How to do when PFO closure failed under routine guidance: the first clinical experience for PFO closure

Abstract

P atent foramen ovale (PFO) is the most common abnormality of fetal origin and is affecting approximately 25% of the worldwide adult population. During the past two decades, instead of surgical closure, catheter-based procedures to close the PFO have become widely used among patients. Periprocedural guidance with fluoroscopy, transesophageal echocardiography (TEE) or intracardiac echocardiography have been the mainstream technique to ensure a safe and successful procedure. However, because of its 2-dimensional (2D) nature, these modalities may be associated with a certain incidence of failure or complication. Herein, we describe an innovative use of 3-dimensional (3D) mapping system to guide the PFO closure which can provide a percutaneous alternative in some patients with a failed PFO closure. We present the following case in accordance with the CARE reporting checklist. We describe a 53-year-old male patient who was admitted to our department because of limb dyskinesia for half a year. He had a medical history of lacunar infarction, which was being treated with relevant medication. Transthoracic echocardiography (TTE) indicated that he had patent foramen ovale (PFO), accompanying with paroxysmal atrial tachycardia. PFO closure had been performed for the patient. Since the PFO was a “simple” defect, which was with a short tunnel and without an aneurismal atrial septum, the closure procedure was performed under fluoroscopy guidance as this would obviate the need for general anesthesia. While, the J-tipped guide wire could not across the PFO tunnel into the left atrium because the foramen ovale was tough and the PFO tunnel was short. Considering that under three-dimensional (3D) mapping system guidance, the foramen ovale can be accurately located, and even the atrial septum can be passed across without X-ray exposure, we decided to apply 3D mapping system (EnSite Velocity 5.0, St. Jude Medical) to guide PFO closure. The catheter was introduced and placed in target position under 3D mapping system guidance. The 3D geometry of the right atrium and proximal coronary sinus was obtained with ablation catheter and then the foramen ovale was accurately located (Figure 1A, purple arrow). Since the PFO tunnel was tough and short, a conventional 4 mm tip ablation catheter could not across the foramen ovale. Therefore, we tried to use steerable decapolar catheter (IBI-AFocusII & Optima, St. Jude Medical), which was more supportive to guide the delivery sheath into the left atrium (Figure 1B and C). When the device was adequately placed, which was confirmed with echocardiography and fluoroscopy, the left atrial disc was deployed, followed by the right disc. The occluder had been released successfully (Figure 1D, white arrow). The patient underwent a successful PFO closure under the 3D mapping system guidance. In the following 12 months, the patient had no further symptom of limb dyskinesia and no recurrence of lacunar infarction. Percutaneous closure of PFO in patients with cryptogenic stroke has been undertaken for years. 3] For the majority of patients, periprocedural guidance with fluoroscopy, transesophageal echocardiography (TEE) or intracardiac echocardiography is required to ensure a safe and successful procedure. LETTER TO THE EDITOR J Geriatr Cardiol 2021; 18(1): 89–90