Our group appreciates the interest of Dr Kapadia and colleagues in our report. Their concern about omitting ultrasound guidance may arise because they missed one of the major points of our communication. Ultrasound guidance is not simply discarded but is replaced by right atrial opacification with contrast medium in the appropriate projection. We scrutinised the few problems for the likelihood of prevention by additional echocardiographic guidance and found none. Moreover, the Amplatzer PFO occluder patients (about 400) had no complications except for one problem at a …