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).