Clinical Value Of Right Atrial Angiography In Percutaneous Catheter Closure Of Patent Foramen Ovale Related Diseases

Background:Patent foramen ovale（PFO）is a common congenital cardiac malformation.PFOs are present in approximately 25%of the adult population and are not associated with any pathology in the vast majority of cases.In recent years,a number of studies have shown that the presence of PFOs is closely related to cryptogenic stroke,migraine,TIA,decompression sickness and other diseases.At present,prophylactic occlusion for high-risk patients with PFO and therapeutic occlusion for hospitalized patients have been widely carried out in clinic.However,sometimes it is difficult to pass through some complex PFO channels with conventional surgical methods,and even residual shunt after transcatheter closure occurs.Then,this study innovatively proposed right atrial angiography（RAG）technique to make up for the deficiencies in the current operation of PFO occlusion.Objective:To explore the clinical application of RAG in the percutaneous catheter closure of PFO-related diseases.Method:A retrospective analysis was performed on 89 patients with PFO who received percutaneous closure in the Department of Cardiovascular Medicine of The Second Affiliated Hospital of Nanchang University from June 2021 to October 2022.According to clinical symptoms of PFO patients,they were divided into CS group（n=19 cases）,TIA group（n=19 cases）and migraine group（n=51 cases）.All patients underwent right atrial angiography during PFO transcatheter closure.The right femoral vein was punctures routinely.The pigtail angiography catheter was sent to the right atrium through the guide wire,and the projection position（LAO45°,CRA10-15°）was selected for high pressure angiography（pressure 500 PSI,contrast agent 25ml,injection rate 18ml/s）.The location,shape of the PFO was initially displayed and then the diameter of the PFO was measured.The pigtail angiography catheter was withdrawn,and the terminal foramen catheter was sent through the sheath to the right atrium,and through the foramen ovale to the left atrium and the left superior pulmonary vein.The PFO morphology was again revealed and its diameter was measured by selective angiography.Select the suitable occluder according to the measured PFO diameter.A vein delivery pathway was established along the guide wire and sent to the occluder delivery system.Before releasing the occluder,RAG was performed again to confirm whether there was residual shunt at the atrial level.Transthoracic echocardiography（TTE）was re-examined at 1 day,1month,3months and 6months after operation,and the contrast-enhanced transcranial doppler（c TCD）was re-examined at 6months after operation.Results:1.The proportion of women in the migraine group was higher than that in the TIA group（P<0.0167）.The analysis did not confirm any significant differences in age,BMI,hypertension,diabetes,hyperlipidemia,h HCY,OSAS,smoking history,LVEF,E/A ratio,positive rate of PFO,PFO diameter and RLS grading between CS,TIA and migraine groups（P>0.05）.The PFO positive rate of TEE was higher than that of TTE（P<0.001）.The inherent type was predominant in the migraine group,while the latent type was predominant in the CS group（P<0.0167）.2.During RAG,two pigtail catheters were used to produce intraoperative high-pressure angiography in the right atrium and measure the pressure of the right atrium.The intracardiac electrophysiological instrument showed no significant changes in the pressure of the right atrium,suggesting that RAG technology was safe.3.All patients can clearly show the location and morphology of PFO under high pressure RAG.The morphology of PFO was divided into tunnel type（51 cases）,volcanic mouth type（27 cases）and fissure type（11 cases）.4.No significant difference was revealed in PFO diameter between RAG and selective angiography measurement[（4.19±1.34）mm vs（4.44±1.07）mm,P₃=0.133].According to RAG,18/25mm occluders were selected for the patients with a PFO diameter of<3mm（59 cases）,25/25mm occluders for the patients with a diameter of 3-5mm or combined with ASA（21 cases）,and 30/30mm occluders for the patients with a diameter of>5mm（9 cases）.5.The radiation time required for RAG was significantly different from that for conventional PFO closure in the same period[（199.13±54.68）s vs（345.93±112.47）s,P<0.001].The Operative effect was satisfactory in all patients.RAG was conducted again to show no residual shunt at the level of the atrial septum.Conclusion:1.RAG techique is safe and effective,which can clearly show the position of fossa ovalis and has a high incidence of PFO.Meanwhile,the PFO morphology can be classified during the operation.2.RAG techique precisely guides the wire through the PFO channel,accurately measures the PFO diameter and selects an appropriate PFO occluder.3.RAG techique can shorten the duration of operative radiation and evaluate the operative effect.