Impact of Transesophageal Echocardiographic Parameters on Procedure-Related Radiation Exposure in Percutaneous Transcatheter Patent Foramen Ovale Closure

Impact of Transesophageal Echocardiographic Parameters on Procedure-Related Radiation Exposure in Percutaneous Transcatheter Patent Foramen Ovale Closure | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Impact of Transesophageal Echocardiographic Parameters on Procedure-Related Radiation Exposure in Percutaneous Transcatheter Patent Foramen Ovale Closure Ayşe İrem Demirtola, Anar Mammadli, Duygu Inan, Aslan Erdoğan, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4100124/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Patent foramen ovale (PFO) is a cardiac congenital anomaly with a prevalence of 20% to 30% in the general population, associated with clinical conditions such as cryptogenic stroke, migraine, and decompression sickness. Percutaneous PFO closure has been proven superior to medical treatment alone for PFO-related stroke, exhibiting a favorable safety profile. However, the procedure's radiation exposure necessitates a deeper understanding of the influencing factors, especially the impact of PFO anatomical characteristics on radiation dose and procedural time. Methods: This study analyzed 83 patients undergoing transcatheter PFO closure for CS. The study evaluated the relationship between the anatomical features of PFO and radiation exposure, measured by Air Kerma. Increased radiation exposure was defined as falling within the highest quintile (5 th quantile) of the Air Kerma. Statistical analyses included univariate and multivariate logistic regression and Receiver Operating Characteristic (ROC) analysis. Results: The study population had a mean age of 40.9 ± 9.0 years, with a slight male predominance (51.8%). The median fluoroscopy time was 10.9 minutes, with an interquartile range (IQR) of 7.5 to 19.9 minutes. The median Air Kerma value was 149 mGy (IQR, 83 – 311). In the multivariate regression analysis, a shorter aortic rim length was identified as an independent predictor of increased radiation exposure, with an odds ratio of 2.01 (95% confidence interval [CI], 1.3 – 3.1; P=0.002). In the ROC analysis, the aortic rim length demonstrated good predictive value for increased radiation exposure, with an area under the curve of 0.872 (95% CI, 0.791 – 0.953; P<0.001). A cutoff value of less than 4.5 mm for the aortic rim length was associated with an 88% sensitivity and 80% specificity in predicting increased radiation exposure. Conclusion: A short aortic rim length is associated with increased radiation exposure during percutaneous closure of PFO. Patent foramen ovale PFO closure radiation exposure INTRODUCTION A cardiac congenital anomaly known as patent foramen ovale (PFO) is prevalent in the general population, with a prevalence ranging from 20–30%( 1 ). Associations have been established between PFO and certain clinical conditions, including cryptogenic stroke (CS)( 2 ), migraine( 3 ), and decompression sickness( 4 ). Among these, PFO-related stroke has garnered significant attention, and numerous studies have demonstrated the superiority of percutaneous PFO closure over medical treatment alone in managing this patient group( 5 – 8 ). The percutaneous closure of PFO has demonstrated a favorable safety profile in numerous randomized controlled trials, revealing no significant increase in severe adverse events( 7 , 8 ). This confirmation establishes percutaneous PFO closure as a viable and secure intervention. Consequently, the procedure is becoming increasingly prevalent in contemporary clinical practice. However, with the widespread adoption of this technique, the associated radiation exposure has gained heightened significance. In the field of interventional cardiology, it is imperative to minimize exposure to ionizing radiation, as even recurrent modest doses can result in adverse outcomes such as the early onset of cataracts( 9 ) and an increased lifelong risk of cancer( 10 ). Therefore, identifying the specific factors that increase the need for fluoroscopic image acquisition—and, consequently, radiation exposure—is essential. Such understanding can inform the development of enhanced protective measures for both staff and patients, mitigating the potential risks associated with radiation in these procedures. Nevertheless, a notable gap persists in our comprehension of how the anatomical characteristics of PFO impact radiation exposure. This study aims to bridge this gap by elucidating the influence of PFO anatomical properties on radiation exposure. METHODS Study Population We conducted an analysis of 83 patients diagnosed with PFO, all of whom were scheduled for transcatheter closure as a therapeutic intervention for cryptogenic stroke. The presence of cerebral infarction in patients diagnosed with CS was confirmed using magnetic resonance imaging. The diagnosis of CS was established following a comprehensive evaluation aimed at excluding other potential etiologies of stroke, including large artery atherosclerosis, cardio-embolism, small vessel disease, and arterial dissection. All medical procedures, including preprocedural assessment, imaging, and closure procedures, were performed at Başakşehir Çam ve Sakura City Hospital in Istanbul. The decision to perform percutaneous closure of PFO was made by a multidisciplinary stroke team of the facility. Written informed consent was obtained from all patients for the examinations. The research received approval from the institution's ethics committee. Echocardiography Pre-closure diagnosis of PFO relied on transesophageal echocardiography (TEE) using the EPIQ CVx ultrasound system and X8-2t probe (Philips Healthcare). The patient received a local anesthetic and sedation at a dosage intended to preserve their ability to perform the Valsalva maneuver without interference. The definitive PFO criterion was microbubble transit from the right atrium to the left atrium within three cardiac cycles after agitated saline contrast injection. Beyond confirming PFO's presence, TEE provided a comprehensive assessment. PFO height, length, and septum primum and secundum lengths were measured. The aortic rim length, presence of lipomatous hypertrophy, Chiari network, Eustachian valve, and prominent crista terminalis were also evaluated. The functional analysis included spontaneous color Doppler transition, bubble transit at rest, bubble crossing with the Valsalva maneuver, and the ratio of the left to right atrium diameters. All echocardiographic examinations and transcranial Doppler evaluations were performed by a specialized echocardiograph team. Procedure The closure procedure was performed by highly experienced operators in a center with extensive PFO closure expertise, utilizing TEE guidance. Fluoroscopic imaging was provided by the Azurion 7 C12 Image-guided therapy system (Philips Healthcare). The femoral vein was the preferred access site. A 6 Fr multipurpose catheter and a 0.035-inch guidewire were used to cross the PFO from the right atrium in most patients. A hydrophilic guidewire or a smaller (4 Fr) catheter was employed to navigate potential tortuous anatomy and ensure smooth guidewire passage if needed. Subsequently, a guidewire was advanced into the left pulmonary vein. A long sheath was extended beyond the PFO tunnel. The left disc of the closure device was deployed within the left atrium and then retracted towards the septum primum. The right disc was deployed within the right atrium and advanced towards the PFO entrance. Before release, meticulous confirmation was obtained to ensure secure device adhesion to both the septum primum and secundum, with no interference with atrioventricular valves or other intracardiac structures. Radiation exposure We used Air Kerma as an indicator of radiation exposure in primary analysis. Although fluoroscopy time is a more direct manifestation of procedural duration, it was not chosen as an indicator due to Air Kerma's superior accuracy in quantifying radiation exposure. Air Kerma represents the kinetic energy transferred from an X-ray beam to a unit mass of air, expressed in Gray, where 1 Gray equals 1 Joule of energy absorbed per kilogram of air. Air Kerma provides a measure of the energy of the radiation field that could potentially be absorbed by any object in that field, including laboratory staff and patients. Given that the radiation dose produced in interventional procedures is relatively low, it was quantified in milli-gray (mGy). The cumulative Dose Area Product (DAP), expressed in Gray-square centimeters (Gy·cm²), was also reported. DAP is practically equivalent to Kerma Area Product, which is the product of the Air Kerma and the cross-sectional area of the x-ray beam. DAP represents the total amount of radiation delivered to the patient. Both Air Kerma and DAP were measured and reported automatically by the fluoroscopy system. Statistical Analysis For continuous variables, data are presented as mean ± standard deviation (SD) for normally distributed variables and as median and interquartile range (IQR) for non-normally distributed variables. Categorical variables are expressed as numbers and percentages. The normality of distribution was assessed using the Kolmogorov-Smirnov test. Increased radiation exposure was defined as falling within the highest quintile (5th quantile) of the Air Kerma. Univariate logistic regression analyses were conducted to identify predictors of increased radiation exposure. Variables demonstrating significant associations in the univariate analysis, along with age and sex, were subsequently included in the multivariate regression. We conducted a Receiver Operating Characteristic (ROC) analysis to assess the diagnostic performance of parameters identified as statistically significant in multivariate analysis for predicting increased radiation exposure. P-values less than 0.05 were considered statistically significant. Statistical analyses were performed using IBM SPSS Statistics, version 26. RESULTS The mean age of the patients was 40.9 ± 9.0 years, with 43 patients (51.8%) being male. The median Risk of Paradoxical Embolism (RoPE) score was 7. The closure was conducted using Amplatzer PFO Occluder (Abbott Cardiovascular) in 58 patients (86.7%) and MemoPart PFO Occluder (Lepu Medical) in 11 patients. The median fluoroscopy time was 10.9 minutes (IQR, 7.5–19.9). The median Air Kerma value was 149 mGy (IQR, 83–311), and the median cumulative DAP value was 24.8 Gy·cm² (IQR, 14.8–41.5). The mean Air Kerma value for 16 procedures identified with increased radiation exposure was 697 ± 248 mGy. An excellent correlation was observed between fluoroscopy times and Air Kerma values (r = 0.9; P < 0.001). Baseline characteristics of the study population are presented in Table 1 . The mean height of PFO was 4.3 ± 2.3 mm, and the mean length of PFO was 12.6 ± 4.3 mm. The mean length of the aortic rim was 5.92 ± 2.33 mm. The atrial septal aneurysm was present in 37 (44.6%) patients. Right-to-left interatrial shunt demonstrated with agitated saline was observed in 39 (47%) patients at rest and 71 (85.5%) patients with the Valsalva maneuver. The echocardiographic characteristics of PFOs are shown in Table 2 . In the univariate regression analysis, PFO length, aortic rim length, the presence of the Eustachian valve, and right-to-left atrial shunt were identified as statistically significant predictors of increased radiation exposure. In the multivariate regression analysis, which included these variables along with age and gender, shorter aortic rim length was an independent predictor of increased radiation exposure (odds ratio 2.01, 95% confidence interval [CI], 1.3–3.1; P = 0.002). In the ROC analysis conducted to assess the diagnostic performance of aortic rim length in identifying increased radiation exposure, the area under the curve was calculated as 0.872 (%95 CI, 0.791–0.953; P < 0.001), indicating a good predictive value. An aortic rim length of less than 4.5 mm predicted increased radiation exposure with a sensitivity of 88% and a specificity of 80%. DİSCUSSİON In this study, we demonstrated that a shorter aortic rim correlates with heightened radiation exposure during percutaneous PFO closure. An inadequate aortic rim may complicate the anatomical configuration of the PFO, leading to prolonged fluoroscopic imaging times and, as a result, increased radiation exposure. Complex anatomy also affects procedural success and complication rate. Numerous studies have explored the link between the anatomical features of PFO and procedural outcomes. Amin identified several echocardiographic indicators that heighten the risk of erosion and perforation in atrial septal defect (ASD) closures, findings that are similarly relevant to patent foramen ovale (PFO) closures. Notably, one of these indicators includes the absence of the aortic rim in multiple echocardiographic views( 11 , 12 ). The Amplatzer PFO occluder's instructions caution against its use if the aortic rim measures less than 9 mm to prevent potential injury to adjacent structures(12). Using an oversized occluder to compensate for a short rim heightens the risk of erosion and iatrogenic complications( 13 ). One of the key indicators of procedural success in PFO closure is the absence of a residual shunt. In a prospective observational cohort study, the occurrence of a residual shunt following patent foramen ovale (PFO) closure was independently associated with the type of occluder used, the presence and extent of a concomitant atrial septal aneurysm, and the length of the PFO canal( 14 ). Certain anatomical features of patent foramen ovale (PFO) are also associated with an increased stroke risk and have been identified as high-risk factors( 15 ). Nakayama et al. demonstrated that characteristics including long-tunnel PFO, the presence of a hypermobile interatrial septum, a prominent Eustachian valve or Chiari's network, a large right-to-left shunt during the Valsalva maneuver, and a low-angle PFO are independently associated with cryptogenic stroke( 16 ). In our research, univariate analysis initially suggested a relationship between increased radiation exposure and some of these anatomic features, such as the length of the PFO, right-to-left atrial shunt, and the presence of an Eustachian valve. However, such associations were not substantiated in the multivariate analysis. The main limitations of our study are its single-center design and the relatively small sample size. CONCLUSION In conclusion, our study has demonstrated that a short aortic rim in patients with PFO is associated with increased radiation exposure during the percutaneous PFO closure procedure. This finding underscores the importance of considering anatomical variations, such as the length of the aortic rim, in the pre-procedural planning phase to potentially minimize radiation exposure for patients and healthcare personnel. Further research with larger, multi-centered cohorts is required to validate these findings and explore strategies to reduce radiation exposure during PFO closure interventions. Declarations Informed Consent: Written informed consent was obtained from the subject prior to participation in the study. Declaration of Interests : The authors have no conflict of interest to declare. Funding : The authors declared that this study had received no financial support. Acknowledgments : None Author Contribution Author Contributions: Conceptualization, AID, AM, DIMethodology,AID, AMformal analysis,AID, AM, DIinvestigation, AE, SY, OP, DG, ID, FSdata curation, DG, ID, FSwriting original draft preparation, AID, AM, DIvisualization, AIDsupervision,AK project administration, A.K. All authors have read and agreed to the published version of the manuscript. References Pristipino C, Sievert H, D'Ascenzo F et al (2019) European position paper on the management of patients with patent foramen ovale. General approach and left circulation thromboembolism. Eur Heart J 40:3182–3195 Mazzucco S, Li L, Binney L, Rothwell PM (2018) Prevalence of patent foramen ovale in cryptogenic transient ischaemic attack and non-disabling stroke at older ages: a population-based study, systematic review, and meta-analysis. Lancet Neurol 17:609–617 Lamy C, Giannesini C, Zuber M et al (2002) Clinical and imaging findings in cryptogenic stroke patients with and without patent foramen ovale: the PFO-ASA Study. Atr Septal Aneurysm Stroke 33:706–711 Torti SR, Billinger M, Schwerzmann M et al (2004) Risk of decompression illness among 230 divers in relation to the presence and size of patent foramen ovale. Eur Heart J 25:1014–1020 Lee PH, Song JK, Kim JS et al (2018) Cryptogenic Stroke and High-Risk Patent Foramen Ovale: The DEFENSE-PFO Trial. J Am Coll Cardiol 71:2335–2342 Søndergaard L, Kasner SE, Rhodes JF et al (2017) Patent Foramen Ovale Closure or Antiplatelet Therapy for Cryptogenic Stroke. N Engl J Med 377:1033–1042 Saver JL, Carroll JD, Thaler DE et al (2017) Long-Term Outcomes of Patent Foramen Ovale Closure or Medical Therapy after Stroke. N Engl J Med 377:1022–1032 Mas JL, Derumeaux G, Guillon B et al (2017) Patent Foramen Ovale Closure or Anticoagulation vs. Antiplatelets after Stroke. N Engl J Med 377:1011–1021 Elmaraezy A, Ebraheem Morra M, Tarek Mohammed A et al (2017) Risk of cataract among interventional cardiologists and catheterization lab staff: A systematic review and meta-analysis. Catheter Cardiovasc Interv 90:1–9 Venneri L, Rossi F, Botto N et al (2009) Cancer risk from professional exposure in staff working in cardiac catheterization laboratory: insights from the National Research Council's Biological Effects of Ionizing Radiation VII Report. Am Heart J 157:118–124 Amin Z (2014) Echocardiographic predictors of cardiac erosion after amplatzer septal occluder placement. Catheter Cardiovasc Interv 83:84–92 Collado FMS, Poulin MF, Murphy JJ, Jneid H, Kavinsky CJ (2018) Patent Foramen Ovale Closure for Stroke Prevention and Other Disorders. J Am Heart Association 7:e007146 Onorato E, Casilli F (2013) Influence of PFO Anatomy on Successful Transcatheter Closure. Interv Cardiol Clin 2:51–84 Hammerstingl C, Bauriedel G, Stüsser C et al (2011) Risk and fate of residual interatrial shunting after transcatheter closure of patent foramen ovale: a long term follow up study. Eur J Med Res 16:13 Scacciatella P, Butera G, Meynet I et al (2011) Percutaneous closure of patent foramen ovale in patients with anatomical and clinical high-risk characteristics: long-term efficacy and safety. J Interv Cardiol 24:477–484 Nakayama R, Takaya Y, Akagi T et al (2019) Identification of High-Risk Patent Foramen Ovale Associated With Cryptogenic Stroke: Development of a Scoring System. J Am Soc Echocardiogr 32:811–816 Tables Table 1 Characteristics of the patients Characteristic, n (%) N=83 Diabetes mellitus 21 (25.3) Hypertension 28 (33.7) Coronary artery disease 13 (15.7) Smoking 28 (33.7) Dyslipidemia 22 (26.5) Migraine 7 (8.4) Deep vein thrombosis 1 (1.2) Atrial fibrillation 2 (2.4) Table 2. Echocardiographic characteristics of the patients* Variable N=83 Height of PFO, mm 4.3±2.3 Length of PFO, mm 12.6±4.3 Length of septum primum, mm 31.4±5.1 Length septum secundum, mm 23±3.5 Length of the aortic rim, mm 5.9±2.3 LA diameter, mm 32.5±4.4 RA diameter, mm 31.9±4.7 The angle between IVC and PFO, degrees 22.9±10.9 Atrial septal aneurysm, n (%) 37 (44.6) Prominent Eustachian valve, n (%) 12 (14.5) Chiari’s network, n (%) 6 (7.2) Lipomatous hypertrophy, n (%) 11(13.3) Prominent crista terminalis, n (%) 6 (7.2) Right-to-left shunt at rest (with agitated saline), n (%) 39 (47) Right-to-left shunt at rest (with agitated saline), n (%) 71 (85.5) Positive transcranial Doppler, n (%) 54 (65.1) *Plus-minus values are means ± SD. PFO denotes Patent foramen ovale, LA Left atrium, RA Right atrium, and IVC Inferior vena cava Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4100124","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":279859051,"identity":"612d11ed-fd27-496d-9cbc-819f4688ac97","order_by":0,"name":"Ayşe İrem 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11:09:26","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4100124/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4100124/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":53150650,"identity":"16547044-0536-419b-9e20-d8220b6fbe81","added_by":"auto","created_at":"2024-03-21 08:29:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":256248,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4100124/v1/5597993c-1797-433d-a198-0f648d385dc4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Impact of Transesophageal Echocardiographic Parameters on Procedure-Related Radiation Exposure in Percutaneous Transcatheter Patent Foramen Ovale Closure","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eA cardiac congenital anomaly known as patent foramen ovale (PFO) is prevalent in the general population, with a prevalence ranging from 20\u0026ndash;30%(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Associations have been established between PFO and certain clinical conditions, including cryptogenic stroke (CS)(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e), migraine(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e), and decompression sickness(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Among these, PFO-related stroke has garnered significant attention, and numerous studies have demonstrated the superiority of percutaneous PFO closure over medical treatment alone in managing this patient group(\u003cspan additionalcitationids=\"CR6 CR7\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe percutaneous closure of PFO has demonstrated a favorable safety profile in numerous randomized controlled trials, revealing no significant increase in severe adverse events(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). This confirmation establishes percutaneous PFO closure as a viable and secure intervention. Consequently, the procedure is becoming increasingly prevalent in contemporary clinical practice. However, with the widespread adoption of this technique, the associated radiation exposure has gained heightened significance. In the field of interventional cardiology, it is imperative to minimize exposure to ionizing radiation, as even recurrent modest doses can result in adverse outcomes such as the early onset of cataracts(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) and an increased lifelong risk of cancer(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Therefore, identifying the specific factors that increase the need for fluoroscopic image acquisition\u0026mdash;and, consequently, radiation exposure\u0026mdash;is essential. Such understanding can inform the development of enhanced protective measures for both staff and patients, mitigating the potential risks associated with radiation in these procedures. Nevertheless, a notable gap persists in our comprehension of how the anatomical characteristics of PFO impact radiation exposure. This study aims to bridge this gap by elucidating the influence of PFO anatomical properties on radiation exposure.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Population\u003c/h2\u003e \u003cp\u003eWe conducted an analysis of 83 patients diagnosed with PFO, all of whom were scheduled for transcatheter closure as a therapeutic intervention for cryptogenic stroke. The presence of cerebral infarction in patients diagnosed with CS was confirmed using magnetic resonance imaging. The diagnosis of CS was established following a comprehensive evaluation aimed at excluding other potential etiologies of stroke, including large artery atherosclerosis, cardio-embolism, small vessel disease, and arterial dissection. All medical procedures, including preprocedural assessment, imaging, and closure procedures, were performed at Başakşehir \u0026Ccedil;am ve Sakura City Hospital in Istanbul. The decision to perform percutaneous closure of PFO was made by a multidisciplinary stroke team of the facility. Written informed consent was obtained from all patients for the examinations. The research received approval from the institution's ethics committee.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eEchocardiography\u003c/h2\u003e \u003cp\u003ePre-closure diagnosis of PFO relied on transesophageal echocardiography (TEE) using the EPIQ CVx ultrasound system and X8-2t probe (Philips Healthcare). The patient received a local anesthetic and sedation at a dosage intended to preserve their ability to perform the Valsalva maneuver without interference. The definitive PFO criterion was microbubble transit from the right atrium to the left atrium within three cardiac cycles after agitated saline contrast injection. Beyond confirming PFO's presence, TEE provided a comprehensive assessment. PFO height, length, and septum primum and secundum lengths were measured. The aortic rim length, presence of lipomatous hypertrophy, Chiari network, Eustachian valve, and prominent crista terminalis were also evaluated. The functional analysis included spontaneous color Doppler transition, bubble transit at rest, bubble crossing with the Valsalva maneuver, and the ratio of the left to right atrium diameters. All echocardiographic examinations and transcranial Doppler evaluations were performed by a specialized echocardiograph team.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eProcedure\u003c/h2\u003e \u003cp\u003eThe closure procedure was performed by highly experienced operators in a center with extensive PFO closure expertise, utilizing TEE guidance. Fluoroscopic imaging was provided by the Azurion 7 C12 Image-guided therapy system (Philips Healthcare). The femoral vein was the preferred access site. A 6 Fr multipurpose catheter and a 0.035-inch guidewire were used to cross the PFO from the right atrium in most patients. A hydrophilic guidewire or a smaller (4 Fr) catheter was employed to navigate potential tortuous anatomy and ensure smooth guidewire passage if needed. Subsequently, a guidewire was advanced into the left pulmonary vein. A long sheath was extended beyond the PFO tunnel. The left disc of the closure device was deployed within the left atrium and then retracted towards the septum primum. The right disc was deployed within the right atrium and advanced towards the PFO entrance. Before release, meticulous confirmation was obtained to ensure secure device adhesion to both the septum primum and secundum, with no interference with atrioventricular valves or other intracardiac structures.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eRadiation exposure\u003c/h2\u003e \u003cp\u003eWe used Air Kerma as an indicator of radiation exposure in primary analysis. Although fluoroscopy time is a more direct manifestation of procedural duration, it was not chosen as an indicator due to Air Kerma's superior accuracy in quantifying radiation exposure.\u003c/p\u003e \u003cp\u003eAir Kerma represents the kinetic energy transferred from an X-ray beam to a unit mass of air, expressed in Gray, where 1 Gray equals 1 Joule of energy absorbed per kilogram of air. Air Kerma provides a measure of the energy of the radiation field that could potentially be absorbed by any object in that field, including laboratory staff and patients. Given that the radiation dose produced in interventional procedures is relatively low, it was quantified in milli-gray (mGy).\u003c/p\u003e \u003cp\u003eThe cumulative Dose Area Product (DAP), expressed in Gray-square centimeters (Gy\u0026middot;cm\u0026sup2;), was also reported. DAP is practically equivalent to Kerma Area Product, which is the product of the Air Kerma and the cross-sectional area of the x-ray beam. DAP represents the total amount of radiation delivered to the patient. Both Air Kerma and DAP were measured and reported automatically by the fluoroscopy system.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eFor continuous variables, data are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD) for normally distributed variables and as median and interquartile range (IQR) for non-normally distributed variables. Categorical variables are expressed as numbers and percentages. The normality of distribution was assessed using the Kolmogorov-Smirnov test. Increased radiation exposure was defined as falling within the highest quintile (5th quantile) of the Air Kerma. Univariate logistic regression analyses were conducted to identify predictors of increased radiation exposure. Variables demonstrating significant associations in the univariate analysis, along with age and sex, were subsequently included in the multivariate regression. We conducted a Receiver Operating Characteristic (ROC) analysis to assess the diagnostic performance of parameters identified as statistically significant in multivariate analysis for predicting increased radiation exposure. P-values less than 0.05 were considered statistically significant. Statistical analyses were performed using IBM SPSS Statistics, version 26.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThe mean age of the patients was 40.9\u0026thinsp;\u0026plusmn;\u0026thinsp;9.0 years, with 43 patients (51.8%) being male. The median Risk of Paradoxical Embolism (RoPE) score was 7. The closure was conducted using Amplatzer PFO Occluder (Abbott Cardiovascular) in 58 patients (86.7%) and MemoPart PFO Occluder (Lepu Medical) in 11 patients.\u003c/p\u003e \u003cp\u003eThe median fluoroscopy time was 10.9 minutes (IQR, 7.5\u0026ndash;19.9). The median Air Kerma value was 149 mGy (IQR, 83\u0026ndash;311), and the median cumulative DAP value was 24.8 Gy\u0026middot;cm\u0026sup2; (IQR, 14.8\u0026ndash;41.5). The mean Air Kerma value for 16 procedures identified with increased radiation exposure was 697\u0026thinsp;\u0026plusmn;\u0026thinsp;248 mGy. An excellent correlation was observed between fluoroscopy times and Air Kerma values (r\u0026thinsp;=\u0026thinsp;0.9; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eBaseline characteristics of the study population are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eThe mean height of PFO was 4.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3 mm, and the mean length of PFO was 12.6\u0026thinsp;\u0026plusmn;\u0026thinsp;4.3 mm. The mean length of the aortic rim was 5.92\u0026thinsp;\u0026plusmn;\u0026thinsp;2.33 mm. The atrial septal aneurysm was present in 37 (44.6%) patients. Right-to-left interatrial shunt demonstrated with agitated saline was observed in 39 (47%) patients at rest and 71 (85.5%) patients with the Valsalva maneuver.\u003c/p\u003e \u003cp\u003eThe echocardiographic characteristics of PFOs are shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eIn the univariate regression analysis, PFO length, aortic rim length, the presence of the Eustachian valve, and right-to-left atrial shunt were identified as statistically significant predictors of increased radiation exposure. In the multivariate regression analysis, which included these variables along with age and gender, shorter aortic rim length was an independent predictor of increased radiation exposure (odds ratio 2.01, 95% confidence interval [CI], 1.3\u0026ndash;3.1; P\u0026thinsp;=\u0026thinsp;0.002). In the ROC analysis conducted to assess the diagnostic performance of aortic rim length in identifying increased radiation exposure, the area under the curve was calculated as 0.872 (%95 CI, 0.791\u0026ndash;0.953; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), indicating a good predictive value. An aortic rim length of less than 4.5 mm predicted increased radiation exposure with a sensitivity of 88% and a specificity of 80%.\u003c/p\u003e"},{"header":"DİSCUSSİON","content":"\u003cp\u003eIn this study, we demonstrated that a shorter aortic rim correlates with heightened radiation exposure during percutaneous PFO closure. An inadequate aortic rim may complicate the anatomical configuration of the PFO, leading to prolonged fluoroscopic imaging times and, as a result, increased radiation exposure. Complex anatomy also affects procedural success and complication rate. Numerous studies have explored the link between the anatomical features of PFO and procedural outcomes.\u003c/p\u003e \u003cp\u003eAmin identified several echocardiographic indicators that heighten the risk of erosion and perforation in atrial septal defect (ASD) closures, findings that are similarly relevant to patent foramen ovale (PFO) closures. Notably, one of these indicators includes the absence of the aortic rim in multiple echocardiographic views(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe Amplatzer PFO occluder's instructions caution against its use if the aortic rim measures less than 9 mm to prevent potential injury to adjacent structures(12). Using an oversized occluder to compensate for a short rim heightens the risk of erosion and iatrogenic complications(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOne of the key indicators of procedural success in PFO closure is the absence of a residual shunt. In a prospective observational cohort study, the occurrence of a residual shunt following patent foramen ovale (PFO) closure was independently associated with the type of occluder used, the presence and extent of a concomitant atrial septal aneurysm, and the length of the PFO canal(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCertain anatomical features of patent foramen ovale (PFO) are also associated with an increased stroke risk and have been identified as high-risk factors(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Nakayama et al. demonstrated that characteristics including long-tunnel PFO, the presence of a hypermobile interatrial septum, a prominent Eustachian valve or Chiari's network, a large right-to-left shunt during the Valsalva maneuver, and a low-angle PFO are independently associated with cryptogenic stroke(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn our research, univariate analysis initially suggested a relationship between increased radiation exposure and some of these anatomic features, such as the length of the PFO, right-to-left atrial shunt, and the presence of an Eustachian valve. However, such associations were not substantiated in the multivariate analysis.\u003c/p\u003e \u003cp\u003eThe main limitations of our study are its single-center design and the relatively small sample size.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eIn conclusion, our study has demonstrated that a short aortic rim in patients with PFO is associated with increased radiation exposure during the percutaneous PFO closure procedure. This finding underscores the importance of considering anatomical variations, such as the length of the aortic rim, in the pre-procedural planning phase to potentially minimize radiation exposure for patients and healthcare personnel. Further research with larger, multi-centered cohorts is required to validate these findings and explore strategies to reduce radiation exposure during PFO closure interventions.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eInformed Consent:\u003c/strong\u003e Written informed consent was obtained from the subject prior to participation in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of Interests\u003c/strong\u003e: The authors have no conflict of interest to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: The authors declared that this study had received no financial support.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e: \u0026nbsp; None\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAuthor Contributions: Conceptualization, AID, AM, DIMethodology,AID, AMformal analysis,AID, AM, DIinvestigation, AE, SY, OP, DG, ID, FSdata curation, DG, ID, FSwriting original draft preparation, AID, AM, DIvisualization, AIDsupervision,AK project administration, A.K. All authors have read and agreed to the published version of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003ePristipino C, Sievert H, D'Ascenzo F et al (2019) European position paper on the management of patients with patent foramen ovale. General approach and left circulation thromboembolism. Eur Heart J 40:3182\u0026ndash;3195\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMazzucco S, Li L, Binney L, Rothwell PM (2018) Prevalence of patent foramen ovale in cryptogenic transient ischaemic attack and non-disabling stroke at older ages: a population-based study, systematic review, and meta-analysis. Lancet Neurol 17:609\u0026ndash;617\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLamy C, Giannesini C, Zuber M et al (2002) Clinical and imaging findings in cryptogenic stroke patients with and without patent foramen ovale: the PFO-ASA Study. Atr Septal Aneurysm Stroke 33:706\u0026ndash;711\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTorti SR, Billinger M, Schwerzmann M et al (2004) Risk of decompression illness among 230 divers in relation to the presence and size of patent foramen ovale. Eur Heart J 25:1014\u0026ndash;1020\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee PH, Song JK, Kim JS et al (2018) Cryptogenic Stroke and High-Risk Patent Foramen Ovale: The DEFENSE-PFO Trial. J Am Coll Cardiol 71:2335\u0026ndash;2342\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eS\u0026oslash;ndergaard L, Kasner SE, Rhodes JF et al (2017) Patent Foramen Ovale Closure or Antiplatelet Therapy for Cryptogenic Stroke. N Engl J Med 377:1033\u0026ndash;1042\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSaver JL, Carroll JD, Thaler DE et al (2017) Long-Term Outcomes of Patent Foramen Ovale Closure or Medical Therapy after Stroke. N Engl J Med 377:1022\u0026ndash;1032\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMas JL, Derumeaux G, Guillon B et al (2017) Patent Foramen Ovale Closure or Anticoagulation vs. Antiplatelets after Stroke. N Engl J Med 377:1011\u0026ndash;1021\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eElmaraezy A, Ebraheem Morra M, Tarek Mohammed A et al (2017) Risk of cataract among interventional cardiologists and catheterization lab staff: A systematic review and meta-analysis. Catheter Cardiovasc Interv 90:1\u0026ndash;9\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVenneri L, Rossi F, Botto N et al (2009) Cancer risk from professional exposure in staff working in cardiac catheterization laboratory: insights from the National Research Council's Biological Effects of Ionizing Radiation VII Report. Am Heart J 157:118\u0026ndash;124\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmin Z (2014) Echocardiographic predictors of cardiac erosion after amplatzer septal occluder placement. Catheter Cardiovasc Interv 83:84\u0026ndash;92\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCollado FMS, Poulin MF, Murphy JJ, Jneid H, Kavinsky CJ (2018) Patent Foramen Ovale Closure for Stroke Prevention and Other Disorders. J Am Heart Association 7:e007146\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOnorato E, Casilli F (2013) Influence of PFO Anatomy on Successful Transcatheter Closure. Interv Cardiol Clin 2:51\u0026ndash;84\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHammerstingl C, Bauriedel G, St\u0026uuml;sser C et al (2011) Risk and fate of residual interatrial shunting after transcatheter closure of patent foramen ovale: a long term follow up study. Eur J Med Res 16:13\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eScacciatella P, Butera G, Meynet I et al (2011) Percutaneous closure of patent foramen ovale in patients with anatomical and clinical high-risk characteristics: long-term efficacy and safety. J Interv Cardiol 24:477\u0026ndash;484\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNakayama R, Takaya Y, Akagi T et al (2019) Identification of High-Risk Patent Foramen Ovale Associated With Cryptogenic Stroke: Development of a Scoring System. J Am Soc Echocardiogr 32:811\u0026ndash;816\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 Characteristics of the patients\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"373\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"68.63270777479893%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic, n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.367292225201073%\"\u003e\n \u003cp\u003e\u003cstrong\u003eN=83\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"68.63270777479893%\"\u003e\n \u003cp\u003eDiabetes mellitus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.367292225201073%\"\u003e\n \u003cp\u003e21 (25.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"68.63270777479893%\"\u003e\n \u003cp\u003eHypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.367292225201073%\"\u003e\n \u003cp\u003e28 (33.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"68.63270777479893%\"\u003e\n \u003cp\u003eCoronary artery disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.367292225201073%\"\u003e\n \u003cp\u003e13 (15.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"68.63270777479893%\"\u003e\n \u003cp\u003eSmoking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.367292225201073%\"\u003e\n \u003cp\u003e28 (33.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"68.63270777479893%\"\u003e\n \u003cp\u003eDyslipidemia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.367292225201073%\"\u003e\n \u003cp\u003e22 (26.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"68.63270777479893%\"\u003e\n \u003cp\u003eMigraine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.367292225201073%\"\u003e\n \u003cp\u003e7 (8.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"68.63270777479893%\"\u003e\n \u003cp\u003eDeep vein thrombosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.367292225201073%\"\u003e\n \u003cp\u003e1 (1.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"68.63270777479893%\"\u003e\n \u003cp\u003eAtrial fibrillation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.367292225201073%\"\u003e\n \u003cp\u003e2 (2.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;2. Echocardiographic characteristics of the patients*\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"522\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"79.65451055662189%\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.34548944337812%\"\u003e\n \u003cp\u003e\u003cstrong\u003eN=83\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"79.65451055662189%\"\u003e\n \u003cp\u003eHeight of PFO, mm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.34548944337812%\"\u003e\n \u003cp\u003e4.3\u0026plusmn;2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"79.65451055662189%\"\u003e\n \u003cp\u003eLength of PFO, mm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.34548944337812%\"\u003e\n \u003cp\u003e12.6\u0026plusmn;4.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"79.65451055662189%\"\u003e\n \u003cp\u003eLength of septum primum, mm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.34548944337812%\"\u003e\n \u003cp\u003e31.4\u0026plusmn;5.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"79.65451055662189%\"\u003e\n \u003cp\u003eLength septum secundum, mm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.34548944337812%\"\u003e\n \u003cp\u003e23\u0026plusmn;3.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"79.65451055662189%\"\u003e\n \u003cp\u003eLength of the aortic rim, mm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.34548944337812%\"\u003e\n \u003cp\u003e5.9\u0026plusmn;2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"79.65451055662189%\"\u003e\n \u003cp\u003eLA diameter, mm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.34548944337812%\"\u003e\n \u003cp\u003e32.5\u0026plusmn;4.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"79.65451055662189%\"\u003e\n \u003cp\u003eRA diameter, mm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.34548944337812%\"\u003e\n \u003cp\u003e31.9\u0026plusmn;4.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"79.65451055662189%\"\u003e\n \u003cp\u003eThe angle between IVC and PFO, degrees\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.34548944337812%\"\u003e\n \u003cp\u003e22.9\u0026plusmn;10.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"79.65451055662189%\"\u003e\n \u003cp\u003eAtrial septal aneurysm, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.34548944337812%\"\u003e\n \u003cp\u003e37 (44.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"79.65451055662189%\"\u003e\n \u003cp\u003eProminent Eustachian valve, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.34548944337812%\"\u003e\n \u003cp\u003e12 (14.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"79.65451055662189%\"\u003e\n \u003cp\u003eChiari\u0026rsquo;s network, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.34548944337812%\"\u003e\n \u003cp\u003e6 (7.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"79.65451055662189%\"\u003e\n \u003cp\u003eLipomatous hypertrophy, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.34548944337812%\"\u003e\n \u003cp\u003e11(13.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"79.65451055662189%\"\u003e\n \u003cp\u003eProminent crista terminalis, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.34548944337812%\"\u003e\n \u003cp\u003e6 (7.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"79.65451055662189%\"\u003e\n \u003cp\u003eRight-to-left shunt at rest (with agitated saline), n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.34548944337812%\"\u003e\n \u003cp\u003e39 (47)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"79.65451055662189%\"\u003e\n \u003cp\u003eRight-to-left shunt at rest (with agitated saline), n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.34548944337812%\"\u003e\n \u003cp\u003e71 (85.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"79.65451055662189%\"\u003e\n \u003cp\u003ePositive transcranial Doppler, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.34548944337812%\"\u003e\n \u003cp\u003e54 (65.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"2\"\u003e\n \u003cp\u003e*Plus-minus values are means \u0026plusmn; SD. PFO denotes Patent foramen ovale, LA Left atrium, RA Right atrium, and IVC Inferior vena cava\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Patent foramen ovale, PFO closure, radiation exposure","lastPublishedDoi":"10.21203/rs.3.rs-4100124/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4100124/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Patent foramen ovale (PFO) is a cardiac congenital anomaly with a prevalence of 20% to 30% in the general population, associated with clinical conditions such as cryptogenic stroke, migraine, and decompression sickness. Percutaneous PFO closure has been proven superior to medical treatment alone for PFO-related stroke, exhibiting a favorable safety profile. However, the procedure's radiation exposure necessitates a deeper understanding of the influencing factors, especially the impact of PFO anatomical characteristics on radiation dose and procedural time.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e This study analyzed 83 patients undergoing transcatheter PFO closure for CS. The study evaluated the relationship between the anatomical features of PFO and radiation exposure, measured by Air Kerma. Increased radiation exposure was defined as falling within the highest quintile (5\u003csup\u003eth \u003c/sup\u003equantile) of the Air Kerma. Statistical analyses included univariate and multivariate logistic regression and Receiver Operating Characteristic (ROC) analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e The study population had a mean age of 40.9 ± 9.0 years, with a slight male predominance (51.8%). The median fluoroscopy time was 10.9 minutes, with an interquartile range (IQR) of 7.5 to 19.9 minutes. The median Air Kerma value was 149 mGy (IQR, 83 – 311). In the multivariate regression analysis, a shorter aortic rim length was identified as an independent predictor of increased radiation exposure, with an odds ratio of 2.01 (95% confidence interval [CI], 1.3 – 3.1; P=0.002). In the ROC analysis, the aortic rim length demonstrated good predictive value for increased radiation exposure, with an area under the curve of 0.872 (95% CI, 0.791 – 0.953; P\u0026lt;0.001). A cutoff value of less than 4.5 mm for the aortic rim length was associated with an 88% sensitivity and 80% specificity in predicting increased radiation exposure.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e A short aortic rim length is associated with increased radiation exposure during percutaneous closure of PFO.\u003c/p\u003e","manuscriptTitle":"Impact of Transesophageal Echocardiographic Parameters on Procedure-Related Radiation Exposure in Percutaneous Transcatheter Patent Foramen Ovale Closure","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-18 07:36:30","doi":"10.21203/rs.3.rs-4100124/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f53abf3d-5ab4-418f-b27e-1396fec86461","owner":[],"postedDate":"March 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-03-21T08:21:17+00:00","versionOfRecord":[],"versionCreatedAt":"2024-03-18 07:36:30","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4100124","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4100124","identity":"rs-4100124","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}