Effectiveness of intraprocedural guidance modalities on PFO closure outcomes: insights from the PROLONG registry

Abstract Background Transcatheter patent foramen ovale (PFO) closure is the gold-standard treatment for patients with cryptogenic embolism and PFO. While current guidelines recommend the use of intraprocedural echocardiography, there is no consensus on the optimal imaging strategy. Objectives To compare the procedural and clinical outcomes of fluoroscopy-only guidance versus echocardiographic guidance—transesophageal echocardiography (TEE) or intracardiac echocardiography (ICE)—during transcatheter PFO closure. Methods The multicenter, retrospective PROLONG registry included 1,302 patients who underwent PFO closure between 1999 and 2013 with available data on intraprocedural guidance. Of these, 714 patients (55%) underwent TEE-guided procedures, 416 (32%) received ICE, and 172 (13%) were treated under fluoroscopy-only guidance. All patients in the fluoroscopy-only group had undergone preprocedural TEE to assess PFO anatomy. Results Baseline characteristics were similar across groups, including atrial septal aneurysm (34%, 33%, and 37% in the TEE, ICE, and fluoroscopy-only groups, respectively; p=0.685) and baseline severe right-to-left shunt (58%, 58%, and 49%, respectively; p=0.143). Procedural success was high across all groups (99.0% for TEE, 99.7% for ICE, and 98.2% for fluoroscopy-only; p=0.163). Echocardiographic guidance was associated with significantly shorter procedure duration (33, 28, and 48 minutes for TEE, ICE, and fluoroscopy-only; p<0.001), lower fluoroscopy time, reduced radiation exposure (11, 7.1, and 31 Gy·cm²; p<0.001), and less frequent contrast use (28%, 17%, and 94%; p<0.001). In-hospital and long-term complication rates, including new-onset atrial fibrillation, residual shunt, and recurrent embolic events, were low and comparable across groups. Conclusions All intraprocedural imaging strategies for PFO closure were safe and effective. However, echocardiographic guidance was associated with significant procedural advantages and may offer added value even in anatomically straightforward cases. A tailored imaging approach based on patient anatomy, operator expertise, and resource availability is recommended.