The protocol and video publication were approved by the ethics committee of the University Hospital Jena. The patient gave his agreement for his anonymized data to be published for article purposes.
1. Physiological monitoring
<ol>
	<li>After bringing the patient to the operating table, establish a peripheral venous access line and connect to 500 cc of NaCl. Fix the arms and legs of the patient.</li>
	<li>Initiate the ECG, peripheral oxygen saturation, and pulse measurements. Perform sterilization of the right groin using an iodine based solution (e.g., Betadine solution).</li>
</ol>
2. Preparation of the sterile equipments
<ol>
	<li>Prepare sterile equipment with the materials required by the catheter assistant/nurse. Cover the sterilized femoral access site with a transparent foil plaster.</li>
</ol>
3. Venous puncture, catheter introduction, and invasive arterial pressure measurement
<ol>
	<li>Prepare ultrasonic guidance under sterile conditions.</li>
	<li>Provide subcutaneous anesthesia with 10-20 mL of Lidocaine subcutaneously above the venous puncture of the groin. Then, access the right femoral vein through palpation, fluoroscopic and/or ultrasound guidance. Introduce a standard wire with a J-tip and a 5 F multipurpose catheter into the superior vena cava.</li>
	<li>Perform an arterial puncture of the femoral artery, and introduce a 4F sheath for pressure monitoring. Many interventional cardiologists may find non-invasive blood pressure monitoring reliable in stable patients. Once the arterial blood pressure measurement is established, start the conscious sedation of the patient.</li>
	<li>Start the conscious sedation with midazolam (3-5 mg as a bolus) and propofol (1% bolus of 0.05-0.01 mL/kg body weight, followed by approximately 0.25 mL/kg/h).</li>
	<li>Measure the pressure in the right atrium. The central venous pressure (CVP) should be in a normal range around 6-12 mmHg. If the mean CVP is below 6 mmHg, give an NaCl infusion until a CVP of 6 mmHg minimum is reached to avoid air embolism during the procedure.</li>
</ol>
4. Local oropharyngeal anesthesia and introduction of the TEE probe
<ol>
	<li>Before the start of conscious sedation, apply a local anesthesia, xylocaine pump spray (10 mg/puff), to the oropharyngeal region 5-10 times.</li>
	<li>Apply bite protection. 
	NOTE: The echo imager should apply a xylocaine gel to the TEE probe. Introduce the probe carefully into the patient&#39;s mouth after the application of the sedation agent. Alternatively, a micro probe can also be introduced via the patient&#39;s nose.</li>
	<li>Further, assess possible pre-existing pericardial effusion in a four-chamber view, and set the bicaval view to include the PFO.</li>
</ol>
5. Wire passage through the PFO
<ol>
	<li>Advance a J-tip standard wire and the multipurpose (MP) catheter into the left atrium (LA) by slightly pushing forward the wire, and place it in the left upper pulmonary vein under fluoroscopy and TEE guidance. Obtain optimal TEE imaging by sweeping from 30&#176; to 110&#176;. Angiographically, the anterior-posterior projection is mostly used. Obtain a 45&#176; left anterior oblique (LAO) view, as this may be helpful.</li>
</ol>
6. Heparin application and measurement of the left atrial pressure (LAP)
<ol>
	<li>Once the catheter had been introduced into the left atrium, administer a bolus injection of 100 IU heparin/kg body weight to reach an activated clotting time (ACT) of around 250 s. The ACT should be controlled after around 5 min by a point-of-care ACT analyzer, which is used as standard in most catheterization labs.</li>
	<li>Measure the left atrial pressure (LAP) via the multipurpose catheter. If it is below 5 mmHg, administer IV fluid to reach a mean LAP of 5-10 mmHg. 
	&#8203;NOTE: The risk of breathing-associated air embolism through the catheter is high when the pressure is below 5 mmHg. The measurement of the oxygen saturation with a blood gas test is optional.</li>
</ol>
7. Advancing into the LA
<ol>
	<li>Advance a stiff and long guide wire with a soft tip (e.g., Amplatz Super Stiff, length of 260 cm) along the catheter into the LA, targeting the upper pulmonary vein.</li>
</ol>
8. TEE-guided balloon sizing of the PFO
NOTE: Although balloon sizing is discussed critically by some experts, it is recommended to use a sizing balloon to determine the size of the PFO according to the instructions for use.
<ol>
	<li>Exchange the MP catheter for a 24 mm sizing balloon.</li>
	<li>Position the balloon across the PFO, and inflate it with a 0.9% NaCl/contrast agent solution (1:4). Use two perpendicular TEE projections (e.g., 45&#176; and 135&#176;) for the PFO measurement.</li>
	<li>Confirm the dimensions by angiography images. In both, the measurement of the smallest balloon tail is crucial.</li>
</ol>
9. Occluder selection
<ol>
	<li>Use a sizing chart to select the size and type of the PFO occluder device using the PFO size and total septum length assessed by TEE or TTE according to the manufacturer&#39;s instructions.</li>
</ol>
10. Introduction of the device delivery system
<ol>
	<li>Prepare an adequately sized closure device according to the instructions for use, and flush properly to eliminate air bubbles.</li>
	<li>Deflate the sizing balloon, and exchange it for the delivery sheath (e.g., Mullins sheath).</li>
	<li>Introduce the delivery sheath into the LA via the stiff guide wire (7 Fr to 10 Fr depending on the device size). After the aspiration of blood, ensure a wet-to-wet connection between the sheath and the delivery system to guarantee air bubble-free advancement of the device.</li>
</ol>
11. Deployment of the PFO occluder
<ol>
	<li>Introduce the device through the sheath via a wet to wet connection.</li>
	<li>Once the device is visible within the sheath, observe if thee is no air bubble in front of the device (maybe cine imaging), then pull the device back approximately 2 cm to confirm the attachment of the device to the delivery cable.</li>
	<li>Push the device forward into the LA, and carefully retract the sheath into the mid-left atrium (push and pull movement) under echocardiographic guidance, which allows the left-sided disc to unfold. Here, TEE guidance instead of angiography is sufficient and recommended to reduce the radiation dose.</li>
	<li>Withdraw the left-sided disc toward the interatrial septum until a subtle resistance is felt and the left-sided disc is seen on the septum by TEE.</li>
	<li>Under discrete tension, pull the sheath further back into the right atrium (RA), which leads to the expansion of the right-sided disc.</li>
	<li>Push the device gently against the interatrial septum until the discs attach.</li>
</ol>
12. Evaluation of the correct device position
<ol>
	<li>Assess the correct position of the device with TEE and angiography. With the latter, the so-called &#34;pacman sign&#34; indicates correct device placement.</li>
	<li>Inspect the edges of the device thoroughly for any misalignments with respect to the aorta or the roof of the LA, which may lead to localized compression damage. A push-pull &#34;tug test&#34; can help to show the stability of the device.&#160;Beside the correct position of the device, the absence of gaps (color doppler) and pericardial effusion should be documented.&#160;Furthermore surrounded structures like the Eustachian valve, the rete chiari etc. should not be interferred with by the device.&#160;</li>
	<li>Once the position of the device is found to be correct, disconnect the delivery cable, and remove the sheath.</li>
	<li>Stop the concious sedation medication and remove the Echo probe.&#160;</li>
</ol>
13. Sealing of the puncture and pressure bandage
<ol>
	<li>Close the femoral vein with a resorbing suture using a figure-of-eight stitch of the subcutaneous tissue material or a vessel closure device. Use a tight-sitting pressure bandage to prevent local bleeding.</li>
	<li>After the removal of the arterial blood pressure monitoring device, perform manual compression of the common femoral artery or use a closure device followed by application of a tight bandage.</li>
</ol>
14. Check-up and post-intervention care
<ol>
	<li>Continue non-invasive monitoring of the blood pressure and heart rate for 24 h.</li>
	<li>Provide heparin (via IV) for 24 h at a target Partial thromboplastin time PTT of two to three times above the upper level of normal. 
	NOTE: The international guidelines recommend dual antiplatelet therapy for up to 3 months, followed by ASA monotherapy for up to 9-21 months13.</li>
</ol>

<ol><li>Moore, K. L., Persaud, T. V. N., Torchia, M. G. <a target="_blank" href="http://scholar.google.com/scholar?hl=en&safe=off&q=author%3aMoore%2C+KL+%22The+Developing+Human%3A+Clinically+Oriented+Embryology.%2C+10th+Edition%22">The Developing Human: Clinically Oriented Embryology., 10th Edition</a>. , Saunders. Philadelphia. (2015).</li>
<li>Hagen, P. T., Scholz, D. G., Edwards, W. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Incidence+and+size+of+patent+foramen+ovale+during+the+first+10+decades+of+life%3A+An+autopsy+study+of+965+normal+hearts%5BTitle%5D)+AND+%22Mayo+Clinic+Proceedings%22%5BJournal%5D)">Incidence and size of patent foramen ovale during the first 10 decades of life: An autopsy study of 965 normal hearts.</a> Mayo Clinic Proceedings. 59 (1), 17-20 (1984).</li>
<li>Meissner, I., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Prevalence+of+potential+risk+factors+for+stroke+assessed+by+transesophageal+echocardiography+and+carotid+ultrasonography%3A+The+SPARC+study%5BTitle%5D)+AND+%22Mayo+Clinic+Proceedings%22%5BJournal%5D)">Prevalence of potential risk factors for stroke assessed by transesophageal echocardiography and carotid ultrasonography: The SPARC study.</a> Mayo Clinic Proceedings. 74 (9), 862-869 (1999).</li>
<li>Rodriguez, C. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Race-ethnic+differences+in+patent+foramen+ovale%2C+atrial+septal+aneurysm%2C+and+right+atrial+anatomy+among+ischemic+stroke+patients%5BTitle%5D)+AND+%22Stroke%22%5BJournal%5D)">Race-ethnic differences in patent foramen ovale, atrial septal aneurysm, and right atrial anatomy among ischemic stroke patients.</a> Stroke. 34 (9), 2097-2102 (2003).</li>
<li>Hara, H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Patent+foramen+ovale%3A+Current+pathology%2C+pathophysiology%2C+and+clinical+status%5BTitle%5D)+AND+%22Journal+of+the+American+College+of+Cardiology%22%5BJournal%5D)">Patent foramen ovale: Current pathology, pathophysiology, and clinical status.</a> Journal of the American College of Cardiology. 46 (9), 1768-1776 (2005).</li>
<li>Saver, J. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Cryptogenic+stroke%5BTitle%5D)+AND+%22New+England+Journal+of+Medicine%22%5BJournal%5D)">Cryptogenic stroke.</a> New England Journal of Medicine. 374 (21), 2065-2074 (2016).</li>
<li>Collado, F. M. S., Poulin, M. F., Murphy, J. J., Jneid, H., Kavinsky, C. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Patent+foramen+ovale+closure+for+stroke+prevention+and+other+disorders%5BTitle%5D)+AND+%22Journal+of+the+American+Heart+Association%22%5BJournal%5D)">Patent foramen ovale closure for stroke prevention and other disorders.</a> Journal of the American Heart Association. 7 (12), 007146(2018).</li>
<li>Choong, C. K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Life-threatening+impending+paradoxical+embolus+caught+%26%2334%3Bred-handed%26%2334%3B%3A+Successful+management+by+multidisciplinary+team+approach%5BTitle%5D)+AND+%22Journal+of+Thoracic+and+Cardiovascular+Surgery%22%5BJournal%5D)">Life-threatening impending paradoxical embolus caught &#34;red-handed&#34;: Successful management by multidisciplinary team approach.</a> Journal of Thoracic and Cardiovascular Surgery. 136 (2), 527-528 (2008).</li>
<li>Madani, H., Ransom, P. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Paradoxical+embolus+illustrating+speed+of+action+of+recombinant+tissue+plasminogen+activator+in+massive+pulmonary+embolism%5BTitle%5D)+AND+%22Emergency+Medicine+Journal%22%5BJournal%5D)">Paradoxical embolus illustrating speed of action of recombinant tissue plasminogen activator in massive pulmonary embolism.</a> Emergency Medicine Journal. 24 (6), 441(2007).</li>
<li>Akagi, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Transcatheter+closure+of+patent+foramen+ovale%3A+Current+evidence+and+future+perspectives%5BTitle%5D)+AND+%22Journal+of+Cardiology%22%5BJournal%5D)">Transcatheter closure of patent foramen ovale: Current evidence and future perspectives.</a> Journal of Cardiology. 77 (1), 3-9 (2021).</li>
<li>Nakayama, R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Identification+of+high-risk+patent+foramen+ovale+associated+with+cryptogenic+stroke%3A+Development+of+a+scoring+system%5BTitle%5D)+AND+%22Journal+of+the+American+Society+of+Echocardiography%22%5BJournal%5D)">Identification of high-risk patent foramen ovale associated with cryptogenic stroke: Development of a scoring system.</a> Journal of the American Society of Echocardiography. 32 (7), 811-816 (2019).</li>
<li>Kent, D. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((An+index+to+identify+stroke-related+vs+incidental+patent+foramen+ovale+in+cryptogenic+stroke%5BTitle%5D)+AND+%22Neurology%22%5BJournal%5D)">An index to identify stroke-related vs incidental patent foramen ovale in cryptogenic stroke.</a> Neurology. 81 (7), 619-625 (2013).</li>
<li>Diener, H. -C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Kryptogener+Schlaganfall+und+offenes+Foramen+ovale%2C+S2eLeitlinie%2C+2018%5BTitle%5D)+AND+%22Deutsche+Gesellschaft+f%C3%BCr+Neurologie+%28Hrsg.%29%2C+Leitlinien+f%C3%BCr+Diagnostik+und+Therapie+in+der+Neurologie%22%5BJournal%5D)">Kryptogener Schlaganfall und offenes Foramen ovale, S2eLeitlinie, 2018.</a> Deutsche Gesellschaft für Neurologie (Hrsg.), Leitlinien für Diagnostik und Therapie in der Neurologie. , (2021).</li>
<li>Zanchetta, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Catheter+closure+of+perforated+secundum+atrial+septal+defect+under+intracardiac+echocardiographic+guidance+using+a+single+amplatzer+device%3A+Feasibility+of+a+new+method%5BTitle%5D)+AND+%22Journal+of+Invasive+Cardiology%22%5BJournal%5D)">Catheter closure of perforated secundum atrial septal defect under intracardiac echocardiographic guidance using a single amplatzer device: Feasibility of a new method.</a> Journal of Invasive Cardiology. 17 (5), 262-265 (2005).</li>
<li>Krizanic, F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+Occlutech+Figulla+PFO+and+ASD+occluder%3A+A+new+nitinol+wire+mesh+device+for+closure+of+atrial+septal+defects%5BTitle%5D)+AND+%22Journal+of+Invasive+Cardiology%22%5BJournal%5D)">The Occlutech Figulla PFO and ASD occluder: A new nitinol wire mesh device for closure of atrial septal defects.</a> Journal of Invasive Cardiology. 22 (4), 182-187 (2010).</li>
<li>Søndergaard, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Patent+foramen+ovale+closure+or+antiplatelet+therapy+for+cryptogenic+stroke%5BTitle%5D)+AND+%22New+England+Journal+of+Medicine%22%5BJournal%5D)">Patent foramen ovale closure or antiplatelet therapy for cryptogenic stroke.</a> New England Journal of Medicine. 377 (11), 1033-1042 (2017).</li>
<li>Saver, J. L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Long-term+outcomes+of+patent+foramen+ovale+closure+or+medical+therapy+after+stroke%5BTitle%5D)+AND+%22New+England+Journal+of+Medicine%22%5BJournal%5D)">Long-term outcomes of patent foramen ovale closure or medical therapy after stroke.</a> New England Journal of Medicine. 377 (11), 1022-1032 (2017).</li>
<li>Mas, J. -L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Patent+foramen+ovale+closure+or+anticoagulation+vs.+antiplatelets+after+stroke%5BTitle%5D)+AND+%22New+England+Journal+of+Medicine%22%5BJournal%5D)">Patent foramen ovale closure or anticoagulation vs. antiplatelets after stroke.</a> New England Journal of Medicine. 377 (11), 1011-1021 (2017).</li>
<li>Furlan, A. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Closure+or+medical+therapy+for+cryptogenic+stroke+with+patent+foramen+ovale%5BTitle%5D)+AND+%22New+England+Journal+of+Medicine%22%5BJournal%5D)">Closure or medical therapy for cryptogenic stroke with patent foramen ovale.</a> New England Journal of Medicine. 366 (11), 991-999 (2012).</li>
<li>Lee, P. H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Cryptogenic+stroke+and+high-risk+patent+foramen+ovale%3A+The+DEFENSE-PFO+trial%5BTitle%5D)+AND+%22Journal+of+the+American+College+of+Cardiology%22%5BJournal%5D)">Cryptogenic stroke and high-risk patent foramen ovale: The DEFENSE-PFO trial.</a> Journal of the American College of Cardiology. 71 (20), 2335-2342 (2018).</li>
<li>Carroll, J. D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Closure+of+patent+foramen+ovale+versus+medical+therapy+after+cryptogenic+stroke%5BTitle%5D)+AND+%22New+England+Journal+of+Medicine%22%5BJournal%5D)">Closure of patent foramen ovale versus medical therapy after cryptogenic stroke.</a> New England Journal of Medicine. 368 (12), 1092-1100 (2013).</li>
<li>Lock, J. E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Transcatheter+umbrella+closure+of+congenital+heart+defects%5BTitle%5D)+AND+%22Circulation%22%5BJournal%5D)">Transcatheter umbrella closure of congenital heart defects.</a> Circulation. 75 (3), 593-599 (1987).</li>
<li>Maloku, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Patent+foramen+ovale-When+to+close+and+how%5BTitle%5D)+AND+%22Herz%22%5BJournal%5D)">Patent foramen ovale-When to close and how.</a> Herz. 46 (5), 445-451 (2021).</li>
<li>Meier, B., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Percutaneous+closure+of+patent+foramen+ovale+in+cryptogenic+embolism%5BTitle%5D)+AND+%22New+England+Journal+of+Medicine%22%5BJournal%5D)">Percutaneous closure of patent foramen ovale in cryptogenic embolism.</a> New England Journal of Medicine. 368 (12), 1083-1091 (2013).</li>
<li>Vanden Branden, B. J., Post, M. C., Plokker, H. W., ten Berg, J. M., Suttorp, M. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Patent+foramen+ovale+closure+using+a+bioabsorbable+closure+device%3A+Safety+and+efficacy+at+6-month+follow-up%5BTitle%5D)+AND+%22JACC+Cardiovascular+Interventions%22%5BJournal%5D)">Patent foramen ovale closure using a bioabsorbable closure device: Safety and efficacy at 6-month follow-up.</a> JACC Cardiovascular Interventions. 3 (9), 968-973 (2010).</li>
<li>Sievert, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Transcatheter+closure+of+atrial+septal+defect+and+patent+foramen+ovale+with+Carag+bioresorbable+septal+occluder%3A+First-in-man+experience+with+24-month+follow-up%5BTitle%5D)+AND+%22EuroIntervention%22%5BJournal%5D)">Transcatheter closure of atrial septal defect and patent foramen ovale with Carag bioresorbable septal occluder: First-in-man experience with 24-month follow-up.</a> EuroIntervention. 17 (18), 1536-1537 (2021).</li>
</ol>

The video article fees were paid by an unrestricted grant from Occlutec SA. The company had no influence on the article content.

The interventional closure of a PFO is relatively simple compared to other procedures in interventional cardiology. It is important to perform it without complications since patients are mostly young and experience no short-term benefit from the procedure due to its prophylactic nature, in contrast to potentially life-saving therapies during acute myocardial infarction.
The critical steps of the procedure from our perspective are the safe puncture of the groin to avoid bleedin...

The foramen ovale is a remnant from embryologic heart development that usually closes within a few years after birth1. Previously, a patent foramen ovale (PFO) was found in 27.3% of cases in an autopsy study of 965 normal hearts2 and in 25.6% of the 581 subjects in a transesophageal echocardiography (TEE) study3. There are no significant differences with respect to sex or race/ethnicity2,3,4, and autopsy data show that the PFO diameter in adults varies from 1 mm to 19 mm (average: 4.9 mm) and increases with age5.
In up to 25% of all ischemic stroke cases, the cause cannot be attributed to clear factors such as the atherosclerosis of large vessels, small artery disease, or cardiac embolism despite extensive vascular, serological, and cardiac evaluation, hence the designation &#34;cryptogenic stroke&#34;6,7. Venous thrombus migration, through a PFO into the arterial circulation, has been shown as a possible cause of stroke in several studies and also by the imaging of the thrombus in transit8,9. PFO can be diagnosed with transthoracic contrast echocardiography when a contrast appears in the left atrium of the heart after filling the right atrium or within three heartbeat cycles after the Valsalva maneuver is terminated. Here, the shunt can be graded using the number of bubbles appearing in the left atrium: Grade 1 (fewer than 5 bubbles), Grade 2 (6-25 bubbles), Grade 3 (25 or more bubbles), and Grade 4 (visualization of the bubbles in the entire heart chamber)10. Further, transesophageal echocardiography (TEE) is necessary to evaluate the specific PFO morphology (see Figure 1). Certain findings are associated with a higher rate of thromboembolic events. These high-risk PFOs may have a large size, the presence of an atrial aneurysm (defined as an excursion of the septal tissue of more than 10 mm from the plane of the atrial septum into the right or left atrium), a large eustachian valve, spontaneous left-to-right shunts, and hypermobility of the septum during the Valsalva maneuver11. A number of scores, such as the RoPE score12, have been established to determine the probability that a discovered PFO is pathogenic. Finally, the PFO closure procedure is recommended by current guidelines for patients with cryptogenic stroke at 16 years to 60 years of age13. A further indication of this procedure is drug-resistant migraines.
Transesophageal echocardiography is regarded as the gold standard for the diagnosis of PFO and is utilized for the procedural planning of PFO closure. This procedure is performed percutaneously in a minimally invasive fashion in a standard cardiac catheterization laboratory using fluoroscopy, TEE guidance, and physiological monitoring. Intracardiac echocardiography (ICE) may be considered as an alternative to TEE by experienced operators14.
We describe the PFO-closure procedure under TEE and fluoroscopic guidance using a double-disc device made from a Nitinol (nickel titanium) wire mesh (i.e., the PFO occluder)15, as depicted in Figure 2.

<table><tbody><tr><td>50 ml syringe- Perfusor syringe Luer-Lock 50 cc</td><td>B. Braun</td><td>8728844F</td><td>Flush syringe</td></tr><tr><td>Amplatz Super stiff Guide wire 260 cm</td><td>Boston Scientific</td><td>M001465021</td><td>exchange wire</td></tr><tr><td>Amplatzer Sizing ballon II 24 mm</td><td>Abbott&amp;nbsp;</td><td>9-SB-024</td><td>sizing</td></tr><tr><td>catheter set- Angiodyn Set Uni Jena</td><td>B. Braun</td><td>6010111-0</td><td>cover set</td></tr><tr><td>Figulla Flex II PFO Occluder Procedure Pack</td><td>Occlutech</td><td>19PFO25DP</td><td>various sizes available</td></tr><tr><td>Mullins Sheat 7-11 fr.- Check Flow Performer Introducer- 9F 75 cm&amp;nbsp;</td><td>Cook Medical</td><td>RCFW-9.0-38-75-RB-MTS</td><td>delivery sheath</td></tr><tr><td>Multi purpose catheter 5 F - Impulse MPA 1</td><td>Boston scientific</td><td>H749163911171</td><td>atrial septal passage</td></tr><tr><td>Sheath 4 F- Radiofocus Introducer II 4 Fr. 10 cm</td><td>Terumo</td><td>RS*B40K10MR</td><td>arterial blood pressure measurement</td></tr><tr><td>Sheath 7-11 Fr- Radiofucus Introducer II 9 F 10 cm</td><td>Terumo</td><td>RS*B90N10MRD</td><td>Device Loading</td></tr></tbody></table>

closure of a patent foramen ovale (pfo): an intervention sequence

A patent foramen ovale (PFO) persists in about one-quarter of people and is the source of up to 25% of all ischemic strokes, especially strokes in young adults. PFO can be easily diagnosed by transthoracic contrast and/or transesophageal echocardiography. Interventional closure of the PFO via the femoral vein is a commonly used cardiological procedure since several trials have demonstrated the superiority of PFO closure over standard medical therapy in patients with PFO and who have experienced post ischemic, cardioembolic, or cryptogenic stroke. The current paper and video show the procedure of PFO closure in a step-by-step manner.

In this study, the closure of a PFO was successfully performed. The Live echo was able to show the closure of the interatrial septum without residual shunt with the utilized device (see the Table of Materials). The control of the placement of the interatrial septum between the left and the right discs of the device is important to guarantee the stability of the device, and this is checked by TEE in several planes before the release of the device. The device lays smoothly on the interatrial septum without...

Watch this Scientific Journal Video about Closure of a Patent Foramen Ovale PFO: An Intervention Sequence at JoVE.com

Closure of a Patent Foramen Ovale PFO: An Intervention Sequence

The closure of a patent foramen ovale (PFO) is a catheter-based intervention to prevent PFO-associated stroke. The PFO-occlusion device is advanced through the femoral vein and deployed across the interatrial septum using transesophageal echocardiography (TEE) and fluoroscopic guidance. The following protocol provides a step-by-step guide for the PFO-closure intervention using a double-disc device.

Closure of a Patent Foramen Ovale (PFO): An Intervention Sequence

A patent foramen ovale (PFO) persists in about one-quarter of people and is the source of up to 25% of all ischemic strokes, especially strokes in young ...

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JoVE Journal

Medicine

3.1K Views.  University Hospital Jena. Dit protocol helpt om alle stappen te leren voor de gestandaardiseerde procedure voor interventionele sluiting van de PFO. We tonen een gestandaardiseerde techniek die veilig en haalbaar is en het mogelijk maakt om bijna elke PFO te sluiten. Om te beginnen, stel een perifere veneuze toegangslijn in en maak verbinding met 500 CC natriumchloride en bevestig vervolgens de armen en benen van de patiënt.Start het ECG, perifere zuurstofverzadiging en pulsmetingen. Voer sterilisatie van de r...

Video: Closure of a Patent Foramen Ovale PFO: An Intervention Sequence

Catheter Ablation in Combination With Left Atrial Appendage Closure for Atrial Fibrillation

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, affecting millions of individuals worldwide 1-3. The rapid, irregular, and disordered electrical activity in the atria gives rise to palpitations, fatigue, dyspnea, chest pain and dizziness with or without syncope 4, 5. Patients with AF have a five-fold higher risk of stroke 6.
Oral anticoagulation (OAC) with warfarin is commonly used for stroke prevention in patients with AF and has been shown to reduce the risk of stroke by 64% 7. Warfarin therapy has several major disadvantages, however, including bleeding, non-tolerance, interactions with other medications and foods, non-compliance and a narrow therapeutic range 8-11. These issues, together with poor appreciation of the risk-benefit ratio, unawareness of guidelines, or absence of an OAC monitoring outpatient clinic may explain why only 30-60% of patients with AF are prescribed this drug 8.
The problems associated with warfarin, combined with the limited efficacy and/or serious side effects associated with other medications used for AF 12,13, highlight the need for effective non-pharmacological approaches to treatment. One such approach is catheter ablation (CA), a procedure in which a radiofrequency electrical current is applied to regions of the heart to create small ablation lesions that electrically isolate potential AF triggers 4. CA is a well-established treatment for AF symptoms 14, 15, that may also decrease the risk of stroke. Recent data showed a significant decrease in the relative risk of stroke and transient ischemic attack events among patients who underwent ablation compared with those undergoing antiarrhythmic drug therapy 16.
Since the left atrial appendage (LAA) is the source of thrombi in more than 90% of patients with non-valvular atrial fibrillation 17, another approach to stroke prevention is to physically block clots from exiting the LAA. One method for occluding the LAA is via percutaneous placement of the WATCHMAN LAA closure device. The WATCHMAN device resembles a small parachute. It consists of a nitinol frame covered by fabric polyethyl terephthalate that prevents emboli, but not blood, from exiting during the healing process. Fixation anchors around the perimeter secure the device in the LAA (Figure 1). To date, the WATCHMAN is the only implanted percutaneous device for which a randomized clinical trial has been reported. In this study, implantation of the WATCHMAN was found to be at least as effective as warfarin in preventing stroke (all-causes) and death (all-causes) 18. This device received the Conformit&eacute; Europ&eacute;enne (CE) mark for use in the European Union for warfarin eligible patients and in those who have a contraindication to anticoagulation therapy 19.
Given the proven effectiveness of CA to alleviate AF symptoms and the promising data with regard to reduction of thromboembolic events with both CA and WATCHMAN implantation, combining the two procedures is hoped to further reduce the incidence of stroke in high-risk patients while simultaneously relieving symptoms. The combined procedure may eventually enable patients to undergo implantation of the WATCHMAN device without subsequent warfarin treatment, since the CA procedure itself reduces thromboembolic events. This would present an avenue of treatment previously unavailable to patients ineligible for warfarin treatment because of recurrent bleeding 20 or other warfarin-associated problems.
The combined procedure is performed under general anesthesia with biplane fluoroscopy and TEE guidance. Catheter ablation is followed by implantation of the WATCHMAN LAA closure device. Data from a non-randomized trial with 10 patients demonstrates that this procedure can be safely performed in patients with a CHADS2 score of greater than 1 21. Further studies to examine the effectiveness of the combined procedure in reducing symptoms from AF and associated stroke are therefore warranted.

Catheter ablation is combined with placement of the WATCHMAN Left Atrial Appendage Closure Device to prevent ischemic stroke in a patient with non-valvular atrial fibrillation.

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, affecting millions of individuals worldwide 1-3. The rapid, irregular, and ...

Permanent Cerebral Vessel Occlusion via Double Ligature and Transection

Stroke is a leading cause of death, disability, and socioeconomic loss worldwide. The majority of all strokes result from an interruption in blood flow (ischemia) 1. Middle cerebral artery (MCA) delivers a great majority of blood to the lateral surface of the cortex 2, is the most common site of human stroke 3, and ischemia within its territory can result in extensive dysfunction or death 1,4,5. Survivors of ischemic stroke often suffer loss or disruption of motor capabilities, sensory deficits, and infarct. In an effort to capture these key characteristics of stroke, and thereby develop effective treatment, a great deal of emphasis is placed upon animal models of ischemia in MCA.
Here we present a method of permanently occluding a cortical surface blood vessel. We will present this method using an example of a relevant vessel occlusion that models the most common type, location, and outcome of human stroke, permanent middle cerebral artery occlusion (pMCAO). In this model, we surgically expose MCA in the adult rat and subsequently occlude via double ligature and transection of the vessel. This pMCAO blocks the proximal cortical branch of MCA, causing ischemia in all of MCA cortical territory, a large portion of the cortex. This method of occlusion can also be used to occlude more distal portions of cortical vessels in order to achieve more focal ischemia targeting a smaller region of cortex. The primary disadvantages of pMCAO are that the surgical procedure is somewhat invasive as a small craniotomy is required to access MCA, though this results in minimal tissue damage. The primary advantages of this model, however, are: the site of occlusion is well defined, the degree of blood flow reduction is consistent, functional and neurological impairment occurs rapidly, infarct size is consistent, and the high rate of survival allows for long-term chronic assessment.

Permanent Cerebral Vessel Occlusion via Double Ligature and Transection

We describe a highly reproducible method for the permanent occlusion of a rodent major cerebral blood vessel. This technique can be accomplished with very little peripheral damage, minimal blood loss, a high rate of long-term survival, and consistent infarct volume commensurate with the human clinical population.

Stroke is a leading cause of death, disability, and socioeconomic loss worldwide. The majority of all strokes result from an interruption in blood flow ...

Non-fluoroscopic Catheter Tracking for Fluoroscopy Reduction in Interventional Electrophysiology

A technological platform (MediGuide) has been recently introduced for non-fluoroscopic catheter tracking. In several studies, we have demonstrated that the application of this non-fluoroscopic catheter visualization system (NFCV) reduces fluoroscopy time and dose by 90-95% in a variety of electrophysiology (EP) procedures. This can be of relevance not only to the patients, but also to the nurses and physicians working in the EP lab. Furthermore, in a subset of indications such as supraventricular tachycardias, NFCV enables a fully non-fluoroscopic procedure and allows the lab staff to work without wearing lead aprons. With this protocol, we demonstrate that even complex procedures such as ablations of atrial fibrillation, that are typically associated with fluoroscopy times of &#62;30 min in conventional settings, can safely be performed with a reduction of &#62;90% in fluoroscopy exposure by the additional use of NFCV.

Radiation exposure is an underestimated risk in complex ablation procedures. Here, we describe a protocol to significantly decrease fluoroscopy time and dosage for both the patient and the lab staff by using a novel non-fluoroscopic catheter visualization system.

A technological platform (MediGuide) has been recently introduced for non-fluoroscopic catheter tracking. In several studies, we have demonstrated that ...

Quantification of Neurovascular Protection Following Repetitive Hypoxic Preconditioning and Transient Middle Cerebral Artery Occlusion in Mice

Experimental animal models of stroke are invaluable tools for understanding stroke pathology and developing more effective treatment strategies. A 2 week protocol for repetitive hypoxic preconditioning (RHP) induces long-term protection against central nervous system (CNS) injury in a mouse model of focal ischemic stroke. RHP consists of 9 stochastic exposures to hypoxia that vary in both duration (2 or 4 hr) and intensity (8% and 11% O2). RHP reduces infarct volumes, blood-brain barrier (BBB) disruption, and the post-stroke inflammatory response for weeks following the last exposure to hypoxia, suggesting a long-term induction of an endogenous CNS-protective phenotype. The methodology for the dual quantification of infarct volume and BBB disruption is effective in assessing neurovascular protection in mice with RHP or other putative neuroprotectants. Adult male Swiss Webster mice were preconditioned by RHP or duration-equivalent exposures to 21% O2 (i.e. room air). A 60 min transient middle cerebral artery occlusion (tMCAo) was induced 2 weeks following the last hypoxic exposure. Both the occlusion and reperfusion were confirmed by transcranial laser Doppler flowmetry. Twenty-two hr after reperfusion, Evans Blue (EB) was intravenously administered through a tail vein injection. 2 hr later, animals were sacrificed by isoflurane overdose and brain sections were stained with 2,3,5- triphenyltetrazolium chloride (TTC). Infarcts volumes were then quantified. Next, EB was extracted from the tissue over 48 hr to determine BBB disruption after tMCAo. In summary, RHP is a simple protocol that can be replicated, with minimal cost, to induce long-term endogenous neurovascular protection from stroke injury in mice, with the translational potential for other CNS-based and systemic pro-inflammatory disease states.

This protocol describes repetitive hypoxic preconditioning, or brief exposures to systemic hypoxia that reduce infarct volumes and blood-brain barrier disruption following transient middle cerebral artery occlusion in mice. It also details dual quantification of infarct volume and blood-brain barrier disruption after stroke to assess the efficacy of neurovascular protection.

Experimental animal models of stroke are invaluable tools for understanding stroke pathology and developing more effective treatment strategies. A 2 week ...

Reduction of Iatrogenic Atrial Septal Defects with an Anterior and Inferior Transseptal Puncture Site when Operating the Cryoballoon Ablation Catheter

The cryoballoon catheter ablates atrial fibrillation (AF) triggers in the left atrium (LA) and pulmonary veins (PVs) via transseptal access. The typical transseptal puncture site is the fossa ovalis (FO) &#8211; the atrial septum&#8217;s thinnest section. A potentially beneficial transseptal site, for the cryoballoon, is near the inferior limbus (IL). This study examines an alternative transseptal site near the IL, which may decrease the frequency of acute iatrogenic atrial septal defect (IASD). Also, the study evaluates the acute pulmonary vein isolation (PVI) success rate utilizing the IL location. 200 patients were evaluated by retrospective chart review for acute PVI success rate with an IL transseptal site. An additional 128 IL transseptal patients were compared to 45 FO transseptal patients by performing Doppler intracardiac echocardiography (ICE) post-ablation to assess transseptal flow after removal of the transseptal sheath. After sheath removal and by Doppler ICE imaging, 42 of 128 (33%) IL transseptal patients demonstrated acute transseptal flow, while 45 of 45 (100%) FO transseptal puncture patients had acute transseptal flow. The difference in acute transseptal flow detection between FO and IL sites was statistically significant (P &#60;0.0001). Furthermore, 186 of 200 patients (with an IL transseptal puncture) did not need additional ablation(s) and had achieved an acute PVI by a &#8220;cryoballoon only&#8221; technique. An IL transseptal puncture site for cryoballoon AF ablations is an effective location to mediate PVI at all four PVs. Additionally, an IL transseptal location can lower the incidence of acute transseptal flow by Doppler ICE when compared to the FO. Potentially, the IL transseptal site may reduce later IASD complications post-cryoballoon procedures.

The goal of this study is to demonstrate the preferential location of transseptal puncture during a cryoballoon catheter ablation procedure for the treatment of atrial fibrillation.

The cryoballoon catheter ablates atrial fibrillation (AF) triggers in the left atrium (LA) and pulmonary veins (PVs) via transseptal access. The typical ...

Comprehensive Endovascular and Open Surgical Management of Cerebral Arteriovenous Malformations

Arteriovenious malformations (AVMs) are associated with significant morbidity and mortality, and have a rupture risk of ~3% per year. Treatment of AVMs must be tailored specifically to the lesion, with surgical resection being the gold standard for small, accessible lesions. Pre-operative embolization of AVMs can reduce nidal blood flow and remove high-risk AVM features such as intranidal or venous aneurysms, thereby simplifying a challenging neurosurgical procedure. Herein, we describe our approach for the staged endovascular embolization and open resection of AVMs, and highlight the advantages of having a comprehensively trained neurovascular surgeon leading a multi-disciplinary clinical team. This includes planning the craniotomy and resection to immediately follow the final embolization stage, thereby using a single session of anesthesia for aggressive embolization, and rapid resection. Finally, we provide a representative case of a 22-year-old female with an unruptured right frontal AVM diagnosed during a seizure workup, who was successfully treated via staged embolizations followed by open surgical resection.

Surgery is the gold standard for accessible arteriovenious malformations (AVMs), and pre-operative embolization can simplify this procedure. We describe our approach for staged endovascular embolization and open resection of AVMs, and provide a representative clinical example highlighting the advantages of a comprehensively trained neurovascular surgeon leading a multi-disciplinary clinical team.

Arteriovenious malformations (AVMs) are associated with significant morbidity and mortality, and have a rupture risk of ~3% per year. Treatment of AVMs ...

Neuroscience

Network Analysis of Foramen Ovale Electrode Recordings in Drug-resistant Temporal Lobe Epilepsy Patients

Approximately 30% of epilepsy patients are refractory to antiepileptic drugs. In these cases, surgery is the only alternative to eliminate/control seizures. However, a significant minority of patients continues to exhibit post-operative seizures, even in those cases in which the suspected source of seizures has been correctly localized and resected. The protocol presented here combines a clinical procedure routinely employed during the pre-operative evaluation of temporal lobe epilepsy (TLE) patients with a novel technique for network analysis. The method allows for the evaluation of the temporal evolution of mesial network parameters. The bilateral insertion of foramen ovale electrodes (FOE) into the ambient cistern simultaneously records electrocortical activity at several mesial areas in the temporal lobe. Furthermore, network methodology applied to the recorded time series tracks the temporal evolution of the mesial networks both interictally and during the seizures. In this way, the presented protocol offers a unique way to visualize and quantify measures that considers the relationships between several mesial areas instead of a single area.

This protocol describes a procedure to track the evolution of mesial network measures in temporal lobe epilepsy (TLE) patients. It is based on the combination of intracranial recordings with a novel numerical technique for data analysis. Specifically, we present a protocol for network analyses of foramen ovale recordings.

Approximately 30% of epilepsy patients are refractory to antiepileptic drugs. In these cases, surgery is the only alternative to eliminate/control ...

Transvenous Embolization of Carotid Cavernous Fistula through Inferior Petrosal Sinus with Detachable Coils and Ethylene Vinyl Alcohol Copolymer

Carotid cavernous fistula (CCF) is a rare disease caused by abnormal communications between the internal carotid artery (direct fistula) or meningeal branches of the external carotid artery (indirect fistula) and the cavernous sinus (CS). Trauma is the most common cause of CCF. The clinical presentation of CCF is closely related to the venous drainage pattern. Orbital and neuro-ophthalmological symptoms are the most common clinical presentation of CCF with drainage through the superior ophthalmic vein (SOV). Endovascular embolization by arterial or venous approaches is the most common management of CCF. Transvenous embolization using detachable coils and ethylene-vinyl alcohol copolymer (EVOH) is an alternative method for the treatment of CCF. Endovascular embolization offers different options to treat CCF by minimally invasive approach decreasing morbidity and residual fistulas. The purpose of this article is to report our treatment experiences via the inferior petrosal sinus (IPS), and immediate-term outcomes of endovascular embolization of CCF by using detachable coils and EVOH.

The purpose of the article is to present our experience in endovascular treatment via the inferior petrosal sinus of the carotid cavernous fistula with detachable coils and ethylene-vinyl alcohol copolymer.

Carotid cavernous fistula (CCF) is a rare disease caused by abnormal communications between the internal carotid artery (direct fistula) or meningeal ...

Echocardiographic Evaluation of Atrial Communications before Transcatheter Closure

Transthoracic (TTE) and transesophageal echocardiography (TEE) is the standard imaging method for atrial septal defect (ASD) and patent foramen ovale (PFO) detection, for patient selection for transcatheter ASD/PFO closure,&#160;for intraoperative guidance and for long-term follow-up. The size, shape, location and the number of the atrial communications schould be determined. The accuracy of PFO detection can be improved by using agitated saline together with maneuvers to transiently increase the right atrial (RA) pressure. The appearance of microbubbles in the left atrium (LA) within 3 cardiac cycles after opacification of the RA is considered positive for the presence of an intracardiac shunt. Three dimensional TEE identifies further septal fenestrations and describes the dynamic morphology of ASD/PFO and atrial septal aneurysm. Follow-up evaluations with TTE is recommended at 1, 6, and 12 months after the procedure, with a subsequent evaluation every year. Previous studies showed an increased incidence of atrial arrhythmias early after device closure. Speckle tracking analysis may help to understand functional left atrial remodeling following percutaneous closure and its impact on atrial arrhythmias.

Transthoracic (TTE) and transesophageal (TEE) echocardiography represent the basic imaging tools for interatrial septum examination. Three dimensional (3D) TEE provides incremental information in the assessment of the interatrial septum. Further advanced echocardiography techniques using speckle tracking echocardiography are applied for sensitive volumetric and functional assessment of the heart chambers.&#160;

Transthoracic (TTE) and transesophageal echocardiography (TEE) is the standard imaging method for atrial septal defect (ASD) and patent foramen ovale ...

Neuronavigation and Laparoscopy Guided Ventriculoperitoneal Shunt Insertion for the Treatment of Hydrocephalus

Hydrocephalus is a common adult neurosurgical condition typically requiring treatment with a cerebrospinal fluid (CSF) shunt, of which the ventriculoperitoneal (VP) shunt is the most common type. Unfortunately, the failure rates of VP shunts are alarmingly high, with up to 50% of patients requiring revision surgery within 2 years. VP shunt failure may occur due to infection, or catheter mispositioning, migration, and occlusion. We undertook a joint neurosurgery and general surgery collaboration in a 7-year prospective non-randomized consecutive quality improvement cohort study to reduce the rates of ventriculoperitoneal (VP) shunt failures in 224 adult patients at a tertiary care institution. The initiative combined the use of electromagnetic stereotactic neuronavigation to guide the placement of the proximal catheter and laparoscopy to place the distal catheter under direct visualization. With laparoscopic assistance, the distal catheter was anchored through a small hole created in the falciform ligament and placed into the right retrohepatic space, free from the omentum, adhesions, or bowel that might obstruct the catheter tip. The surgeries were performed using a shunt infection prevention protocol to reduce the risk of shunt infections. Here, we present an intraoperative video of the surgical procedure. Compliance with shunt infection reduction strategies and the combined utilization of neuronavigation and laparoscopy techniques in adult VP shunt surgery resulted in a 44% reduction in the risk of overall shunt failure. The significant positive impact with regard to shunt-failure-free patient outcomes among patients who underwent VP shunt surgery using this strategy underscores the value associated with the use of these modern intraoperative techniques and cross-specialty collaboration during VP shunt surgery.

Patient outcomes of ventriculoperitoneal (VP) shunt surgery, the mainstay treatment for hydrocephalus in adults, are poor due to high shunt failure rates. We present intraoperative footage of VP shunt insertion using neuronavigation and laparoscopy guidance, with the goal to reduce the risks of proximal and distal shunt catheter failures, respectively.

Closure of a Patent Foramen Ovale (PFO): An Intervention Sequence

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