Intracardiac echocardiography is the newest imaging technology permitting whole-heart evaluation from a right-sided catheter position and contrast transcranial Doppler is an ideal method to noninvasively quantify right-to-left cardiac shunt in real time, by the detection of bubble passage across the brain arteries. The combination of these two methods enables us to take advantage of online therapeutic information for successful deployment of the Amplatzer PFO Occluder in a 63-year-old man with severe chronic obstructive pulmonary disease, avoiding the need for transesophageal echocardiography and general anaesthesia or sedation.