Safety and efficiency of multimodal imaging approach of patent foramen ovale closure in patients with cryptogenic stroke

Abstract

Recent studies have shown a significant superiority of patent foramen ovale (PFO) closure over antithrombotic therapy in stroke recurrence prevention. However, uncertainty about the guidance technique remains. Most centers perform percutaneous closure of PFO using simultaneously fluoroscopic and intra-procedural echocardiography to select the optimal device. While transoesophageal echocardiography (TEE) requires general anaesthesia, intracardiac echocardiography (ICE) is costly and has inherent risks. We report the safety and efficiency data of a simplified technique: local anaesthesia, PFO closure under fluoroscopic guidance, with only pulmonary vein opacification using contrast angiography and transthoracic echocardiography control before releasing the device. Single center retrospective registry enrolling 134 consecutive patients who underwent PFO closure between May 2016 and December 2019 to cryptogenic stroke. The closure decision was taken by multidisciplinary team. All the patients underwent a preprocedure TEE for morphological evaluation of PFO. An echocardiography control was done at 1 month. At 6 and 12 months a bubble test was done. All procedures were successful, regardless PFO complexity (ASA 62.7%), without major procedural complications. Total fluoroscopic time was 5.1 minutes, the dose-area product was 5047.8 mGy/m 2 and the application of contrast medium was 7.2 mL. During a mean follow-up period of 17.2 months, one transient ischemic attack, one deep vein thrombosis and one thrombus on the occluder was reported. Contrast echocardiography at 6 months showed complete closure in 92% of patients, whereas a minimal or moderate residual shunt persisted in 4.6%, 1.8% respectively. At 12 months only 2 patients presented a residual shunt. Percutaneous PFO closure with multimodal imaging approach is a safe and effective procedure and allows a lower radiological exposure and contrast administration.