• alternative method
• percutaneous closure of interatrial shunts

Background. The interatrial communications that could be treated by percutaneous approach are represented by the patent foramen ovale (PFO) and secundum type of atrial septum defect (ASD). The indications to ASD closure are well defined by the international guidelines for the management of the congenital heart diseases. The management of PFO related to thromboembolic events is still controversial, despite an increase in interventional closure procedures with newer devices.
Aim. The aim of this study was to identify an alternative approach to the standard percutaneous closure procedure of the interatrial shunts, in order to reduce the intraprocedural risk.
Methods: Between 2005 and 2015, a total of 176 patients underwent percutaneous PFO and ASDs closure in our institution. A contemporary and retrospective of the interventional reports identified 3 groups of patients: Group A, represented by the patients treated under general anaesthesia with transesophageal echocardiographic (TEE) guidance; Group B, represented by the patients treated with intracardiac echocardiography (ICE); Group C, represented by the patients who were treated without general anaesthesia, and under TEE guidance. Data on the pre-procedural evaluation (clinic, imaging), on percutaneous procedure and the ultrasound controls during the first 6 months after the procedure were collected.
Results: A total of 176 pts were enrolled (mean age 49±12.2 yrs, 68 females) and distributed in 3 groups: Group A: 53 pts, Group B: 55 pts, and Group C 68 pts. The main indications to perform the interatrial shunt closure was represented by TIA in 91 pts (51.7%), stroke in 64 pts (36.3%), migraine in 15 (8.5%), increased right heart chambers in 11 pts (6.2%). Successful device deployment was obtained in 172 pts (97.7%). There was a statistically significant difference of total procedure time between the groups: 82.5±16.6 min for Group A, 65.8±22.7 min for Group B, and 59.9±25.4 min for Group C (p= .06 Group B vs. Group A; p< .001 Group C vs. Group A; p= n.s. Group B vs. Group C). The total radiation exposure was higher in Group A (3995.6±4486 cGy/cm2) compared to Group B (2223.4±2540 cGy/cm2, p= .02) and Group C (1452.6±1158 cGy/cm2, p< .0001). The dose of contrast agent was significantly lower in Group C (15.8±18 ml) than in the other groups (Group A: 39.6±35 ml, p< .0001, Group B: 25.4±18.4, p= .01). No major intraprocedural complications were observed. At the 6 months follow-up assessed by transcranial Doppler, a minimal shunt with the appearance of late micromebolic signals was observed in 5 cases (1 in Group A and 2 in each of the other groups), with no clinical impact.
Conclusion: To our knowledge this is the first study that demonstrates that the percutaneous closure of interatrial shunts is feasible and safe in conscious patients under transesophageal echocardiographic guidance. This “alternative approach” helps to reduce the intraprocedural risk of complications and the complexity of the procedure, reducing the total procedure time, the contrast agent dose and total radiation exposure.