317 Value of real-time three-dimensional transesophageal echocardiography during patent foramen ovale closure: a case report Barış Buğan (*), Oben Baysan (**), Sait Demirkol (**), Yalçın Gökoğlan (**), Cem Barçın (**), Hürkan Kurşaklıoğlu (**) * Malatya Military District Hospital, Department of Cardiology ** Gulhane Military Medical Academy, Department of Cardiology Reprint request: Dr. Barış Buğan, Malatya Military District Hospital, Department of Cardiology, Malatya, Turkey E-mail: bbugan@hotmail.com Date submitted: April 07, 2011 Date accepted: August 15, 2011 Online publication date: December 26, 2012 OLGU SUNUMU/CASE REPORT Gülhane Tıp Derg 2012; 54: 317-319 © Gülhane Askeri Tıp Akademisi 2012 doi:10.5455/gulhane.30577 SUMMARY Although contrast injection during percutaneous closure of patent foramen ovale (PFO) has been used for assessing the adequacy of the procedure, transesophageal echocardiography (TEE) has an important role in both di- agnosis and percutaneous closure of PFO. Three-dimensional (3D) TEE may have incremental value in PFO closure such that direct anatomic informa- tion about PFO can be obtained. More importantly, successful closure can be directly assessed via Real-time 3D TEE. This case report emphasizes the importance of Live 3D TEE usage during PFO closure in a 32-year-old male patient with two transient ischemic attacks and normal hematological tests. Key words: Real-time, transesophageal echocardiography, patent foramen ovale, percutaneous closure ÖZET Patent foramen ovale kapatılması esnasında anlık üç boyutlu transözofajeal ekokardiyografinin önemi: olgu sunumu Patent foramen ovale’nin perkutan kapatılması esnasında kontrast enjek- siyonu, işlemin uygunluğunu tespit etmek için kullanılmasına rağmen, transözofageal ekokardiyografi (TEE) hem tanı, hem de PFO’nun perkutan kapatılmasında önemli bir araçtır. Üç boyutlu (3D) TEE, PFO kapatılmasın- da önemi zamanla artmaktadır, öyle ki defekt hakkında direk anatomik bilgi sağlayabilmektedir. Daha da önemlisi, işlem başarısı, anlık üç boyut aracı- lığıyla doğrudan gösterilebilir. Bu olgu sunumu, iki geçici iskemik atak ge- çiren ve hematolojik testleri normal olan 32 yaşında erkek bir hastada, PFO kapatılması esnasında, anlık 3D TEE kullanımının önemini vurgulamaktadır. Anahtar kelimeler: Gerçek zamanlı, transözofageal ekokardiyografi, patent foramen ovale, perkutan kapama Introduction Patent foramen ovale (PFO) is the failure of the primum and secundum atrial septa to fuse postpar- tum(1-3). It has been implicated in several pathologic processes, including paradoxical embolism in crypto- genic stroke and venous-to-arterial gas embolism in serious forms of decompression sickness and migra- ine with aura(2,3). Many studies have demonstrated that transcatheter PFO closure significantly reduced the incidence of recurrent strokes in high-risk pati- ents with PFO compared with antithrombotic drugs. Two-dimensional transoesophageal echocardiog- raphy (2D TEE) has been used for guiding atrial septal defect (ASD) and PFO closure. Real-time three-dimen- sional transoesophageal echocardiography (3D TEE) may be potentially superior to 2D TEE in the accurate assessment of the morphology and efficacy of trans- catheter closure because of a better spacial visualizati- on(1,4,5). We, herein, reported percutaneous closure of PFO with 3D TEE in a 32 years old male patient with two transient ischemic attacks. Case Report A 32-year-old male patient with two transient isc- hemic attacks and normal hematological tests was re- ferred to our clinic for embolic source detection. We performed transesophageal echocardiographic study with a Philips EnVisor machine equipped with a mul- tiplane S6 probe, which revealed right to left bubb- le passage during Valsalva maneuver with contrast injection. We performed PFO closure procedure one week after the diagnosis. The patient was under ge- neral anesthesia and we used Philips I33 ultrasound unit and an S7 probe capable of 3D imaging. Three- dimensional zoom property of the machine was acti-