place.
Irregularly shaped PFOs, which were encountered in 13 9. We had to rotate the catheter back and forth several times in the fovea ovale area of nine patients to adjust the tip of the multi-purpose catheter before passing through the PFO.
Straight-tip loach guidewire was used to pass the PFO through in three patients. Complications such as displacement of occlude, pericardial effusion, aortic erosion, infective endocarditis, occluder thrombosis, hemolysis, and femoral arteriovenous fistula were found during the follow-up period.
The foramen ovale is a potential door capable of opening from the right to left atrium. Patients with PFO are several times more likely to have stroke, migraine, peripheral arterial embolism, decompression sickness, and other risks than the normal population.
The pathogenicity of PFO attracted the attention of numerous experts and scholars, and PFO closure has been explored to prevent recurrent stroke events, treat migraine, and platypnea-orthodeoxia [ 12 ].
Although the efficacy of PFO closure for cryptogenic stroke has been controversial, numerous experimental studies showed that PFO closure is superior to medical therapy in terms of preventing further stroke. Guidelines must be updated to reflect this procedure [ 13 , 14 , 15 ]. In most centers, fluoroscopy-guided approach has been generally used for the percutaneous closure of PFO, and TEE is only used for pre- or intra-procedural evaluation. However, X-rays emitted by fluoroscopy negatively affect the health of patients and operators.
The contrast agents used in the process of digital subtraction angiography may also adversely affect the health of patients. The TEE-only guided occlusion of several simple congenital heart diseases, such as atrial septal defect ASD , ventricular septal defect, and patent ductus arteriosus, is safe and effective [ 16 , 17 , 18 ]. TEE can clearly show the location of the catheter and guide the catheter through PFO to establish the path during the occlusion process.
Accurately understanding the morphology of PFO in patients to improve the success rate of procedures and reduce complications is necessary for operators. Meanwhile, echocardiography is better than radiation guidance in assessing anatomy and hemodynamics [ 19 ].
TEE can observe the following in detail: the sizes of inlet and outlet of PFO, the tunnel length of PFO, the thickness of secondary septum, whether interatrial septal aneurysm was combined and its sizes, and whether abnormal eustachian valve and other abnormalities exist. TEE can also be used to monitor the whole process of occluder release, especially when determining whether or not the occluder was correctly placed, finding whether residual shunts exist, whether it affected the heart valves or coronary sinus, and whether aortic erosion occurs.
The use of TEE also allowed for occluder replacement if the occluder was incorrectly positioned. After completely releasing the occluder, TEE was also applied to reevaluate the effect of the occlusion.
The main advantages of this type of approach is the avoidance of X-ray radiation and contrast agent application. Moreover, incision is not necessary. All of our procedures were performed in the operating room, and the disinfected areas included the chest and groin to avoid delay in transfer or re-anesthesia of the patients in the event of severe complications detachment of occluder or pericardial tamponade due to operational failure.
The procedure can be immediately converted to thoracotomy. In our procedures, the patients usually need general anesthesia with endotracheal intubation, which is a fly in the ointment. We may perform PFO closure for some suitable patients whose pictures are sufficiently clear by only using TTE under local anesthesia. However, TTE cannot provide a picture as clear as that produced by TEE and can be highly inaccurate in overweight, barrel-chested patients [ 7 ].
PFO is closely associated with migraines, but the underlying mechanism of PFO-induced migraine remains unclear. One hypothesis states that some specific metabolites such as serotonin and endothelial vasoconstrictor peptide, or subclinical emboli that enter the cerebral circulation system through PFO cause the migraine [ 20 , 21 ]. A clinical meta-analysis shows that patients with PFO are 2. Whether or not the PFO closure is effective in treating migraines remains controversial. Several randomized studies have failed to confirm that the improvement in migraine is due to the closure of the foramen ovale.
In the present study, migraine relief was reported in The proportion of patients with a score of more than 60 before the closure procedure was as high as PFO occlusion showed good efficacy despite the lack of randomized control group. During long-term follow-up of However, although no blood flow signal between the atriums was observed by echocardiography after PFO closure, the residual right-left shunt in 39 The high incidence of residual shunt in the follow-up period of this study may be due to the use of c-TTE for assessing RLS.
In some other trials c-TEE was used for follow-up. TEE is a semi-traumatic and painful examination for patients, and completing Valsalva maneuver successfully during the process was difficult for some of them. Thus, the residual shunt may have been underestimated. We assumed that the application of transseptal puncture may have contributed to the large residual shunt. Transseptal puncture technique may be an effective option for facilitating device closure after the failure of conventional approach, but an increased incidence of residual shunt was observed with this technique [ 23 ].
Comparative studies between Cardi-O-fix PFO occluder and other type of occluders have been rarely conducted. Perhaps the lack of effectiveness of the device was also a factor affecting the high rate of residual shunt. Moreover, other reasons for residual shunt after occlusion exists. Atrial-level shunt is not the sole source of paradoxical emboli.
Pulmonary arteriovenous malformations, venous abnormalities, including persistent left-sided superior vena cava to the left atrium, or an unroofed coronary sinus may also cause paradoxical embolization. Positive results on bubble testing after PFO closure are not uncommon; important anatomic lesions may coexist and remain a potential risk factor for recurrent paradoxical embolization [ 24 ]. Emory University researchers will compare the technique to nuclear stress testing in a small group of patients.
Morbidity and mortality conferences offer chances to review negative outcomes and implement practice changes to avoid similar events in the future. The Chicago-based chain of plus Medicare clinics said it first received a civil investigative demand last week.
PFO closure found to be cost-effective following cryptogenic stroke. Around the web Health Imaging. Health Imaging. Health Exec. Enter the email you used to register to reset your password.
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