PMC8143726_01
Contrast TEE showing no atrial shunt. The Eustachian valve (white arrow) keeps the microbubbles away from the septum. TEE = transesophageal echocardiography.
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Nonetheless, conventional color Doppler and contrast transesophageal echocardiography (TEE) did not show any atrial shunting neither at rest nor following a Valsalva maneuver (Figs. 1 and 2).
Color Doppler TEE showing no atrial shunt. TEE = transesophageal echocardiography.
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Nonetheless, conventional color Doppler and contrast transesophageal echocardiography (TEE) did not show any atrial shunting neither at rest nor following a Valsalva maneuver (Figs. 1 and 2).
Large Eustachian valve noticed on TEE (white arrow). TEE = transesophageal echocardiography.
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Importantly, a large Eustachian valve (EV) was noticed (Fig. 3).
Contrast TTE with injection through upper extremity vein. Contrast bubbles arriving from above (the arm) are kept away from the atrial septum by the Eustachian valve guiding the blood from below (IVC via femoral vein) directly onto the PFO and thereby monopolizing that area (black area to the left of the septum). TTE = transthoracic echocardiography.
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While no contrast reached the area of the fossa ovalis and no shunt was observed following upper extremity injection (Fig. 4), >20 bubbles crossed the inter-atrial septum (IAS) after injection from the femoral vein (Fig. 5).
Percutaneous closure of PFO under ICE guidance. ICE = intracardiac echocardiography; PFO =patent foramen ovale.
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Percutaneous closure was performed one month later with a 25mm Amplatzer   PFO Occluder (Abbott Vascular) under intracardiac echocardiography guidance (Fig. 6).