PROCEDURAL TECHINQUE
Left basilic vein and right internal jugular vein access was obtained
using ultrasound guidance (Figure 2a). A regular J wire was advanced
through the basilic vein to the right atrium and was exchanged to an
Amplatz Extra stiff wire overwhich a 10 Fr x 40 cm Cook sheath was
advanced to right atrium. A St Jude ICE catheter (Abbott Vascular, Santa
Clara, CA) was advanced to the right atrium and was passively exposed
(Figure 2b). ICE was used to take detailed images of the intra-atrial
septum and the PFO tunnel (Video 1). The treating team should understand
that ICE images are inverted compared to when ICE is used from the
femoral side.
A short 9 Fr sheath was placed in the RIJ access. A small curl Agilis
deflectable (Abbott Vascular, Santa Clara, CA) catheter and an angled
glide wire was used to cross the septum (Video 2). In the first patient,
the Agilis catheter was used to deploy the PFO closure device. In the
second patient, the Agilis catheter was exchanged to TorqVue 120° sheath
(Abbott Vascular, Santa Clara, CA) using an Amplatz Extra stiff wire in
the pulmonary vein (Figure 3). A 35 mm PFO closure device (Abbott
Vascular, Santa Clara, CA) is advanced to the left atrium through the
TorqVue sheath (Figure 4) and deployed in the usual manner under ICE and
flouro guidance (Figure 5 and Video 3). ICE was used to study the
intra-atrial septum and once satisfied with the result, the device can
be released (Video 4). ICE is used again to interrogate the PFO closure
device (Figure 6).