Transnasal transesophageal echocardiography: a new approach for the PFO occlusion in awake patients

To reduce risks, discomfort, cost, and operative time for percutaneous patent foramen ovale (PFO) closure, we propose to perform this procedure under transesophageal echo-guidance using a 10 Fr. catheter introduced through nasal way (TEENW).

Transesophageal or intracardiac echocardiography is commonly used to guide percutaneous PFO closure. Sedation needed quite frequently during transesophageal echocardiography, increased patients' discomfort, procedure prolongation, costs, use of both femoral veins, and additional intracardiac manipulations are the main limitations of standard techniques.

We enrolled 20 consecutive patients with a history of cerebral ischemia and PFO with right-to-left shunt. In 15 patients Amplatzer PFO occluder was used, whereas in five patients with longer PFO tunnel (>10 mm) Cardia Intrasept was selected. Without sedation, a multifrequency monoplane probe, developed for intracardiac echocardiography, was introduced into the nostril and advanced forward the esophagus. Then under echo guidance, the closing device was presented, opened and released.

Procedure lasted for an average of 33.3 min, and no complications were seen. At procedure's completion, six patients showed persistence of reduced shunt during Valsalva manoeuvre. At six-month follow-up, shunts disappeared in all patients.

TEENW is safe and well tolerated, and images' quality is high enough to deserve widespread adoption of this technique for PFO closure.