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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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102
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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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103
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Diener HC, Nickenig G. [Secondary stroke prevention after TIA or ischemic stroke]. Herz 2021; 46:293-302. [PMID: 33914089 DOI: 10.1007/s00059-021-05035-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2021] [Indexed: 10/21/2022]
Abstract
Stroke is one of the main causes of mortality and permanent disability. Secondary prevention of stroke recurrence therefore has a high priority. Secondary prevention of ischemic stroke includes optimization of the lifestyle and diet, treatment of risk factors, such as hypertension, diabetes mellitus and hyperlipidemia, prophylaxis of recurrence with antiplatelet treatment in patients with high vascular risk and anticoagulation in atrial fibrillation. In addition, secondary prevention includes carotid surgery or stenting in selected symptomatic patients and closure of a patent foramen ovale after cryptogenic stroke.
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Affiliation(s)
- Hans Christoph Diener
- Institut für Medizinische Informatik, Biometrie und Epidemiologie (IMIBE), Medizinische Fakultät, Universität Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Deutschland.
| | - Georg Nickenig
- Herzzentrum, Medizinische Klinik und Poliklinik II, Universitätsklinikum Bonn, Bonn, Deutschland
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104
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Chen JZJ, Thijs VN. Presence of Atrial Fibrillation in Stroke Patients With Patent Foramen Ovale: Systematic Review and Meta-Analysis. Front Neurol 2021; 12:613758. [PMID: 33935933 PMCID: PMC8081982 DOI: 10.3389/fneur.2021.613758] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 03/11/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose: Patent foramen ovale (PFO) is associated with ischemic stroke, especially in patients with embolic stroke of undetermined source. This study aims to evaluate the presence of atrial fibrillation (AF) in ischemic stroke patients with PFO. Methods: We systematically searched EMBASE and MEDLINE databases on May 21, 2020 for studies that analyzed the presence of AF in patients with PFO. The primary outcome was the presence of AF in patients with PFO compared with those without. Outcomes were pooled using a random-effects model using the method of DerSimonian and Laird. We recorded demographic characteristics and the methods used for AF detection in the studies included (unspecified, history/medical records review, ECG, Holter monitor, or loop recorder). Results: A total of 14 studies and 13,245 patients fulfilled the entry criteria. The average age was 61.2 years and 41.3% of the participants were female. There was a lower risk of AF in patients with PFO compared with those without (RR 0.52, 95% confidence interval, 0.41-0.63, p < 0.001). There was no evidence of heterogeneity. The lower risk of AF was found in cross-sectional and longitudinal studies and in studies stratified by average age (<60 or ≥60) and in cryptogenic stroke. Meta-regression by PFO detection technique suggested that studies using transoesophageal echocardiogram for PFO detection reported higher risk of AF (1.39, 95% confidence interval 1.14-1.70, p = 0.004). Conclusion: The presence of a PFO in patients with ischemic stroke/TIA may be associated with a lower risk of AF. Few studies have estimated the risk of future AF in patients with PFO.
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Affiliation(s)
| | - Vincent N Thijs
- Department of Neurology, Austin Health, Heidelberg, VIC, Australia.,Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, VIC, Australia
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105
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Gusdon AM, Farrokh S, Grotta JC. Antithrombotic Therapy for Stroke Patients with Cardiovascular Disease. Semin Neurol 2021; 41:365-387. [PMID: 33851394 DOI: 10.1055/s-0041-1726331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Prevention of ischemic stroke relies on the use of antithrombotic medications comprising antiplatelet agents and anticoagulation. Stroke risk is particularly high in patients with cardiovascular disease. This review will focus on the role of antithrombotic therapies in the context of different types of cardiovascular disease. We will discuss oral antiplatelet medications and both IV and parental anticoagulants. Different kinds of cardiovascular disease contribute to stroke via distinct pathophysiological mechanisms, and the optimal treatment for each varies accordingly. We will explore the mechanism of stroke and evidence for antithrombotic therapy in the following conditions: atrial fibrillation, prosthetic heart values (mechanical and bioprosthetic), aortic arch atherosclerosis, congestive heart failure (CHF), endocarditis (infective and nonbacterial thrombotic endocarditis), patent foramen ovale (PFO), left ventricular assist devices (LVAD), and extracorporeal membrane oxygenation (ECMO). While robust data exist for antithrombotic use in conditions such as atrial fibrillation, optimal treatment in many situations remains under active investigation.
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Affiliation(s)
- Aaron M Gusdon
- Department of Neurosurgery, UTHealth Neurosciences, McGovern School of Medicine, University of Texas Health Science Center, Houston, Texas
| | - Salia Farrokh
- Division of Neurocritical Care, Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - James C Grotta
- Mobile Stroke Unit, Memorial Hermann Hospital, Texas Medical Center, Houston
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106
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Poli S, Siebert E, Mbroh J, Poli K, Krumbholz M, Mengel A, Greulich S, Härtig F, Müller KAL, Bocksch W, Gawaz M, Ziemann U, Zuern CS. Closure or medical therapy of patent foramen ovale in cryptogenic stroke: prospective case series. Neurol Res Pract 2021; 3:16. [PMID: 33789756 PMCID: PMC8015114 DOI: 10.1186/s42466-021-00114-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 03/01/2021] [Indexed: 11/17/2022] Open
Abstract
Background Results of randomized controlled trials (RCT) do not provide definite guidance for secondary prevention after ischemic stroke (IS)/transient ischemic attack (TIA) attributed to patent foramen ovale (PFO). No recommendations can be made for patients > 60 years. We aimed to compare interventional and medical PFO-management in cryptogenic IS/TIA patients, including patients > 60 years. Methods Prospective case series including consecutive cryptogenic IS/TIA patients with PFO at Tuebingen university stroke unit, Germany. ‘PFO-closure’ was recommended in patients ≤70 years when featuring high-risk PFO (i.e., with atrial septal aneurysm, spontaneous, or high-grade right-to-left shunt during Valsalva). Primary (recurrent IS/intracranial hemorrhage) and secondary endpoints (e.g., disability) were assessed during ≥1-year follow-up; planned subgroup analyses of patients ≤60/> 60 years. Results Among 236 patients with median age of 58 (range 18–88) years, 38.6% were females and median presenting National Institutes of Health Stroke Scale score was 1 (IQR 0–4). Mean follow-up was 2.8 ± 1.3 years. No intracranial hemorrhage was observed. Recurrent IS rate after ‘PFO-closure’ was 2.9% (95%CI 0–6.8%) and 7% (4–16.4) in high-risk PFO patients ≤60 (n = 103) and > 60 years (n = 43), respectively, versus 4% (0–11.5) during ‘medical therapy alone’ MTA (n = 28). 42 low-risk PFO patients treated with MTA experienced no recurrent IS/TIA. Conclusions In our real-world study, IS recurrence rate in ‘PFO-closure’ high-risk PFO patients ≤60 years was comparable to that observed in recent RCT. High-risk PFO patients > 60 years who underwent PFO-closure had similar IS recurrence rates than those who received MTA. MTA seems the appropriate treatment for low-risk PFO. Trial registration ClinicalTrials.gov, registration number: NCT04352790, registered on: April 20, 2020 – retrospectively registered. Supplementary Information The online version contains supplementary material available at 10.1186/s42466-021-00114-3.
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Affiliation(s)
- Sven Poli
- Department of Neurology & Stroke, Eberhard-Karls University, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany. .,Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tuebingen, Germany.
| | - Elisabeth Siebert
- Department of Cardiology, Eberhard-Karls University, Tuebingen, Germany
| | - Joshua Mbroh
- Department of Neurology & Stroke, Eberhard-Karls University, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tuebingen, Germany
| | - Khouloud Poli
- Department of Neurology & Stroke, Eberhard-Karls University, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tuebingen, Germany
| | - Markus Krumbholz
- Department of Neurology & Stroke, Eberhard-Karls University, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tuebingen, Germany
| | - Annerose Mengel
- Department of Neurology & Stroke, Eberhard-Karls University, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tuebingen, Germany
| | - Simon Greulich
- Department of Cardiology, Eberhard-Karls University, Tuebingen, Germany
| | - Florian Härtig
- Department of Neurology & Stroke, Eberhard-Karls University, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tuebingen, Germany
| | - Karin A L Müller
- Department of Cardiology, Eberhard-Karls University, Tuebingen, Germany
| | - Wolfgang Bocksch
- Department of Cardiology, Eberhard-Karls University, Tuebingen, Germany
| | - Meinrad Gawaz
- Department of Cardiology, Eberhard-Karls University, Tuebingen, Germany
| | - Ulf Ziemann
- Department of Neurology & Stroke, Eberhard-Karls University, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tuebingen, Germany
| | - Christine S Zuern
- Department of Neurology & Stroke, Eberhard-Karls University, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany.,Department of Cardiology, Eberhard-Karls University, Tuebingen, Germany.,Cardiology Division, Department of Medicine, University Hospital, and Cardiovascular Research Institute, Basel, Switzerland
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107
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Filomena D, Cimino S, Maestrini V, Monosilio S, Birtolo LI, Vicenzini E, Mancone M, Fedele F, Agati L. The evolving role of echocardiography in the assessment of patent foramen ovale in patients with left-side thromboembolism. Echocardiography 2021; 38:657-675. [PMID: 33740289 DOI: 10.1111/echo.15018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 02/09/2021] [Accepted: 02/17/2021] [Indexed: 12/27/2022] Open
Abstract
Patent foramen ovale (PFO) is the most common congenital cardiac abnormality found approximately in 25% of the adult population The pathophysiological role of paradoxical embolization through the PFO in ischemic stroke is well established. "Self-expanding double disk" and, more recently, suture-based "deviceless" systems are used for PFO closure in the setting of secondary prevention after ischemic stroke likely related to paradoxical embolization. Ultrasound plays a significant role in PFO assessment, indication to treatment, intra-procedural guidance, and follow-up for those undergoing PFO closure. Three different techniques are frequently used for these purposes: transesophageal echocardiography, transthoracic echocardiogram, and transcranial Doppler. In this review, advantages and limits of these techniques are discussed in detail to improve our skills in detection and treatment of this important condition by using ultrasound.
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Affiliation(s)
- Domenico Filomena
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences "Sapienza" University of Rome, Policlinico Umberto I, Rome, Italy
| | - Sara Cimino
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences "Sapienza" University of Rome, Policlinico Umberto I, Rome, Italy
| | - Viviana Maestrini
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences "Sapienza" University of Rome, Policlinico Umberto I, Rome, Italy
| | - Sara Monosilio
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences "Sapienza" University of Rome, Policlinico Umberto I, Rome, Italy
| | - Lucia Ilaria Birtolo
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences "Sapienza" University of Rome, Policlinico Umberto I, Rome, Italy
| | - Edoardo Vicenzini
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Massimo Mancone
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences "Sapienza" University of Rome, Policlinico Umberto I, Rome, Italy
| | - Francesco Fedele
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences "Sapienza" University of Rome, Policlinico Umberto I, Rome, Italy
| | - Luciano Agati
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences "Sapienza" University of Rome, Policlinico Umberto I, Rome, Italy
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108
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Chen JZJ, Thijs VN. Atrial Fibrillation Following Patent Foramen Ovale Closure: Systematic Review and Meta-Analysis of Observational Studies and Clinical Trials. Stroke 2021; 52:1653-1661. [PMID: 33611943 DOI: 10.1161/strokeaha.120.030293] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Jessie Ze-Jun Chen
- Department of Neurology, Austin Health, Heidelberg, Victoria, Australia (J.Z.-J.C., V.N.T.)
| | - Vincent N Thijs
- Department of Neurology, Austin Health, Heidelberg, Victoria, Australia (J.Z.-J.C., V.N.T.).,Stroke Theme, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Victoria, Australia (V.N.T.)
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109
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Kolte D, Palacios IF. Patent foramen ovale closure for secondary prevention of cryptogenic stroke. Expert Rev Cardiovasc Ther 2021; 19:211-220. [PMID: 33605829 DOI: 10.1080/14779072.2021.1878026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: A patent foramen ovale (PFO) is highly prevalent among the adult population. It allows shunting of blood through the inter-atrial septum and has been associated with cryptogenic stroke, transient ischemic attack, platypnea-orthodeoxia syndrome, decompression sickness (e.g. deep-water divers), and migraines.Areas Covered: In this manuscript, we will review the anatomy of PFO with particular emphasis on the factors associated with increased risk of paradoxical embolization, as well as the different modalities for the diagnosis of PFO. We will discuss medical, surgical, and transcatheter therapy for secondary prevention in patients with PFO and cryptogenic stroke, and summarize the data from observational studies, randomized controlled trials (RCTs), and meta-analysis of RCTs that have established the beneficial effect of transcatheter PFO closure in this patient population. Finally, we will provide a brief overview of the role of transcatheter PFO closure in patients with migraine.Expert Opinion: Transcatheter closure is the preferred treatment option in young (<60 years) patients with PFO and cryptogenic stroke. A multi-disciplinary approach with input from clinical cardiologist, neurologist, hematologist, cardiac surgeon, and interventional cardiologist provides the best therapeutic plan for each patient taking into account the available data, but also medical, social, and occupational considerations.
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Affiliation(s)
- Dhaval Kolte
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Igor F Palacios
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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110
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Abstract
PURPOSE OF REVIEW Recent data have changed the landscape of patent foramen ovale (PFO) closure for secondary stroke prevention. This review synthesizes the data and provides a framework for optimal management of stroke patients with PFO. RECENT FINDINGS The cumulative evidence indicates that PFO closure reduces the risk of recurrent stroke in carefully selected young cryptogenic stroke patients, with an annualized risk reduction of ∼0.6%. The benefit of PFO closure is particularly evident in patients with embolic appearing strokes, large right-to-left shunt, or an associated atrial septal aneurysm. There may be little or no benefit in patients with small deep infarcts, a small PFO, or an indication for long-term anticoagulation. Closure is accompanied by a small risk of major procedural complication and atrial fibrillation. SUMMARY The annual risk of stroke from PFO is low relative to other stroke mechanisms, but the life-time cumulative risk in young patients who have experienced a prior stroke may be substantial, in which case the absolute benefit of closure is likely impactful. PFO is highly prevalent in the general population, present in about one in four adults, and should not be considered to be the cause of the stroke until a thorough workup has excluded alternative mechanisms.
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111
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D'Andrea A, Dweck MR, Holte E, Fontes-Carvalho R, Cameli M, Aboumarie HS, Diener HC, Haugaa KH. EACVI survey on the management of patients with patent foramen ovale and cryptogenic stroke. Eur Heart J Cardiovasc Imaging 2021; 22:135-141. [PMID: 33346351 PMCID: PMC7822641 DOI: 10.1093/ehjci/jeaa318] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 11/05/2020] [Indexed: 11/14/2022] Open
Abstract
AIMS The European Association of Cardiovascular Imaging (EACVI) Scientific Initiatives Committee performed a global survey to evaluate the current practice for the assessment and management of patients with suspected patent foramen ovale (PFO) and cryptogenic stroke. METHODS AND RESULTS In total, 79 imaging centres from 34 countries across the world responded to the survey, which comprised 17 questions. Most non-invasive investigations for PFO were widely available in the responding centres, with the exception of transcranial colour Doppler which was only available in 70% of sites, and most commonly performed by neurologists. Standard transthoracic echocardiography, with or without bubbles, was considered the first-level test for suspected PFO in the majority of the centres, whereas transoesophageal echocardiography was an excellent second-level modality. Most centres would rule out atrial fibrillation (AF) as a source of embolism in all patients with cryptogenic stroke (63%), with the remainder reserving investigation for patients with multiple AF risk factors (33%). Cardiac magnetic resonance was the preferred tool for identifying other unusual aetiologies, like cardiac masses or thrombi. After PFO closure, there was variation in the use of antiplatelet therapy: a quarter recommended treatment for life, while only 12% recommended 5 years as stipulated in the guidelines (12%). Antibiotic prophylaxis prior to dental or endoscopic procedures was not recommended in 41% of centres, contrary to what the guidelines recommended. CONCLUSION Our survey revealed a variable adherence to the current recommendations for the diagnosis and management of patients with cryptogenic stroke and PFO. Efforts should focus on optimizing and standardizing diagnostic tests and treatment of this condition.
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Affiliation(s)
- Antonello D'Andrea
- Department of Cardiology, Umberto I_ Hospital, Luigi Vanvitelli University - Nocera Inferiore (ASL Salerno), Viale San Francesco - 84014 Caserta, Italy
| | - Marc R Dweck
- BHF Centre for Cardiovascular Science, Department of Cardiology, University of Edinburgh, Edinburgh, EH16 4SB, UK
| | - Espen Holte
- Department of Cardiology, St. Olavs Hospital, Postboks 3250 Torgarden, 7006 Trondheim, Norway
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology NTNU, Trondheim, PO Box 8905, 7491 Trondheim, Norway
| | - Ricardo Fontes-Carvalho
- Cardiovascular Research and Development Unit, Department of Physiology and Cardiothoracic Surgery, Faculty of Medicine, University of Porto, Al. Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
| | - Matteo Cameli
- Department of Cardiovascular Diseases, University of Siena, Policlinico Le Scotte, Viale Bracci 16, 53100 Siena, Italy
| | - Hatem Soliman Aboumarie
- Department of Cardiology - Harefield Hospital, Royal Brompton and Harefield NHS Foundation Trust, UB9 6JH London, UK
| | - Hans Christoph Diener
- Department of Neurology - Medical Faculty of the University Duisburg-Essen—Institute for Medical Informatics, Biometry and Epidemiology, Hufelandstraße, 26, 45147 Essen, Germany
| | - Kristina H Haugaa
- Department of Cardiology, Oslo University Hospital, Postboks 4950 Nydalen, 0424 Oslo, Norway
- Department of Cardiology - Institute for Clinical Medicine, University of Oslo, Postboks 1171 Blindern, 0318 Oslo, Norway
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112
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Marenghi A, Ceriani E, Fiorelli EM, Bonzi M, Montano N, Annoni F. Diagnostic Accuracy of Carotid Doppler Ultrasound for the Detection of Right-to-Left Cardiac Shunt. J Cardiovasc Echogr 2021; 30:201-205. [PMID: 33828941 PMCID: PMC8021086 DOI: 10.4103/jcecho.jcecho_70_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 08/14/2020] [Accepted: 09/19/2020] [Indexed: 11/23/2022] Open
Abstract
Background: Right-to-left cardiac shunt is a condition anatomically related to patent foramen ovale (PFO) and potentially related to cryptogenic cerebrovascular events. As recent studies demonstrated a reduction of recurrent stroke in patients undergoing percutaneous PFO closure after a cryptogenic cerebrovascular event, it is now of pivotal importance to screen these patients for Right-to-left shunt(RLS) presence. At this regard, transcranial color Doppler (TCCD) with contrast has a good sensitivity (97%) and specificity (93%) compared to transesophageal echocardiography and became the test of choice to assess RLS presence, thanks to its noninvasive nature. However, temporal bone window is not accessible in 6%–20% patients. Several approaches have been explored to overcome this limitation with encouraging but not definitive results for extracranial internal carotid artery (ICA) approach, proposed in previous pivotal studies. Aims of this study were to further assess the diagnostic accuracy of ICA Doppler ultrasound with contrast for RLS detection compared to TCCD, with the two tests performed simultaneously. Materials and Methods: Sixty-four patients underwent simultaneously to TCCD and ICA Doppler ultrasound, both performed at rest and after Valsalva maneuver. Diagnosis of RLS was made, both for TCCD and ICA ultrasound, if=1 microembolic signals (MES) were detected during the examination (either at rest or after Valsalva maneuver). Results: ICA Doppler ultrasound sensitivity and specificity resulted respectively of 97% (confidence interval [CI] 95%) and 100% ([CI] 95%), while negative likelihood ratio was 0.03 (CI 95%). Conclusions: ICA Doppler ultrasound represents a valid alternative to TCCD for RLS screening in patients without adequate transcranial acoustic window.
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Affiliation(s)
- Anna Marenghi
- Department of Internal Medicine, Allergology and Immunology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Elisa Ceriani
- Department of Internal Medicine, L. Sacco Hospital, University of Milan, Milan, Italy
| | - Elisa Maria Fiorelli
- Department of Internal Medicine, Allergology and Immunology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Mattia Bonzi
- Emergency Department and Emergency Medicine Unit, Foundation Irccs Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nicola Montano
- Department of Internal Medicine, Allergology and Immunology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Federico Annoni
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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Drakopoulou M, Soulaidopoulos S, Stathogiannis K, Oikonomou G, Papanikolaou A, Toutouzas K, Tousoulis D. Antiplatelet and Antithrombotic Therapy After Patent Foramen Oval and Atrial Septal Defect Closure. Curr Pharm Des 2021; 26:2769-2779. [PMID: 32338207 DOI: 10.2174/1385272824999200427083838] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 05/18/2020] [Indexed: 12/18/2022]
Abstract
Pathologies of the atrial septum include different interatrial communications varying from patent foramen ovale (PFO) to actual defects. Atrial septal defects (ASDs) may be localized within the fossa ovalis such as the secundum type ASD or outside the region of fossa ovalis, such as the ostium primum defect and sinus venosus defect. Over the last decades, the percutaneous closure of interatrial shunts has become a feasible and safe method. During these procedures, the delicate balance between thrombotic risk, device sealing process and bleeding risk is crucial. In this review, we sought to describe current available data on the antiplatelet and antithrombotic management of patients after percutaneous ASD or PFO closure.
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Affiliation(s)
- Maria Drakopoulou
- First Department of Cardiology, Hippokration Hospital, Medical School of Athens University, Athens, Greece
| | - Stergios Soulaidopoulos
- First Department of Cardiology, Hippokration Hospital, Medical School of Athens University, Athens, Greece
| | - Konstantinos Stathogiannis
- First Department of Cardiology, Hippokration Hospital, Medical School of Athens University, Athens, Greece
| | - Georgios Oikonomou
- First Department of Cardiology, Hippokration Hospital, Medical School of Athens University, Athens, Greece
| | - Aggelos Papanikolaou
- First Department of Cardiology, Hippokration Hospital, Medical School of Athens University, Athens, Greece
| | - Konstantinos Toutouzas
- First Department of Cardiology, Hippokration Hospital, Medical School of Athens University, Athens, Greece
| | - Dimitrios Tousoulis
- First Department of Cardiology, Hippokration Hospital, Medical School of Athens University, Athens, Greece
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Leitman M, Blondheim DS, Sabetay S, Tyomkin V. Diagnosis of patent foramen ovale using maximum intensity T-projection imaging. Int J Cardiovasc Imaging 2021; 37:1343-1348. [PMID: 33394216 DOI: 10.1007/s10554-020-02123-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 11/24/2020] [Indexed: 11/29/2022]
Abstract
Accurate diagnosis of patent foramen ovale (PFO) and grading of right-to-left shunt severity by the standard method of transthoracic or transesophageal echocardiography (TEE) with bubble injection is often challenging. We proposed the novel Maximum Intensity T-Projection (MIP) Imaging method as a complementary or alternative approach for simplified diagnosis and grading of PFO. MIP Imaging represents the superimposition of all frames of an echocardiographic video onto one image. Thus, all bubbles passing from right to left atrium are represented in this single image. Diagnosis and quantification of PFO by MIP Images were compared to those obtained by standard echocardiographic methods, using the same echocardiography video loops. We applied the MIP Imaging approach to 122 echo examinations (75% of them TEE studies), performed to rule out PFOs. The average time needed to manually analyze video loops taken during bubble injection was 102 ± 52 s vs. less than 1 s using the MIP Imaging method. There was good concordance between the conventional echo method and MIP Imaging in the diagnosis and quantification of PFOs. MIP Imaging for diagnosis and quantification of PFOs was much less time consuming than the classical method and at least as accurate as the classical method. Thus MIP Imaging may be used initially as an adjunct method for PFO diagnosis and quantification and may eventually replace the classical method.
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Affiliation(s)
- Marina Leitman
- Department of Cardiology, Shamir Medical Center, Zerifin, and Sackler School of Medicine Tel-Aviv University, Tel-Aviv, Israel.
| | - David S Blondheim
- Department of Cardiology, Hillel Yaffe Medical Center, Hadera, affiliated with the Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Sergiu Sabetay
- Department of Neurology, Hillel Yaffe Medical Center, Hadera, affiliated with the Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Vladimir Tyomkin
- Department of Cardiology, Shamir Medical Center, Zerifin, Israel
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Ortiz Garcia JG, Nathan S, Brorson JR. Neurologic complications of implantable devices. HANDBOOK OF CLINICAL NEUROLOGY 2021; 177:211-220. [PMID: 33632440 DOI: 10.1016/b978-0-12-819814-8.00019-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Technologies for repairing cardiac structures or sustaining cardiac function with implantable devices have helped patients with an ever-expanding array of cardiac conditions. Patients are surviving and thriving with cardiac conditions that would formerly have been disabling or fatal. With the implantation of devices in the heart, however, comes the inevitable risk of neurological complications. This chapter focuses on devices implanted in the chambers or valves of the heart itself, including prosthetic heart valves, closure devices for patent foramen ovale, atrial appendage occluder devices, short-term implantable circulatory assist devices, and long-term ventricular assist devices, but excluding coronary artery stents or extracardiac devices. Further, it considers the procedural and postprocedural risks of the devices, leaving the discussion of clinical effectiveness of the devices to other chapters of this book.
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Affiliation(s)
- Jorge G Ortiz Garcia
- Department of Neurology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Sandeep Nathan
- Section of Cardiology, Department of Internal Medicine, University of Chicago, Chicago, IL, United States
| | - James R Brorson
- Department of Neurology, University of Chicago, Chicago, IL, United States.
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Abstract
PURPOSE OF REVIEW Cryptogenic stroke represents a heterogenous but clinically important collection of stroke etiologies for which our understanding continues to grow. Here, we review our current knowledge and most recent recommendations on secondary prevention for common causes of cryptogenic stroke including paroxysmal atrial fibrillation, atrial cardiopathy, patent foramen ovale, and substenotic atherosclerotic disease as well as the under-recognized mechanisms of occult malignancy, heart failure, and, most recently, infection with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). RECENT FINDINGS The results from recent observational studies and randomized clinical trials have provided greater insight into the causal relationship and attributable risk of these suspected etiologies and have identified potential strategies to reduce the rates of recurrence. However, further clinical trials are needed to confirm the benefits of specific stroke prevention strategies, including the patient populations most likely to benefit from anticoagulation. There is ongoing research aimed at both reducing the proportion of ischemic strokes classified as cryptogenic and resolving much of the clinical equipoise that still exists. The results of these studies have the potential to provide us with a better understanding of these occult mechanisms and allow for more targeted interventions.
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Affiliation(s)
- Chinwe Ibeh
- grid.413734.60000 0000 8499 1112Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University and New York-Presbyterian Hospital, 710 W 168th St, New York, NY USA
| | - Mitchell S. V. Elkind
- grid.413734.60000 0000 8499 1112Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University and New York-Presbyterian Hospital, 710 W 168th St, New York, NY USA ,grid.21729.3f0000000419368729Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY USA
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118
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Shen Y, Nie Q, Zhang Y, Cao Q, Hou Z, Xu L. Treatment Strategies for Cryptogenic Stroke Patients with Patent Foramen Ovale: What Do We Choose? Neuropsychiatr Dis Treat 2021; 17:3205-3214. [PMID: 34712049 PMCID: PMC8548060 DOI: 10.2147/ndt.s333930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 10/08/2021] [Indexed: 11/23/2022] Open
Abstract
IMPORTANCE The treatment of cryptogenic stroke patients with patent foramen ovale to prevent recurrence of stroke, especially when patients consider drug prevention alone, has caused serious treatment dilemmas in clinical practice. OBJECTIVE To study the safety and efficacy of different treatment strategies using a network meta-analysis of randomized controlled trials in this population with cryptogenic stroke and patent foramen ovale. STUDY SELECTION PUBMED, EMBASE, The Cochrane Library, WangFang, and China National Knowledge Infrastructure were searched to identify RCT comparing different treatment strategies. Eleven randomized studies were included (n = 5706). MAIN OUTCOMES The primary efficacy outcome was recurrence of ischemic stroke, including fatal and non-fatal ischemic strokes. The primary safety outcome was major hemorrhage, but closure surgery includes systemic thrombotic events, persistent atrial fibrillation, surgical deaths and other major events. RESULTS In terms of efficacy and safety events, compared with antiplatelet, the OR of vitamin K antagonists for stroke recurrence was 0.81 (95% CI, 0.41-1.6), the OR of surgical closure was 0.38 (95% CI, 0.16-0.63), and the OR of NOAC was 0.79 (95% CI, 0.27-2.3). Compared with antiplatelet, the safety event OR of vitamin K antagonists was 1.7 (95% CI, 0.65-4.8), the OR of surgical closure was 1.7 (95% CI, 0.68-3.8), and the OR of NOAC was 2.2 (95% CI, 0.67-7.6). CONCLUSION In terms of effectiveness, surgical occlusion has the best performance, while anticoagulation is the second best. Vitamin K antagonists and non-vitamin K antagonists are difficult to distinguish between the best in effectiveness. Antiplatelet drugs are considered the worst option. Regarding the safety results, it is generally believed that there are no obvious beneficial interventions, but antiplatelet drugs are considered to be relatively best, followed by surgical intervention and vitamin K antagonists, and non-vitamin K antagonists are considered to be the least safe.
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Affiliation(s)
- Yu Shen
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People's Republic of China
| | - Qiurui Nie
- Department of Cardiovascular Medicine, People's Hospital Affiliated of Nanchang University, Jiangxi Provincial People's Hospital, Nanchang, Jiangxi, People's Republic of China
| | - Yibi Zhang
- Department of Cardiovascular Medicine, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People's Republic of China
| | - Qian Cao
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People's Republic of China
| | - Zhuo Hou
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People's Republic of China
| | - Lijun Xu
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People's Republic of China
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119
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Arnold CE. A Review of Potential Mechanisms of Cryptogenic Stroke and a Recommended Approach to Diagnosis. Neurology 2021. [DOI: 10.17925/usn.2021.17.2.104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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120
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Berkman SA, Song SS. Ischemic Stroke in the Young. Clin Appl Thromb Hemost 2021; 27:10760296211002274. [PMID: 33870763 PMCID: PMC8718160 DOI: 10.1177/10760296211002274] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 02/09/2021] [Accepted: 02/22/2021] [Indexed: 01/25/2023] Open
Abstract
The purpose of this article is to address several challenging questions in the management of young patients (those age 60 and under) who present with ischemic stroke. Do genetic thrombophilic states, strongly associated with venous thrombosis, independently cause arterial events in adults? Should cases of patent foramen ovale be closed with mechanical devices in patients with cryptogenic stroke? What are the optimal treatments for cerebral vein thrombosis, carotid artery dissection, and antiphospholipid syndrome and are DOACs acceptable treatment for these indications? What is the mechanism underlying large vessel stroke in patients with COVID-19? This is a narrative review. We searched PubMed and Embase and American College of physicians Journal club database for English language articles since 2000 looking mainly at randomized clinical trials, Meta analyses, Cochran reviews as well as some research articles viewed to be cutting edge regarding anticoagulation and cerebrovascular disease. Searches were done entering cerebral vein thrombosis, carotid dissection, anticoagulation therapy and stroke, antiphospholipid antibody and stroke, stroke in young adults, cryptogenic stroke and anticoagulation, patent foramen ovale and cryptogenic stroke, COVID-19 and stroke.
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Affiliation(s)
- Samuel A. Berkman
- Division of Hematology-Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Shlee S. Song
- Department of Neurology, Comprehensive Stroke Center Program, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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121
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Advances and ongoing controversies in PFO closure and cryptogenic stroke. HANDBOOK OF CLINICAL NEUROLOGY 2021; 177:43-56. [PMID: 33632456 DOI: 10.1016/b978-0-12-819814-8.00009-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Approximately one-third of strokes are cryptogenic in origin. These patients have a higher prevalence of patent foramen ovale (PFO) compared to individuals with stroke of known origin. It has been proposed that some cryptogenic strokes (CSs) can be caused by paradoxical embolism across a PFO. PFOs can be treated medically with antithrombotic agents and percutaneously with occluder devices. Large randomized clinical trials have found transcatheter PFO closure to be superior to medical treatment for the prevention of recurrent stroke in young patients with CS. However, the superiority of PFO closure over medical treatment in unselected populations has not been demonstrated. In this chapter, we review the evidence supporting PFO closure and the selection of patients for such intervention.
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122
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Kheiwa A, Hari P, Madabhushi P, Varadarajan P. Patent foramen ovale and atrial septal defect. Echocardiography 2020; 37:2172-2184. [PMID: 33368546 DOI: 10.1111/echo.14646] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 02/07/2020] [Indexed: 11/30/2022] Open
Abstract
Atrial septal defects (ASD) are among the most common congenital heart diseases encountered in adulthood. Patent foramen ovale (PFO) is present in up to 25% of the population. ASD could present as isolated lesion or in association with more complex congenital heart disease form as tetralogy of Fallot, or Ebstein's anomaly of tricuspid valve. There is a wide range of clinical presentation ranging from asymptomatic subjects surviving to adulthood undiagnosed to subjects presenting with right heart failure and severe pulmonary vascular disease (Eisenmenger syndrome). This manuscript is an in depth review of the complex atrial septation, the variable clinical presentation of ASD and PFO, and its clinical and therapeutic implications.
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Affiliation(s)
- Ahmed Kheiwa
- Division of Cardiology, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Pawan Hari
- Division of Cardiology, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Pranav Madabhushi
- Division of Cardiology, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Padmini Varadarajan
- Division of Cardiology, Loma Linda University Medical Center, Loma Linda, CA, USA
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123
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Diener HC, Hankey GJ. Primary and Secondary Prevention of Ischemic Stroke and Cerebral Hemorrhage: JACC Focus Seminar. J Am Coll Cardiol 2020; 75:1804-1818. [PMID: 32299593 DOI: 10.1016/j.jacc.2019.12.072] [Citation(s) in RCA: 169] [Impact Index Per Article: 42.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 12/12/2019] [Accepted: 12/22/2019] [Indexed: 01/30/2023]
Abstract
Stroke is a leading cause of permanent disability. Therefore, primary prevention of first stroke and secondary prevention of recurrent stroke are a high priority. Primary prevention of ischemic stroke includes lifestyle modification and diet, treatment of risk factors including hypertension, diabetes mellitus and lipid disorders, antiplatelet therapy for high vascular risk patients, and anticoagulation in atrial fibrillation. Secondary prevention of ischemic stroke includes additional carotid surgery or stenting in selected symptomatic patients, closure of patent foramen ovale after cryptogenic stroke, treatment of insulin resistance, and best medical treatment of intracranial stenosis. The most important preventive strategies in the primary and secondary prevention of cerebral hemorrhage include the treatment of hypertension, reduction in alcohol intake, and occlusion of the left atrial appendage in patients with atrial fibrillation and permanent contraindications for oral anticoagulation.
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Affiliation(s)
- Hans-Christoph Diener
- Institute for Medical Informatics, Biometry and Epidemiology, Medical Faculty, University Duisburg-Essen, Essen, Germany.
| | - Graeme J Hankey
- Medical School, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Australia
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124
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Lee M, Oh JH. Echocardiographic diagnosis of right-to-left shunt using transoesophageal and transthoracic echocardiography. Open Heart 2020; 7:openhrt-2019-001150. [PMID: 32763965 PMCID: PMC7412608 DOI: 10.1136/openhrt-2019-001150] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 03/09/2020] [Accepted: 06/01/2020] [Indexed: 01/16/2023] Open
Abstract
Background The diagnosis and quantification of right-to-left shunt (RLS) using transthoracic echocardiography (TTE) as well as transoesophageal echocardiography (TOE) have not been well established. We aimed to diagnose RLS by TOE using direct visualisation of the shunt and to compare the diagnosis with TTE diagnosis using conventional methods. Methods and results We evaluated 141 patients with ischaemic stroke for RLS by both non-sedation TOE and TTE using saline contrast and Valsalva manoeuvre. The amount (graded as 0 to IV) and timing of RLS were demonstrated. All patients were classified into four groups by TOE based on direct visualisation of shunt through a patent foramen ovale (PFO) or either pulmonary vein: no shunt (group 1: n=11), PFO (group 2: n=47), pulmonary RLS (group 3: n=25) and indeterminate RLS (group 4: n=58). All cases in group 3 showed delayed shunt, and all cases in group 4 had small shunt. On TTE findings, all cases with early appearing large shunt (cardiac cycles ≤3 and shunt grade ≥III) were group 2. Six of the eight patients with delayed appearing large shunt on TTE were group 3. TTE diagnosis of PFO using criteria of cardiac beats ≤3 and grade ≥II had a sensitivity of 85% and a specificity of 98% compared with TOE diagnosis using shunt visualisation. Conclusions Compared with TOE using shunt visualisation, TTE accurately diagnosed large PFO using criteria of cardiac cycles ≤3 and shunt grade ≥III. TTE possibly diagnosed pulmonary shunt using criteria of cardiac cycles >3 and shunt grade ≥III. Both modalities showed limitations in diagnosing small amount of RLS.
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Affiliation(s)
- Mirae Lee
- Division of Cardiology, Department of Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Gyeongsangnam-Do, Republic of Korea
| | - Ju Hyeon Oh
- Division of Cardiology, Department of Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Gyeongsangnam-Do, Republic of Korea
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Liu K, Song B, Palacios IF, Inglessis-Azuaje I, Deng W, McMullin D, Wang X, Lo EH, Xu Y, Buonanno FS, Ning M. Patent Foramen Ovale Attributable Cryptogenic Embolism With Thrombophilia Has Higher Risk for Recurrence and Responds to Closure. JACC Cardiovasc Interv 2020; 13:2745-2752. [PMID: 33303111 PMCID: PMC9612803 DOI: 10.1016/j.jcin.2020.09.059] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [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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Affiliation(s)
- Kai Liu
- Cardio-Neurology Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Bo Song
- Cardio-Neurology Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Igor F Palacios
- Cardio-Neurology Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ignacio Inglessis-Azuaje
- Cardio-Neurology Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - WenJun Deng
- Cardio-Neurology Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - David McMullin
- Cardio-Neurology Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - XiaoYing Wang
- Department of Neurosurgery, Clinical Neuroscience Research Center, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Eng H Lo
- Cardio-Neurology Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Neuroprotection Research Laboratory, Massachusetts General Hospital, Harvard Medical School, Massachusetts, USA
| | - YuMing Xu
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China.
| | - Ferdinando S Buonanno
- Cardio-Neurology Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
| | - MingMing Ning
- Cardio-Neurology Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Neuroprotection Research Laboratory, Massachusetts General Hospital, Harvard Medical School, Massachusetts, USA.
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Specktor P, Yalonetsky S, Agmon Y, Sprecher E, Ali FH, Telman G. The effect of TEE on treatment change in patients with acute ischemic stroke. PLoS One 2020; 15:e0243142. [PMID: 33270736 PMCID: PMC7714247 DOI: 10.1371/journal.pone.0243142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 11/17/2020] [Indexed: 11/19/2022] Open
Abstract
Background and purpose Ischemic stroke is a widespread disease carrying high morbidity and mortality. Transesophageal echocardiography (TEE) is considered an important tool in the work-up of patients with acute ischemic stroke (AIS) and transient ischemic attack (TIA) patients; its utility is limited by a semi-invasive nature. The purpose of this study was to evaluate the probability of treatment change due to TEE findings (yield) in the work-up of AIS and TIA patients. Methods Retrospective data on patients with AIS or TIA who underwent TEE examination between 2000–2013 were collected from the institutional registry. Results The average age of 1284 patients who were included in the study was 57±10.4, 66% of patients were male. The most frequent TEE findings included aortic plaques in 54% and patent foramen ovale (PFO) in 15%. TEE findings led to treatment change in 135 (10.5%) patients; anticoagulant treatment was initiated in 110 of them (81%). Most common etiology for switch to anticoagulation was aortic plaques (71 patients); PFO was second most common reason (26 patients). Significant TEE findings (thrombus, endocarditis, tumor) were found in 1.9% of patients, they were more common in young patients (<55; 56% of the patients). Conclusions The beginning of anticoagulation treatment in patients with thick and complicated plaques was found frequently in our study. Significant TEE findings, were infrequent, constituted an absolute indication for treatment change and were more common in younger patients.
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Affiliation(s)
- Polina Specktor
- Department of Neurology, Rambam Health Care Campus, Haifa, Israel
- Department of Neurology, Carmel Hospital, Haifa, Israel
| | | | - Yoram Agmon
- Department of Neurology, Rambam Health Care Campus, Haifa, Israel
| | - Elliot Sprecher
- Department of Neurology, Rambam Health Care Campus, Haifa, Israel
| | - Faten Haj Ali
- Department of Neurology, Rambam Health Care Campus, Haifa, Israel
| | - Gregory Telman
- Department of Neurology, Rambam Health Care Campus, Haifa, Israel
- Technion, Israel Institute of Technology, Haifa, Israel
- * E-mail:
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127
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Secondary Stroke Prevention and Management for the Neuro-Ophthalmologist. J Neuroophthalmol 2020; 40:463-471. [DOI: 10.1097/wno.0000000000001133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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128
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Seeger J, Hildick-Smith D. Patent Foramen Ovale. JACC Cardiovasc Interv 2020; 13:2753-2754. [DOI: 10.1016/j.jcin.2020.10.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 10/26/2020] [Indexed: 11/25/2022]
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Role of transoesophageal echocardiography in detecting patent foramen ovale in stroke patients aged ≤60 years: A retrospective study. PLoS One 2020; 15:e0242885. [PMID: 33253218 PMCID: PMC7703908 DOI: 10.1371/journal.pone.0242885] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 11/10/2020] [Indexed: 11/19/2022] Open
Abstract
Background The underlying aetiology of ischaemic strokes is unknown in as many as 50% of cases. Patent foramen ovale (PFO) has become an increasingly recognised cause of ischaemic strokes in young patients. The present study aimed (1) to assess the frequency of transoesophageal echocardiography (TOE) performed and the proportion of PFOs detected in patients aged ≤60 years and (2) examine the effect of PFO closure on reducing stroke reoccurrence. Methods This was a retrospective clinical audit based on de-identified, secure medical records of the Canberra Hospital, Australia. A review of records was conducted on discharged patients aged 18–60 years admitted to the stroke unit following an ischaemic stroke episode between January 1, 2015, and December 31, 2018. Results A total of 214 acute ischaemic stroke patients were admitted to the stroke unit (mean age, 49.2 ± 9.7 years). Concerning aetiology, 47.2% were cryptogenic in origin, whereas 52.8% had a stroke of a determined cause. 12 patients were diagnosed with a PFO and 7 venous thromboembolic events were identified, 1 in the cryptogenic group and 6 in the determined cause group. 91.7% of PFOs were diagnosed in patients with a cryptogenic stroke. Trans-thoracic echocardiography (TTE) was performed in 37.3% of patients and had detected 4 PFOs (sensitivity 27.3%, specificity 92.5%). TOE was performed in 26.2% of patients and had detected 11 PFOs (sensitivity 90.0%, specificity 100%). The number needed to treat to prevent the occurrence of an ischaemic stroke through PFO closure was estimated at 30. Conclusions An inverse association between age and PFO presence was found in patients aged 18–60 years. Additionally, TOE was superior to TTE for detecting PFO, particularly in those with stroke of an undetermined cause. Our results suggest an increased need for TOE as a routine imaging procedure for acute ischaemic stroke patients aged ≤60.
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Network meta-analysis on patent foramen ovale: is a stroke or atrial fibrillation worse? Neurol Sci 2020; 42:101-109. [PMID: 33244742 PMCID: PMC7819966 DOI: 10.1007/s10072-020-04922-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 11/18/2020] [Indexed: 01/15/2023]
Abstract
OBJECTIVE Systematic reviews suggest that patent foramen ovale closure (PFOc) is performed percutaneously with low complication rates. We did a network meta-analysis (NMA) comparing devices for PFO closures, evaluating safety and efficacy of transcatheter PFOc in preventing neurological events in patients with stroke when compared with medical therapy (MT), and assessing risk of atrial fibrillation (AF). METHODS We searched 3 databases (MEDLINE, EMBASE, CENTRAL/CCTR) identifying six randomized controlled trials from 2012 until December 2019. We performed a Bayesian NMA; number-needed-to-treat and number-needed-to-harm were derived by applying the estimated odds ratios (ORs). The likelihood of being helped or harmed (LHH) was evaluated to estimate the risk-effectiveness balance. RESULTS The 3560 patients allocated to PFOc were less subject to a stroke than patients with MT. The overall ORs of PFOc versus MT were 0.41 with fixed-effects, and 0.22 with random-effects model. NMA proves that PFOc induces AF episodes significantly higher than MT, even when analysis is limited to only new episodes of "serious AF." LHH (0.68 fixed-effects, 0.79 random-effects) showed that strokes saved are less than cases of AFs added. By considering only serious AF, strokes saved are higher than serious AFs induced by the PFOc (LHH was 3.46 and 4.00 respectively). CONCLUSIONS NMA supported PFOc in patients with cryptogenic stroke, confirming that devices are better than MT, but increase the risk of AF by over 2/4 times (serious or unserious AF). Considering serious AFs (real risky clinical condition), patients have more advantages in being treated, since LHH is ≥ 3-4.
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131
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A Case of Paradoxical Coil Embolism through a Patent Foramen Ovale. J Vasc Interv Radiol 2020; 32:312-314. [PMID: 33223389 DOI: 10.1016/j.jvir.2020.09.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 09/26/2020] [Accepted: 09/28/2020] [Indexed: 11/20/2022] Open
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Abstract
Up to a third of strokes are cryptogenic. The prevalence of patent foramen ovale (PFO) in patients with cryptogenic stroke is higher than in individuals with stroke of known origin. It has been proposed that some cryptogenic strokes can be caused by paradoxic embolism across a PFO. The treatment of PFO includes medical treatment with antithrombotic agents and percutaneous PFO closure. There is limited evidence to support PFO closure in unselected cases of cryptogenic stroke. However, large randomized clinical trials confirmed the superiority of transcatheter PFO closure compared with medical treatment in young patients with cryptogenic stroke.
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Transcatheter closure of patent foramen ovale: Current evidence and future perspectives. J Cardiol 2020; 77:3-9. [PMID: 33144025 DOI: 10.1016/j.jjcc.2020.09.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 09/03/2020] [Indexed: 11/21/2022]
Abstract
Recent prospective controlled studies have demonstrated that transcatheter closure of a patent foramen ovale (PFO) reduces recurrent stroke risk in select patients, especially in patients younger than 60 years with PFO and embolic-appearing infarct and where no other mechanism of stroke was identified. Detection of PFO depends on the intensity of the Valsalva maneuver, and not all PFOs can be diagnosed using transesophageal echocardiography. Transthoracic contrast echocardiography using abdominal compression during the Valsalva maneuver is an easy method that can increase the detection sensitivity of PFO shunt. PFO with two or more of the following factors is most likely considered a "high-risk PFO" and as such, has a significantly higher probability of cryptogenic stroke: (1) a long-tunnel PFO (≥10 mm in length), (2) atrial septal aneurysm and/or hypermobile interatrial septum, (3) prominent Eustachian valve or Chiari's network, (4) large right-to-left shunt at rest and during the Valsalva maneuver, and (5) low-angle PFO. In order to establish the benefit of catheter-based PFO closure as a safe and effective treatment in clinical practice, the degree of accuracy of PFO diagnosis and its long-term safety need to be confirmed.
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134
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Parrini I, Cecchi E, Forno D, Lyon AR, Asteggiano R. Device closure for patent foramen ovale in patients with cryptogenic stroke: which patients should get it? Eur Heart J Suppl 2020; 22:M43-M50. [PMID: 33664639 PMCID: PMC7916420 DOI: 10.1093/eurheartj/suaa163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Patent foramen ovale (PFO) and cryptogenic stroke (CS) both have a high prevalence. The optimal treatment to reduce stroke recurrence after CS remains controversial. Results from clinical trials, meta-analyses, and position papers, support percutaneous PFO device closure and medical therapy compared to medical therapy alone. However, the procedure may be associated with cardiac complications including an increased incidence of new atrial fibrillation. The benefit/risk balance should be determined on a case-by-case basis with the greatest benefit of PFO closure in patients with atrial septal aneurysm and PFO with large shunts. Future studies should address unsolved questions such as the choice of medical therapy in patients not undergoing closure, the duration of antiplatelet therapy, and the role of PFO closure in patients over 60 years old.
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Affiliation(s)
- Iris Parrini
- Division of Cardiology, Mauriziano Hospital Turin, Italy
| | - Enrico Cecchi
- Division of Cardiology, MariaVittoria Hospital Turin, Italy
| | - Davide Forno
- Division of Cardiology, MariaVittoria Hospital Turin, Italy
| | - Alexander R Lyon
- Department of Cardiology, Royal Brompton Hospital and Imperial College London, SW3 6NP, UK
| | - Riccardo Asteggiano
- LARC (Laboratorio Analisi e Ricerca Clinica) C.so Venezia 10—Turin – Italy and School of Medicine—, Insubria University, Varese, Italy
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135
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Huang YX, Chen Y, Cao Y, Qiu YG, Zheng JY, Li TC. Thrombus straddling a patent foramen ovale and pulmonary embolism: A case report. World J Clin Cases 2020; 8:4902-4907. [PMID: 33195659 PMCID: PMC7642556 DOI: 10.12998/wjcc.v8.i20.4902] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 08/20/2020] [Accepted: 09/09/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Venous thromboembolism is a common vascular syndrome presenting as deep vein thrombosis and/or pulmonary embolism. Thrombus has the possibility of migrating into the left circulation via patent foramen ovale in certain extreme circumstances. Thrombus straddling a patent foramen ovale is a direct evidence of this scenario. However, the confirmed cases of thrombus in transit are still rare.
CASE SUMMARY A 32-year-old man suffered from recurrent syncope and intermittent dyspnea for 1 wk. Transthoracic echocardiography confirmed a thrombus straddling the patent foramen ovale, and thrombi were also found in the bilateral pulmonary artery by computed tomography. The man underwent inferior vena cava filter placement and thrombolysis with alteplase. Echocardiography showed the absence of thrombi in both the right atrium and left atrium 2 d after hospitalization. The man was discharged to home on warfarin without any complications 2 wk later.
CONCLUSION Scrutinizing intracardiac thrombi provides measurable value in pulmonary embolism as closure of patent foramen ovale may be considered in certain patients. Early intervention plays a critical role in thrombus straddling a patent foramen ovale. A sedentary lifestyle may predispose young adults to thromboembolism, even if there are no other risk factors.
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Affiliation(s)
- Yi-Xiong Huang
- Department of Cardiology, Sixth Medical Center of PLA General Hospital, Beijing 100048, China
| | - Yu Chen
- Department of Cardiology, Sixth Medical Center of PLA General Hospital, Beijing 100048, China
| | - Yi Cao
- Department of Cardiology, Sixth Medical Center of PLA General Hospital, Beijing 100048, China
| | - Yi-Gang Qiu
- Department of Cardiology, Sixth Medical Center of PLA General Hospital, Beijing 100048, China
| | - Jian-Yong Zheng
- Department of Cardiology, Sixth Medical Center of PLA General Hospital, Beijing 100048, China
| | - Tian-Chang Li
- Department of Cardiology, Sixth Medical Center of PLA General Hospital, Beijing 100048, China
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136
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Zhang ZH, Yao Q, Huang HY, Zhu P, Xu X, Song ZY, Li HK. "One-stop shop": safety and efficacy of combining atrial septal defect occlusion and left atrial appendage closure for patients with atrial septal defect and atrial fibrillation. BMC Cardiovasc Disord 2020; 20:444. [PMID: 33045999 PMCID: PMC7552475 DOI: 10.1186/s12872-020-01708-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 09/16/2020] [Indexed: 11/21/2022] Open
Abstract
Background One-stop occlusion, which is defined as the combination of atrial septal defect [ASD] or patent foramen ovale [PFO] occlusion and left atrial appendage [LAA] closure, in patients with ASD/PFO and atrial fibrillation (AF) has not yet been investigated systematically. This study aimed to evaluate the safety and efficacy of one-stop occlusion in the treatment of adult patients with ASD/PFO and AF. Methods Inpatients with AF and ASD/PFO were recruited between August 2014 and April 2019. Preoperatively, transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) were conducted to identify the ASD/PFO size and margin, presence of thrombus in the LAA, and LAA orifice width and depth at 0°, 45°, 90°, and 135°. After confirmation of the indications of LAA closure (LAAC) and ASD/PFO occlusion, the procedures were performed simultaneously under general anesthesia. Oral anticoagulants were administered for 45–60 days, followed with regular evaluation of TTE and TEE. Results Forty-nine patients (age, 65.6 ± 9.6 years) were recruited in this study, including 24 patients with ASD and 25 patients with PFO. They were treated with LAAC and ASD/PFO occlusion successfully. The mean ASD size and mean diameter of the ASD occluders were 14.2 ± 7.7 and 25.4 ± 8.5 mm, respectively. The mean PFO size was 3.5 ± 0.4 mm. The mean maximal LAA orifice width and depth were 20.5 ± 3.4 and 28.3 ± 3.6 mm, respectively. All patients were implanted with a Watchman device (diameter, 27.1 ± 2.9 mm). Postoperatively, all patients took anticoagulants orally for 45–60 days, and their mean postoperative follow-up duration was 29.0 ± 12.1 months. Postoperative TEE showed that all had normal positioning of the LAA and ASD/PFO occluders. At 45–60 days after operation, TEE showed that the LAA and ASD/PFO occluder were in the normal position; however, two patients who took warfarin and novel oral anticoagulants, respectively, have developed occluder thrombosis. After adjusted anticoagulant therapy, TEE showed that the thrombus disappeared at 6 months after operation. Conclusion One-stop occlusion is safe and effective for the treatment of adult patients with ASD/PFO and AF. It is also feasible to administer warfarin or novel oral anticoagulants after operation.
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Affiliation(s)
- Zhi-Hui Zhang
- Department of Cardiology, Southwest Hospital, Army Medical University, Chongqing, China
| | - Qing Yao
- Department of Cardiology, Southwest Hospital, Army Medical University, Chongqing, China
| | - Hai-Yun Huang
- Department of ultrasound, Southwest Hospital, Army Medical University, Chongqing, China
| | - Ping Zhu
- Department of Cardiology, Southwest Hospital, Army Medical University, Chongqing, China
| | - Xiang Xu
- Department of Cardiology, Southwest Hospital, Army Medical University, Chongqing, China
| | - Zhi-Yuan Song
- Department of Cardiology, Southwest Hospital, Army Medical University, Chongqing, China
| | - Hua-Kang Li
- Department of Cardiology, Southwest Hospital, Army Medical University, Chongqing, China.
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137
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Fukutomi M, Wilkins B, Søndergaard L. The role of device closure of patent foramen ovale in patients with cryptogenic stroke. J Intern Med 2020; 288:400-409. [PMID: 32812297 DOI: 10.1111/joim.13143] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 06/16/2020] [Accepted: 06/16/2020] [Indexed: 01/16/2023]
Abstract
One of the most frequent causes of cardiac embolism in cryptogenic stroke is a paradoxical embolus, which originate from systemic venous source though an unidentified patent foramen ovale (PFO). PFO is a common finding in the general population with a prevalence of 25% to 30%. Transcatheter PFO device closure is known to be feasible and safety treatment for such patients. In recent years, several randomized controlled trials (RCTs) have been conducted to address the superiority of PFO closure over medical therapy alone in the prevention of stroke recurrence in patients with PFO. In contrast to findings from early 3 RCTs, recent 4 RCTs could successfully show the benefits of PFO device closure compared with medical therapy, with less peri- and postprocedural complication. Based on these data, PFO device closure is recommended to carefully select cryptogenic stroke patients aged from 18 to 65 years, with a high probability of a causal role of the PFO in stroke events. However, it is still uncertain whether PFO closure is superior to oral anticoagulants therapy in these patients. Therefore, further prospective randomized trials are needed to address the efficacy of PFO device closure to oral anticoagulants therapy.
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Affiliation(s)
- M Fukutomi
- From the Heart Center, Rigshospitalet, Copenhagen, Denmark
| | - B Wilkins
- From the Heart Center, Rigshospitalet, Copenhagen, Denmark
| | - L Søndergaard
- From the Heart Center, Rigshospitalet, Copenhagen, Denmark
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138
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Pietzsch JB, Geisler BP, Daniels MJ, Busca RM, Tarantini G, Søndergaard L, Kasner SE. An assessment of annual procedure volumes and therapy adoption of transcatheter closure of patent foramen ovale in four European countries. Eur Stroke J 2020; 6:72-80. [PMID: 33817337 DOI: 10.1177/2396987320939804] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 06/12/2020] [Indexed: 01/10/2023] Open
Abstract
Introduction Patent foramen ovale closure reduces recurrence of cryptogenic ischaemic stroke compared to anti-platelet therapy. Our goal was to determine procedure volumes and closure utilisation as a proportion of candidates in four large European countries. Patients and methods National statistics were obtained for Germany, England, France, and Italy for the last available five years (2014-2018). Eligibility was aligned to the enrolment criteria of pivotal trials and current consensus documents. Stroke and transient ischaemic attack incidences were obtained from epidemiological registries and claims data. The eligible candidate pool for analysis included current year candidates plus untreated patients from the prior two years. Absolute strokes avoided assumed the hazard ratio for ischaemic stroke recurrence from a recent meta-analysis. Results In 2018, closure incidence rates were 5.64, 0.53, 2.94 and 5.26 per 100,000 in Germany, England, France and Italy, respectively. This reflects five-year increases of 128% in Germany, 462% in France and 36% in Italy (p < 0.05 for all), and a decline of 37% in England. The proportions of treated patients versus candidates for the combined stroke and transient ischaemic attack pool were 55%, 30%, 80%, and 6%, respectively. Discussion Patent foramen ovale closure volumes increased after the 2017 announcement of positive trial results but still differ substantially across large European countries. If all closure candidates in 2018 with prior ischaemic stroke were treated, the resulting absolute reduction of recurrent ischaemic strokes, compared to anti-platelet therapy alone, would be between 782 and 2295 across the four countries over five years. Conclusion Many eligible patients at risk for a recurrent cryptogenic event might remain untreated due to regional practice variations.
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Affiliation(s)
| | - Benjamin P Geisler
- Wing Tech Inc., Menlo Park, CA, USA.,Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Matthew J Daniels
- Division of Cardiovascular Sciences, University of Manchester, Manchester, UK
| | | | - Giuseppe Tarantini
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | | | - Scott E Kasner
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
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139
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Kent DM, Saver JL, Ruthazer R, Furlan AJ, Reisman M, Carroll JD, Smalling RW, Jüni P, Mattle HP, Meier B, Thaler DE. Risk of Paradoxical Embolism (RoPE)-Estimated Attributable Fraction Correlates With the Benefit of Patent Foramen Ovale Closure: An Analysis of 3 Trials. Stroke 2020; 51:3119-3123. [PMID: 32921262 PMCID: PMC7831886 DOI: 10.1161/strokeaha.120.029350] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND PURPOSE In patients with cryptogenic stroke and patent foramen ovale (PFO), the Risk of Paradoxical Embolism (RoPE) Score has been proposed as a method to estimate a patient-specific "PFO-attributable fraction"-the probability that a documented PFO is causally-related to the stroke, rather than an incidental finding. The objective of this research is to examine the relationship between this RoPE-estimated PFO-attributable fraction and the effect of closure in 3 randomized trials. METHODS We pooled data from the CLOSURE-I (Evaluation of the STARFlex Septal Closure System in Patients With a Stroke and/or Transient Ischemic Attack due to Presumed Paradoxical Embolism through a Patent Foramen Ovale), RESPECT (Randomized Evaluation of Recurrent Stroke Comparing PFO Closure to Established Current Standard of Care Treatment), and PC (Clinical Trial Comparing Percutaneous Closure of Patent Foramen Ovale [PFO] Using the Amplatzer PFO Occluder With Medical Treatment in Patients With Cryptogenic Embolism) trials. We examine the treatment effect of closure in high RoPE score (≥7) versus low RoPE score (<7) patients. We also estimated the relative risk reduction associated with PFO closure across each level of the RoPE score using Cox proportional hazard analysis. We estimated a patient-specific attributable fraction using a PC trial-compatible (9-point) RoPE equation (omitting the neuroradiology variable), as well as a 2-trial analysis using the original (10-point) RoPE equation. We examined the Pearson correlation between the estimated attributable fraction and the relative risk reduction across RoPE strata. RESULTS In the low RoPE score group (<7, n=912), the rate of recurrent strokes per 100 person-years was 1.37 in the device arm versus 1.68 in the medical arm (hazard ratio, 0.82 [0.42-1.59] P=0.56) compared with 0.30 versus 1.03 (hazard ratio, 0.31 [0.11-0.85] P=0.02) in the high RoPE score group (≥7, n=1221); treatment-by-RoPE score group interaction, P=0.12. The RoPE score estimated attributable fraction anticipated the relative risk reduction across all levels of the RoPE score, in both the 3-trial (r=0.95, P<0.001) and 2-trial (r=0.92, P<0.001) analyses. CONCLUSIONS The RoPE score estimated attributable fraction is highly correlated to the relative risk reduction of device versus medical therapy. This observation suggests the RoPE score identifies patients with cryptogenic stroke who are likely to have a PFO that is pathogenic rather than incidental.
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Affiliation(s)
- David M Kent
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center/Tufts University School of Medicine, Boston, MA. (D.M.K., R.R.).,Department of Neurology, Tufts Medical Center/Tufts University School of Medicine, Boston, MA. (D.M.K., D.E.T.)
| | - Jeffrey L Saver
- Comprehensive Stroke Center and Department of Neurology, David Geffen School of Medicine/University of California Los Angeles (J.L.S.)
| | - Robin Ruthazer
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center/Tufts University School of Medicine, Boston, MA. (D.M.K., R.R.)
| | - Anthony J Furlan
- Department of Neurology, Case Western Reserve University, Cleveland, OH (A.J.F.)
| | - Mark Reisman
- Division of Cardiology, University of Washington Medical Center, Seattle (M.R.)
| | - John D Carroll
- Division of Cardiology, Department of Medicine, University of Colorado Denver, Aurora (J.D.C.)
| | - Richard W Smalling
- Division of Cardiology, Department of Medicine, University of Texas Medical School at Houston (R.W.S.)
| | - Peter Jüni
- Applied Health Research Centre (AHRC), Li Ka Shing Knowledge Institute of St. Michael's Hospital, Department of Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, ON, Canada (P.J.)
| | - Heinrich P Mattle
- Department of Neurology, Bern University Hospital, Bern, Switzerland. (H.P.M.)
| | - Bernhard Meier
- Department of Cardiology, Bern University Hospital, Bern, Switzerland. (B.M.)
| | - David E Thaler
- Department of Neurology, Tufts Medical Center/Tufts University School of Medicine, Boston, MA. (D.M.K., D.E.T.)
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140
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Park S, Oh JK, Song JK, Kwon B, Kim BJ, Kim JS, Kang DW, Chang JY, Lee JS, Kwon SU. Transcranial Doppler as a Screening Tool for High-Risk Patent Foramen Ovale in Cryptogenic Stroke. J Neuroimaging 2020; 31:165-170. [PMID: 32896963 DOI: 10.1111/jon.12783] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/29/2020] [Accepted: 08/22/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND AND PURPOSE The identification of high-risk patent foramen ovale (PFO) is important for selecting suitable patients for PFO closure to prevent recurrent stroke in those with cryptogenic stroke. We aimed to evaluate the predictability of transcranial Doppler (TCD) in diagnosing high-risk PFO compared with that of transesophageal echocardiography (TEE), which is not feasible for some stroke patients. METHODS We retrospectively reviewed the data of 461 cryptogenic stroke patients who underwent TEE and TCD for PFO evaluation. High-risk PFO on TEE was defined as PFO with atrial septal aneurysm (phasic septal excursion ≥10 mm) or large PFO (≥2 mm). Spencer grading of right-to-left shunt was used to classify the amount of shunt on TCD. RESULTS PFO on TEE was observed for 242 (52.5%) patients, and high-risk PFO was detected for 123 (26.7%) patients. However, PFO on TCD was observed for 336 (72.9%) patients. Among patients with significant shunt (Spencer grade III or higher) who underwent TCD after Valsalva maneuver (VM), 60.0% of patients had high-risk PFO. However, only 5.3% of patients had high-risk PFO among those without significant shunt. Receiver operating characteristic curves showed that significant shunt after VM had higher predictability (AUC = .876, 95% CI: .843-.905) for detecting the high-risk PFO compared with the predictability based on significant shunt at rest (AUC = .718, 95% CI: .674-.759). (P<.0001 for the differences between two AUCs). CONCLUSIONS TCD is a good screening tool for evaluating high-risk PFO. VM is important for the evaluation of PFO. Patients with minimal or no shunt on TCD after VM are unlikely to have high-risk PFO.
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Affiliation(s)
- Seongho Park
- Department of Neurology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Jin Kyung Oh
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.,Division of Cardiology, Department of Internal Medicine, Sejong Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea
| | - Jae-Kwan Song
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Boseong Kwon
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Bum Joon Kim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jong S Kim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Wha Kang
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jun Young Chang
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ji Sung Lee
- Clinical Research Center, Asan Institute for Life Sciences, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sun U Kwon
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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141
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Recurrent cerebrovascular events in patients after percutaneous closure of patent foramen ovale. J Stroke Cerebrovasc Dis 2020; 29:104860. [PMID: 32430239 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104860] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 03/20/2020] [Accepted: 03/31/2020] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Recent published trials have shown the efficacy of transcatheter closure of patent foramen ovale (PFO) for preventing recurrent cryptogenic cerebrovascular events. However, the risk of recurrent cerebrovascular events (rCVEs) is up to 5.7%, and the etiology is unclear. OBJECTIVE This study aimed to investigate the risk factors for rCVEs after closure of PFO during long-term follow-up. METHODS In our center, 282 consecutive patients underwent PFO closure because of a cryptogenic cerebrovascular event between 2006 and 2014. Their Risk of Paradoxical Embolism (RoPE) score was calculated retrospectively. We followed up with the patients by telephone, using hospital records to identify those who suffered from rCVEs. Patients with rCVEs were matched with two control patients of the same sex and RoPE score without rCVEs who underwent PFO closure at approximately the same time. The patients with rCVEs and controls participated in a clinical examination, including contrast transthoracic echocardiography (TTE) and Holter electrocardiography, to investigate the possible cause of rCVEs compared with controls. RESULTS Fourteen (5%) out of the 282 consecutive patients who underwent PFO closure suffered from rCVEs during a mean follow-up of 8.4 years (1.7 rCVEs per 100 patient-years). The median RoPE score of the patients was 7. Recurrent CVE occurred in 3.2 patients per 100 patient-years in patients with residual shunting compared with 0.8 patients per 100 patient-years in those without residual shunt. These patients were on antiplatelet treatment or without any effective anticoagulant treatment at the time rCVE occurred. The risk ratio of rCVEs in patients with residual shunting was 2.9-times higher than in patients without residual shunting (95% CI: 1.4-6.1) at follow-up visit. Four patients who had the BioSTAR device implanted suffered from an rCVE despite lack of residual shunting. CONCLUSIONS This study indicates that residual shunting and choice of the device may be the major reasons for rCVEs.
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142
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Miton N, Godart F, Milani G, Jalal Z, Karsenty C, Baruteau AE, Gronier C, Aldebert P, Douchin S, Lucron H, Chalard A, Houeijeh A, Petit J, Hascoet S, Thambo JB, Dauphin C. Patent foramen ovale closure in children without cardiopathy: Child-PFO study. Arch Cardiovasc Dis 2020; 113:513-524. [PMID: 32680737 DOI: 10.1016/j.acvd.2020.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 03/09/2020] [Accepted: 03/11/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Closure of patent foramen ovale is well-managed in adults, but is performed less frequently in children. AIM To analyse all patent foramen ovale closures performed in the past 20 years in French paediatric centres. METHODS Retrospective study of patent foramen ovale closures in children without cardiopathy in nine centres between 2000 and 2019. RESULTS Forty-one procedures were carried out in children (median age: 14.9 years). Thirty-one patent foramen ovales were closed after a transient ischaemic attack or stroke, six for a left-to-right shunt and four for other reasons. Transthoracic echocardiography was used for 72.2% of the diagnoses and transoesophageal echocardiography for 27.8%. A substantial degree of shunting was found in 42.9% of patients and an atrial septal aneurysm in 56.2%. General anaesthesia with transoesophageal echocardiography guidance was performed in 68.3% of the procedures; local anaesthesia and transthoracic echocardiography or intracardiac echocardiography was performed in 31.7%. The success rate was 100%. The median fluoroscopy time was 4.14minutes: 3.55minutes with transoesophageal echocardiography; and 4.38minutes with transthoracic echocardiography (P=0.67). There was only one periprocedural complication (2.4%). Postoperatively, 80,5% of patients were treated with aspirin and 12,2% with an anticoagulant. The rate of complete occlusion was 56.8% immediately after the procedure, 68.6% at 1 year and 92.3% at the last follow-up. There were no delayed complications or cases of recurrent stroke during follow-up (median follow-up: 568 days). CONCLUSION Closure of patent foramen ovale in children appears to be safe and effective, as we noted a low rate of immediate complications, no delayed complications and no stroke recurrence in this indication.
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Affiliation(s)
- Noelie Miton
- Department of Cardiology, M3C Regional Reference CHD Centre, Gabriel Montpied University Hospital, 63000 Clermont-Ferrand, France
| | - François Godart
- Paediatric Cardiology and Congenital Heart Disease, Institut Coeur Poumon, Lille University, 59000 Lille, France
| | - Guiti Milani
- Paediatric Cardiology Department, Necker-Enfants Malades Hospital, AP-HP, M3C National Reference CHD Centre, Paris Descartes University, Sorbonne Paris, 75015 Paris, France
| | - Zakaria Jalal
- Department of Paediatric and Adult Congenital Cardiology, Bordeaux University Hospital (CHU), 33604 Pessac, France; IHU Liryc, Electrophysiology and Heart Modelling Institute, Fondation Bordeaux Université, 33600 Pessac, France; Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM, 33600 Pessac, France
| | - Clément Karsenty
- Institut des Maladies Métaboliques et Cardiovasculaires, Toulouse University, 31432 Toulouse, France; Paediatric and Congenital Cardiology, Children's Hospital, CHU Toulouse, Toulouse University, 31300 Toulouse, France
| | - Alban-Elouen Baruteau
- L'institut du Thorax, INSERM, CNRS, Nantes University, CHU Nantes, 44007 Nantes, France; Department of Congenital Cardiology, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London SE1 7EH, UK
| | - Céline Gronier
- Groupe d'Exploration Cardiovasculaire, Clinique de l'Orangerie, 67000 Strasbourg, France
| | - Philippe Aldebert
- Paediatric and Congenital Medico-Surgical Cardiology Department, M3C Regional Reference CHD Centre, AP-HM, La Timone University Hospital, 13005 Marseille, France
| | - Stéphanie Douchin
- Department of Cardiology, M3C Regional Reference CHD Centre, CHU Grenoble, 38700 La Tronche, France
| | - Hugues Lucron
- Paediatric Cardiology, M3C Antilles-Guyane Centre, University Hospital (CHU de Martinique), 97200 Fort-de-France, France
| | - Aurélie Chalard
- Department of Cardiology, M3C Regional Reference CHD Centre, Gabriel Montpied University Hospital, 63000 Clermont-Ferrand, France
| | - Ali Houeijeh
- Paediatric Cardiology and Congenital Heart Disease, Institut Coeur Poumon, Lille University, 59000 Lille, France
| | - Jérome Petit
- Paris-Sud Faculty of Medicine, INSERM U999, Marie-Lannelongue Hospital, M3C National Reference CHD Centre, Paris-Sud University, Paris-Saclay University, 92350 Le Plessis-Robinson, France
| | - Sébastien Hascoet
- Paris-Sud Faculty of Medicine, INSERM U999, Marie-Lannelongue Hospital, M3C National Reference CHD Centre, Paris-Sud University, Paris-Saclay University, 92350 Le Plessis-Robinson, France
| | - Jean-Benoit Thambo
- Department of Paediatric and Adult Congenital Cardiology, Bordeaux University Hospital (CHU), 33604 Pessac, France; IHU Liryc, Electrophysiology and Heart Modelling Institute, Fondation Bordeaux Université, 33600 Pessac, France; Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM, 33600 Pessac, France
| | - Claire Dauphin
- Department of Cardiology, M3C Regional Reference CHD Centre, Gabriel Montpied University Hospital, 63000 Clermont-Ferrand, France.
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Kahles T, Michel P, Hapfelmeier A, Eberli FR, Zedde M, Thijs V, Kraemer M, Engelter ST, Serena J, Weimar C, Mallmann A, Luft A, Hemelsoet D, Thaler DE, Müller-Eichelberg A, De Pauw A, Sztajzel R, Armon C, Kent DM, Meier B, Mattle HP, Fischer U, Arnold M, Mono ML, Nedeltchev K. Prior Stroke in PFO Patients Is Associated With Both PFO-Related and -Unrelated Factors. Front Neurol 2020; 11:503. [PMID: 32582015 PMCID: PMC7289181 DOI: 10.3389/fneur.2020.00503] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 05/07/2020] [Indexed: 01/10/2023] Open
Abstract
Background and Purpose: To identify factors associated with prior stroke at presentation in patients with cryptogenic stroke (CS) and patent foramen ovale (PFO). Methods: We studied cross-sectional data from the International PFO Consortium Study (NCT00859885). Patients with first-ever stroke and those with prior stroke at baseline were analyzed for an association with PFO-related (right-to-left shunt at rest, atrial septal aneurysm, deep venous thrombosis, pulmonary embolism, and Valsalva maneuver) and PFO-unrelated factors (age, gender, BMI, hypertension, diabetes mellitus, hypercholesterolemia, smoking, migraine, coronary artery disease, aortic plaque). A multivariable analysis was used to adjust effect estimation for confounding, e.g., owing to the age-dependent definition of study groups in this cross-sectional study design. Results: We identified 635 patients with first-ever and 53 patients with prior stroke. Age, BMI, hypertension, diabetes mellitus, hypercholesterolemia, coronary artery disease, and right-to-left shunt (RLS) at rest were significantly associated with prior stroke. Using a pre-specified multivariable logistic regression model, age (Odds Ratio 1.06), BMI (OR 1.06), hypercholesterolemia (OR 1.90) and RLS at rest (OR 1.88) were strongly associated with prior stroke.Based on these factors, we developed a nomogram to illustrate the strength of the relation of individual factors to prior stroke. Conclusion: In patients with CS and PFO, the likelihood of prior stroke is associated with both, PFO-related and PFO-unrelated factors.
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Affiliation(s)
- Timo Kahles
- Department of Neurology, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Patrik Michel
- Department of Neurology, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Alexander Hapfelmeier
- Institute of Medical Informatics, Statistics and Epidemiology, School of Medicine, Technical University Munich, München, Germany
| | - Franz R Eberli
- Department of Cardiology, Municipal Hospital Triemli, Zurich, Switzerland
| | - Marialuisa Zedde
- Department of Neurology, Azienda Unità Sanitaria Locale-IRCCS, Reggio Emilia, Italy
| | - Vincent Thijs
- Department of Neurology, University Hospitals of Leuven, Leuven, Belgium.,Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, VIC, Australia
| | - Markus Kraemer
- Department of Neurology, Alfried-Krupp Krankenhaus, Essen, Germany.,Department of Neurology, Heinrich Heine University Duesseldorf, Duesseldorf, Germany
| | - Stefan T Engelter
- Department of Neurology, University Hospital of Basel, Basel, Switzerland.,Felix-Platter Hospital, Basel, Switzerland
| | - Joaquin Serena
- Department of Neurology, University Hospital of Girona, Girona, Spain
| | - Christian Weimar
- Department of Neurology, University Hospital of Essen, Essen, Germany
| | | | - Andreas Luft
- Department of Neurology, University Hospital of Zurich, Zurich, Switzerland
| | - Dimitri Hemelsoet
- Department of Neurology, University Hospital of Ghent, Ghent, Belgium
| | - David E Thaler
- Department of Neurology, Tufts Medical Center, Boston, MA, United States
| | | | - Adinda De Pauw
- Department of Neurology, AZ Sint Blasius, Dendermonde, Belgium
| | - Roman Sztajzel
- Department of Neurology, University Hospital of Geneva, Geneva, Switzerland
| | - Carmel Armon
- Department of Neurology, Baystate Health Center, Springfield, MA, United States.,Sackler School of Medicine and Department of Neurology, Yitzchak Shamir Medical Center, Tel Aviv University, Tel Aviv-Yafo, Israel
| | - David M Kent
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, United States
| | - Bernhard Meier
- Department of Cardiology, University Hospital of Bern, Bern, Switzerland
| | - Heinrich P Mattle
- Department of Neurology, University Hospital of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, University Hospital of Bern, Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, University Hospital of Bern, Bern, Switzerland
| | - Marie-Luise Mono
- Department of Neurology, University Hospital of Bern, Bern, Switzerland
| | - Krassen Nedeltchev
- Department of Neurology, Cantonal Hospital Aarau, Aarau, Switzerland.,Department of Neurology, University Hospital of Bern, Bern, Switzerland
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144
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Sgarra L, Bortone AS, Potenza MA, Nacci C, De Salvia MA, Acquaviva T, De Cillis E, Ciccone MM, Grimaldi M, Montagnani M. Endothelial Dysfunction May Link Interatrial Septal Abnormalities and MTHFR-Inherited Defects to Cryptogenic Stroke Predisposition. Biomolecules 2020; 10:biom10060861. [PMID: 32512924 PMCID: PMC7355772 DOI: 10.3390/biom10060861] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 05/22/2020] [Accepted: 06/02/2020] [Indexed: 12/21/2022] Open
Abstract
We explored the significance of the L-Arginine/asymmetric dimethylarginine (L-Arg/ADMA) ratio as a biomarker of endothelial dysfunction in stroke patients. To this aim, we evaluated the correlation, in terms of severity, between the degree of endothelial dysfunction (by L-Arg/ADMA ratio), the methylene tetrahydrofolate reductase (MTHFR) genotype, and the interatrial septum (IAS) phenotype in subject with a history of stroke. Methods and Results: L-Arg, ADMA, and MTHFR genotypes were evaluated; the IAS phenotype was assessed by transesophageal echocardiography. Patients were grouped according to the severity of IAS defects and the residual enzymatic activity of MTHFR-mutated variants, and values of L-Arg/ADMA ratio were measured in each subgroup. Of 57 patients, 10 had a septum integrum (SI), 38 a patent foramen ovale (PFO), and 9 an ostium secundum (OS). The L-Arg/ADMA ratio differed across septum phenotypes (p ≤ 0.01), and was higher in SI than in PFO or OS patients (p ≤ 0.05, p ≤ 0.01, respectively). In the PFO subgroup a negative correlation was found between the L-Arg/ADMA ratio and PFO tunnel length/height ratio (p ≤ 0.05; r = − 0.37; R2 = 0.14). Interestingly, the L-Arg/ADMA ratio varied across MTHFR genotypes (p ≤ 0.0001) and was lower in subgroups carrying the most impaired enzyme with respect to patients carrying the conservative MTHFR (p ≤ 0.0001, p ≤ 0.05, respectively). Consistently, OS patients carried the most dysfunctional MTHFR genotypes, whereas SI patients the least ones. Conclusions: A low L-Arg/ADMA ratio correlates with impaired activity of MTHFR and with the jeopardized IAS phenotype along a severity spectrum encompassing OS, PFO with long/tight tunnel, PFO with short/large tunnel, and SI. This infers that genetic MTHFR defects may underlie endothelial dysfunction-related IAS abnormalities, and predispose to a cryptogenic stroke. Our findings emphasize the role of the L-Arg/ADMA ratio as a reliable marker of stroke susceptibility in carriers of IAS abnormalities, and suggest its potential use both as a diagnostic tool and as a decision aid for therapy.
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Affiliation(s)
- Luca Sgarra
- Department of Biomedical Sciences and Human Oncology—Section of Pharmacology, Medical School, University of Bari “Aldo Moro”, 70124 Bari, Italy; (L.S.); (M.A.P.); (C.N.); (M.A.D.S.)
| | - Alessandro Santo Bortone
- Department of Emergency and Organ Transplantation—Section of Cardiovascular Diseases, Medical School, University of Bari “Aldo Moro”, 70124 Bari, Italy; (A.S.B.); (T.A.); (E.D.C.); (M.M.C.)
| | - Maria Assunta Potenza
- Department of Biomedical Sciences and Human Oncology—Section of Pharmacology, Medical School, University of Bari “Aldo Moro”, 70124 Bari, Italy; (L.S.); (M.A.P.); (C.N.); (M.A.D.S.)
| | - Carmela Nacci
- Department of Biomedical Sciences and Human Oncology—Section of Pharmacology, Medical School, University of Bari “Aldo Moro”, 70124 Bari, Italy; (L.S.); (M.A.P.); (C.N.); (M.A.D.S.)
| | - Maria Antonietta De Salvia
- Department of Biomedical Sciences and Human Oncology—Section of Pharmacology, Medical School, University of Bari “Aldo Moro”, 70124 Bari, Italy; (L.S.); (M.A.P.); (C.N.); (M.A.D.S.)
| | - Tommaso Acquaviva
- Department of Emergency and Organ Transplantation—Section of Cardiovascular Diseases, Medical School, University of Bari “Aldo Moro”, 70124 Bari, Italy; (A.S.B.); (T.A.); (E.D.C.); (M.M.C.)
| | - Emanuela De Cillis
- Department of Emergency and Organ Transplantation—Section of Cardiovascular Diseases, Medical School, University of Bari “Aldo Moro”, 70124 Bari, Italy; (A.S.B.); (T.A.); (E.D.C.); (M.M.C.)
| | - Marco Matteo Ciccone
- Department of Emergency and Organ Transplantation—Section of Cardiovascular Diseases, Medical School, University of Bari “Aldo Moro”, 70124 Bari, Italy; (A.S.B.); (T.A.); (E.D.C.); (M.M.C.)
| | - Massimo Grimaldi
- General Hospital “F. Miulli” Acquaviva delle Fonti, 70021 Bari, Italy;
| | - Monica Montagnani
- Department of Biomedical Sciences and Human Oncology—Section of Pharmacology, Medical School, University of Bari “Aldo Moro”, 70124 Bari, Italy; (L.S.); (M.A.P.); (C.N.); (M.A.D.S.)
- Correspondence:
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145
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Safouris A, Kargiotis O, Psychogios K, Kalyvas P, Ikonomidis I, Drakopoulou M, Toutouzas K, Tsivgoulis G. A Narrative and Critical Review of Randomized-Controlled Clinical Trials on Patent Foramen Ovale Closure for Reducing the Risk of Stroke Recurrence. Front Neurol 2020; 11:434. [PMID: 32655469 PMCID: PMC7326015 DOI: 10.3389/fneur.2020.00434] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 04/23/2020] [Indexed: 01/03/2023] Open
Abstract
Patent foramen ovale (PFO) is a common cardiac anatomic variant that has been increasingly found in young (<60 years) cryptogenic stroke patients. Despite initial neutral randomized-controlled clinical trials (RCTs), there have been four recent RCTs providing consistent data in favor of the efficacy and safety of PFO closure compared to medical therapy for secondary stroke prevention. However, taking into consideration the high prevalence of PFO, the low risk of stroke recurrence under medical treatment and the uncommon yet severe adverse events of the intervention, patient selection is crucial for attaining meaningful clinical benefits. Thorough workup to exclude alternative causes of stroke and identification of high-risk PFOs through clinical, neuroimaging and echocardiographic criteria are essential. Cost effectiveness of the procedure cannot be proven for the time being, since there are no robust data on clinical outcome after PFO-associated stroke but only limited anecdotal data suggesting low risk for long-term disability.
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Affiliation(s)
| | | | - Klearchos Psychogios
- Stroke Unit, Metropolitan Hospital, Pireus, Greece.,Second Department of Neurology, School of Medicine, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Ignatios Ikonomidis
- Department of Echocardiography and Laboratory of Preventive Cardiology, Second Cardiology Department, Attikon Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria Drakopoulou
- First Department of Cardiology, Athens School of Medicine, Hippokration Hospital, Athens, Greece
| | - Konstantinos Toutouzas
- First Department of Cardiology, Medical School of Athens University, Hippokration Hospital, Athens, Greece
| | - Georgios Tsivgoulis
- Second Department of Neurology, School of Medicine, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece.,Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, United States
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146
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Structural heart intervention for prevention of embolic and hemorrhagic stroke: The new field of neurocardiology. J Cardiol 2020; 76:227-235. [PMID: 32482326 DOI: 10.1016/j.jjcc.2020.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 04/02/2020] [Indexed: 11/23/2022]
Abstract
Cardiogenic stroke (CS), characteristic causes of which include atrial fibrillation (AF) and right-to-left shunting due to a patent foramen ovale (PFO), has a well-known tendency to be associated with a more extensive ischemic area. This may result in severe neurological damage, and require strict life-long antithrombotic therapy. However, the fact that some patients have problems complying with the requirement for extended oral antithrombotic treatment has motivated the development of alternative approaches for stroke prevention. Heart structures such as the left atrial appendage (LAA) and PFO are potential targets for stroke prevention by way of device implantation. Several large prospective randomized clinical trials have demonstrated efficacy and safety of devices dedicated to this purpose. Percutaneous LAA occlusion for patients with non-valvular AF resulted in similar embolic event rates but significantly reduced bleeding events than did therapy with warfarin. Furthermore, PFO closure significantly reduced the frequency of recurrent embolic stroke relative to oral antithrombotic treatment. Current unsolved problems remaining in the application of these two strategies can be identified as the lack of standardized regimens for post-procedural antithrombotic therapy, ambiguity of determining the indications therefore, and the problem of device-related thrombus, which need to be investigated in depth in future. Cost-benefit analysis in comparison with standard medication is also required for each instance. A heart-brain multidisciplinary team approach, mandated to start such structural heart interventions, will become the future standard unit of personnel for stroke management, which promises to usher in the new field of neurocardiology.
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147
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Deng W, Yin S, McMullin D, Inglessis-Azuaje I, Elmariah S, Hung J, Lo EH, Palacios IF, Buonanno FS, Ning M. Residual Shunt After Patent Foramen Ovale Closure and Long-Term Stroke Recurrence: A Prospective Cohort Study. Ann Intern Med 2020; 172:717-725. [PMID: 32422058 PMCID: PMC10021023 DOI: 10.7326/m19-3583] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Residual shunt is observed in up to 25% of patients after patent foramen ovale (PFO) closure, but its long-term influence on stroke recurrence currently is unknown. OBJECTIVE To investigate the association of residual shunt after PFO closure with the incidence of recurrent stroke and transient ischemic attack (TIA). DESIGN Prospective cohort study comparing stroke or TIA recurrence in patients with and without residual shunt after PFO closure. SETTING Single hospital center. PARTICIPANTS 1078 consecutive patients (mean age, 49.3 years) with PFO-attributable cryptogenic stroke who were undergoing percutaneous PFO closure were followed for up to 11 years. MEASUREMENTS Residual shunt was evaluated by transthoracic echocardiography with saline contrast. Primary outcome was a composite of the first recurrent ischemic stroke or TIA after PFO closure. RESULTS Compared with complete closure, the presence of residual shunt after PFO closure was associated with an increased incidence of recurrent stroke or TIA: 2.32 versus 0.75 events per 100 patient-years (hazard ratio [HR], 3.05 [95% CI, 1.65 to 5.62]; P < 0.001). This result remained robust after adjustment for important covariates, namely age; study period; device; presence of atrial septal aneurysm, hypertension, hyperlipidemia, diabetes, hypercoagulability, or hypermobile septum; and medication use (HR, 3.01 [CI, 1.59 to 5.69]; P < 0.001). Further stratification based on shunt size revealed that moderate or large residual shunts were associated with a higher risk for stroke or TIA recurrence (HR, 4.50 [CI, 2.20 to 9.20]; P < 0.001); the result for small residual shunts was indeterminate (HR, 2.02 [CI, 0.87 to 4.69]; P = 0.102). LIMITATION Nonrandomized study with potential unmeasured confounding. CONCLUSION Among patients undergoing PFO closure to prevent future stroke, the presence of residual shunt, particularly a moderate or large residual shunt, was associated with an increased risk for stroke or TIA recurrence. PRIMARY FUNDING SOURCE National Institutes of Health.
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Affiliation(s)
- Wenjun Deng
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (W.D., S.Y., D.M., I.I., S.E., J.H., E.H.L., I.F.P., F.S.B., M.N.)
| | - Shanye Yin
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (W.D., S.Y., D.M., I.I., S.E., J.H., E.H.L., I.F.P., F.S.B., M.N.)
| | - David McMullin
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (W.D., S.Y., D.M., I.I., S.E., J.H., E.H.L., I.F.P., F.S.B., M.N.)
| | - Ignacio Inglessis-Azuaje
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (W.D., S.Y., D.M., I.I., S.E., J.H., E.H.L., I.F.P., F.S.B., M.N.)
| | - Sammy Elmariah
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (W.D., S.Y., D.M., I.I., S.E., J.H., E.H.L., I.F.P., F.S.B., M.N.)
| | - Judy Hung
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (W.D., S.Y., D.M., I.I., S.E., J.H., E.H.L., I.F.P., F.S.B., M.N.)
| | - Eng H Lo
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (W.D., S.Y., D.M., I.I., S.E., J.H., E.H.L., I.F.P., F.S.B., M.N.)
| | - Igor F Palacios
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (W.D., S.Y., D.M., I.I., S.E., J.H., E.H.L., I.F.P., F.S.B., M.N.)
| | - Ferdinando S Buonanno
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (W.D., S.Y., D.M., I.I., S.E., J.H., E.H.L., I.F.P., F.S.B., M.N.)
| | - MingMing Ning
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (W.D., S.Y., D.M., I.I., S.E., J.H., E.H.L., I.F.P., F.S.B., M.N.)
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148
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Guo L, Wang L, Liu W. Ability of the number of territories involved on DWI-MRI to predict occult systemic malignancy in cryptogenic stroke patients. J Stroke Cerebrovasc Dis 2020; 29:104823. [PMID: 32362555 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104823] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 03/01/2020] [Accepted: 03/19/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Lesions in multiple arterial territories is one of the typical features of malignancy patients with cryptogenic stroke. Hence, if patients with cryptogenic stroke display such feature, occult cancer could be predicted. The study aimed to analyze the predictive ability of the number of territories involved on DWI-MRI for occult systemic malignancy (OSM) in patients with cryptogenic stroke. METHODS We enrolled patients with cryptogenic stroke without a diagnosis of malignancy at stroke onset between January 2013 and November 2018. Clinical variables were analyzed between cryptogenic stroke patients with and without OSM through univariate and multiple logistic regression analyses. Points for OSM were generated by β-coefficients. The sensitivity and specificity of the risk score were assessed by the area under the receiver operating characteristic curve (AUROC). The cutoff value for predicting OSM was determined by the maximum Youden index. RESULTS Among 108 cyptogenic stroke patients, compared to patients without OSM (n = 96), patients with OSM (n = 12) had a lower nutrition status (P = 0.031), higher plasma D-dimer levels (P < 0.001) and more territories involved on DWI-MRI (P < 0.001). Multiple logistic regression analysis revealed that plasma D-dimer levels (OR, 3.54; 95% Cl, 1.62-7.76; P = 0.002) and the number of territories involved (OR, 4.45; 95% CI, 1.25-15.80; P = 0.021) independently predicted OSM. The predictive score system built upon the number of territories showed good discrimination with an AUROC of 0.84 (95% CI, 0.71-0.96). The cutoff value was 2 with a maximum Youden's index of 0.56, which means that patients with more than one territory involved on DWI-MRI may need extensive screening for OSM. CONCLUSIONS The number of territories involved on DWI-MRI was a valid predictor for OSM in cryptogenic stroke patients who need to undergo further evaluations .
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Affiliation(s)
- Linjia Guo
- Department of Neurology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China.
| | - Lili Wang
- Department of Neurology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Wenhong Liu
- Department of Neurology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
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149
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Hong CS, Politzer C, Ryan SP, Wellman SS, Jiranek WA, Bolognesi MP, Seyler TM. Impact of Patent Foramen Ovale on Total Knee Arthroplasty Cerebrovascular Accident Perioperative Management. Orthopedics 2020; 43:e151-e158. [PMID: 32077965 DOI: 10.3928/01477447-20200213-06] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 02/25/2019] [Indexed: 02/03/2023]
Abstract
Venous thromboembolism and ischemic stroke are major complications following total knee arthroplasty (TKA) and potentially are associated with a patent foramen ovale (PFO). Although this association has been shown in other surgical disciplines, it has not been demonstrated in patients undergoing TKA. This study was undertaken to determine whether patients with a PFO would have a significantly increased risk of cerebrovascular accident (CVA) following TKA. The Humana national database was used to identify TKA patients who were stratified by the presence of a PFO from 2007 to 2016. Ninety-day follow-up was used for the primary outcome of CVA. Potential confounding comorbidities also were investigated, including age, sex, anticoagulation, insurance type, arrhythmia, valvular disease, peripheral vascular disease, chronic kidney disease, and diabetes mellitus. Of 153,245 TKAs, a total of 2272 patients had strokes; 479 of these patients had a PFO. On multivariable analysis, PFO remained an independent predictor of CVA postoperatively (odds ratio, 3.824; 95% confidence interval, 2.614-5.406; P<.0001). Other significant comorbidities associated with CVA included arrhythmia, chronic kidney disease, diabetes mellitus, peripheral vascular disease, and coronary valve disease. Importantly, low-molecular weight heparin or factor Xa inhibitor administration postoperatively had a negative correlation with stroke (odds ratio, 0.762; 95% confidence interval, 0.663-0.871; P=.0001 and odds ratio, 0.749; 95% confidence interval, 0.628-0.885; P=.0009, respectively). The findings of the multivariable analysis indicate PFO is associated with early postoperative CVA within 90 days following TKA. If known preoperatively, appropriate referral should be made to a cardiologist for PFO management and anticoagulation to reduce the overall risk of stroke. [Orthopedics. 2020;43(3):e151-e158.].
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150
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Messé SR, Gronseth GS, Kent DM, Kizer JR, Homma S, Rosterman L, Carroll JD, Ishida K, Sangha N, Kasner SE. Practice advisory update summary: Patent foramen ovale and secondary stroke prevention: Report of the Guideline Subcommittee of the American Academy of Neurology. Neurology 2020; 94:876-885. [PMID: 32350058 DOI: 10.1212/wnl.0000000000009443] [Citation(s) in RCA: 108] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 03/06/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To update the 2016 American Academy of Neurology (AAN) practice advisory for patients with stroke and patent foramen ovale (PFO). METHODS The guideline panel followed the AAN 2017 guideline development process to systematically review studies published through December 2017 and formulate recommendations. MAJOR RECOMMENDATIONS In patients being considered for PFO closure, clinicians should ensure that an appropriately thorough evaluation has been performed to rule out alternative mechanisms of stroke (level B). In patients with a higher risk alternative mechanism of stroke identified, clinicians should not routinely recommend PFO closure (level B). Clinicians should counsel patients that having a PFO is common; that it occurs in about 1 in 4 adults in the general population; that it is difficult to determine with certainty whether their PFO caused their stroke; and that PFO closure probably reduces recurrent stroke risk in select patients (level B). In patients younger than 60 years with a PFO and embolic-appearing infarct and no other mechanism of stroke identified, clinicians may recommend closure following a discussion of potential benefits (absolute recurrent stroke risk reduction of 3.4% at 5 years) and risks (periprocedural complication rate of 3.9% and increased absolute rate of non-periprocedural atrial fibrillation of 0.33% per year) (level C). In patients who opt to receive medical therapy alone without PFO closure, clinicians may recommend an antiplatelet medication such as aspirin or anticoagulation (level C).
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Affiliation(s)
- Steven R Messé
- From the Department of Neurology (S.R.M., S.E.K.), University of Pennsylvania School of Medicine, Philadelphia; Department of Neurology (G.S.G., L.R.), University of Kansas Medical Center, MO; Institute for Clinical Research and Health Policy Studies (D.M.K.), Tufts University School of Medicine, Boston, MA; Cardiology Section (J.R.K.), San Francisco Veterans Affairs Health Care System, and Departments of Medicine, and Epidemiology and Biostatistics (J.R.K.), University of California San Francisco; Division of Cardiology (S.H.), Columbia University Medical Center, New York; Department of Medicine (Cardiology) (J.D.C.), University of Colorado School of Medicine, Aurora; Department of Neurology (K.I.), New York University; and Department of Neurology (N.S.), Kaiser Permanente, Los Angeles, CA
| | - Gary S Gronseth
- From the Department of Neurology (S.R.M., S.E.K.), University of Pennsylvania School of Medicine, Philadelphia; Department of Neurology (G.S.G., L.R.), University of Kansas Medical Center, MO; Institute for Clinical Research and Health Policy Studies (D.M.K.), Tufts University School of Medicine, Boston, MA; Cardiology Section (J.R.K.), San Francisco Veterans Affairs Health Care System, and Departments of Medicine, and Epidemiology and Biostatistics (J.R.K.), University of California San Francisco; Division of Cardiology (S.H.), Columbia University Medical Center, New York; Department of Medicine (Cardiology) (J.D.C.), University of Colorado School of Medicine, Aurora; Department of Neurology (K.I.), New York University; and Department of Neurology (N.S.), Kaiser Permanente, Los Angeles, CA
| | - David M Kent
- From the Department of Neurology (S.R.M., S.E.K.), University of Pennsylvania School of Medicine, Philadelphia; Department of Neurology (G.S.G., L.R.), University of Kansas Medical Center, MO; Institute for Clinical Research and Health Policy Studies (D.M.K.), Tufts University School of Medicine, Boston, MA; Cardiology Section (J.R.K.), San Francisco Veterans Affairs Health Care System, and Departments of Medicine, and Epidemiology and Biostatistics (J.R.K.), University of California San Francisco; Division of Cardiology (S.H.), Columbia University Medical Center, New York; Department of Medicine (Cardiology) (J.D.C.), University of Colorado School of Medicine, Aurora; Department of Neurology (K.I.), New York University; and Department of Neurology (N.S.), Kaiser Permanente, Los Angeles, CA
| | - Jorge R Kizer
- From the Department of Neurology (S.R.M., S.E.K.), University of Pennsylvania School of Medicine, Philadelphia; Department of Neurology (G.S.G., L.R.), University of Kansas Medical Center, MO; Institute for Clinical Research and Health Policy Studies (D.M.K.), Tufts University School of Medicine, Boston, MA; Cardiology Section (J.R.K.), San Francisco Veterans Affairs Health Care System, and Departments of Medicine, and Epidemiology and Biostatistics (J.R.K.), University of California San Francisco; Division of Cardiology (S.H.), Columbia University Medical Center, New York; Department of Medicine (Cardiology) (J.D.C.), University of Colorado School of Medicine, Aurora; Department of Neurology (K.I.), New York University; and Department of Neurology (N.S.), Kaiser Permanente, Los Angeles, CA
| | - Shunichi Homma
- From the Department of Neurology (S.R.M., S.E.K.), University of Pennsylvania School of Medicine, Philadelphia; Department of Neurology (G.S.G., L.R.), University of Kansas Medical Center, MO; Institute for Clinical Research and Health Policy Studies (D.M.K.), Tufts University School of Medicine, Boston, MA; Cardiology Section (J.R.K.), San Francisco Veterans Affairs Health Care System, and Departments of Medicine, and Epidemiology and Biostatistics (J.R.K.), University of California San Francisco; Division of Cardiology (S.H.), Columbia University Medical Center, New York; Department of Medicine (Cardiology) (J.D.C.), University of Colorado School of Medicine, Aurora; Department of Neurology (K.I.), New York University; and Department of Neurology (N.S.), Kaiser Permanente, Los Angeles, CA
| | - Lee Rosterman
- From the Department of Neurology (S.R.M., S.E.K.), University of Pennsylvania School of Medicine, Philadelphia; Department of Neurology (G.S.G., L.R.), University of Kansas Medical Center, MO; Institute for Clinical Research and Health Policy Studies (D.M.K.), Tufts University School of Medicine, Boston, MA; Cardiology Section (J.R.K.), San Francisco Veterans Affairs Health Care System, and Departments of Medicine, and Epidemiology and Biostatistics (J.R.K.), University of California San Francisco; Division of Cardiology (S.H.), Columbia University Medical Center, New York; Department of Medicine (Cardiology) (J.D.C.), University of Colorado School of Medicine, Aurora; Department of Neurology (K.I.), New York University; and Department of Neurology (N.S.), Kaiser Permanente, Los Angeles, CA
| | - John D Carroll
- From the Department of Neurology (S.R.M., S.E.K.), University of Pennsylvania School of Medicine, Philadelphia; Department of Neurology (G.S.G., L.R.), University of Kansas Medical Center, MO; Institute for Clinical Research and Health Policy Studies (D.M.K.), Tufts University School of Medicine, Boston, MA; Cardiology Section (J.R.K.), San Francisco Veterans Affairs Health Care System, and Departments of Medicine, and Epidemiology and Biostatistics (J.R.K.), University of California San Francisco; Division of Cardiology (S.H.), Columbia University Medical Center, New York; Department of Medicine (Cardiology) (J.D.C.), University of Colorado School of Medicine, Aurora; Department of Neurology (K.I.), New York University; and Department of Neurology (N.S.), Kaiser Permanente, Los Angeles, CA
| | - Koto Ishida
- From the Department of Neurology (S.R.M., S.E.K.), University of Pennsylvania School of Medicine, Philadelphia; Department of Neurology (G.S.G., L.R.), University of Kansas Medical Center, MO; Institute for Clinical Research and Health Policy Studies (D.M.K.), Tufts University School of Medicine, Boston, MA; Cardiology Section (J.R.K.), San Francisco Veterans Affairs Health Care System, and Departments of Medicine, and Epidemiology and Biostatistics (J.R.K.), University of California San Francisco; Division of Cardiology (S.H.), Columbia University Medical Center, New York; Department of Medicine (Cardiology) (J.D.C.), University of Colorado School of Medicine, Aurora; Department of Neurology (K.I.), New York University; and Department of Neurology (N.S.), Kaiser Permanente, Los Angeles, CA
| | - Navdeep Sangha
- From the Department of Neurology (S.R.M., S.E.K.), University of Pennsylvania School of Medicine, Philadelphia; Department of Neurology (G.S.G., L.R.), University of Kansas Medical Center, MO; Institute for Clinical Research and Health Policy Studies (D.M.K.), Tufts University School of Medicine, Boston, MA; Cardiology Section (J.R.K.), San Francisco Veterans Affairs Health Care System, and Departments of Medicine, and Epidemiology and Biostatistics (J.R.K.), University of California San Francisco; Division of Cardiology (S.H.), Columbia University Medical Center, New York; Department of Medicine (Cardiology) (J.D.C.), University of Colorado School of Medicine, Aurora; Department of Neurology (K.I.), New York University; and Department of Neurology (N.S.), Kaiser Permanente, Los Angeles, CA
| | - Scott E Kasner
- From the Department of Neurology (S.R.M., S.E.K.), University of Pennsylvania School of Medicine, Philadelphia; Department of Neurology (G.S.G., L.R.), University of Kansas Medical Center, MO; Institute for Clinical Research and Health Policy Studies (D.M.K.), Tufts University School of Medicine, Boston, MA; Cardiology Section (J.R.K.), San Francisco Veterans Affairs Health Care System, and Departments of Medicine, and Epidemiology and Biostatistics (J.R.K.), University of California San Francisco; Division of Cardiology (S.H.), Columbia University Medical Center, New York; Department of Medicine (Cardiology) (J.D.C.), University of Colorado School of Medicine, Aurora; Department of Neurology (K.I.), New York University; and Department of Neurology (N.S.), Kaiser Permanente, Los Angeles, CA
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