Imaging-aided percutaneous patent foramen ovale (PFO) closure1 has undergone progressive consolidation over the past decade, particularly following the publication of randomized controlled trials demonstrating its benefit in secondary stroke prevention in carefully selected patients. In this context, the study presented by Magariños et al.2 constitutes a valuable contribution, not only for the number of patients enrolled but for its systematic, intracardiac echocardiography (ICE)-guided procedural approach.

The primary strength of this study lies in the integration of ICE as a main tool across all procedural stages: diagnostic confirmation, detailed anatomical assessment, device selection, implant guidance, and immediate post-deployment evaluation. This approach eliminates the need for intraprocedural transesophageal echocardiography (TEE) and avoids general anesthesia, thus reducing the logistical complexities associated to the procedure and potentially improving patient tolerability.

From a technical standpoint, the systematic use of ICE offers clear advantages. The direct visualization of the PFO tunnel, identification of atrial septal aneurysms (ASA), detection of prominent Eustachian valve or Chiari network, and assessment of septum primum mobility all allow for more precise device sizing and selection. Additionally, real-time guidance facilitates controlled device deployment, minimizing the risk of malapposition or embolization.

A particularly noteworthy aspect of the aforementioned study is the detailed technical description, which reflects a refined and standardized protocol. Minimizing intracavitary wire manipulation during anatomical assessment to reduce thrombogenic risk — along with a systematic emphasis on air embolism prevention — is a strategy that exemplifies the technical refinement that emerges only through substantial cumulative experience.

The reported outcomes — a 100-% procedural success rate, absence of major complications, and a low rate of minor complications — are consistent with those of high-volume centers. However, as with any single-center retrospective series, interpretation must account for potential selection bias and the absence of a comparative arm (e.g., TEE-guided closure).

From a broader conceptual perspective, this work also informs the ongoing debate regarding the respective roles of ICE versus TEE in PFO closure. While TEE remains the standard at many centers, ICE has become a robust alternative, particularly at institutions with dedicated structural interventional programs. Learning curve requirements, associated costs, and equipment availability remain relevant considerations; however, a growing body of evidence suggests that ICE may optimize anatomical precision while simplifying the procedural environment.

In summary, this series reinforces the principle that percutaneous PFO closure, when performed at experienced centers under systematic ICE guidance, can achieve high success rates with a favorable safety profile. Beyond clinical outcomes, the true value of this work lies in the standardization and communication of a reproducible technique with advanced intracardiac imaging as the procedural cornerstone. Nevertheless, it raises important questions regarding the optimal imaging approach for procedure guidance: TEE or ICE3.

This demands a comparative analysis of both approaches.

Transesophageal echocardiography (TEE)4

Advantages:

1. Widespread availability and established operator experience.

2. Excellent anatomical resolution of the interatrial septum.

3. Detailed pre-procedural assessment.

4. No additional venous access requirement.

5. Likely lower overall cost in terms of supplies.

Disadvantages:

1. General anesthesia or deep sedation required.

2. Anesthesiology support required at many sites.

3. Greater logistical complexity.

4. Poor tolerance in some patients.

5. Valsalva maneuver hindered by endotracheal intubation.

6. No direct real-time evaluation from the right atrium with the same spatial flexibility as ICE

Intracardiac echocardiography (ICE)

Advantages:

1. Performed under conscious sedation.

2. No general anesthesia required in most cases.

3. Direct visualization of the septum from the right atrium.

4. Superior identification of the PFO tunnel and its dynamic behavior.

5. Precise assessment of ASA, Chiari network, and Eustachian valve.

6. Greater operator autonomy (independence from an external echocardiographer).

7. Potential reduction in total room time at experienced sites.

Disadvantages:

1. Higher upfront cost (dedicated catheter).

2. Specific learning curve required.

3. Second venous access site needed.

4. Small but non-negligible additional vascular risk.

5. Not universally available.

TEE remains highly effective, particularly at sites with established logistics and consolidated expertise5. In resource-limited settings, it remains an appropriate cost-effective tool.

A final consideration: current evidence does not establish the absolute superiority of one technique over the other, but rather positions ICE as a robust alternative — especially at sites with structural interventional expertise. This series reinforces the feasibility of a systematic ICE-guided approach, yielding reproducible outcomes and a low complication rate.

Rather than establishing a competition between techniques, the real challenge is identifying the clinical and institutional context in which each alternative delivers the greatest value.

Dr. Carlos Fernández Pereira, PhD, FACC, FESC, FSCAI
Editor-in-Chief of the Argentinian Journal of Interventional Cardiology (RACI)
cfernandezpereira@centroceci.com.ar

1. Rana B., Thomas M., Calvert P., Monaghan M., Hildick‐Smith D. Echocardiographic Evaluation of Patent Foramen Ovale Prior to Device Closure. JACC Cardiovascular Imaging 2010;3(7):749-760.

2. Magariños E, Henestrosa G, Scuteri A, et al. Cierre de Foramen oval permeable guiado por ecocardiografía intracardiaca: resultados iniciales y descripción de la técnica.Revista Argentina de cardioangiología intervencionista.

3. Chaturvedi A., Moroni F., Axline M., Tomdio A., Mojadidi M., et al. Comparative evaluation of intracardiac, transesophageal, and transthoracic echocardiography in the assessment of patent foramen ovale: A retrospective single‐center study. Catheterization and Cardiovascular Interventions 2023;102(7):1348-1356.

4. Vitarelli A. Patent Foramen Ovale: Pivotal Role of Transesophageal Echocardiography in the Indications for Closure, Assessment of Varying Anatomies and Post-procedure Follow-up. Ultrasound in Medicine & Biology 2019;45(8):1882-1895.

5. Song J. Pearls and Pitfalls in the Transesophageal Echocardiographic Diagnosis of Patent Foramen Ovale. Journal of the American Society of Echocardiography 2023;36(9):895-905.

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Intracardiac echocardiography as a strategic alternative in percutaneous closure of patent foramen ovale

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