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Lee OH, Kim JS. Percutaneous Patent Foramen Ovale Closure After Stroke. Korean Circ J 2022; 52:801-807. [PMID: 36347516 PMCID: PMC9643566 DOI: 10.4070/kcj.2022.0258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 09/26/2022] [Accepted: 10/05/2022] [Indexed: 09/02/2023] Open
Abstract
Percutaneous patent foramen ovale (PFO) closure in patients with a prior PFO-associated stroke showed a risk reduction of the stroke recurrence compared to the medical therapy alone in recent several studies. Nevertheless, optimal patient selection for PFO closure has not been clarified. In this paper, we discuss the characteristics of PFO-associated strokes and discuss the recently published evidence and patient selection for PFO closure in patients with ischemic stroke. The lesions characteristics of PFO-associated stroke are associated with multiple scattered lesion, small sized cerebral cortical lesion, or posterior circulation. Overcoming the failure of early studies in CLOSURE I, PC, and RESPECT trials, PFO closure showed a significant reduction in recurrent stroke in recently published REDUCE, CLOSE, DEFENSE-PRO trials, and long-term follow-up data of RESPECT study. However, considering that PFO closure cannot completely prevent stroke recurrence and that complications including atrial fibrillation, we should be selectively performed in patients with high-risk PFO.
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Affiliation(s)
- Oh-Hyun Lee
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine and Cardiovascular Center, Yongin Severance Hospital, Yongin, Korea
| | - Jung-Sun Kim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea.
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Katsianos E, Oikonomou E, Kalogeras K, Manousaki A, Kalantzis C, Pantelidis P, Vavuranakis MA, Aggeli K, Siasos G, Tsioufis C, Vavuranakis M. Residual Right-to-Left-Shunt Following Transcatheter Patent Foramen Ovale Closure: The Role of Antithrombotic Treatment. Curr Pharm Des 2022; 28:3305-3312. [PMID: 36306457 DOI: 10.2174/1381612829666221028095839] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 09/26/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND Transcatheter closure of patent foramen ovale (PFO) is a highly effective therapy for patients with left circulation thromboembolism, not attributable to other conditions. OBJECTIVES This retrospective cohort study investigates the impact of baseline foramen ovale anatomy on the severity of the postclosure shunt. METHODS Patients with PFO, who underwent percutaneous closure, were followed up for at least 5 years postimplantation. Patients were classified into two groups based on the presence of high-risk features of the baseline PFO anatomy. At the follow-up follow-up, residual right-to-left shunt was assessed for the high and non-highrisk anatomy groups, via transcranial Doppler at rest and after performing the Valsalva maneuver, with the injection of agitated saline. RESULTS 38 patients were examined after a mean follow-up period of 9 ± 3 years after implantation. After retrospective evaluation of the baseline transthoracic and transesophageal echo studies, 14 patients with high-risk PFO anatomy were identified. The degree of the residual right-to-left shunt, as assessed by the number of microbubbles was higher in the high-risk PFO anatomy group compared to the non-high-risk group, both at rest [1.50 (IQR: 0.00-3.25) vs. 0.00 (IQR: 0.00-0.00), p < 0.001] and post-Valsalva maneuver [7.50 (IQR: 1.50- 10.25) vs. 0.00 (IQR: 0.00-3.75), p = 0.003]. Furthermore, in the high-risk group, more microbubbles were detected at rest (p = 0.008) and post-Valsalva (p = 0.002) in subjects without antiplatelet treatment compared to subjects on prolonged antiplatelet therapy. CONCLUSION Baseline PFO anatomy affects the severity of the residual right-to-left shunt. Prolonged antiplatelet therapy may benefit patients with high-risk anatomical features.
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Affiliation(s)
- Efstratios Katsianos
- 3rd Cardiology Clinic, National and Kapodistrian University of Athens, Medical School, Sotiria Chest Disease Hospital, Athens. Greece
| | - Evangelos Oikonomou
- 3rd Cardiology Clinic, National and Kapodistrian University of Athens, Medical School, Sotiria Chest Disease Hospital, Athens. Greece.,1st Cardiology Clinic, National and Kapodistrian University of Athens, Medical School, "Hippokration" General Hospital, Athens, Greece
| | - Konstantinos Kalogeras
- 3rd Cardiology Clinic, National and Kapodistrian University of Athens, Medical School, Sotiria Chest Disease Hospital, Athens. Greece
| | - Alexandra Manousaki
- 1st Cardiology Clinic, National and Kapodistrian University of Athens, Medical School, "Hippokration" General Hospital, Athens, Greece
| | - Charalambos Kalantzis
- 1st Cardiology Clinic, National and Kapodistrian University of Athens, Medical School, "Hippokration" General Hospital, Athens, Greece
| | - Panteleimon Pantelidis
- 3rd Cardiology Clinic, National and Kapodistrian University of Athens, Medical School, Sotiria Chest Disease Hospital, Athens. Greece
| | | | - Konstantina Aggeli
- 3rd Cardiology Clinic, National and Kapodistrian University of Athens, Medical School, Sotiria Chest Disease Hospital, Athens. Greece
| | - Gerasimos Siasos
- 3rd Cardiology Clinic, National and Kapodistrian University of Athens, Medical School, Sotiria Chest Disease Hospital, Athens. Greece.,1st Cardiology Clinic, National and Kapodistrian University of Athens, Medical School, "Hippokration" General Hospital, Athens, Greece
| | - Costas Tsioufis
- 1st Cardiology Clinic, National and Kapodistrian University of Athens, Medical School, "Hippokration" General Hospital, Athens, Greece
| | - Manolis Vavuranakis
- 3rd Cardiology Clinic, National and Kapodistrian University of Athens, Medical School, Sotiria Chest Disease Hospital, Athens. Greece.,1st Cardiology Clinic, National and Kapodistrian University of Athens, Medical School, "Hippokration" General Hospital, Athens, Greece
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Antithrombotic Therapy Duration after Patent Foramen Ovale Closure for Stroke Prevention: Impact on Long-Term Outcome. J Interv Cardiol 2022; 2022:6559447. [PMID: 36348991 PMCID: PMC9633204 DOI: 10.1155/2022/6559447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 08/26/2022] [Accepted: 09/10/2022] [Indexed: 11/18/2022] Open
Abstract
Background The optimal duration of antithrombotic therapy (ATT) after patent foramen ovale (PFO) closure remains under debate. This study sought to compare the clinical outcome of patients receiving antithrombotic agents for a short (6 months) versus extended (>6 months) period after the procedure. Methods This was a retrospective cohort study using a propensity score matching analysis on 259 consecutive patients (131 males, 43 ± 10 years) undergoing PFO closure due to cryptogenic stroke, with complete follow-up (median duration of 10 [4–13] years). The outcome was compared between patients receiving short-term (Group short, N = 88) versus extended ATT (Group long, N = 171). Results The PFO closure device was successfully implanted in all cases, with 3% of minor complications. After propensity score matching, there were no differences between Groups short and long in the rate of stroke (0.3 vs. 0.4% patient-year, p=1.00), bleeding (2 vs. 2% patient-year, p=0.17), and device thrombosis (0.3 vs. 0.1% patient-year; p=0.60). Univariate analysis showed that short-term ATT was not associated with an increased risk of recurrent stroke (HR: 1.271 [95% CI: 0.247–6.551], p=0.775) or prosthesis thrombus (HR: 0.50 [95% CI: 0.070–3.548], p=0.72). Kaplan–Meier analysis revealed similar overall survival in Group short and long (100 vs. 99 ± 1%, respectively; p=0.25). Conclusions Short-term (6 months) ATT after PFO closure did not impair the clinical outcome, with a preserved low rate of recurrent stroke (0.3% patient-year) and device thrombosis (0.2% patient-year) at 10-year follow-up.
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Total Joint Arthroplasty in Patients With Atrial Septal Defects: What Are the 90-Day Complications? Arthroplast Today 2022; 17:43-46. [PMID: 36032792 PMCID: PMC9399375 DOI: 10.1016/j.artd.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 07/08/2022] [Indexed: 11/23/2022] Open
Abstract
Background Methods Results Conclusions Level of evidence
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Borg B, Buttigieg LL, Magri CJ. Paradoxical coronary artery embolisation: an unusual cause of myocardial infarction. Br J Hosp Med (Lond) 2022; 83:1-4. [DOI: 10.12968/hmed.2022.0157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Bernard Borg
- Department of Medicine, Mater Dei Hospital, Msida, Malta
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Willits I, Keltie K, Henderson R, de Belder M, Linker N, Patrick H, Powell H, Berry L, Urwin S, Cole H, Sims AJ. Patent foramen ovale closure: A prospective UK registry linked to hospital episode statistics. PLoS One 2022; 17:e0271117. [PMID: 35834516 PMCID: PMC9282467 DOI: 10.1371/journal.pone.0271117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 06/23/2022] [Indexed: 11/24/2022] Open
Abstract
Aims PFO closure is a percutaneous intervention, which aims to reduce risk of recurrent stroke by preventing paradoxical embolism. The objective of this study was to measure procedural safety and longer-term effectiveness of PFO closure in a UK setting. Methods and results Prospective registry data from patients with cryptogenic stroke eligible for PFO closure were collected for up to 2 years and linked to routine data sources for additional follow-up. Outcomes of interest included procedural success rate, health related quality of life, and longer-term death and neurological event rates. A total of 973 PFO closure procedures in 971 patients were included in analysis. Successful device implantation was achieved in 99.4 [95% CI 98.6 to 99.8]% of procedures, with one in-hospital death. During median follow-up of 758 (Q1:Q3 527:968) days, 33 patients experienced a subsequent neurological event, 76% of which were ischaemic in origin. Neurological event rate was 2.7 [95%CI 1.6 to 3.9]% at 1-year (n = 751) and 4.1 [95% CI 2.6 to 5.5]% at 2-years (n = 463) using Kaplan-Meier analysis. Improvements in patient quality of life (utility and visual analogue scale) were observed at 6-weeks and 6-months follow-up. Conclusion Our observational study demonstrates that PFO closure for prevention of recurrent stroke is a relatively safe procedure but in routine clinical practice is associated with a slightly higher risk of recurrent neurological events than in randomised trials. We hypothesize that our study enrolled unselected patients with higher baseline risk, who were excluded from randomised trials, but who may benefit from a similar relative reduction in risk from the intervention.
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Affiliation(s)
- Iain Willits
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Northern Medical Physics and Clinical Engineering, Newcastle, United Kingdom
| | - Kim Keltie
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Northern Medical Physics and Clinical Engineering, Newcastle, United Kingdom
- Translational and Clinical Research Institute, Newcastle University, Newcastle, United Kingdom
| | - Robert Henderson
- Trent Cardiac Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Mark de Belder
- National Institute for Cardiovascular Outcomes Research (NICOR), Barts Health NHS Trust, London, United Kingdom
| | - Nicholas Linker
- South Tees Hospitals NHS Foundation Trust, Cardiology, Middlesbrough, United Kingdom
| | - Hannah Patrick
- National Institute for Health and Care Excellence, London, United Kingdom
| | - Helen Powell
- National Institute for Health and Care Excellence, Manchester, United Kingdom
| | - Lee Berry
- National Institute for Health and Care Excellence, Manchester, United Kingdom
| | - Samuel Urwin
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Northern Medical Physics and Clinical Engineering, Newcastle, United Kingdom
| | - Helen Cole
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Northern Medical Physics and Clinical Engineering, Newcastle, United Kingdom
- Translational and Clinical Research Institute, Newcastle University, Newcastle, United Kingdom
| | - Andrew J. Sims
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Northern Medical Physics and Clinical Engineering, Newcastle, United Kingdom
- Translational and Clinical Research Institute, Newcastle University, Newcastle, United Kingdom
- * E-mail:
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Advances in Percutaneous Patent Foramen Ovale Closure: From the Procedure to the Echocardiographic Guidance. J Clin Med 2022; 11:jcm11144001. [PMID: 35887765 PMCID: PMC9319304 DOI: 10.3390/jcm11144001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 07/02/2022] [Accepted: 07/07/2022] [Indexed: 02/05/2023] Open
Abstract
Percutaneous patent foramen ovale (PFO) closure by traditional, double disc occluder devices was shown to be safe for patients with PFO, and more effective than prolonged medical therapy in preventing recurrent thromboembolic events. The novel suture-mediated “deviceless” PFO closure system overcomes most of the risks and limitations associated with the traditional PFO occluders, appearing to be feasible in most interatrial septum anatomies, even if data about its long-term effectiveness and safety are still lacking. The aim of the present review was to provide to the reader the state of the art about the traditional and newer techniques of PFO closure, focusing both on the procedural aspects and on the pivotal role of transesophageal echocardiography (TEE) in patient’s selection, peri-procedural guidance, and post-interventional follow-up.
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Gaetti G, Beneduce A, La Fauci D, Scardoni A, Chiappa F, Bellini L, Franzin M, Natale AM, Marras P, Ranieri P, Signorelli C, Bossi E, Ferrario L, Foglia E, Montorfano M, Odone A. Suture-Mediated Patent Foramen Ovale Closure Using the NobleStitch EL: Results from a Hospital-Based HTA. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19137863. [PMID: 35805522 PMCID: PMC9266135 DOI: 10.3390/ijerph19137863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 06/18/2022] [Accepted: 06/24/2022] [Indexed: 11/17/2022]
Abstract
(1) Background: Patent foramen ovale (PFO) is a congenital abnormality present in up to 25% of the general population, and it is a relevant cause of cryptogenic stroke. We applied the hospital-based HTA model (AdHopHTA) to conduct a multidimensional assessment of NobleStitch EL, an innovative suture-mediated PFO closure device. We compared it to Amplatzer PFO Occluder (APO) to provide evidence to inform technologies’ governance in hospital settings. (2) Methods: For each AdHopHTA dimension we: systematically retrieved available evidence from the literature applying the PRISMA guidelines and then analyzed original clinical and cost data of a NobleStitch EL device at San Raffaele research hospital in Milan (Italy). The economic dimension was analyzed through activity-based costing and a cost analysis. We conducted semi-structured interviews with selected healthcare professionals to explore the organizational, legal, social, and ethical impact. (3) Results: A single study was included for the NobleStitch EL, with 10 for APO. Both literature data and original data showed comparable safety. Efficacy data analysis found that the PFO closure was at 89% for NobleStitch EL vs. 89–97% for APO. APO has a better impact on the budget and minor process costs. Consulted experts reported that the organizational impact of NobleStitch EL in the short and the long run as null, albeit a better impact under the social and the ethical aspects. (4) Conclusion: We suggest that there is inadequate evidence to conclude the relative efficacy of NobleStitch EL as compared to APO. Nevertheless, this report shows a good safety profile and higher costs for NobleStitch EL, with no organizational or legal impact. Further studies in selected population are recommended.
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Affiliation(s)
- Giovanni Gaetti
- School of Public Health, Vita-Salute San Raffaele University, 20132 Milan, Italy; (G.G.); (A.S.); (F.C.); (L.B.); (E.B.)
| | - Alessandro Beneduce
- Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (A.B.); (M.M.)
| | - Dario La Fauci
- HTA Committee, IRCCS San Raffaele Hospital, 20132 Milan, Italy; (D.L.F.); (M.F.); (A.M.N.); (P.M.); (P.R.); (C.S.)
| | - Alessandro Scardoni
- School of Public Health, Vita-Salute San Raffaele University, 20132 Milan, Italy; (G.G.); (A.S.); (F.C.); (L.B.); (E.B.)
| | - Federica Chiappa
- School of Public Health, Vita-Salute San Raffaele University, 20132 Milan, Italy; (G.G.); (A.S.); (F.C.); (L.B.); (E.B.)
| | - Lorenzo Bellini
- School of Public Health, Vita-Salute San Raffaele University, 20132 Milan, Italy; (G.G.); (A.S.); (F.C.); (L.B.); (E.B.)
| | - Michela Franzin
- HTA Committee, IRCCS San Raffaele Hospital, 20132 Milan, Italy; (D.L.F.); (M.F.); (A.M.N.); (P.M.); (P.R.); (C.S.)
| | - Anna Maria Natale
- HTA Committee, IRCCS San Raffaele Hospital, 20132 Milan, Italy; (D.L.F.); (M.F.); (A.M.N.); (P.M.); (P.R.); (C.S.)
| | - Paola Marras
- HTA Committee, IRCCS San Raffaele Hospital, 20132 Milan, Italy; (D.L.F.); (M.F.); (A.M.N.); (P.M.); (P.R.); (C.S.)
| | - Paolo Ranieri
- HTA Committee, IRCCS San Raffaele Hospital, 20132 Milan, Italy; (D.L.F.); (M.F.); (A.M.N.); (P.M.); (P.R.); (C.S.)
| | - Carlo Signorelli
- HTA Committee, IRCCS San Raffaele Hospital, 20132 Milan, Italy; (D.L.F.); (M.F.); (A.M.N.); (P.M.); (P.R.); (C.S.)
| | - Eleonora Bossi
- School of Public Health, Vita-Salute San Raffaele University, 20132 Milan, Italy; (G.G.); (A.S.); (F.C.); (L.B.); (E.B.)
| | - Lucrezia Ferrario
- Centre for Research on Health Economics, Social and Health Care Management, Carlo Cattaneo-LIUC University, 21053 Castellanza, Italy; (L.F.); (E.F.)
| | - Emanuela Foglia
- Centre for Research on Health Economics, Social and Health Care Management, Carlo Cattaneo-LIUC University, 21053 Castellanza, Italy; (L.F.); (E.F.)
| | - Matteo Montorfano
- Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (A.B.); (M.M.)
| | - Anna Odone
- HTA Committee, IRCCS San Raffaele Hospital, 20132 Milan, Italy; (D.L.F.); (M.F.); (A.M.N.); (P.M.); (P.R.); (C.S.)
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, 27100 Pavia, Italy
- Correspondence:
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Khan R, Hosseini F, Kohli N. Patent Foramen Ovale Closure for Remote Stroke - Better Late Than Never? Can J Cardiol 2022; 38:1132-1134. [PMID: 35688411 DOI: 10.1016/j.cjca.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 05/30/2022] [Accepted: 06/03/2022] [Indexed: 11/26/2022] Open
Affiliation(s)
- Razi Khan
- Royal Columbian Hospital, University of British Columbia, New Westminster, British Columbia, Canada.
| | - Farshad Hosseini
- School of Medicine, University of British Columbia, New Westminster, British Columbia, Canada
| | - Natasha Kohli
- Royal Columbian Hospital, University of British Columbia, New Westminster, British Columbia, Canada
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Asbeutah AA, Junaid M, Hassan F, Avila Vega J, Efeovbokhan N, Khouzam RN, Ibebuogu UN. Same day discharge after structural heart disease interventions in the era of the coronavirus-19 pandemic and beyond. World J Cardiol 2022; 14:271-281. [PMID: 35702323 PMCID: PMC9157608 DOI: 10.4330/wjc.v14.i5.271] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 03/14/2022] [Accepted: 04/21/2022] [Indexed: 02/06/2023] Open
Abstract
With recent advancements in imaging modalities and techniques and increased recognition of the long-term impact of several structural heart disease interventions, the number of procedures has significantly increased. With the increase in procedures, also comes an increase in cost. In view of this, efficient and cost-effective methods to facilitate and manage structural heart disease interventions are a necessity. Same-day discharge (SDD) after invasive cardiac procedures improves resource utilization and patient satisfaction. SDD in appropriately selected patients has become the standard of care for some invasive cardiac procedures such as percutaneous coronary interventions. This is not the case for the majority of structural heart procedures. With the coronavirus disease 2019 pandemic, safely reducing the duration of time spent within the hospital to prevent unnecessary exposure to pathogens has become a priority. In light of this, it is prudent to assess the feasibility of SDD in several structural heart procedures. In this review we highlight the feasibility of SDD in a carefully selected population, by reviewing and summarizing studies on SDD among patients undergoing left atrial appendage occlusion, patent foramen ovale/atrial septal defect closure, Mitra-clip, and trans-catheter aortic valve replacement procedures.
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Affiliation(s)
- Abdulaziz A Asbeutah
- Internal Medicine, University of Tennessee Health Science Center, Memphis, TN 38013, United States
| | - Muhammad Junaid
- Internal Medicine, Forrest City Medical Center, Forrest City, AR 72335, United States
| | - Fatima Hassan
- Internal Medicine, University of Tennessee Health Science Center, Memphis, TN 38013, United States
| | - Jesus Avila Vega
- Internal Medicine, University of Tennessee Health Science Center, Memphis, TN 38013, United States
| | | | - Rami N Khouzam
- Department of Medicine, The University of Tennessee Health Science Center, Memphis, TN 38104, United States
| | - Uzoma N Ibebuogu
- Department of Cardiology, University of Tennessee Health Science Center, Memphis, TN 38103, United States
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Beneduce A, Ancona MB, Moroni F, Ancona F, Ingallina G, Melillo F, Russo F, Ferri LA, Bellini B, Vella C, Chieffo A, Agricola E, Montorfano M. A systematic transoesophageal echocardiography study of suture-mediated percutaneous patent foramen ovale closure. EUROINTERVENTION 2022; 18:63-67. [PMID: 34219660 PMCID: PMC9903155 DOI: 10.4244/eij-d-21-00242] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Alessandro Beneduce
- Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marco Bruno Ancona
- Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Moroni
- Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Ancona
- Cardiovascular Imaging Unit, Cardio-Thoracic-Vascular Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giacomo Ingallina
- Cardiovascular Imaging Unit, Cardio-Thoracic-Vascular Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Melillo
- Cardiovascular Imaging Unit, Cardio-Thoracic-Vascular Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Filippo Russo
- Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Luca A. Ferri
- Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Barbara Bellini
- Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Ciro Vella
- Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alaide Chieffo
- Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Eustachio Agricola
- Cardiovascular Imaging Unit, Cardio-Thoracic-Vascular Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Matteo Montorfano
- Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
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Diener HC, Easton JD, Hart RG, Kasner S, Kamel H, Ntaios G. Review and update of the concept of embolic stroke of undetermined source. Nat Rev Neurol 2022; 18:455-465. [PMID: 35538232 DOI: 10.1038/s41582-022-00663-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2022] [Indexed: 12/28/2022]
Abstract
Ischaemic strokes have traditionally been classified according to the TOAST criteria, in which strokes with unclear aetiology are classified as cryptogenic strokes. However, the definition of cryptogenic stroke did not meet the operational criteria necessary to define patient populations for randomized treatment trials. To address this problem, the concept of embolic stroke of undetermined source (ESUS) was developed and published in 2014. A hypothesis that underpinned this concept was that most strokes in patients with ESUS are caused by embolic events, perhaps many cardioembolic, and that anticoagulation would prevent secondary ischaemic events. On this basis, two large randomized trials were conducted to compare the non-vitamin K antagonist oral anticoagulants (NOACs) dabigatran and rivaroxaban with aspirin. Neither NOAC was superior to aspirin in these trials, although subgroups of patients with ESUS seemed to benefit specifically from anticoagulation or antiplatelet therapy. The neutral results of the trials of anticoagulation and insights into ESUS from research conducted since the concept was introduced warrant reassessment of the ESUS construct as a research concept and a treatment target. In this Review, we discuss the evidence produced since the concept of ESUS was introduced, and propose updates to the criteria and diagnostic algorithm in light of the latest knowledge.
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Affiliation(s)
- Hans-Christoph Diener
- Department of Neuroepidemiology, Institute for Medical Informatics, Biometry and Epidemiology (IMIBE) Medical Faculty of the University Duisburg-Essen, Essen, Germany.
| | - J Donald Easton
- Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
| | - Robert G Hart
- Population Health Research Institute/McMaster University, David Braley Cardiac, Vascular and Stroke Research Institute (DBCVSRI), Hamilton, Ontario, Canada
| | - Scott Kasner
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
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Guo Y, Shi Z, Zheng Y, Xie C, Yi J, Chen Z, Shu Y, Zhou D. Short-term results of percutaneous closure of a patent foramen ovale guided by transoesophageal echocardiography in patients with cryptogenic stroke: a retrospective study. J Cardiothorac Surg 2022; 17:96. [PMID: 35505434 PMCID: PMC9066844 DOI: 10.1186/s13019-022-01845-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 04/18/2022] [Indexed: 11/30/2022] Open
Abstract
Background A patent foramen ovale (PFO) is a risk factor for cryptogenic stroke (CS), and interventional therapy for PFO can reduce the recurrence rate of CS. However, interventional therapies are primarily guided by X-ray imaging, and data on regular post-surgical follow-up with the transthoracic ultrasound foaming test (UFT) are rare. Thus, this study aimed to assess the short-term (12 months) results of PFO occlusion guided by transoesophageal echocardiography (TEE) and the results of regular UFTs. Methods Clinical records, echocardiographic data, and UFT results of 75 patients who underwent interventional therapy for PFO and CS were retrospectively analysed. The patients were grouped according to their preoperative UFT results: group A (n = 21), small volume of right-to-left shunts; group B (n = 22), moderate volume of right-to-left shunts; and group C (n = 32), large volume of right-to-left shunts. All patients were treated with an Amplatzer occluder under TEE guidance. UFT follow-up was conducted regularly until 12 months after surgery. Results No significant differences in preoperative data, length of hospital stay, or operative time were noted between the groups (p > 0.05). The length of the PFO and diameter of the occluder differed between the groups as follows: group A = group B < group C (p < 0.001). Notably, 1 patient in group C developed recurrent stroke 11 months postoperatively, and 2 patients in group C developed atrial arrhythmia, which improved after 3 months of antiarrhythmic treatment. However, 19 patients still had positive UFT results 12 months postoperatively. Furthermore, the positive UFT rate 12 months postoperatively differed between the groups as follows: group A = group B < group C (p < 0.05). A preoperative large-volume shunt was negatively associated with a negative UFT rate 12 months postoperatively (OR = 0.255, 95% CI: 0.104–0.625). Conclusions In patients with PFO and CS, interventional therapy guided by TEE could lead to satisfactory short-term (12 months) outcomes. Although the positive UFT rate gradually decreased, some patients still had positive UFT results 12 months postoperatively. Preoperatively, a large volume of right-to-left shunts and a longer PFO were the two risk factors for positive UFT results postoperatively. Further studies are required to clarify the relationship between postoperative positive UFT results and stroke recurrence.
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Affiliation(s)
- Yilong Guo
- Medical School of Chinese PLA, Beijing, People's Republic of China.,Department of Cardiovascular Surgery, The Second Affiliated Hospital of Hainan Medical University, 48th of Bai Shui Tang Road, Haikou, Hainan, 570311, People's Republic of China
| | - Zhensu Shi
- Department of Cardiovascular Surgery, The Second Affiliated Hospital of Hainan Medical University, 48th of Bai Shui Tang Road, Haikou, Hainan, 570311, People's Republic of China
| | - Yin Zheng
- Department of Special Medical Services, Hainan Cancer Hospital, No. 6th Changbin West 4th Street, Haikou, Hainan, 570300, People's Republic of China
| | - Caichan Xie
- Department of Cardiovascular Surgery, The Second Affiliated Hospital of Hainan Medical University, 48th of Bai Shui Tang Road, Haikou, Hainan, 570311, People's Republic of China
| | - Jiao Yi
- Department of Cardiovascular Surgery, The Second Affiliated Hospital of Hainan Medical University, 48th of Bai Shui Tang Road, Haikou, Hainan, 570311, People's Republic of China
| | - Zelun Chen
- Department of Cardiovascular Surgery, The Second Affiliated Hospital of Hainan Medical University, 48th of Bai Shui Tang Road, Haikou, Hainan, 570311, People's Republic of China
| | - Yue Shu
- Department of Cardiovascular Surgery, The Second Affiliated Hospital of Hainan Medical University, 48th of Bai Shui Tang Road, Haikou, Hainan, 570311, People's Republic of China. .,Department of Special Medical Services, Hainan Cancer Hospital, No. 6th Changbin West 4th Street, Haikou, Hainan, 570300, People's Republic of China.
| | - Dexing Zhou
- Department of Cardiovascular Surgery, The Second Affiliated Hospital of Hainan Medical University, 48th of Bai Shui Tang Road, Haikou, Hainan, 570311, People's Republic of China.
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Aarnink EW, Huijboom MF, Bor WL, Maarse M, Zheng KL, ten Cate H, Ten Berg JM, Boersma LV. Hemostatic biomarkers and antithrombotic strategy in percutaneous left atrial interventions: State-of-the-art review. Thromb Res 2022; 215:41-51. [DOI: 10.1016/j.thromres.2022.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 04/29/2022] [Accepted: 05/16/2022] [Indexed: 11/24/2022]
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Huber C, Wachter R, Pelz J, Michalski D. Current Challenges and Future Directions in Handling Stroke Patients With Patent Foramen Ovale—A Brief Review. Front Neurol 2022; 13:855656. [PMID: 35572930 PMCID: PMC9103873 DOI: 10.3389/fneur.2022.855656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 03/30/2022] [Indexed: 11/13/2022] Open
Abstract
The role of patent foramen ovale (PFO) in stroke was debated for decades. Randomized clinical trials (RCTs) have shown fewer recurrent events after PFO closure in patients with cryptogenic stroke (CS). However, in clinical practice, treating stroke patients with coexisting PFO raises some questions. This brief review summarizes current knowledge and challenges in handling stroke patients with PFO and identifies issues for future research. The rationale for PFO closure was initially based on the concept of paradoxical embolism from deep vein thrombosis (DVT). However, RCTs did not consider such details, limiting their impact from a pathophysiological perspective. Only a few studies explored the coexistence of PFO and DVT in CS with varying results. Consequently, the PFO itself might play a role as a prothrombotic structure. Transesophageal echocardiography thus appears most appropriate for PFO detection, while a large shunt size or an associated atrial septum aneurysm qualify for a high-risk PFO. For drug-based treatment alone, studies did not find a definite superiority of oral anticoagulation over antiplatelet therapy. Remarkably, drug-based treatment in addition to PFO closure was not standardized in RCTs. The available literature rarely considers patients with transient ischemic attack (TIA), over 60 years of age, and competing etiologies like atrial fibrillation. In summary, RCTs suggest efficacy for closure of high-risk PFO only in a small subgroup of stroke patients. However, research is also needed to reevaluate the pathophysiological concept of PFO-related stroke and establish strategies for older and TIA patients and those with competing risk factors or low-risk PFO.
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Affiliation(s)
- Charlotte Huber
- Department of Neurology, University of Leipzig, Leipzig, Germany
| | - Rolf Wachter
- Department of Cardiology, University of Leipzig, Leipzig, Germany
| | - Johann Pelz
- Department of Neurology, University of Leipzig, Leipzig, Germany
| | - Dominik Michalski
- Department of Neurology, University of Leipzig, Leipzig, Germany
- *Correspondence: Dominik Michalski
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Kim M, Park SY, Hong JM. Simultaneous monitoring of the middle cerebral and basilar arteries to detect right-to-left shunts using transcranial Doppler by agitated saline administration. Sci Rep 2022; 12:6658. [PMID: 35459924 PMCID: PMC9033880 DOI: 10.1038/s41598-022-10645-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 04/04/2022] [Indexed: 11/18/2022] Open
Abstract
Transcranial Doppler (TCD) is an easy, non-invasive, and real-time monitoring device for detecting right-to-left shunts (RLS). Nonetheless, it has limited benefits in patients with poor temporal windows. Therefore, we aimed to investigate whether the basilar artery (BA) window was as effective as the middle cerebral artery (MCA) in detecting RLS during TCD monitoring. Overall, we enrolled 344 patients with stroke, transient ischemic attack, headache, or dizziness. MCA and BA were monitored using a modified headset. To investigate the feasibility of the suboccipital window in detecting RLS, we instituted an evaluation tool with three tiers to evaluate microembolic signals (MESs) during TCD monitoring. Tier 1: TCD monitoring of the MCA (bilaterally) in the resting state, tier 2: TCD monitoring of the MCA (bilaterally) while performing the Valsalva maneuver, and tier 3: TCD monitoring of the index MCA and BA while performing the Valsalva maneuver. In tiers 2 and 3, a high agreement rate of 0.808 and 0.809 (p < 0.001), respectively, on the weighted kappa index, and a high intra-class correlation coefficient of 0.982 and 0.986 (p < 0.001), respectively, were observed on detecting MESs. Our data suggests that the BA window is as effective as the MCA window for detecting RLS on TCD.
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Affiliation(s)
- Min Kim
- Department of Neurology, School of Medicine, Ajou University, 164, World cup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do, 16499, Republic of Korea
| | - So Young Park
- Department of Neurology, School of Medicine, Ajou University, 164, World cup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do, 16499, Republic of Korea
| | - Ji Man Hong
- Department of Neurology, School of Medicine, Ajou University, 164, World cup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do, 16499, Republic of Korea.
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67
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Mac Grory B, Ohman EM, Feng W, Xian Y, Yaghi S, Kamel H, Reznik ME. Advances in the management of cardioembolic stroke associated with patent foramen ovale. BMJ 2022; 376:e063161. [PMID: 35140114 DOI: 10.1136/bmj-2020-063161] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Patent foramen ovale (PFO) describes a valve in the interatrial septum that permits shunting of blood or thrombotic material between the atria. PFOs are present in approximately 25% of the healthy population and are not associated with any pathology in the vast majority of cases. However, comparisons between patients with stroke and healthy controls suggest that PFOs may be causative of stroke in certain patients whose stroke is otherwise cryptogenic. Options for the diagnosis of PFO include transthoracic echocardiography, transesophageal echocardiography, and transcranial Doppler ultrasonography. PFOs associated with an interatrial septal aneurysm seem to be more strongly linked to risk of recurrent stroke. Therapeutic options for secondary stroke prevention in the setting of a PFO include antiplatelet therapy, anticoagulation, and percutaneous device closure. Recent randomized clinical trials suggest that percutaneous closure reduces the subsequent risk of stroke in appropriately selected patients, with a large relative benefit but small absolute benefit. Referral for percutaneous PFO closure should therefore be considered in certain patients after a multidisciplinary, patient centered discussion. Areas for future study include structural biomarkers to aid in determining the role of PFO closure in older people with possible PFO associated stroke, the role of direct oral anticoagulants, and very long term outcomes after device closure.
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Affiliation(s)
- Brian Mac Grory
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - E Magnus Ohman
- Duke Clinical Research Institute, Durham, NC, USA
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Wuwei Feng
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
| | - Ying Xian
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Shadi Yaghi
- Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Hooman Kamel
- Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Michael E Reznik
- Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI, USA
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Percutaneous Patent Foramen Ovale Closure in Patients with Cryptogenic Stroke or Transient Ischemic Attack: A Retrospective Study. BIOMED RESEARCH INTERNATIONAL 2022; 2022:2614225. [PMID: 35178445 PMCID: PMC8844344 DOI: 10.1155/2022/2614225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 12/06/2021] [Indexed: 11/17/2022]
Abstract
Background Patent foramen ovale (PFO) is associated with cryptogenic stroke (CS). Transcatheter closure of PFO is superior to pharmacotherapy for patients with CS or transient ischemic attack (TIA). More evidence is needed to evaluate the efficacy and safety of PFO closure in Chinese patients. Methods This study enrolled ten CS patients and two TIA patients (mean age of 40.8 ± 9.7 y), including seven males (58%) and five females (42%) who underwent PFO closure in our center from January 2017 to July 2019. Baseline data, imaging data, and RoPE (Risk of Paradoxical Embolism) score were collected retrospectively. The preprocedural assessment and percutaneous transcatheter PFO closure were described in detail. The perioperative complications and follow-ups were recorded from all patients. Results Among ten patients with CS, eight patients had a RoPE score of >6 and two patients had a RoPE score of 6. MRI confirmed multiple infarcts in seven cases, and infarct involving the cortex in nine cases. Abnormal ECG was found in three patients and abnormal Echo in four patients. Right-to-left shunt (RLS) was detected in all the patients by cTCD or cTTE. To be specific, RLS was observed in nine of the ten TEE-detected patients. No case had PFO complicated with atrial septal aneurysm (ASA). The success rate of PFO closure was 91.6%. No serious perioperative complications were observed. During a mean time of 26.5 ± 8 months (15-41 months) of follow-up, no recurrent cerebral infarction, TIA, or thromboembolism were detected in postoperative patients. Conclusions PFO closure is safe and effective in the treatment of Chinese patients with CS or TIA.
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Secondary Prevention of Cardioembolic Stroke. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00064-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Racharla L, Kher A, Patel Z, Maitz T, Kluck B. The Hype Surrounding Patent Foramen Ovale Closure and Cryptogenic Stroke: A Walk Through History. Heart Int 2022; 16:59-63. [DOI: 10.17925/hi.2022.16.1.59] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 04/04/2022] [Indexed: 11/24/2022] Open
Abstract
Cryptogenic stroke (CS) represents one-third of all ischaemic strokes. Studies have shown approximately that half of patients with CS have concomitant patent foramen ovale (PFO), with clear data supporting paradoxical embolization as an aetiology of CS. This article is the first of a multi-part review and will detail the history of PFO closure and the clinical trials that have evaluated the efficacy of PFO device closure. Data favour PFO closure in CS for reducing stroke in appropriate patients and should be considered as a treatment modality.
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Yeh RW, DeFaria Yeh D. Patent Foramen Ovale Closure-Harnessing Clinical Trial Evidence to Inform Individualized Treatment Decisions. JAMA 2021; 326:2265-2267. [PMID: 34905044 DOI: 10.1001/jama.2021.21317] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Robert W Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Doreen DeFaria Yeh
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Kent DM, Saver JL, Kasner SE, Nelson J, Carroll JD, Chatellier G, Derumeaux G, Furlan AJ, Herrmann HC, Jüni P, Kim JS, Koethe B, Lee PH, Lefebvre B, Mattle HP, Meier B, Reisman M, Smalling RW, Soendergaard L, Song JK, Mas JL, Thaler DE. Heterogeneity of Treatment Effects in an Analysis of Pooled Individual Patient Data From Randomized Trials of Device Closure of Patent Foramen Ovale After Stroke. JAMA 2021; 326:2277-2286. [PMID: 34905030 PMCID: PMC8672231 DOI: 10.1001/jama.2021.20956] [Citation(s) in RCA: 83] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 11/03/2021] [Indexed: 01/10/2023]
Abstract
Importance Patent foramen ovale (PFO)-associated strokes comprise approximately 10% of ischemic strokes in adults aged 18 to 60 years. While device closure decreases stroke recurrence risk overall, the best treatment for any individual is often unclear. Objective To evaluate heterogeneity of treatment effect of PFO closure on stroke recurrence based on previously developed scoring systems. Design, Setting, and Participants Investigators for the Systematic, Collaborative, PFO Closure Evaluation (SCOPE) Consortium pooled individual patient data from all 6 randomized clinical trials that compared PFO closure plus medical therapy vs medical therapy alone in patients with PFO-associated stroke, and included a total of 3740 participants. The trials were conducted worldwide from 2000 to 2017. Exposures PFO closure plus medical therapy vs medical therapy alone. Subgroup analyses used the Risk of Paradoxical Embolism (RoPE) Score (a 10-point scoring system in which higher scores reflect younger age and the absence of vascular risk factors) and the PFO-Associated Stroke Causal Likelihood (PASCAL) Classification System, which combines the RoPE Score with high-risk PFO features (either an atrial septal aneurysm or a large-sized shunt) to classify patients into 3 categories of causal relatedness: unlikely, possible, and probable. Main Outcomes and Measures Ischemic stroke. Results Over a median follow-up of 57 months (IQR, 24-64), 121 outcomes occurred in 3740 patients. The annualized incidence of stroke with medical therapy was 1.09% (95% CI, 0.88%-1.36%) and with device closure was 0.47% (95% CI, 0.35%-0.65%) (adjusted hazard ratio [HR], 0.41 [95% CI, 0.28-0.60]). The subgroup analyses showed statistically significant interaction effects. Patients with low vs high RoPE Score had HRs of 0.61 (95% CI, 0.37-1.00) and 0.21 (95% CI, 0.11-0.42), respectively (P for interaction = .02). Patients classified as unlikely, possible, and probable using the PASCAL Classification System had HRs of 1.14 (95% CI, 0.53-2.46), 0.38 (95% CI, 0.22-0.65), and 0.10 (95% CI, 0.03-0.35), respectively (P for interaction = .003). The 2-year absolute risk reduction was -0.7% (95% CI, -4.0% to 2.6%), 2.1% (95% CI, 0.6%-3.6%), and 2.1% (95% CI, 0.9%-3.4%) in the unlikely, possible, and probable PASCAL categories, respectively. Device-associated adverse events were generally higher among patients classified as unlikely; the absolute risk increases in atrial fibrillation beyond day 45 after randomization with a device were 4.41% (95% CI, 1.02% to 7.80%), 1.53% (95% CI, 0.33% to 2.72%), and 0.65% (95% CI, -0.41% to 1.71%) in the unlikely, possible, and probable PASCAL categories, respectively. Conclusions and Relevance Among patients aged 18 to 60 years with PFO-associated stroke, risk reduction for recurrent stroke with device closure varied across groups classified by their probabilities that the stroke was causally related to the PFO. Application of this classification system has the potential to guide individualized decision-making.
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Affiliation(s)
- David M. Kent
- Predictive Analytics and Comparative Effectiveness Center, Tufts Medical Center/Tufts University School of Medicine, Boston, Massachusetts
| | - Jeffrey L. Saver
- Comprehensive Stroke Center and Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles
| | - Scott E. Kasner
- Comprehensive Stroke Center, Department of Neurology, University of Pennsylvania Medical Center, Philadelphia
| | - Jason Nelson
- Predictive Analytics and Comparative Effectiveness Center, Tufts Medical Center/Tufts University School of Medicine, Boston, Massachusetts
| | - John D. Carroll
- Division of Cardiology, Department of Medicine, University of Colorado Denver, Aurora
| | - Gilles Chatellier
- Centre d’Investigations Cliniques, Unité de Recherche Clinique, Hôpital Européen Georges–Pompidou, Assistance Publique–Hôpitaux de Paris, Paris, France
| | - Geneviève Derumeaux
- Département de Physiologie, Hôpital Henri Mondo, Assistance Publique–Hôpitaux de Paris, Créteil, France
| | - Anthony J. Furlan
- Department of Neurology, Case Western Reserve University, Cleveland, Ohio
| | - Howard C. Herrmann
- Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Peter Jüni
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael’s Hospital, University of Toronto, Ontario, Canada
| | - Jong S. Kim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Benjamin Koethe
- Predictive Analytics and Comparative Effectiveness Center, Tufts Medical Center/Tufts University School of Medicine, Boston, Massachusetts
| | - Pil Hyung Lee
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Benedicte Lefebvre
- Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | | | - Bernhard Meier
- Department of Cardiology, Bern University Hospital, Bern, Switzerland
| | - Mark Reisman
- Division of Cardiology, University of Washington Medical Center, Seattle
| | - Richard W. Smalling
- Division of Cardiology, Department of Medicine, UTHealth/McGovern Medical School, Houston, Texas
| | - Lars Soendergaard
- Department of Cardiology, University of Copenhagen Hospital Rigshospitalet, Copenhagen, Denmark
| | - Jae-Kwan Song
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jean-Louis Mas
- GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne, Département of Neurology, Institut de Psychiatrie et Neurosciences de Paris, Université de Paris, Paris, France
| | - David E. Thaler
- Department of Neurology, Tufts Medical Center/Tufts University School of Medicine, Boston, Massachusetts
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Oguntade AS, Oguntade MS. Patent foramen ovale closure review: decades of research and the evolution of the evidence. THE EGYPTIAN JOURNAL OF INTERNAL MEDICINE 2021. [DOI: 10.1186/s43162-021-00059-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
A quarter of the population suffers from patent foramen ovale, a form of interatrial shunt. It has been linked to cryptogenic strokes and is a common cause of paradoxical embolism.
Main text
The benefit of closing the patent foramen ovale in cryptogenic stroke patients aged 18-60 years to prevent recurrent strokes, particularly in those with large shunts or associated atrial septal aneurysms, was recently demonstrated. It is a relatively safe procedure that necessitates post-operative anticoagulation, but it has been linked to new-onset atrial fibrillation of uncertain significance. The effectiveness of patent foramen closure depends on patient selection, and prediction scores such as the Risk of Paradoxical Embolism (RoPE) score should be used. Newer closure devices, such as bioabsorbable devices like the Biostar system and ‘device-less’ devices like the Noble Stitch, are becoming more common due to their lower operative risks. The use of such devices in future trials, as well as careful case selection, could improve the acceptability of patent foramen ovale closure in the general population, removing the need for perioperative anticoagulation.
Conclusion
Individuals aged 18-60 years with cryptogenic stroke who have adverse patent foramen ovale morphology on imaging should be offered patent foramen ovale closure, preferably using the newer closure devices. More studies are needed to determine the significance of periprocedural atrial fibrillation after device closure.
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Abstract
This concise review of the epidemiology, pathophysiology, evaluation, acute management, and prevention of ischemic stroke targets internists, family practitioners, and emergency physicians who manage patient with stroke.
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Affiliation(s)
- Steven K Feske
- Department of Neurology, Boston Medical Center, Boston University School of Medicine, Boston, Mass.
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Harjai KJ, Blankenship JC. The blueprint for successful device development: Disruptive innovation and co-opetition, then randomized trials. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 40:195-200. [PMID: 34887200 DOI: 10.1016/j.carrev.2021.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 10/25/2021] [Accepted: 11/05/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Kishore J Harjai
- Saint Louis University School of Medicine, Saint Louis, MO, United States of America.
| | - James C Blankenship
- University of New Mexico Health Sciences Center, Albuquerque, NM, United States of America
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Andersen A, Matzen KL, Andersen G, Settergren M, Sjostrand C, Iversen HK, Roine RO, Hildick-Smith D, Spence JD, Rhodes JF, Kasner SE, Sondergaard L, Nielsen-Kudsk JE. Atrial fibrillation after closure of patent foramen ovale in the REDUCE clinical study. Catheter Cardiovasc Interv 2021; 99:1551-1557. [PMID: 34773685 DOI: 10.1002/ccd.30019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 10/27/2021] [Accepted: 11/04/2021] [Indexed: 11/07/2022]
Abstract
OBJECTIVES To describe the occurrence of postprocedural atrial fibrillation (AF) among patients with cryptogenic stroke undergoing patent foramen ovale (PFO) closure in the REDUCE clinical study and analyze for potential risk factors for the development of postprocedural AF. BACKGROUND AF is an adverse event that might potentially counterbalance the stroke prevention benefit from PFO closure. Data on AF after transcatheter PFO closure are sparse. METHODS We evaluated data from patients having PFO closure (Gore HELEX or Gore Cardioform Septal Occluder) in the REDUCE clinical trial (n = 408) in at post hoc explorative analysis. Median follow-up was 5.0 years. RESULTS AF occurred in 30 patients (7.4%) after PFO closure with a total of 34 AF events. Most were reported as non-serious (68%), detected within 45 days post-procedure (79%), and resolved within 2 weeks of onset (63%). One subject with AF had recurrent stroke. Postprocedural AF occurred more frequently among subjects with higher age and large device sizes. Male sex was the only independent predictor of postprocedural AF. We found no association between the type of occluder (HELEX or Gore Cardioform Septal Occluder) or PFO anatomical characteristics and post-procedural AF. CONCLUSION In the REDUCE clinical study, postprocedural atrial fibrillation was mostly early onset, transient and with no later recurrence. Postprocedural AF occurred more frequently among patients with higher age and larger devices. Male sex was the only independent predictor of postprocedural AF.
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Affiliation(s)
- Asger Andersen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Grethe Andersen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Magnus Settergren
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | | | - Helle K Iversen
- Department of Neurology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Risto O Roine
- Department of Clinical Neurosciences, Turku University Hospital and University of Turku, Turku, Finland
| | - David Hildick-Smith
- Department of Cardiology, Sussex Cardiac Centre, Brighton & Sussex University Hospitals, Brighton, UK
| | - John David Spence
- Stroke Prevention & Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, Ontario, Canada
| | - John F Rhodes
- Department of Cardiology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Scott E Kasner
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lars Sondergaard
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Messé SR, Erus G, Bilello M, Davatzikos C, Andersen G, Iversen HK, Roine RO, Sjöstrand C, Rhodes JF, Søndergaard L, Kasner SE. Patent Foramen Ovale Closure Decreases the Incidence but Not the Size of New Brain Infarction on Magnetic Resonance Imaging: An Analysis of the REDUCE Trial. Stroke 2021; 52:3419-3426. [PMID: 34455822 PMCID: PMC8545852 DOI: 10.1161/strokeaha.121.034451] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 05/18/2021] [Accepted: 06/15/2021] [Indexed: 12/03/2022]
Abstract
Background and Purpose Randomized patent foramen ovale closure trials have used open-label end point ascertainment which increases the risk of bias and undermines confidence in the conclusions. The Gore REDUCE trial prospectively performed baseline and follow-up magnetic resonance imaging (MRIs) for all subjects providing an objective measure of the effectiveness of closure. Methods We performed blinded evaluations of the presence, location, and volume of new infarct on diffusion-weighted imaging of recurrent clinical stroke or new infarct (>3 mm) on T2/fluid attenuated inversion recovery from baseline to follow-up MRI at 2 years, comparing closure to medical therapy alone. We also examined the effect of shunt size and the development of atrial fibrillation on infarct burden at follow-up. Results At follow-up, new clinical stroke or silent MRI infarct occurred in 18/383 (4.7%) patients who underwent closure and 19/177 (10.7%) medication-only patients (relative risk, 0.44 [95% CI, 0.24–0.81], P=0.02). Clinical strokes were less common in closure patients compared with medically treated patients, 5 (1.3%) versus 12 (6.8%), P=0.001, while silent MRI infarcts were similar, 13 (3.4%) versus 7 (4.0%), P=0.81. There were no differences in number, volumes, and distribution of new infarct comparing closure patients to those treated with medication alone. There were also no differences of number, volumes, and distribution comparing silent infarcts to clinical strokes. Infarct burden was also similar for patients who developed atrial fibrillation and for those with large shunts. Conclusions The REDUCE trial demonstrates that patent foramen ovale closure prevents recurrent brain infarction based on the objective outcome of new infarcts on MRI. Only clinical strokes were reduced by closure while silent infarctions were similar between study arms, and there were no differences in infarct volume or location comparing silent infarcts to clinical strokes. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT00738894.
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Affiliation(s)
- Steven R. Messé
- Department of Neurology (S.R.M., S.E.K.), University of Pennsylvania, Philadelphia
| | - Guray Erus
- Department of Radiology (G.E., M.B., C.D.), University of Pennsylvania, Philadelphia
| | - Michel Bilello
- Department of Radiology (G.E., M.B., C.D.), University of Pennsylvania, Philadelphia
| | - Christos Davatzikos
- Department of Radiology (G.E., M.B., C.D.), University of Pennsylvania, Philadelphia
| | | | - Helle K. Iversen
- Department of Neurology (H.K.I.), Rigshospitalet, University of Copenhagen, Denmark
| | - Risto O. Roine
- Division of Clinical Neurosciences, Turku University Hospital and University of Turku, Finland (R.O.R.)
| | - Christina Sjöstrand
- Department of Clinical Neurosciences, Karolinska Institutet, Stockholm, Sweden (C.S.)
| | - John F. Rhodes
- Department of Cardiology, Medical University of South Carolina, Charleston (J.F.R.)
| | - Lars Søndergaard
- Department of Cardiology (L.S.), Rigshospitalet, University of Copenhagen, Denmark
| | - Scott E. Kasner
- Department of Neurology (S.R.M., S.E.K.), University of Pennsylvania, Philadelphia
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Abstract
BACKGROUND: Cryptogenic stroke leading to cerebellar infarction is a rare but serious cause of acute nausea and vomiting. This has the potential of devastating consequences if this occurs in aviators during flight. We present a case of cryptogenic stroke causing incapacitating nausea and vomiting in a U.S. Air Force pilot.CASE REPORT: A 36-yr-old active-duty U.S. Air Force male pilot developed acute onset severe vertigo, nausea, and vomiting during initial descent. Initial computed tomography imaging was normal and his initial assessment yielded a diagnosis of benign paroxysmal positional vertigo. MRI-Brain at 1 mo revealed a small right inferomedial cerebellar infarct. Echocardiography revealed a patent foramen ovale and bilateral atrial enlargement. He made a full neurological recovery and was eventually returned to active flight status with Flying Class IIC waiver.DISCUSSION: Cryptogenic stroke caused by patent foramen ovale (PFO) is uncommon. However, this is increased in patients younger than 50 yr of age. This can lead to an acute incapacitation with varying degrees of dysfunction. There is controversial discussion of treatment options for secondary stroke prevention with PFO. However, there is no significant literature on primary prevention in these patients. A small subset of patients benefit from closure of PFO and most patients benefit from antiplatelet therapy after a stroke occurs. There may also be a significant subset of patients with PFO that may benefit from antiplatelet therapy as a primary prevention of stroke.Lytle ME, Martin BR. Acute cerebellar stroke in a military active-duty pilot. Aerosp Med Hum Perform. 2021; 92(11): 919-923.
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Thaler A, Kvernland A, Kelly S, Song C, Aparicio HJ, Mac Grory B, Yaghi S. Stroke Prevention in Patients with Patent Foramen Ovale. Curr Cardiol Rep 2021; 23:183. [PMID: 34718891 DOI: 10.1007/s11886-021-01605-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/31/2021] [Indexed: 01/10/2023]
Abstract
PURPOSE OF REVIEW Patent foramen ovale (PFO) is widely prevalent and studies have suggested an association with ischemic stroke. In this review, we aim to highlight current management of patients with ischemic stroke in the setting of PFO and discuss some areas of controversy. RECENT FINDINGS Upon reviewing the literature, we have found that the evidence regarding the management of patients with cryptogenic stroke and PFO has come a long way in the past several years, and many uncertainties remain in clinical practice. The Risk of Paradoxical Embolism (RoPE) score helps to predict the probability of a pathogenic PFO, and recent trial data confirms the benefit of closure in carefully selected patients. The benefit of closure in older patients and in patients with alternate, competing mechanisms is still uncertain, and the long-term risks of closure are not known. Finally, the efficacy of direct oral anticoagulants (DOACs) in this patient population as compared to other medical therapy or mechanical closure has not yet been investigated. Randomized data is needed to help answer these questions. PFO closure is a safe and effective strategy in reducing stroke risk in carefully selected patients with cryptogenic stroke in the setting of a PFO. More studies are needed to test optimal medical treatment strategies and the safety and efficacy of PFO closure in patient subgroups not included in prior PFO closure trials.
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Affiliation(s)
- Alison Thaler
- Department of Neurology, New York University Grossman School of Medicine, New York, NY, USA
| | - Alexandra Kvernland
- Department of Neurology, New York University Grossman School of Medicine, New York, NY, USA
| | - Sean Kelly
- Department of Neurology, New York University Grossman School of Medicine, New York, NY, USA
| | - Christopher Song
- Department of Internal Medicine, Brown University, Providence, RI, USA
| | - Hugo J Aparicio
- Department of Neurology, Boston University, Boston, MA, USA
- Department of Neurology, Boston Medical Center, Boston, MA, USA
| | | | - Shadi Yaghi
- Department of Neurology, Brown University, 593 Eddy Street APC 5, Providence, RI, 02903, USA.
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80
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Kasner SE, Lattanzi S, Fonseca AC, Elgendy AY. Uncertainties and Controversies in the Management of Ischemic Stroke and Transient Ischemic Attack Patients With Patent Foramen Ovale. Stroke 2021; 52:e806-e819. [PMID: 34702068 DOI: 10.1161/strokeaha.121.034778] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Multiple randomized clinical trials have demonstrated the benefit of patent foramen ovale closure over medical therapy alone for patients who have had a stroke that has been attributed to the patent foramen ovale. Nevertheless, there are many areas of uncertainty and controversy related to patient selection, pathophysiology, diagnosis, and treatment. We summarize the available data on these challenging topics and attempt to provide some clarity and future directions for clinicians and investigators.
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Affiliation(s)
- Scott E Kasner
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia (S.E.K.)
| | - Simona Lattanzi
- Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy (S.L.)
| | - Ana Catarina Fonseca
- Department of Neurology, Centro Hospitalar Universitário Lisboa Norte, Faculdade de Medicina, Universidade de Lisboa, Portugal (A.C.F.)
| | - Akram Y Elgendy
- Division of Cardiovascular Medicine, University of California San Francisco (A.Y.E.).,Division of Cardiovascular Medicine, Harrington Heart and Vascular Institute, Case Western Reserve University, Cleveland, OH (A.Y.E.)
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81
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Vazquez-Sosa C, Clegg SD, Blankenship JC. How Old is Too Old? Closure of Patent Foramen Ovale in Older Patients. US CARDIOLOGY REVIEW 2021. [DOI: 10.15420/usc.2020.40] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Percutaneous closure of a patent foramen ovale (PFO) reduces the risk of recurrent cryptogenic stroke specifically in younger patients. The three randomized controlled trials that led to the widespread adoption of PFO closure excluded patients over the age of 60 years. Older patients frequently have other cardiac and vascular conditions that are common risk factors for stroke, whereas paradoxical embolism through a PFO is relatively rare. Younger patients theoretically benefit the most from closure due to longer lifetime exposure risk and absence of other traditional risk factors. PFO in older patients with cryptogenic strokes is often encountered in clinical practice, making up an increasing number of cardiology referrals, yet cardiologists lack guidelines and evaluation tools for these patients. This review explores the history of PFO closure – emphasizing data in older adults – and discusses the evaluation and treatment of older people with cryptogenic stroke and PFO while further trials in this important population are awaited.
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Affiliation(s)
| | - Stacey D Clegg
- University of New Mexico Health Science Center, Albuquerque, NM; New Mexico Veterans Administration Medical Center, Albuquerque, NM
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Radico F, Foglietta M, Di Fulvio M, Appignani M, Rossi S, Angelis MVD, Gallina S, Zimarino M. The ‘dreaded PFO’: anatomical and functional features of high risk for stroke. Eur Heart J Suppl 2021; 23:E189-E193. [PMID: 35233215 PMCID: PMC8876301 DOI: 10.1093/eurheartj/suab119] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Patent foramen ovale (PFO) has a high prevalence in general population and can be implicated in cryptogenic stroke among young people. Recent trials have shown that transcatheter PFO closure is superior to medical treatment in the secondary prevention of ischaemic stroke. The benefit in the reduction of stroke recurrence is particularly evident in patients who have documentation of a PFO with high-risk characteristics. Therefore, after the assessment of a clear causal relationship with the event, a thoughtful documentation of anatomic (height, length, presence of an aneurysmatic or a floppy atrial septum, a prominent Eustachian valve or Chiari’s network, an acute angle with the inferior vena cava) and functional high-risk characteristics is mandatory.
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Affiliation(s)
- Francesco Radico
- ASL 2 Abruzzo, Chieti, Italy
- Cardiology Department, “G. D’Annunzio” University, Chieti, Italy
| | | | - Maria Di Fulvio
- Intensive Cardiac Care Unit, Heart Department, “SS. Annunziata” Hospital, Chieti, Italy
| | - Marianna Appignani
- Intensive Cardiac Care Unit, Heart Department, “SS. Annunziata” Hospital, Chieti, Italy
| | | | | | - Sabina Gallina
- Department of Neuroscience, Imaging and Clinical Sciences, Chieti, Italy
| | - Marco Zimarino
- ASL 2 Abruzzo, Chieti, Italy
- Cath Lab, ASL 2 Abruzzo, Chieti, Italy
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83
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Mendelson MA. Pregnancy in women with left-to-right cardiac shunts: Any risk? INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2021. [DOI: 10.1016/j.ijcchd.2021.100209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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84
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He L, Cheng G, Du Y, Zhang Y. Importance of Persistent Right-to-Left Shunt After Patent Foramen Ovale Closure in Cryptogenic Stroke Patients. Tex Heart Inst J 2021; 47:244-249. [PMID: 33472221 DOI: 10.14503/thij-17-6582] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Percutaneous closure of patent foramen ovale (PFO) is widely performed to prevent recurrent stroke or transient ischemic attack in patients with cryptogenic stroke. However, the influence of different degrees of right-to-left shunting (RLS) has rarely been reported. We retrospectively evaluated the cases of 268 patients with cryptogenic stroke who underwent PFO closure at our hospital from April 2012 through April 2015. In accordance with RLS severity, we divided the patients into 2 groups: persistent RLS during normal breathing and the Valsalva maneuver (n=112) and RLS only during the Valsalva maneuver (n=156). Baseline characteristics, morphologic features, and procedural and follow-up data were reviewed. The primary endpoint was stroke or transient ischemic attack. More patients in the persistent group had multiple or bilateral ischemic lesions, as well as a larger median PFO diameter (2.5 mm [range, 1.8-3.9 mm]) than did patients in the Valsalva maneuver group (1.3 mm [range, 0.9-1.9 mm]) (P <0.001). Atrial septal aneurysm was more frequent in the persistent group: 25 patients (22.3%) compared with 18 (11.5%) (P=0.018). Three patients in the persistent group had residual shunting. The annual risk of recurrent ischemic stroke was similar between groups: 0.298% (persistent) and 0.214% (Valsalva maneuver). Our findings suggest that patients with persistent RLS have more numerous severe ischemic lesions, larger PFOs, and a higher incidence of atrial septal aneurysm than do those without. Although our persistent group had a greater risk of residual shunting after PFO closure, recurrence of ischemic events did not differ significantly from that in the Valsalva maneuver group.
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Affiliation(s)
- Lu He
- Department of Structural Heart Disease, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710068, People's Republic of China
| | - Gesheng Cheng
- Department of Structural Heart Disease, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710068, People's Republic of China
| | - Yajuan Du
- Department of Structural Heart Disease, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710068, People's Republic of China
| | - Yushun Zhang
- Department of Structural Heart Disease, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710068, People's Republic of China
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85
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Maloku A, Hamadanchi A, Franz M, Dannberg G, Günther A, Klingner C, Schulze PC, Möbius-Winkler S. Patent foramen ovale-When to close and how? Herz 2021; 46:445-451. [PMID: 34463786 DOI: 10.1007/s00059-021-05061-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2021] [Indexed: 12/29/2022]
Abstract
Closure of a patent foramen ovale (PFO) in patients after cryptogenic/cardioembolic stroke is recommended by current guidelines for patients who are 16-60 years of age with a high-risk PFO (class of recommendation A, level of evidence I). The use of double-disk occlusion devices followed by antiplatelet therapy is recommended. The procedure of interventional PFO closure compared with other interventions in cardiology is rather easy to learn. However, it should be performed carefully to avoid postinterventional complications. The number needed to treat (NNT) to avoid one stroke in 5 years in the RESPECT trial was 42, in the CLOSE trial even lower with 20. In the REDUCE trial, the NNT was 28 at 2 years. This can be reduced by longer follow-up, e.g., at 10 years the NNT is 18. While other conditions such as migraine are currently under investigation with respect to the impact of PFO closure, sufficiently powered trials are lacking so that closure in diseases other than stroke should always be individualized.
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Affiliation(s)
- Aurel Maloku
- Department of Internal Medicine I, Cardiology, Angiology, Intensive Medical Care, University Hospital Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Ali Hamadanchi
- Department of Internal Medicine I, Cardiology, Angiology, Intensive Medical Care, University Hospital Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Marcus Franz
- Department of Internal Medicine I, Cardiology, Angiology, Intensive Medical Care, University Hospital Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Gudrun Dannberg
- Department of Internal Medicine I, Cardiology, Angiology, Intensive Medical Care, University Hospital Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Albrecht Günther
- Hans-Berger-Department of Neurology, University Hospital Jena, Jena, Germany
| | - Carsten Klingner
- Hans-Berger-Department of Neurology, University Hospital Jena, Jena, Germany
| | - P Christian Schulze
- Department of Internal Medicine I, Cardiology, Angiology, Intensive Medical Care, University Hospital Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Sven Möbius-Winkler
- Department of Internal Medicine I, Cardiology, Angiology, Intensive Medical Care, University Hospital Jena, Am Klinikum 1, 07747, Jena, Germany.
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86
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Rhoades R, Tzeng D, Ruggiero N. Secondary stroke prevention in patients with patent foramen ovale. Curr Opin Hematol 2021; 28:292-300. [PMID: 34261880 DOI: 10.1097/moh.0000000000000672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Although a patent foramen ovale (PFO) is an established risk factor for cryptogenic ischemic stroke, strategies for secondary prevention remain controversial. Increasing evidence over the past decade from well designed clinical trials supports transcatheter PFO closure for selected patients whose stroke was likely attributable to the PFO. However, patient selection using imaging findings, clinical scoring systems, and in some cases, thrombophilia testing, is crucial for determining patients most likely to benefit from closure, anticoagulation, or antiplatelet therapy. RECENT FINDINGS Recent studies have found that patients with a high Risk of Paradoxical Embolism (RoPE) score and those with a thrombophilia benefit more from closure than medical therapy (including antiplatelet or anticoagulant therapy) alone. Meta-analyses have demonstrated an increased short-term risk of atrial fibrillation in closure patients, and that residual shunt after closure predicts stroke recurrence. Last, recent data have been inconclusive as to whether patients receiving medical therapy only benefit more from anticoagulation or antiplatelet therapy, so this remains an area of controversy. SUMMARY Transcatheter PFO closure is an evidence-based, guideline-supported therapy for secondary stroke prevention in patients with a PFO and cryptogenic stroke. However, proper patient selection is critical to achieve benefit, and recent studies have helped clarify those patients most likely to benefit from closure.
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Affiliation(s)
| | | | - Nicholas Ruggiero
- Division of Cardiology, Department of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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87
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Di Tullio MR. Prevention of Patent Foramen Ovale-Related Stroke: An Evolving Concept. Stroke 2021; 52:3427-3429. [PMID: 34455824 DOI: 10.1161/strokeaha.121.035735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Marco R Di Tullio
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
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88
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Jerzyna L, Prashar A, Youssef G, Sader M. Recurrent stroke secondary to late patent foramen ovale-closure device thrombus: a case report. EUROPEAN HEART JOURNAL-CASE REPORTS 2021; 5:ytab313. [PMID: 34423249 PMCID: PMC8377246 DOI: 10.1093/ehjcr/ytab313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 03/29/2021] [Accepted: 07/22/2021] [Indexed: 11/14/2022]
Abstract
Background Percutaneous patent foramen ovale (PFO) closure has been well established in the secondary prevention of cryptogenic stroke with overall low rates of procedural complications. One such complication is PFO closure device thrombus formation which is now rarely reported with newer generation devices. Case summary We present the unusual case of a 59-year-old woman with myelofibrosis who developed late-onset recurrent embolic strokes related to Amplatzer PFO closure device thrombus whilst therapeutically anticoagulated on Warfarin. Surgical management was deemed too high risk and our patient was conservatively managed with enoxaparin. Serial transthoracic echocardiography demonstrated a reduction in thrombus size and the patient had no further neurological events. Discussion Overall, the risk of serious complications following percutaneous PFO closure, such as device-associated thrombus, remains low. The risk of thrombus formation in patients with hypercoagulable states is not well characterized. Despite good evidence for the efficacy in preventing recurrent cryptogenic stroke, the role of PFO closure in addition to anticoagulation is unclear. Given this uncertain benefit of PFO closure in anticoagulated patients and the unclear risk profile, patient selection, and thorough pre-procedural evaluation are vital when assessing the appropriateness of percutaneous PFO closure.
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Affiliation(s)
- Lennox Jerzyna
- Division of Medicine, Wollongong Hospital, Wollongong, NSW 2500, Australia
| | - Abhisheik Prashar
- Department of Cardiology, St George Hospital, Sydney, NSW 2217, Australia.,Faculty of Medicine, University of New South Wales, Sydney, NSW 2052, Australia
| | - George Youssef
- Department of Cardiology, St George Hospital, Sydney, NSW 2217, Australia.,Faculty of Medicine, University of New South Wales, Sydney, NSW 2052, Australia
| | - Mark Sader
- Department of Cardiology, St George Hospital, Sydney, NSW 2217, Australia.,Faculty of Medicine, University of New South Wales, Sydney, NSW 2052, Australia
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Montoro LC, Ortiz MR, Hurtado NP, Ortega MD, Almodovar AR, Saint-Gerons JMS, Bellido FM, Sepulveda JJO, Moyano RV, Moreno MAR, Alvarez-Ossorio MP, Rubio MDM. Impact on daily clinical practice of the latest evidence on percutaneous closure of patent foramen ovale after cryptogenic stroke: a single-center experience. Neurol Sci 2021; 43:1865-1871. [PMID: 34383161 DOI: 10.1007/s10072-021-05524-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 07/25/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION AND OBJECTIVES At the end of 2017, three clinical trials demonstrated that, in selected patients, percutaneous closure of patent foramen ovale (PFO) after cryptogenic stroke (CS) reduces the risk of recurrence. Our aim was to determine the impact of these findings on routine clinical practice in a tertiary hospital. METHODS Patients with CS and percutaneous closure of PFO during 2001-2020 were included. The clinical characteristics of the patient and the anatomical characteristics of the foramen were analyzed. Based on both, the closure indications were classified into three groups according to the latest European recommendations and were analyzed in two periods, before and after the publication date of the clinical trials. RESULTS A total of 293 patients were included. The mean age was 49 ± 11 years, and 15% were older than 60 years. The median RoPE score was 6 [p25-75, 5-7] and 75% had complex anatomy (CA). After the publication of the studies, the frequency of CA and the mean age of the patients were significantly higher (89% vs. 69% p < 0.0005 and 51 ± 11 vs. 48 ± 11 years, p = 0.02, respectively), and the RoPE score, significantly lower (5 [5-7] versus 6 [5-7], p = 0.02). Inadequate closure indications were significantly reduced (8% vs. 18%, p = 0.02). CONCLUSION After the publication of clinical trials that have shown benefit of PFO closure after CS, the number of inappropriate indications for closure has decreased significantly in our institution, with a higher percentage of CA, despite a clinical profile suggestive of lower causal probability of PFO.
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Affiliation(s)
- Lucia Carnero Montoro
- Cardiology Service, Reina Sofia University Hospital, Avenue Menendez Pidal s/n, 14004, Cordoba, Spain.
| | - Martin Ruiz Ortiz
- Cardiology Service, Reina Sofia University Hospital, Avenue Menendez Pidal s/n, 14004, Cordoba, Spain
| | - Nick Paredes Hurtado
- Cardiology Service, Reina Sofia University Hospital, Avenue Menendez Pidal s/n, 14004, Cordoba, Spain
| | - Monica Delgado Ortega
- Cardiology Service, Reina Sofia University Hospital, Avenue Menendez Pidal s/n, 14004, Cordoba, Spain
| | - Ana Rodriguez Almodovar
- Cardiology Service, Reina Sofia University Hospital, Avenue Menendez Pidal s/n, 14004, Cordoba, Spain
| | | | | | | | | | | | | | - Maria Dolores Mesa Rubio
- Cardiology Service, Reina Sofia University Hospital, Avenue Menendez Pidal s/n, 14004, Cordoba, Spain
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90
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Patent Foramen Ovale Attributable Cryptogenic Embolism With Thrombophilia Has Higher Risk for Recurrence and Responds to Closure. JACC Cardiovasc Interv 2021; 13:2745-2752. [PMID: 33303111 DOI: 10.1016/j.jcin.2020.09.059] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 07/22/2020] [Accepted: 09/15/2020] [Indexed: 01/22/2023]
Abstract
OBJECTIVES The aim of this study was to investigate the effect of management on the risk for recurrent events among patients with cryptogenic ischemic stroke or transient ischemic attack. BACKGROUND The combination of patent foramen ovale (PFO) and hypercoagulability may greatly increase the risk for paradoxical embolism. However, previous randomized controlled trials evaluating the efficacy of PFO closure excluded these potential high-risk patients. METHODS Patients diagnosed with PFO attributable cryptogenic embolism were prospectively, without randomization, recruited from January 2005 to March 2018. The relationship between thrombophilia and recurrent events was evaluated in overall patients. Multivariate Cox regression was conducted to assess the relative risk for recurrence in PFO closure and medical therapy groups. RESULTS A total of 591 patients with cryptogenic embolism with PFO were identified. The median duration of follow-up was 53 months, and thrombophilia significantly increased the risk for recurrent events (hazard ratio [HR]: 1.85; 95% confidence interval [CI]: 1.09 to 3.16; p = 0.024). PFO closure was superior to medical therapy in overall patients (HR: 0.16; 95% CI: 0.09 to 0.30; p < 0.001). Of the 134 patients (22.7%) with thrombophilia, there was a difference in the risk for recurrence events between the PFO closure (6 of 89) and medical therapy (15 of 45) groups (HR: 0.25; 95% CI: 0.08 to 0.74; p = 0.012). There was no potential heterogeneity in the further subgroup analysis. CONCLUSIONS Patients with cryptogenic stroke with PFO and hypercoagulable state had increased risk for recurrent stroke or transient ischemic attack. PFO closure provided a lower risk for recurrent events compared with medical therapy alone.
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91
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Gaspardone A, Sgueglia GA, De Santis A, D'Ascoli E, Iamele M, Piccioni F, Giannico B, D'Errico F, Gioffrè G, Summaria F, Gaspardone C, Versaci F. Predictors of Residual Right-to-Left Shunt After Percutaneous Suture-Mediated Patent Fossa Ovalis Closure. JACC Cardiovasc Interv 2021; 13:2112-2120. [PMID: 32972572 DOI: 10.1016/j.jcin.2020.06.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 05/27/2020] [Accepted: 06/02/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES This study sought to assess patent fossa ovalis (PFO) anatomy by transesophageal echocardiography (TEE) in patients undergoing percutaneous suture-mediated PFO closure to identify predictors of post-procedural residual atrial right-to-left shunt (RLS). BACKGROUND Percutaneous suture-mediated PFO closure has been proven to be a safe and effective technique in most PFO patients. METHODS From June 2016 to October 2019, 247 consecutive patients underwent percutaneous suture-mediated PFO closure at our institution. Of them, 230 (46 ± 13 years of age, 146 women) had complete and technically evaluable pre-procedural TEE. The following parameters in short-axis view were assessed: presence and grade of spontaneous RLS, PFO length and width, presence of atrial septal aneurysm and its maximal bulge, and presence of an embryonic or fetal remnant (Chiari network or Eustachian valve). RESULTS At the first follow-up transthoracic echocardiography performed between 3 and 6 months from the closure procedure, a residual RLS ≥2 grade was found in 37 (16%) patients. Grade of pre-procedural spontaneous RLS (hazard ratio: 1.99; 95% confidence interval: 1.14 to 3.48; p = 0.016) shunt and PFO width (hazard ratio: 2.52; 95% confidence interval: 1.85 to 3.43; p < 0.001) were both found to be significantly associated with significant residual RLS at multivariable analysis. The presence of atrial septal aneurysm and its maximal bulge and of congenital remnants was not associated with significant residual RLS. CONCLUSIONS Percutaneous suture-mediated PFO closure is feasible in the majority of septal anatomies; however, PFO >5 mm in width and spontaneous large RLS are less likely to be closed with 1 stitch only.
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Affiliation(s)
| | | | | | | | - Maria Iamele
- Division of Cardiology, Sant'Eugenio Hospital, Rome, Italy
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Kleindorfer DO, Towfighi A, Chaturvedi S, Cockroft KM, Gutierrez J, Lombardi-Hill D, Kamel H, Kernan WN, Kittner SJ, Leira EC, Lennon O, Meschia JF, Nguyen TN, Pollak PM, Santangeli P, Sharrief AZ, Smith SC, Turan TN, Williams LS. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. Stroke 2021; 52:e364-e467. [PMID: 34024117 DOI: 10.1161/str.0000000000000375] [Citation(s) in RCA: 1112] [Impact Index Per Article: 370.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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93
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Lefebvre B, Naidu S, Nathan AS, Chen Z, Ky B, Silvestry FE, Søndergaard L, Settergren M, Nielsen-Kudsk JE, Rhodes JF, Kasner SE, Herrmann HC. Impact of Echocardiographic Parameters on Recurrent Stroke in the Randomized REDUCE PFO Cryptogenic Stroke Trial. STRUCTURAL HEART 2021. [DOI: 10.1080/24748706.2021.1907639] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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94
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Kokkinidis DG, Katsanos AH, Giannakoulas G, Singh HS, Turc G, Thijs V. Editorial: Patent Foramen Ovale (PFO) Closure for Prevention of Stroke. Front Neurol 2021; 12:718457. [PMID: 34262528 PMCID: PMC8273288 DOI: 10.3389/fneur.2021.718457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 06/02/2021] [Indexed: 11/25/2022] Open
Affiliation(s)
- Damianos G Kokkinidis
- Section of Cardiovascular Medicine, Yale University School of Medicine, Yale New Haven Hospital, New Haven, CT, United States
| | - Aristeidis H Katsanos
- Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, ON, Canada
| | | | - Harsimran S Singh
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine-New York Presbyterian Hospital, New York, NY, United States
| | - Guillaume Turc
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences, Université de Paris, INSERM U1266, and FHU Neurovasc, Paris, France
| | - Vincent Thijs
- Stroke Theme, Florey Institute of Neuroscience, Melbourne, VIC, Australia
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96
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Mazzucco S, Li L, Rothwell PM. Prognosis of Cryptogenic Stroke With Patent Foramen Ovale at Older Ages and Implications for Trials: A Population-Based Study and Systematic Review. JAMA Neurol 2021; 77:1279-1287. [PMID: 32628255 PMCID: PMC7550974 DOI: 10.1001/jamaneurol.2020.1948] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Importance Patent foramen ovale (PFO) closure may prevent recurrent stroke after cryptogenic transient ischemic attack (TIA) or stroke (TIA/stroke) in patients aged 60 years or younger. Patent foramen ovale is associated with cryptogenic stroke in the older population, but risk of recurrence is unknown. Data on prognosis of patients receiving medical treatment at older ages (≥60 years) are essential to justify trials of PFO closure. Objective To examine the age-specific risk of recurrence in patients with cryptogenic TIA/stroke with PFO. Design, Setting, and Participants A prospective study was nested in the population-based Oxford Vascular Study between September 1, 2014, and March 31, 2019, with face-to-face follow-up for 5 years. A total of 416 consecutive patients with a diagnosis of cryptogenic TIA or nondisabling stroke, screened for PFO at a rapid-access TIA/stroke clinic, were included. A systematic review and meta-analysis of cohort studies reporting on ischemic stroke recurrence after cryptogenic TIA/stroke in patients with PFO who were receiving medical therapy alone, or with PFO vs no-PFO was conducted. Sample size calculation for future trials on PFO closure was performed for patients aged 60 years or older. Exposures Patent foramen ovale and age as modifiers of risk of recurrent stroke after cryptogenic TIA/stroke in patients receiving only medical therapy. Main Outcomes and Measures Risk of ischemic stroke recurrence in patients with cryptogenic TIA/stroke and PFO receiving medical therapy only, and in patients with vs without PFO, stratified by age (<65 vs ≥65 years), as well as sample-size calculation for future trials of PFO closure in patients aged 60 years or older. Results Among the 153 Oxford Vascular Study patients with PFO (mean [SD] age, 66.7 [13.7] years; 80 [52.3%] men), recurrent ischemic stroke risk (2.05 per 100 patient-years) was similar to the pooled estimate from a systematic review of 23 other studies (9 trials and 14 observational studies) (2.00 per 100 patient-years; 95% CI, 1.55-2.58). However, there was heterogeneity between studies (P < .001 for heterogeneity), owing mainly to risk increasing with mean cohort age (meta-regression: R2 = 0.31; P = .003). In the pooled analysis of 4 studies including patients with or without PFO, increased risk of stroke recurrence with PFO was seen only at age 65 years or older (odds ratio, 2.5; 95% CI, 1.4-4.2; P = .001 for difference; P = .39 for heterogeneity). The pooled ischemic stroke risk was 3.27 per 100 patient-years (95% CI, 2.59-4.13) in 4 cohorts with mean age 60 years or older. Assuming the more conservative 2.0 per 100 patient-years ischemic stroke risk in the PFO nonclosure arms of future trials in patients aged 60 years or older, projected sample sizes were 1080 per arm for 80% power to detect a 33% relative risk reduction. Conclusions and Relevance The findings of this study suggest that age is a determinant of risk of ischemic stroke after cryptogenic TIA/stroke in patients with PFO, such that trials of PFO closure at older ages are justified; however, projected sample sizes are large.
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Affiliation(s)
- Sara Mazzucco
- Wolfson Centre for Prevention of Stroke and Dementia, University of Oxford, Oxford, United Kingdom
| | - Linxin Li
- Wolfson Centre for Prevention of Stroke and Dementia, University of Oxford, Oxford, United Kingdom
| | - Peter M Rothwell
- Wolfson Centre for Prevention of Stroke and Dementia, University of Oxford, Oxford, United Kingdom
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Nykl R, Precek J, Sluka M, Hudec S, Richter D, Heinc P, Taborsky M. Interventional prevention of paradoxical embolism as the gold standard: End of discussion? Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2021; 165:241-248. [PMID: 34158673 DOI: 10.5507/bp.2021.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 06/03/2021] [Indexed: 11/23/2022] Open
Abstract
Paradoxical embolism is one of the predominant causes of cryptogenic stroke and interventional secondary prevention, i.e., closure of the patent foramen ovale (PFO), is a much discussed issue. This review aims to provide a complex perspective on this topic, aggregates and comments on the available data and current guidelines. Several large trials were performed, some of which proved the superiority of PFO closure over pharmacotherapy while others have not. Studies detecting significant superiority of intervention worked with disproportionately high representation of large shunts compared to the general population. Other controversies also remain, such as the lack of comparison of the effect of modern anticoagulant/antiplatelet treatment to PFO closure or the risk of developing unwanted side effects after intervention, and these are discussed in detail. PFO closure is a suitable method for secondary prevention of paradoxical embolism and, therefore, cryptogenic stroke. However, this is only true for carefully selected patient populations and such selection is of the utmost importance in deciding on interventional or conservative treatment.
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Affiliation(s)
- Radomir Nykl
- Department of Internal Medicine I - Cardiology, University Hospital Olomouc, Czech Republic
| | - Jan Precek
- Department of Internal Medicine I - Cardiology, University Hospital Olomouc, Czech Republic
| | - Martin Sluka
- Department of Internal Medicine I - Cardiology, University Hospital Olomouc, Czech Republic
| | - Stepan Hudec
- Department of Internal Medicine I - Cardiology, University Hospital Olomouc, Czech Republic
| | - David Richter
- Department of Internal Medicine I - Cardiology, University Hospital Olomouc, Czech Republic
| | - Petr Heinc
- Department of Internal Medicine I - Cardiology, University Hospital Olomouc, Czech Republic
| | - Milos Taborsky
- Department of Internal Medicine I - Cardiology, University Hospital Olomouc, Czech Republic
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Saunders H, Melody M, Chirila R. 23-Year-Old Female With Right-Sided Weakness and Aphasia. Mayo Clin Proc 2021; 96:1634-1638. [PMID: 34088421 DOI: 10.1016/j.mayocp.2020.10.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 09/28/2020] [Accepted: 10/02/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Hollie Saunders
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Jacksonville, FL
| | - Megan Melody
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Jacksonville, FL
| | - Razvan Chirila
- Advisor to residents and Consultant in Internal Medicine, Mayo Clinic, Jacksonville, FL.
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Deng W, McMullin D, Inglessis-Azuaje I, Locascio JJ, Palacios IF, Buonanno FS, Lo EH, Ning M. Effect of Patent Foramen Ovale Closure After Stroke on Circulatory Biomarkers. Neurology 2021; 97:e203-e214. [PMID: 33986139 DOI: 10.1212/wnl.0000000000012188] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 04/13/2021] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE To determine the influence of patent foramen ovale (PFO) closure on circulatory biomarkers. METHODS Consecutive patients with PFO-related stroke were prospectively enrolled and followed with serial sampling of cardiac atrial and venous blood pre- and post-PFO closure over time. Candidate biomarkers were identified by mass spectrometry in a discovery cohort first, and lead candidates were validated in an independent cohort. RESULTS Patients with PFO-related stroke (n = 254) were recruited and followed up to 4 years (median 2.01; interquartile range 0.77-2.54). Metabolite profiling in the discovery cohort (n = 12) identified homocysteine as the most significantly decreased factor in intracardiac plasma after PFO closure (false discovery rate 0.001). This was confirmed in a validation cohort (n = 181), where intracardiac total homocysteine (tHcy) was immediately reduced in patients with complete closure, but not in those with residual shunting, suggesting association of PFO shunting with tHcy elevation (β 0.115; 95% confidence interval [CI] 0.047-0.183; p = 0.001). tHcy reduction was more dramatic in left atrium than right (p < 0.001), suggesting clearance through pulmonary circulation. Long-term effect of PFO closure was also monitored and compared to medical treatment alone (n = 61). Complete PFO closure resulted in long-term tHcy reduction in peripheral blood, whereas medical therapy alone showed no effect (β -0.208; 95% CI -0.375∼-0.058; p = 0.007). Residual shunting was again independently associated with persistently elevated tHcy (β 0.184; 95% CI 0.051-0.316; p = 0.007). CONCLUSIONS PFO shunting may contribute to circulatory tHcy elevation, which is renormalized by PFO closure. PFO is not just a door for clots, but may itself enhance clot formation and injure neurovasculature by clot-independent mechanisms. Biomarkers such as tHcy can potentially serve as cost-effective measures of residual shunting and neurovascular risk for PFO stroke.
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Affiliation(s)
- Wenjun Deng
- From the Clinical Proteomics Research Center (W.D., D.M., F.S.B., E.H.L., M.M.N.), Cardio-Neurology Division (W.D., I.I.-A., J.J.L., I.F.P., F.S.B., E.H.L., M.M.N.), and Neuroprotection Research Laboratory (E.H.L., M.M.N.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - David McMullin
- From the Clinical Proteomics Research Center (W.D., D.M., F.S.B., E.H.L., M.M.N.), Cardio-Neurology Division (W.D., I.I.-A., J.J.L., I.F.P., F.S.B., E.H.L., M.M.N.), and Neuroprotection Research Laboratory (E.H.L., M.M.N.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Ignacio Inglessis-Azuaje
- From the Clinical Proteomics Research Center (W.D., D.M., F.S.B., E.H.L., M.M.N.), Cardio-Neurology Division (W.D., I.I.-A., J.J.L., I.F.P., F.S.B., E.H.L., M.M.N.), and Neuroprotection Research Laboratory (E.H.L., M.M.N.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Joseph J Locascio
- From the Clinical Proteomics Research Center (W.D., D.M., F.S.B., E.H.L., M.M.N.), Cardio-Neurology Division (W.D., I.I.-A., J.J.L., I.F.P., F.S.B., E.H.L., M.M.N.), and Neuroprotection Research Laboratory (E.H.L., M.M.N.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Igor F Palacios
- From the Clinical Proteomics Research Center (W.D., D.M., F.S.B., E.H.L., M.M.N.), Cardio-Neurology Division (W.D., I.I.-A., J.J.L., I.F.P., F.S.B., E.H.L., M.M.N.), and Neuroprotection Research Laboratory (E.H.L., M.M.N.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Ferdinando S Buonanno
- From the Clinical Proteomics Research Center (W.D., D.M., F.S.B., E.H.L., M.M.N.), Cardio-Neurology Division (W.D., I.I.-A., J.J.L., I.F.P., F.S.B., E.H.L., M.M.N.), and Neuroprotection Research Laboratory (E.H.L., M.M.N.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Eng H Lo
- From the Clinical Proteomics Research Center (W.D., D.M., F.S.B., E.H.L., M.M.N.), Cardio-Neurology Division (W.D., I.I.-A., J.J.L., I.F.P., F.S.B., E.H.L., M.M.N.), and Neuroprotection Research Laboratory (E.H.L., M.M.N.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - MingMing Ning
- From the Clinical Proteomics Research Center (W.D., D.M., F.S.B., E.H.L., M.M.N.), Cardio-Neurology Division (W.D., I.I.-A., J.J.L., I.F.P., F.S.B., E.H.L., M.M.N.), and Neuroprotection Research Laboratory (E.H.L., M.M.N.), Massachusetts General Hospital, Harvard Medical School, Boston.
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Kim JS, Hong KS. Patent Foramen Ovale Closure: Opportunity Closed in Old Patients? J Stroke 2021; 23:147-148. [PMID: 34102751 PMCID: PMC8189853 DOI: 10.5853/jos.2021.01690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 05/10/2021] [Accepted: 05/10/2021] [Indexed: 11/29/2022] Open
Affiliation(s)
- Jong S. Kim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Keun-Sik Hong
- Department of Neurology, Inje University Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
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