The puncture technique: a new method for transcatheter closure of patent foramen ovale

Long-term clinical outcomes for patients with uncrossable patent foramen ovale

Introduction

Patent foramen ovale (PFO) closure is performed in selected patients with cryptogenic stroke to prevent recurrence. The prognosis of patients with uncrossable PFO after failed guidewire or catheter passage during the procedure remains unknown. We compared the long-term prognosis between uncrossable PFO and successful PFO closure in patients with high-grade PFO shunts.

Methods

We analyzed patients who underwent PFO closure for stroke or transient ischemic attack (TIA) prevention at Gachon University Gil Medical Center between April 2010 and March 2022. The primary outcome was a composite of recurrent stroke or TIA. Secondary outcomes included stroke, TIA, all-cause death, and a composite of stroke, TIA, and all-cause death.

Results

Of 286 patients, 245 were included in the analysis after excluding those with transseptal puncture technique usage or concurrent atrial septal defect. Among them, 82 had uncrossable PFO, and 163 underwent successful PFO closure. Large shunts were more prevalent in the PFO closure group compared to the uncrossable PFO group (62.0% vs. 34.1%, P < 0.001), and resting shunts were also more common in the PFO closure group (17.8% vs. 2.4%, P < 0.001). Stroke or TIA occurred in 2 patients (2.4%) in the uncrossable PFO group and 8 patients (4.9%) in the PFO closure group (hazard ratio, 1.44; 95% confidence interval, 0.30-6.81; P = 0.647). Additionally, no disparities in the occurrence of stroke or TIA were found in subgroups divided by baseline characteristics, RoPE score, or shunt grade.

Conclusion

Clinical outcomes for patients with uncrossable PFO seem similar to those with successful PFO closure.

A Review of Transcatheter Closure of Patent Foramen Ovale

A patent foramen ovale (PFO) is a common variant in cardiac anatomy found in 25% to 30% of U.S. adults. While PFOs are a normal part of fetal development and commonly seen in asymptomatic adults, they have been implicated in a variety of pathophysiologic conditions. The most clinically important of these is paradoxical embolization of venous thrombus resulting in stroke or systemic embolism. Various devices can be used to close PFOs via a transcatheter approach to prevent recurrent stroke. Data regarding the safety and effectiveness of these devices is rapidly evolving, with recent long-term results suggesting efficacy in preventing secondary stroke in carefully selected patients. This review discusses historical data on PFO occurrence and treatment, a risk score that can assess the likelihood of a stroke being attributable to a PFO, a variety of other conditions that may be linked to PFOs, and current research regarding the role transcatheter closure plays in their treatment.

PFO "angioplasty": The preparation of a very stiff and long tunnel for device closure

INTRODUCTION

Patent foramen ovale (PFO) closure is a widely performed procedure. Understanding the anatomy is mandatory in order to perform the procedure successfully. The degree of overlap between the septum primum and secundum is called the tunnel. In particular, long and stiff tunnels may prevent the correct positioning of devices that have a fixed distance between the right and left atrial discs.

PATIENTS AND METHODS

We evaluated retrospectively 361 patients with PFO closure between January 2012 and June 2014 in our institution and were treated due to previous history of ischemic stroke. By TEE, the overlap between septum primum and secundum is usually better seen on the bicaval view that is obtained at 75-90° midesophageal views. Tunnel length and PFO opening were measured. Twelve subjects (median age 35 years; range 30-58 years; three females) showed a long (median 22 mm; range 15-32 mm) and rigid tunnel (median opening 2 mm; range 1-4 mm).

RESULTS

Angioplasty of the tunnel was performed by using peripheral angioplasty balloons with a length ranging from 4 to 8 cm and a diameter between 8 and 12 mm. After angioplasty, the tunnel appeared shorter (12 mm; range 8-16 mm) and less rigid (median opening 8 mm; range 7-12 mm). The following devices were implanted: 25 mm Amplatzer PFO occluder in three patients; 25 mm Gore septal occluder in nine subjects. Median fluoroscopy time was 8 min (range 6-10 min). No complications occurred. At a median follow-up of 12 months (range 2-18 months), no problems occurred and all subjects but one (trivial residual shunting) showed a complete closure.

CONCLUSIONS

Angioplasty of a PFO rigid and stiff tunnel is a feasible and safe option. © 2016 Wiley Periodicals, Inc.

Transseptal puncture to facilitate device closure of "long-tunnel" patent foramen ovale

BACKGROUND

Patent foramen ovale (PFO) is common and may predispose to paradoxical embolism. Transcatheter device closure of PFO can be challenging in certain cases of "long-tunnel" PFO morphology. We report our experience with device closure of long-tunnel PFO using transseptal puncture.

METHODS

We retrospectively reviewed all cases of PFO device closure using transseptal puncture at the Mayo Clinic from January 1, 2010 to September 30, 2013. We arbitrarily defined a PFO tunnel configuration as a tunnel length ≥ 12 mm as observed in intracardiac echocardiography (ICE) at the time of device closure.

RESULTS

Twelve patients (mean age 40.8 [range 15-67] years; 7 males [58%]) underwent PFO device closure with transseptal puncture. The most common indication for PFO closure was previous stroke (n = 7, 58%). Median tunnel length measured by ICE was 15 mm (12-20 mm). GORE® HELEX® Septal Occluder was used for closure in all but one patient. The only significant procedural complication was a minor perforation of the left atrial wall during attempted septal puncture, which resulted in a trivial pericardial effusion that resolved without intervention. At latest follow-up (mean 543 days, [range 170-1162]) one patient had a residual shunt and subsequently died due to complications during surgical PFO closure. No recurrent strokes or TIAs were reported.

CONCLUSION

Though not without risk, transseptal puncture can be a valuable tool for facilitating device closure of long-tunnel type PFOs. GORE® HELEX® Septal Occluder may be an effective option for facilitating device closure for patients with long-tunnel type PFO.

Influence of PFO Anatomy on Successful Transcatheter Closure

Patent foramen ovale (PFO) is considered a risk factor for serious clinical syndromes, the most important of which is cryptogenic stroke in the setting of paradoxic embolism. The safety and feasibility of transcatheter PFO closure have been addressed in several studies; this procedure is performed worldwide with excellent results. Variations in the atrial septal configuration and PFO are frequent and have an impact on the technical aspects and success in transcatheter PFO closure. To minimize the rate of complications of percutaneous closure of PFO, patients must be carefully selected on the basis of morphology and location of the interatrial defect.

Patent foramen ovale, systemic embolization, and closure

Patent foramen ovale has become the subject of increasing interest in modern cardiovascular disease. This has been the result of several factors including, among others, description of paradoxical embolism, documentation of patent foramen ovale with right to left shunt, the rather ubiquitous use of echocardiography, the issue of stroke prevention, and more recently, the relationship between patent foramen ovale and migraine.

Determinants and clinical significance of persistent residual shunting in patients with percutaneous patent foramen ovale closure devices

BACKGROUND

Percutaneous patent foramen closure has emerged as a dynamic therapy for stroke prevention secondary to paradoxical embolism. Recent reports, however, have documented uncertain clinical efficacy and patients with incomplete PFO closure may remain at risk of recurrent events. We sought to identify echocardiographic determinants and the clinical significance of persistent residual shunting after percutaneous PFO closure.

METHODS

From 2002 to 2008, 51 consecutive patients with recurrent stroke (n=46) or transient ischemic attack (TIA) (n=5) underwent percutaneous PFO closure at a tertiary care hospital. PFO size, degree of shunt, tunnel length, and atrial septal aneurysm geometry were documented at the time of device implantation. All patients received follow-up with transesophageal (n=43) or transthoracic (n=8) echocardiography 6.7+/-2 months post procedure and presence of residual shunting and recurrent stroke/TIA were recorded.

RESULTS

All patients underwent percutaneous PFO closure without complication. Ten patients (20%) demonstrated residual right-to-left shunting at the time of follow-up: color Doppler (2), mild (n=3), moderate (n=2) and severe (n=3). Univariate analysis revealed larger PFO size (F=4.71, p=0.036) as the only independent predictor of residual shunting after PFO closure. Ninety six percent of patients remained stroke and TIA free 3 years+/-8 months post closure, with no clinical differences between the two groups.

CONCLUSIONS

In patients undergoing percutaneous PFO closure for stroke or TIA, a larger PFO size predisposes to residual shunting approximately 6 months post PFO closure, but with no short term increased risk of recurrent thromboembolic events.

Percutaneous Closure of Patent Foramen Ovale and Atrial Septal Defect: Procedure Outcome and Medium-Term Follow-Up

Percutaneous closure of atrial septal defect (ASD) and patent foramen ovale (PFO) has become increasingly utilized. The indications and results of percutaneous closure are diverse.

AIM

To assess the indications, results, and complications of percutaneous closure of ASD and PFO in our tertiary center.

METHOD

Case note review and retrospective analysis of all consecutive patients undergoing percutaneous closure over a 3-year period from January 2003 to October 2005 with a mean follow-up of 19 months (4-36).

RESULTS

There were 185 consecutive patients. The mean age was 44.9 years (SD 12.9) and 53% (n = 98) were males. There was 59% (n = 109) PFO and 41% (n = 76) ASD. The predominant indication for PFO closure was cerebrovascular accident (CVA) (42.2%, n = 46)- and for ASD, dilated right ventricle (68.4%, n = 52). Of all procedures, 94.6% (n = 175) were first time and 5.4% (n = 10) were redo for residual shunt. Overall, the success rate was 96.8% (n = 179) with two patients referred for surgical closure due to the large size of ASD and unsuitability for percutaneous closure, two procedures abandoned due to pericardial effusion, and two abandoned because the PFO was too small to cross. The Amplatzer device was used in 92.7% (n = 166) and the Starflex in 7.3% (n = 13). Minor complications were recorded in 10 patients (5.4%), of which 4 (2.2%) had minor venous access bleeding, 1 patient (0.5%) had retroperitoneal hematoma, and 2 patients (1.1%) had transient atrial fibrillation. One patient (0.5%) had transient inferior ST elevation during the procedure, one patient (0.5%) reported chest pain postprocedure, and one patient (0.5%) developed septicemia 3 weeks postprocedure. Major complications were recorded in three patients (1.5%), one patient (0.5%) with retroperitoneal hematoma requiring blood transfusion and two patients (1%) with pericardial effusion following transseptal puncture, requiring aspiration. No death, stroke, or device embolization was recorded.

CONCLUSION

Our experience with percutaneous closure in adults demonstrates excellent results and safety with few complications. Percutaneous device closure will replace surgical closure for many ASDs and PFOs.

Five-year experience with percutaneous closure of patent foramen ovale

Patent foramen ovale (PFO) has been implicated in the pathogenesis of cryptogenic stroke, arterial desaturation, decompression illness, and migraine headache (MH). This study evaluated the safety of percutaneous transcatheter PFO closure in patients with cryptogenic stroke, transient ischemic attack, or arterial desaturation. Additionally, symptomatic reduction in MH was determined after interatrial shunt closure. Of the 252 patients referred to the University of California, Los Angeles, with PFO, 131 underwent closure of the interatrial communication with a CardioSEAL (n = 30) or Amplatzer (n = 101) device. PFO morphology was evaluated with transesophageal echocardiography. Follow-up was conducted at 1 to 2 months with echocardiography, with clinical assessment annually thereafter. At an average follow-up of 30 months, there was no recurrence of any thromboembolic event (transient ischemic attack, stroke, or peripheral). There was a reduction in MH, defined as the complete resolution of headache or a >50% reduction in the number of headache days, in 85% of patients after PFO closure. Temporary problems after device implantation, including chest discomfort and palpitations, were reported in 23% of patients and occurred more frequently in patients with nickel hypersensitivity (p <0.05). In conclusion, transcatheter PFO closure is an effective and safe therapeutic modality in the prevention of thromboembolic events and MH associated with interatrial shunting in patients who present with cryptogenic stroke. Pending randomized, controlled trials are necessary to determine if this invasive approach is preferable to medical therapy for the prevention of recurrent stroke or as primary treatment for patients with MH.

BioSTAR Evaluation STudy (BEST)

Background— The use of permanent synthetic implants to close atrial septal defects (ASD) and patent foramen ovale (PFO) has a number of limitations, including late complications and the limiting of transeptal access to the left heart should it be required for the later treatment of acquired heart disease. BioSTAR is a novel, bioabsorbable, atrial septal repair implant. This phase I pilot study evaluates the feasibility, safety, and effectiveness of BioSTAR for the first time in humans.

Methods and Results— We conducted a prospective, open-label, multicenter clinical study in 58 patients aged 28 to 68 years who had a clinically significant ASD or PFO. Percutaneous shunt closure was undertaken with the BioSTAR septal repair implant. Successful device implantation was achieved in 57 (98%) of 58 patients. Closure at 30 days and 6 months, assessed by contrast transthoracic echocardiography, was 48 (92%) of 52 and 54 (96%) of 56, respectively. There was no evidence of a clinically significant response to the device. Transient atrial arrhythmia occurred in 5 patients after implantation. No major safety issues were observed.

Conclusions— This study demonstrates the feasibility, safety, and effectiveness of BioSTAR for the closure of ASD and PFO in humans with a high rate of early and complete shunt closure. BioSTAR is a novel septal repair implant designed to provide biological closure of atrial-level defects using the patient’s natural healing response. Because 90% to 95% of the implant is absorbed and replaced with healthy native tissue, future access to the left atrium may be achieved.

Transseptal technique of percutaneous PFO closure results in persistent interatrial shunting

Our goal was to review the effectiveness of the transseptal and tunnel techniques of patent foramen ovale (PFO) closure. Percutaneous PFO closure is an increasingly common treatment for prevention of paradoxical embolism and is typically performed by passing the device through the defect tunnel itself. The transseptal technique, in which the septum primum is punctured to create a hole through which the device is passed, has been proposed for patients with long-tunnel PFO. From May 2001 to December 2003, 120 patients underwent PFO closure at our institution and were included in this analysis. Defect closure was assessed by transesophageal echocardiography (TEE) with bubble study. Clinical follow-up data were obtained by clinic visits or standardized telephone interviews. Device closure was successfully completed in all patients, with 12 (10%) undergoing transseptal closure and 108 (90%) undergoing tunnel closure. Immediately following the procedure, complete closure occurred in 6 of 12 (50%) of the transseptal group and 88 of 108 (81.5%) of the tunnel group (P = 0.0120). Of the 89 patients (74.2%) who returned for 6-month TEE, complete closure was demonstrated in 4 out of 10 (40%) of the transseptal group and 58 out of 79 (73.4%) of the tunnel group (P = 0.0303). There have been four transient ischemic attacks during a mean follow-up of 11 months. The transseptal technique of PFO closure results in a higher proportion of patients with persistent interatrial shunting when compared with the tunnel technique. Whether this is due to a difference in technique, device, or patient anatomy is unclear.

Association of interatrial shunts and migraine headaches

OBJECTIVES

To examine the relationship between patent foramen ovale (PFO) or atrial septal defect (ASD) with the incidence of migraine headache (MHA) and assess whether closure of the interatrial shunt in patients with MHA would result in improvement of MHA.

BACKGROUND

Migraine headache is present in 12% of adults and has been associated with interatrial communications. This study examined the relationship between PFO or ASD with the incidence of MHA and assessed whether closure of the interatrial shunt in patients with MHA would result in improvement of MHA.

METHODS

A sample of 89 (66 PFO/23 ASD) adult patients underwent transcatheter closure of an interatrial communication using the CardioSEAL (n = 22), Amplatzer PFO (n = 43), or the Amplatzer ASD (n = 24) device.

RESULTS

Before the procedure, MHA was present in 42% of patients (45% of patients with PFO and 30% of patients with ASD). At three months after the procedure, MHA disappeared completely in 75% of patients with MHA and aura and in 31% of patients with MHA without aura. Of the remaining patients, 40% had significant improvement (>or=2 grades by the Migraine Disability Assessment Questionnaire) of MHA.

CONCLUSIONS

Transcatheter closure of PFO or ASD results in complete resolution of MHA in 60% of patients (75% of patients with migraine and aura) and improvement in symptoms in 40% of the remaining patients. Interatrial communications may play a role in the etiology of MHA either through paradoxic embolism or humoral factors that escape degradation in bypassing the pulmonary circulation. A randomized trial is needed to determine whether transcatheter closure of interatrial shunts is an effective treatment for MHA.

Patent foramen ovale closure: role of the pediatric cardiologist

This article discusses the role of the pediatric cardiologist in understanding complex patent foramen ovale closure.

Percutaneous patent foramen ovale and atrial septal defect closure in adults: Results and device comparison in 100 consecutive implants at a single center

Closure of interatrial septal defects with percutaneous devices is increasingly common. However, the indications for closure and techniques for device implantation are diverse. We reviewed our first 100 consecutive implants to assess and compare the indications, results, complications, and evolution of techniques for percutaneous patent foramen ovale (PFO) and atrial septal defect (ASD) closure. The mean age of patients was 52 years and 70% were female. Paradoxical embolism was the predominant indication (94%) for PFO closure and significant left-to-right shunt was the most frequent indication (89%) for ASD closure. Implantation success was 94% with major complications in 3 patients (2.8%). Transesophageal echocardiography was utilized in the initial 27 procedures and then replaced by intracardiac echocardiography in subsequent ones, with an associated reduction in procedure and physician time. During 6 months of follow-up, 3 patients were readmitted for atrial arrhythmias (2 patients) and an MRI-negative neurologic event (1 patient). Echocardiography at 6 months in 83% of the PFO patients revealed moderate and severe positive contrast studies for right-to-left shunting in one third of patients, with differences between devices and insertion techniques. This single-center experience with percutaneous device closure of PFO and ASD in adults demonstrates excellent results with few complications.

Incidence of thrombus formation on the CardioSEAL and the Amplatzer interatrial closure devices

Transcatheter closure for atrial septal defect (ASD) and patent foramen ovale (PFO) is a promising alternative to surgical closure or anticoagulant therapy. A potential complication is thrombus formation on the device after implantation. From February 2001 to June 2003, 66 patients with atrial communication were treated successfully with the Amplatzer device (16 septal and 20 PFO occluders) or the CardioSEAL device (30). Patients were discharged on antiplatelet medication (aspirin and clopidogrel) and/or anticoagulation. Fifty patients (76%) had transesophageal echocardiography (TEE) 1 month after device implantation (28 +/- 10 days). No patient experienced a thromboembolic episode during follow-up. TEE revealed that thrombus formation occurred more frequently on the CardioSEAL device (5 of 23 patients; 22%) than on the Amplatzer device (0 of 27 patients; 0%) (p = 0.02). Although thrombus disappeared or markedly diminished after additional anticoagulation therapy in 3 patients, 1 patient had surgical explantation of the device due to progressive increase in the size of thrombus with hypermobility despite intensive anticoagulation therapy. There was no variable associated with the presence of thrombus formation on the occluder other than the use of the CardioSEAL device. One month after insertion, the CardioSEAL device is more likely to have thrombus present than the Amplatzer device.

Use of balloon pull-through technique to assist in CardioSEAL device closure of patent foramen ovale

CardioSEAL device closure of patent foramen ovale (PFO) has been advocated for the treatment of patients with cryptogenic stroke. Using the standard delivery technique, partial deployment of the CardioSEAL device can occur, especially in patients with a thick septum secundum and/or long PFO tunnel. We hypothesized that using a left atrial-to-right atrial balloon pull-through to make the septum primum incompetent would result in improved final device position regardless of septal thickness or tunnel length. Catheterization reports, cineangiograms, and transesophageal echocardiograms of 51 patients who underwent CardioSEAL device closure of PFO between March 2000 and August 2002 were retrospectively reviewed. Group 1 (n = 21) included patients with CardioSEAL placement using the standard technique and group 2 (n = 30) included patients with CardioSEAL placement using the balloon pull-through technique. There were no differences between the groups in terms of age (43.6 vs. 45.3 years; P = NS), weight (83.3 vs. 89.9 kg; P = NS), septum secundum thickness (6.4 vs. 7.0 mm; P = NS), PFO tunnel length (15.5 vs. 13.1 mm; P = NS), or device size. In group 1, 4/21 (19%) had partial deployment of the CardioSEAL device, while in group 2, no partial CardioSEAL deployment (0/30) was observed. No complications were associated with the balloon pull-through technique. We conclude that the left atrial-to-right atrial balloon pull-through technique is safe and may allow for better final position of the CardioSEAL device during PFO closure.

Closure of secundum atrial septal defects with the Amplatzer septal occluder device: techniques and problems

Percutaneous transvenous closure of atrial septal defects (ASDs) has become feasible in recent years, as later-generation devices have largely overcome initial difficulties in device deployment and complication rates. The Amplatzer septal occluder (ASO) is one such device that we have used extensively and is, in our opinion, the most versatile and practical to use. It is capable of closing defects up to 40 mm in diameter via a relatively low-profile delivery sheath. More importantly, the ASO may be easily withdrawn into the sheath after deployment but prior to release, which is essential in safely closing difficult defects where successful positioning on the initial deployment is not guaranteed. In this article based on our experience, review of the literature, and communications with other operators, we describe the various problems encountered in closing atrial septal defects and make suggestions as to the best way of overcoming these difficulties.