Name: closure of a patent foramen ovale (pfo): an intervention sequence
Uploaded: 2022-12-23T12:30:00
Description: Watch this Scientific Journal Video about Closure of a Patent Foramen Ovale PFO: An Intervention Sequence at JoVE.com

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...

<ol>
	<li>Moore, K. L., Persaud, T. V. N., Torchia, M. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> The Developing Human: Clinically Oriented Embryology., 10th Edition. , (2015).</li><li>Hagen, P. T., Scholz, D. G., Edwards, W. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Incidence+and+size+of+patent+foramen+ovale+during+the+first+10+decades+of+life:+An+autopsy+study+of+965+normal+hearts.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Prevalence+of+potential+risk+factors+for+stroke+assessed+by+transesophageal+echocardiography+and+carotid+ultrasonography:+The+SPARC+study.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Race-ethnic+differences+in+patent+foramen+ovale,+atrial+septal+aneurysm,+and+right+atrial+anatomy+among+ischemic+stroke+patients.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Patent+foramen+ovale:+Current+pathology,+pathophysiology,+and+clinical+status.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Cryptogenic+stroke.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Patent+foramen+ovale+closure+for+stroke+prevention+and+other+disorders.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Life-threatening+impending+paradoxical+embolus+caught+&amp;#34;red-handed&amp;#34;:+Successful+management+by+multidisciplinary+team+approach.">Life-threatening impending paradoxical embolus caught &amp;#34;red-handed&amp;#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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Paradoxical+embolus+illustrating+speed+of+action+of+recombinant+tissue+plasminogen+activator+in+massive+pulmonary+embolism.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transcatheter+closure+of+patent+foramen+ovale:+Current+evidence+and+future+perspectives.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Identification+of+high-risk+patent+foramen+ovale+associated+with+cryptogenic+stroke:+Development+of+a+scoring+system.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=An+index+to+identify+stroke-related+vs+incidental+patent+foramen+ovale+in+cryptogenic+stroke.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Kryptogener+Schlaganfall+und+offenes+Foramen+ovale,+S2eLeitlinie,+2018.">Kryptogener Schlaganfall und offenes Foramen ovale, S2eLeitlinie, 2018.</a> Deutsche Gesellschaft f&#252;r Neurologie (Hrsg.), Leitlinien f&#252;r Diagnostik und Therapie in der Neurologie. , (2021).</li><li>Zanchetta, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Catheter+closure+of+perforated+secundum+atrial+septal+defect+under+intracardiac+echocardiographic+guidance+using+a+single+amplatzer+device:+Feasibility+of+a+new+method.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+Occlutech+Figulla+PFO+and+ASD+occluder:+A+new+nitinol+wire+mesh+device+for+closure+of+atrial+septal+defects.">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>S&#248;ndergaard, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Patent+foramen+ovale+closure+or+antiplatelet+therapy+for+cryptogenic+stroke.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Long-term+outcomes+of+patent+foramen+ovale+closure+or+medical+therapy+after+stroke.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Patent+foramen+ovale+closure+or+anticoagulation+vs.+antiplatelets+after+stroke.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Closure+or+medical+therapy+for+cryptogenic+stroke+with+patent+foramen+ovale.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Cryptogenic+stroke+and+high-risk+patent+foramen+ovale:+The+DEFENSE-PFO+trial.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Closure+of+patent+foramen+ovale+versus+medical+therapy+after+cryptogenic+stroke.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transcatheter+umbrella+closure+of+congenital+heart+defects.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Patent+foramen+ovale-When+to+close+and+how.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Percutaneous+closure+of+patent+foramen+ovale+in+cryptogenic+embolism.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Patent+foramen+ovale+closure+using+a+bioabsorbable+closure+device:+Safety+and+efficacy+at+6-month+follow-up.">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/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transcatheter+closure+of+atrial+septal+defect+and+patent+foramen+ovale+with+Carag+bioresorbable+septal+occluder:+First-in-man+experience+with+24-month+follow-up.">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 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 border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<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&#160;</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&#160;</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 ...

This protocol helps to learn all the steps for the standardized procedure for interventional closure of the PFO. We show a standardized technique that is safe and feasible and allows to close nearly every PFO. To begin, establish a peripheral venous access line and connect to 500 CC of sodium chloride, then fix the arms and legs of the patient.Initiate the ECG, peripheral oxygen saturation and pulse measurements. Perform sterilization of the right groin using an iodine-based solution. Prepare sterile equipment with the materials required by the catheter assistant or nurse.Cover the sterilized femoral access site with a transparent foil plaster. Apply local anesthesia to the oropharyngeal region five to 10 times, then apply bite protection. Prepare ultrasound guidance under sterile conditions.Access the right femoral vein through palpation, fluoroscopic, or ultrasound guidance. Provide subcutaneous anesthesia. Perform the venous puncture of the groin.Then introduce a standard wire with a J-Tip and a five French multipurpose catheter into the superior vena cava. Perform an arterial puncture of the femoral artery and introduce a four French sheath for pressure monitoring. Many interventional cardiologists may find non-invasive blood pressure monitoring reliable in stable patients or use a radial access.Once the arterial blood pressure measurement is established, start the conscious sedation of the patient with midazolam and propofol as described in the text manuscript. Measure the pressure in the right atrium. The CVP should be in a normal range of around six to 12 millimeters of mercury.If the main CVP is lower, give a sodium chloride infusion until the CVP reaches a minimum of six millimeters of mercury to avoid air embolism during the procedure. Introduce the TEE probe and assess possible preexisting pericardial effusion in a four-chamber view and set the bicaval view to include the PFO. Advance, a J-Tip standard wire and the multipurpose catheter into the left atrium by slightly pushing forward the wire and placing it in the left upper pulmonary vein under fluoroscopy and TEE guidance.Obtain optimal TEE imaging by sweeping from 30 degree to 110 degree. Obtain a 45-degree left anterior oblique view as this may be helpful. Once the catheter is introduced into the left atrium, administer a bolus injection of 100 IU heparin per kilogram body weight to reach an activated clotting time of around 250 seconds.The activated clotting time should be controlled after around five minutes by a point-of-care ACT analyzer. Measure the left atrial pressure via the multipurpose catheter. If it is below five millimeters of mercury, administer IV fluid to reach a mean left atrial pressure of five to 10 millimeters of mercury.Advance a stiff, long guide wire with a soft tip along the catheter into the left atrium, targeting the upper pulmonary vein. Then deair the balloon carefully with one-fourth to two-fourth contrast dye and saline mix outside the patient. Exchange the multipurpose catheter for a 24-millimeter sizing balloon.Position the balloon across the PFO and inflate it with a 0.9%sodium chloride in the contrast agent solution in a three-to-one ratio. Use two perpendicular TEE projections for the PFO measurement. Confirm the dimensions by angiography images.In both cases, the measurement of the smallest balloon tail is crucial. Use a sizing chart to select the size and type of the PFO-occluded device using the PFO size and total septum length assessed by TEE or TTE according to the manufacturer's instructions. Prepare an adequately-sized closure device as described in the text manuscript.And flush properly to eliminate air bubbles. Deflate the sizing balloon and exchange it for the delivery sheath. Introduce the delivery sheath via the stiff guide wire.Then remove the introducer and wire. After the aspiration of blood, ensure a wet-to-wet connection between the sheath and the PFO closure device to guarantee air bubble-free advancement of the device. Introduce the closure device through the sheath via a wet-to-wet connection by flushing saline through the side port and ensuring back bleeding from the sheath.Then push the device forward into the sheath. Once the device is visible within the sheath, observe if there is no air bubble in front of the device. Then pull the device back approximately two centimeters to confirm the attachment of the device to the delivery cable.Push the device forward into the left atrium and carefully retract the sheath into the mid-left atrium in a push and pull movement and the 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. We draw 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.Under discreet tension, pull the sheath back into the right atrium, expanding the right-sided disc. Push the device gently against the interatrial septum until the discs attach. Assess the correct position of the closure device with TEE and angiography.With the latter, the Pacman sign indicates the correct device placement. Inspect the edges of the device thoroughly for any misalignments concerning the aorta or the roof of the left atrium, which may lead to localized compression damage. A push-pull tug test can help to show the stability of the device.Once the position of the device is correct, disconnect the delivery cable and remove the sheath. Close the femoral vein with the 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.After removing the arterial blood pressure monitoring device, perform manual compression of the common femoral artery or use a closure device followed by applying a tight bandage. Continue non-invasive monitoring of the blood pressure and heart rate for 24 hours. Provide heparin for 24 hours as described in the text manuscript.In young patients, less than 65 years old, a lower risk for recurrent strokes and mortality was observed after interventional PFO closure compared to medical therapy only. Peri-interventional complications in PFO closure were rare. Pericardial tamponade rarely occurred in the RESPECT and REDUCE trials at a rate of 0.4 and 0.2%respectively.Cardiac perforation was a severe complication that occurred in 0.25%of patients in the CLOSURE-I trial and 0.2%in the RESPECT trial. It is crucial that the device opening and positioning is done under TEE control to obtain the best possible result. If TEE is unavailable, the device position can also be checked by contrast dye injection.

Research

JoVE Journal

Medicine

The WATCHMAN Left Atrial Appendage Closure Device for Atrial Fibrillation

Atrial fibrillation (AF) is the most common cardiac arrhythmia, affecting an estimated 6 million people in the United States 1. Since AF affects primarily ...

Using Quantitative Real-time PCR to Determine Donor Cell Engraftment in a Competitive Murine Bone Marrow Transplantation Model

Murine bone marrow transplantation models provide an important tool in measuring hematopoietic stem cell (HSC) functions and determining genes/molecules ...

A Possible Zebrafish Model of Polycystic Kidney Disease: Knockdown of wnt5a Causes Cysts in Zebrafish Kidneys

A Possible Zebrafish Model of Polycystic Kidney Disease: Knockdown of wnt5a Causes Cysts in Zebrafish Kidneys

Polycystic kidney disease (PKD) is one of the most common causes of end-stage kidney disease, a devastating disease for which there is no cure. The ...

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 ...

A Case Series of Successful Abdominal Closure Utilizing a Novel Technique Combining a Mechanical Closure System with a Biologic Xenograft that Accelerates Wound Healing

In the acute setting, once intra-abdominal injuries have been addressed, the next great hurdle is restoring a functional and intact abdominal compartment. ...

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 ...

Preparation of a Non-Cardiomyocyte Cell Suspension for Single-Cell RNA Sequencing from a Post-Myocardial Infarction Adult Mouse Heart

Myocardial infarction (MI) is one of the most common cardiovascular diseases, with increasing mortality worldwide. Non-cardiomyocytes account for more ...

3D Printing Model of a Patient's Specific Lumbar Vertebra

Selective dorsal rhizotomy (SDR) is a difficult, risky, and sophisticated operation, in which a laminectomy should not only expose an adequate surgical ...

In Vitro Application of a Wireless Sensor in Flexion-Extension Gap Balance of Unicompartmental Knee Arthroplasty

In Vitro Application of a Wireless Sensor in Flexion-Extension Gap Balance of Unicompartmental Knee Arthroplasty

Unicompartmental knee arthroplasty (UKA) is an effective treatment for end-stage anteromedial osteoarthritis (AMOA). The key to UKA is the ...

Quantitative Analysis of Liver Stiffness Distribution

A Three-Dimensional Digital Model for Early Diagnosis of Hepatic Fibrosis Based on Magnetic Resonance Elastography

Author Spotlight: Advancing Hepatic Fibrosis Diagnosis Using Magnetic Resonance Elastography and AI 

Hepatic fibrosis is an early stage of liver cirrhosis, and there are no better non-invasive and convenient methods for the detection and evaluation of the ...