151
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Nie H, Hu Y, Tang Z. Efficacy and safety of percutaneous patent foramen ovale closure devices for recurrent stroke: A systemic review and network metaanalysis. BRAIN SCIENCE ADVANCES 2020. [DOI: 10.26599/bsa.2019.9050014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Background: Randomized controlled trials (RCTs) that directly compare the efficacy and safety of percutaneous patent foramen ovale (PFO) closure devices have not been conducted. Thus, we performed a network meta-analysis to identify the efficacy and safety of occluder devices. Methods: From 1st January, 2000 to 1st May, 2018, we searched Embase, PubMed, and Cochrane Library for RCTs about percutaneous closure devices (such as STARFlex, GORE, and Amplatzer) and medical therapy for cryptogenic cerebral ischemic patients with PFO. The occurrence rate of recurrent stroke, atrial fibrillation (AF), major vascular complication (MVC), headache, transient ischemic attack, and bleeding were compared with the frequentist and Bayesian methods using R statistics. Results: We included 3747 patients from six RCTs. The GORE and Amplatzer occluders were found to be significantly associated with a decreased risk of recurrent stroke [relative risk (RR): 0.37 and 0.49; 95% confidence interval (CI): 0.17–0.81, 0.29–0.83, respectively]. Moreover, STARFlex was correlated to an increased risk of postoperative AF and MVCs (RR: 11.66 and 7.63; 95% CI: 4.87–21.91, 2.34–24.88). Conclusions: Among the three devices, the GORE and Amplatzer occluders are found to be the most effective in preventing secondary stroke in patients with PFO. Meanwhile, STARFlex is the least recommended device because it cannot decrease the risk of recurrent stroke and is the most likely to cause adverse events.
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Affiliation(s)
- Hao Nie
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei, China
| | - Yang Hu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei, China
| | - Zhouping Tang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei, China
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152
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Alakbarzade V, Keteepe-Arachi T, Karsan N, Ray R, Pereira AC. Patent foramen ovale. Pract Neurol 2020; 20:225-233. [DOI: 10.1136/practneurol-2019-002450] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2020] [Indexed: 11/03/2022]
Abstract
Patent foramen ovale (PFO) is the most common anatomical cause of an interatrial shunt. It is usually asymptomatic but may cause paradoxical embolism, manifesting as stroke, myocardial infarction or visceral/peripheral ischaemia. PFO is a risk factor for stroke and may be associated with migraine with aura. New evidence suggests PFO closure reduces the risk of recurrent ischaemic stroke in a highly selected population of stroke survivors: those aged 60 years or younger with a cryptogenic stroke syndrome, a large right-to-left shunt, an atrial septal aneurysm and no evidence of atrial fibrillation. They benefit from percutaneous PFO closure in addition to antiplatelet therapy, rather than antiplatelet therapy alone. Current evidence does not support PFO closure in the treatment of migraine.
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153
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Giblett JP, Williams LK, Kyranis S, Shapiro LM, Calvert PA. Patent Foramen Ovale Closure: State of the Art. Interv Cardiol 2020; 15:e15. [PMID: 33318751 PMCID: PMC7726850 DOI: 10.15420/icr.2019.27] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Accepted: 09/22/2020] [Indexed: 12/29/2022] Open
Abstract
Patent foramen ovale (PFO) is a common abnormality affecting between 20% and 34% of the adult population. For most people, it is a benign finding; however, in some people, the PFO can open widely to enable paradoxical embolus to transit from the venous to arterial circulation, which is associated with stroke and systemic embolisation. Percutaneous closure of the PFO in patients with cryptogenic stroke has been undertaken for a number of years, and a number of purpose-specific septal occluders have been marketed. Recent randomised control trials have demonstrated that closure of PFO in patients with cryptogenic stroke is associated with reduced rates of recurrent stroke. After a brief overview of the anatomy of a PFO, this article considers the evidence for PFO closure in cryptogenic stroke. The article also addresses other potential indications for closure, including systemic arterial embolisation, decompression sickness, platypnoea-orthodeoxia syndrome and migraine with aura. The article lays out the pre-procedural investigations and preparation for the procedure. Finally, the article gives an overview of the procedure itself, including discussion of closure devices.
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Affiliation(s)
- Joel P Giblett
- Liverpool Centre for Cardiovascular Science, Liverpool Heart and Chest Hospital Liverpool, UK
| | - Lynne K Williams
- Department of Cardiology, Royal Papworth Hospital NHS Foundation Trust Cambridge, UK
| | - Stephen Kyranis
- Department of Cardiology, Royal Papworth Hospital NHS Foundation Trust Cambridge, UK
| | - Leonard M Shapiro
- Department of Cardiology, Royal Papworth Hospital NHS Foundation Trust Cambridge, UK
| | - Patrick A Calvert
- Department of Cardiology, Royal Papworth Hospital NHS Foundation Trust Cambridge, UK
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154
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Cappato R. Light anti-thrombotic regimen after interatrial shunt device closure: A strategy for all patients? Eur J Intern Med 2020; 74:35-36. [PMID: 31980329 DOI: 10.1016/j.ejim.2020.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 01/13/2020] [Indexed: 11/21/2022]
Affiliation(s)
- Riccardo Cappato
- Humanitas Clinical and Research Center, Via Manzoni 56, 20089 Rozzano - Milan, Italy and Humanitas University, Department of Biomedical Sciences, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele - Milan, Italy..
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155
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Rigatelli G, Zuin M, Dell'Avvocata F, Roncon L, Vassilev D, Nghia N. Light anti-thrombotic regimen for prevention of device thrombosis and/or thrombotic complications after interatrial shunts device-based closure. Eur J Intern Med 2020; 74:42-48. [PMID: 31902564 DOI: 10.1016/j.ejim.2019.12.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 11/28/2019] [Accepted: 12/17/2019] [Indexed: 11/17/2022]
Abstract
AIMS The optimal antiplatelet therapy after atrial septal defect (ASD) or patent foramen ovale device closure (PFO) remain to be established. We evaluated the safety and effectiveness of 6-month 100 mg Aspirin (ASA) regimen in the very long-term follow up after intracardiac echocardiography (ICE) -aided interatrial shunt closure in a large retrospective cohort. METHODS Single-center retrospective analysis which included medical and instrumental data of 789 consecutive patients referred to our institution over a 15 years period due interatrial shunt catheter-based closure. RESULTS Finally, 734 patients were included in the analysis (mean age 46.1 ± 14.6 years, 398 females): ASD and PFO closure were successfully performed in 281 and 453 patients, respectively. Over the follow-up period, no major bleeding events were observed while the rate of minor bleeding events was 0.9%. Tolerance problems were detected in 3.4% of cases (n==28). In 11 patients (1.5%) an abnormal complete blood count was detected and monitored up to normalization. On a mean follow -up of 10.3 ± 3.0 years (range 1-15), 10 patients (1.36%) had a persistent moderate shunt 12 months after closure and maintained Aspirin 100 mg life-long, whereas the remaining 724 suspended the treatment after 6 months. Device thrombosis in ASD and PFO groups were 0% and 0.2%, respectively. A cerebral ischemic event occurred in 0.4% of the entire cohort. CONCLUSIONS A regimen of 100 mg of ASA for six months after ASD/PFO closure appeared to be both safe and effective in preventing device thrombosis and major bleedings.
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Affiliation(s)
- Gianluca Rigatelli
- Section of Adult and Congenital Heart Disease, Cardiovascular Diagnosis and Endoluminal Interventions, Rovigo General Hospital, 45100, Rovigo Italy.
| | - Marco Zuin
- Section of Adult and Congenital Heart Disease, Cardiovascular Diagnosis and Endoluminal Interventions, Rovigo General Hospital, 45100, Rovigo Italy; University of Ferrara, Faculty of Medicine, Ferrara, Italy
| | - Fabio Dell'Avvocata
- Section of Adult and Congenital Heart Disease, Cardiovascular Diagnosis and Endoluminal Interventions, Rovigo General Hospital, 45100, Rovigo Italy
| | - Loris Roncon
- Section of Adult and Congenital Heart Disease, Cardiovascular Diagnosis and Endoluminal Interventions, Rovigo General Hospital, 45100, Rovigo Italy
| | - Dobrin Vassilev
- Department of Cardiology, Alesandrovska University School of Medicine, Sofia, Bulgaria
| | - Nguyen Nghia
- Department of Interventional cardiology, Cho Ray Hospital, Ho Chi Minh City, Vietnam
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156
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157
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Villablanca PA, Lemor A, So CY, Kang G, Jain T, Gupta T, Ando T, Mohananey D, Ranka S, Hernandez-Suarez DF, Michel P, Frisoli T, Wang DD, Eng M, O'Neill W, Ramakrishna H. Increased Risk of Perioperative Ischemic Stroke in Patients Who Undergo Noncardiac Surgery with Preexisting Atrial Septal Defect or Patent Foramen Ovale. J Cardiothorac Vasc Anesth 2020; 34:2060-2068. [PMID: 32127264 DOI: 10.1053/j.jvca.2020.01.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 01/08/2020] [Accepted: 01/09/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To evaluate whether a preoperative diagnosis of atrial septal defect (ASD) or patent foramen ovale (PFO) is associated with perioperative stroke in noncardiac surgery and their outcomes. DESIGN Retrospective cohort analysis. SETTING United States hospitals. PARTICIPANTS Adults patients (≥18 years old) who underwent major noncardiac surgery from 2010 to 2015 were identified using the Healthcare Cost and Utilization Project's National Readmission Database. INTERVENTIONS Preoperative diagnosis of ASD or patent foramen ovale. MEASUREMENTS AND MAIN RESULTS Among the 19,659,161 hospitalizations for major noncardiac surgery analyzed, 12,248 (0.06%) had a preoperative diagnosis of ASD/PFO. Perioperative ischemic stroke occurred in 723 (5.9%) of patients with ASD/PFO and 373,291 (0.02%) of those without ASD/PFO (adjusted odds ratio [aOR], 16.7; 95% confidence interval [CI]: 13.9-20.0). Amongst the different types of noncardiac surgeries, obstetric, endocrine, and skin and burn surgery were associated with higher risk of stroke in patients with pre-existing ASD/PFO. Moreover, patients with ASD/PFO also had an increased in-hospital mortality (aOR, 4.6, 95% CI: 3.6-6.0), 30-day readmission (aOR, 1.2, 95% CI: 1.04-1.38), and 30-day stroke (aOR, 7.2, 95% CI: 3.1-16.6). After adjusting for atrial fibrillation, ischemic stroke remained significantly high in the ASD/PFO group (aOR: 23.7, 95%CI 19.4-28.9), as well as in-hospital mortality (aOR: 5.6, 95% CI 4.1-7.7), 30-day readmission (aOR: 1.19, 95%CI 1.0-1.4), and 30-day stroke (aOR: 9.3, 95% CI 3.7-23.6). CONCLUSIONS Among adult patients undergoing major noncardiac surgery, pre-existing ASD/PFO is associated with increased risk of perioperative ischemic stroke, in-hospital mortality, 30-day stroke, and 30-day readmission after surgery.
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Affiliation(s)
| | - Alejandro Lemor
- Center for Structural Heart Disease, Henry Ford Hospital, Detroit, MI; Universidad de San Martín de Porres, Facultad de Medicina, Centro de Investigación de Epidemiología Clínica y Medicina Basada en la Evidencia, Lima, Peru
| | - Chak-Yu So
- Universidad de San Martín de Porres, Facultad de Medicina, Centro de Investigación de Epidemiología Clínica y Medicina Basada en la Evidencia, Lima, Peru; Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong
| | - Guson Kang
- Center for Structural Heart Disease, Henry Ford Hospital, Detroit, MI
| | - Tarun Jain
- Center for Structural Heart Disease, Henry Ford Hospital, Detroit, MI
| | - Tanush Gupta
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY
| | - Tomo Ando
- Department of Cardiology, Wayne State University/Detroit Medical Center, Detroit, MI
| | | | - Sagar Ranka
- Department of Internal Medicine, John H Stroger Jr. Hospital of Cook County, Chicago, IL
| | - Dagmar F Hernandez-Suarez
- Division of Cardiovascular Medicine, Department of Medicine, University of Puerto Rico School of Medicine, San Juan, PR
| | - Pablo Michel
- University of Texas Health Science Center San Antonio, San Antonio, TX
| | - Tiberio Frisoli
- Center for Structural Heart Disease, Henry Ford Hospital, Detroit, MI
| | - Dee Dee Wang
- Center for Structural Heart Disease, Henry Ford Hospital, Detroit, MI
| | - Marvin Eng
- Center for Structural Heart Disease, Henry Ford Hospital, Detroit, MI
| | - William O'Neill
- Center for Structural Heart Disease, Henry Ford Hospital, Detroit, MI
| | - Harish Ramakrishna
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, AZ.
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158
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Michel P, Villablanca PA, Ranka S, Lemor A, Jain T, Ramakrishna H. Patent Foramen Ovale and Risk of Cryptogenic Stroke – Analysis of Outcomes and Perioperative Implications. J Cardiothorac Vasc Anesth 2020; 34:819-826. [DOI: 10.1053/j.jvca.2019.04.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 04/18/2019] [Indexed: 01/09/2023]
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159
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Khan R. Examining the evidence for PFO closure and novel oral anticoagulants for treatment of cryptogenic stroke. Expert Rev Cardiovasc Ther 2020; 18:139-148. [PMID: 32085690 DOI: 10.1080/14779072.2020.1733977] [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: 10/24/2022]
Abstract
Introduction: There has been considerable study assessing the treatment of cryptogenic stroke (CS) recently. This review examines the role of patent foramen ovale (PFO) closure in CS, while also discussing the evidence for alternative medical therapies in disease treatment.Areas covered: PFO closure for treatment of CS has been assessed in 6 randomized controlled trials (RCTs). This review summarizes the background, results and limitations of these trials. Methodological and treatment-related differences in RCTs provide potential explanations for the discordance in outcomes observed between older (CLOSURE, PC, RESPECT-Early) and newer PFO closure trials (RESPECT-Late, CLOSE, REDUCE, DEFENSE-PFO). With regards to medical therapy for CS, two RCTs (NAVIGATE ESUS and RE-SPECT ESUS) did not show any benefit in recurrent stroke prevention with the use of novel oral anticoagulants (NOAC) compared with aspirin. Marked differences in baseline characteristics and rates of recurrent stroke between PFO closure and NOAC trials underlie the heterogeneous nature of CS.Expert commentary: In young patients with CS, PFO closure reduces the risk of recurrent stroke, with newer RCTs emphasizing the importance of identifying those with 'high-risk' PFO and the need for continued antiplatelet therapy. Additionally, treatment for CS should not be uniform but directed at disease-specific pathologies.
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Affiliation(s)
- Razi Khan
- Department of Cardiology, Royal Columbian Hospital, New Westminster, Canada
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160
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Noble S. PFO Closure and Migraine: Does Residual Shunt Matter? JACC Cardiovasc Interv 2020; 13:303-305. [PMID: 32029247 DOI: 10.1016/j.jcin.2019.10.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 10/08/2019] [Indexed: 12/22/2022]
Affiliation(s)
- Stéphane Noble
- Structural Cardiology Unit, University Hospital of Geneva, Geneva, Switzerland.
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161
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Abstract
BACKGROUND Stroke is a common neurological disorder and may present with visual symptoms. A thorough workup is warranted to determine the underlying cause of stroke to optimize secondary prevention. Despite a full workup, a high-risk mechanism may not be identified. Optimal treatment in this patient population has been the subject of recent research, particularly with regard to low-risk stroke mechanisms such as patent foramen ovale (PFO). EVIDENCE ACQUISITION Using PubMed and published stroke guidelines, an evidence-based literature review was performed. RESULTS In this review, we compare cryptogenic stroke with the newer concept of embolic stroke of undetermined source, summarize the most common causes presumed to underlie these strokes, and review the evidence for optimal antithrombotic management. We also review recent clinical trials demonstrating a benefit for percutaneous closure of PFO for secondary stroke prevention in select patients. CONCLUSIONS Stroke management is based on evaluation of individual patient-risk factors. Evaluation and treatment is ideally directed by a vascular neurologist to ensure optimal secondary prevention, especially in cases where an underlying etiology is not identified on initial workup.
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162
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Rat N, Muntean I, Opincariu D, Gozar L, Togănel R, Chițu M. Cardiovascular Imaging for Guiding Interventional Therapy in Structural Heart Diseases. Curr Med Imaging 2020; 16:111-122. [DOI: 10.2174/1573405614666180612081736] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 10/05/2017] [Accepted: 03/19/2018] [Indexed: 11/22/2022]
Abstract
Development of interventional methods has revolutionized the treatment of structural
cardiac diseases. Given the complexity of structural interventions and the anatomical variability of
various structural defects, novel imaging techniques have been implemented in the current clinical
practice for guiding the interventional procedure and for selection of the device to be used. Three–
dimensional echocardiography is the most used imaging method that has improved the threedimensional
assessment of cardiac structures, and it has considerably reduced the cost of complications
derived from malalignment of interventional devices. Assessment of cardiac structures with
the use of angiography holds the advantage of providing images in real time, but it does not allow
an anatomical description. Transesophageal Echocardiography (TEE) and intracardiac ultrasonography
play major roles in guiding Atrial Septal Defect (ASD) or Patent Foramen Ovale (PFO)
closure and device follow-up, while TEE is the procedure of choice to assess the flow in the Left
Atrial Appendage (LAA) and the embolic risk associated with a decreased flow. On the other hand,
contrast CT and MRI have high specificity for providing a detailed description of structure, but
cannot assess the flow through the shunt or the valvular mobility. This review aims to present the
role of modern imaging techniques in pre-procedural assessment and intraprocedural guiding of
structural percutaneous interventions performed to close an ASD, a PFO, an LAA or a patent ductus
arteriosus.
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Affiliation(s)
- Nora Rat
- Department of Cardiology, University of Medicine and Pharmacy of Targu Mures, Targu Mures, Romania
| | - Iolanda Muntean
- Clinic of Pediatric Cardiology, Institute of Cardiovascular Disease and Transplantation, University of Medicine and Pharmacy of Targu Mures, Targu Mures, Romania
| | - Diana Opincariu
- Department of Cardiology, University of Medicine and Pharmacy of Targu Mures, Targu Mures, Romania
| | - Liliana Gozar
- Clinic of Pediatric Cardiology, Institute of Cardiovascular Disease and Transplantation, University of Medicine and Pharmacy of Targu Mures, Targu Mures, Romania
| | - Rodica Togănel
- Clinic of Pediatric Cardiology, Institute of Cardiovascular Disease and Transplantation, University of Medicine and Pharmacy of Targu Mures, Targu Mures, Romania
| | - Monica Chițu
- Department of Cardiology, University of Medicine and Pharmacy of Targu Mures, Targu Mures, Romania
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163
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Roeder HJ, Lopez JR, Miller EC. Ischemic stroke and cerebral venous sinus thrombosis in pregnancy. HANDBOOK OF CLINICAL NEUROLOGY 2020; 172:3-31. [PMID: 32768092 PMCID: PMC7528571 DOI: 10.1016/b978-0-444-64240-0.00001-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Maternal ischemic stroke and cerebral venous sinus thrombosis (CVST) are dreaded complications of pregnancy and major contributors to maternal disability and mortality. This chapter summarizes the incidence and risk factors for maternal arterial ischemic stroke (AIS) and CVST and discusses the pathophysiology of maternal AIS and CVST. The diagnosis, treatment, and secondary preventive strategies for maternal stroke are also reviewed. Special populations at high risk of maternal stroke, including women with moyamoya disease, sickle cell disease, HIV, thrombophilia, and genetic cerebrovascular disorders, are highlighted.
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Affiliation(s)
- Hannah J Roeder
- Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States
| | - Jean Rodriguez Lopez
- Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States
| | - Eliza C Miller
- Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States; NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, United States.
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164
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Nagarajarao HS, Ojha CP, Kedar A, Mukherjee D. Patent Foramen Ovale, the Role of Antiplatelet Therapy Alone or Anticoagulant Therapy Alone Versus Device Closure for Cryptogenic Stroke: A Review of the Literature and Current Recommendations. Cardiovasc Hematol Agents Med Chem 2020; 18:135-150. [PMID: 32013839 DOI: 10.2174/1871525718666200203111641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 11/22/2019] [Accepted: 01/16/2020] [Indexed: 06/10/2023]
Abstract
Cryptogenic stroke and its relation to the Patent Foramen Ovale (PFO) is a long-debated topic. Recent clinical trials have unequivocally established the relationship between cryptogenic strokes and paradoxical embolism across the PFO. This slit-like communication exists in everyone before birth, but most often closes shortly after birth. PFO may persist as a narrow channel of communication between the right and left atria in approximately 25-27% of adults. In this review, we examine the clinical relevance of the PFO with analysis of the latest trials evaluating catheter-based closure of PFO's for cryptogenic stroke. We also review the current evidence examining the use of antiplatelet medications versus anticoagulants for stroke prevention in those patients with PFO who do not qualify for closure per current guidelines.
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Affiliation(s)
- Harsha S Nagarajarao
- Department of Medicine, Texas Tech University of Health Sciences, El Paso, TX, United States
| | - Chandra P Ojha
- Department of Medicine, Texas Tech University of Health Sciences, El Paso, TX, United States
| | - Archana Kedar
- Department of Medicine, Clinical Instructor, University of Louisville, Kentucky, Louisville, Kentucky, United States
| | - Debabrata Mukherjee
- Department of Medicine, Texas Tech University of Health Sciences, El Paso, TX, United States
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165
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Makhija RR, Palaniswamy C, Aronow WS. Closure of patent foramen ovale for secondary prevention of cryptogenic stroke: current perspectives. Arch Med Sci 2020; 16:1243-1246. [PMID: 32864016 PMCID: PMC7444727 DOI: 10.5114/aoms.2019.81744] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Accepted: 06/25/2018] [Indexed: 11/17/2022] Open
Affiliation(s)
| | - Chandrasekar Palaniswamy
- Department of Medicine, Division of Cardiology, UCSF Fresno Medical Education Program, Fresno, CA, USA
| | - Wilbert S. Aronow
- Department of Medicine, Division of Cardiology, New York Medical College at Westchester Medical Center, Valhalla, NY, USA
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166
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(Rapidly progressive early onset dementia as the first symptom of paradoxical embolism). COR ET VASA 2019. [DOI: 10.33678/cor.2019.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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167
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Mas JL, Derex L, Guérin P, Guillon B, Habib G, Juliard JM, Marijon E, Massardier E, Meneveau N, Vuillier F. Reprint of : Transcatheter closure of patent foramen ovale to prevent stroke recurrence in patients with otherwise unexplained ischaemic stroke: Expert consensus of the French Neurovascular Society and the French Society of Cardiology. Rev Neurol (Paris) 2019; 176:53-61. [PMID: 31787326 DOI: 10.1016/j.neurol.2019.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Unlike previous randomized clinical trials (RCTs), recent trials and meta-analyses have shown that transcatheter closure of patent foramen ovale (PFO) reduces stroke recurrence risk in young and middle-aged adults with an otherwise unexplained PFO-associated ischaemic stroke. AIM To produce an expert consensus on the role of transcatheter PFO closure and antithrombotic drugs for secondary stroke prevention in patients with PFO-associated ischaemic stroke. METHODS Five neurologists and five cardiologists with extensive experience in the relevant field were nominated by the French Neurovascular Society and the French Society of Cardiology to make recommendations based on evidence from RCTs and meta-analyses. RESULTS The experts recommend that any decision concerning treatment of patients with PFO-associated ischaemic stroke should be taken after neurological and cardiological evaluation, bringing together the necessary neurovascular, echocardiography and interventional cardiology expertise. Transcatheter PFO closure is recommended in patients fulfilling all the following criteria: age 16-60 years; recent (≤6 months) ischaemic stroke; PFO associated with atrial septal aneurysm (>10mm) or with a right-to-left shunt>20 microbubbles or with a diameter≥2mm; PFO felt to be the most likely cause of stroke after thorough aetiological evaluation by a stroke specialist. Long-term oral anticoagulation may be considered in the event of contraindication to or patient refusal of PFO closure, in the absence of a high bleeding risk. After PFO closure, dual anti-platelet therapy with aspirin (75mg/day) and clopidogrel (75mg/day) is recommended for 3 months, followed by monotherapy with aspirin or clopidogrel for≥5 years. CONCLUSIONS Although a big step forward that will benefit many patients has been taken with recent trials, many questions remain unanswered. Pending results from further studies, decision-making regarding management of patients with PFO-associated ischaemic stroke should be based on a close coordination between neurologists/stroke specialists and cardiologists.
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Affiliation(s)
- Jean-Louis Mas
- Service de neurologie et unité neurovasculaire, DHU NeuroVasc Sorbonne Paris-Cité, université Paris-Descartes, hôpital Sainte-Anne, Inserm U1266, 1, rue Cabanis, 75014 Paris, France.
| | - Laurent Derex
- HESPER EA 7425, service de neurologie et unité neurovasculaire, hôpital neurologique, hospices civils de Lyon, 69677 Bron cedex, France
| | - Patrice Guérin
- Unité de cardiologie interventionnelle, institut du thorax et du système nerveux, CHU de Nantes, 44093 Nantes, France
| | - Benoit Guillon
- Unité neurovasculaire, institut du thorax et du système nerveux, CHU de Nantes, 44093 Nantes, France
| | - Gilbert Habib
- IRD, MEPHI, service de cardiologie, IHU-Méditerranée infection, université Aix-Marseille, hôpital de la Timone, AP-HM, 13005 Marseille, France
| | - Jean-Michel Juliard
- Service de cardiologie, université Paris-Diderot, hôpital Bichat, Inserm U1148, AP-HP, 75877 Paris, France
| | - Eloi Marijon
- Unité de rythmologie, département de cardiologie, hôpital Européen Georges-Pompidou, 75015 Paris, France
| | | | - Nicolas Meneveau
- EA 3920, Service de cardiologie, université de Franche-Comté, université de Bourgogne-Franche-Comté, CHU Jean-Minjoz, 25000 Besançon, France
| | - Fabrice Vuillier
- Service de neurologie, université de Franche-Comté, CHU de Jean Minjoz, 25000 Besançon, France
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168
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169
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Abstract
PURPOSE OF REVIEW Ischemic stroke describes a condition in which inadequate blood flow leads to lack of oxygenation to the brain tissue and ensuing neuronal death. There are multiple causes of ischemic stroke, each of which may indicate different antithrombotic management strategies. The goal of this review is to provide information about antithrombotic therapies for secondary stroke prevention based on etiology of stroke. RECENT FINDINGS New studies of existing antiplatelet and antithrombotic therapies have demonstrated varied efficacies of treatments based on the underlying risk factor of ischemic stroke. Understanding the optimal therapies for secondary stroke prevention can enhance care of stroke patients and lower the incidence of recurrent cerebrovascular ischemia.
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170
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Abstract
PURPOSE OF REVIEW We aim to evaluate the epidemiology, racial and gender disparity, etiology, and treatment of stroke in the younger population. RECENT FINDINGS The younger age group without vascular risk factors exhibits an increased prevalence of cardio-embolism in context of patent foramen ovale/atrial septal aneurysm strokes, from other determined etiology of non-atherosclerotic vasculopathy including dissection, inherited or acquired thrombophilia, and other unusual causes of stroke. Ethnic disparities also exist in certain populations. The prevalence of stroke in the young is increasing due to several factors. Since stroke is often disabling, this trend poses an enormous threat to socioeconomic stability especially in developing countries. In young patients with an absence of conventional vascular risk factors and negative preliminary stroke work-up, clinicians must consider less common causes of stroke in this population. There is prime opportunity for future investigations as there is currently a lack of evidence-based management guidelines for these uncommon etiologies based on research completed to date.
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171
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Yang H, Nassif M, Khairy P, de Groot JR, Roos YBWEM, de Winter RJ, Mulder BJM, Bouma BJ. Cardiac diagnostic work-up of ischaemic stroke. Eur Heart J 2019; 39:1851-1860. [PMID: 29788298 DOI: 10.1093/eurheartj/ehy043] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 08/17/2016] [Indexed: 12/20/2022] Open
Abstract
Cardioembolic sources account for 20-30% of ischaemic strokes and are important to identify considering their prognostic and therapeutic implications. During the past years, new developments have been made in the cardiac diagnostic evaluation and management of patients with ischaemic stroke, especially regarding strokes of unknown aetiology. These recent advances have had a major impact on our understanding of embolic strokes, their diagnostic work-up, and clinical management. Herein, we propose a cardiac diagnostic work-up scheme for patients with ischaemic stroke from definite cardioembolic sources and embolic strokes of undetermined source.
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Affiliation(s)
- Hayang Yang
- Department of Cardiology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Interuniversity Cardiology Institute of the Netherlands-Netherlands Heart Institute, Moreelsepark 1, 3511 EP, Utrecht, The Netherlands
| | - Martina Nassif
- Department of Cardiology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Paul Khairy
- Department of Cardiology, Montreal Heart Institute, Université de Montréal, 5000 Rue Bélanger, QC H1T 1C8, Montreal, Canada
| | - Joris R de Groot
- Department of Cardiology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Yvo B W E M Roos
- Department of Neurology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Robbert J de Winter
- Department of Cardiology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Barbara J M Mulder
- Department of Cardiology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Interuniversity Cardiology Institute of the Netherlands-Netherlands Heart Institute, Moreelsepark 1, 3511 EP, Utrecht, The Netherlands
| | - Berto J Bouma
- Department of Cardiology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
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172
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Abstract
PURPOSE OF REVIEW To highlight recent advancements in the management of acute ischemic stroke patients with patent foramen ovale (PFO). RECENT FINDINGS One significant recent development was publication of long-term follow-up data from the RESPECT trial demonstrating evidence in favor of PFO closure over medical management. This data subsequently led to FDA approval for AMPLATZER™ septal occluder in the treatment of patients aged 18 to 60 years with both PFO and no other determined etiology for ischemic stroke, otherwise referred to as embolic stroke of undetermined source. Several subsequent closure trial results have recently been published, which also demonstrated benefit of PFO closure over medical management for ischemic stroke risk reduction in select patients. Based on the results of the more recently published REDUCE trial, the FDA granted approval for the GORE™ septal occluder. There is current, well-established evidence that PFO closure for secondary stroke prevention is effective in select cases.
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173
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Sagris D, Georgiopoulos G, Perlepe K, Pateras K, Korompoki E, Makaritsis K, Vemmos K, Milionis H, Ntaios G. Antithrombotic Treatment in Cryptogenic Stroke Patients With Patent Foramen Ovale. Stroke 2019; 50:3135-3140. [DOI: 10.1161/strokeaha.119.026512] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background and Purpose—
It is unclear whether treatment with anticoagulants or antiplatelets is the optimal strategy in patients with stroke or transient ischemic attack of undetermined cause and patent foramen ovale that is not percutaneously closed. We aimed to perform a systematic review and meta-analysis of randomized controlled trials to compare anticoagulant or antiplatelet treatment in this population.
Methods—
We searched PubMed until July 16, 2019 for trials comparing anticoagulants and antiplatelet treatment in patients with stroke/transient ischemic attack and medically treated patent foramen ovale using the terms: “cryptogenic or embolic stroke of undetermined source” and “stroke or cerebrovascular accident or transient ischemic attack” and “patent foramen ovale or patent foramen ovale or paradoxical embolism” and “trial or study” and “antithrombotic or anticoagulant or antiplatelet.” The outcomes assessed were stroke recurrence, major bleeding, and the composite end point of stroke recurrence or major bleeding. We used 3 random-effects models: (1) a reference model based on the inverse variance method with the Sidik and Jonkman heterogeneity estimator; (2) a strict model, implementing the Hartung and Knapp method; and (3) a commonly used Bayesian model with a prior that assumes moderate to large between-study variance.
Results—
Among 112 articles identified in the literature search, 5 randomized controlled trials were included in the meta-analysis (1720 patients, mean follow-up 2.3±0.5 years). Stroke recurrence occurred at a rate of 1.73 per 100 patient-years in anticoagulant-assigned patients and 2.39 in antiplatelet-assigned patients (hazard ratio, 0.68; 95% CI, 0.32–1.48 for the Sidik and Jonkman estimator). Major bleeding occurred at a rate of 1.16 per 100 patient-years in anticoagulant-assigned patients and 0.68 in antiplatelet-assigned patients (hazard ratio, 1.61; 95% CI, 0.72–3.59 for the Sidik and Jonkman estimator). The composite outcome occurred in 52 anticoagulant-assigned and 54 antiplatelet-assigned patients (odds ratio, 1.05; 95% CI, 0.65–1.70 for the Sidik and Jonkman estimator).
Conclusions—
We cannot exclude a large reduction of stroke recurrence in anticoagulant-assigned patients compared with antiplatelet-assigned, without significant differences in major bleeding. An adequately powered randomized controlled trial of a non–vitamin K antagonist versus aspirin is warranted.
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Affiliation(s)
- Dimitrios Sagris
- From the Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece (D.S., K. Perlepe, K.M., G.N.)
| | - Georgios Georgiopoulos
- School of Biomedical Engineering and Imaging Sciences, King’s College, London, United Kingdom (G.G.)
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Greece (G.G., K.V.)
| | - Kalliopi Perlepe
- From the Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece (D.S., K. Perlepe, K.M., G.N.)
| | - Konstantinos Pateras
- Department of Biostatistics and Research Support, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands (K. Pateras)
| | | | - Konstantinos Makaritsis
- From the Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece (D.S., K. Perlepe, K.M., G.N.)
| | - Konstantinos Vemmos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Greece (G.G., K.V.)
| | - Haralampos Milionis
- Department of Internal Medicine, School of Medicine, University of Ioannina, Greece (H.M.)
| | - George Ntaios
- From the Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece (D.S., K. Perlepe, K.M., G.N.)
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174
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Zuin M, Rigatelli G, Rigatelli A, Ronco F, Conte L, Roncon L, Mazza A. Correlations between serum homocysteine levels and RoPE score in patients with patent foramen ovale. Heart Vessels 2019; 35:705-711. [DOI: 10.1007/s00380-019-01528-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 10/18/2019] [Indexed: 10/25/2022]
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175
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Goel S, Patel S, Zakin E, Pasam RT, Gotesman J, Malik BA, Ayzenberg S, Frankel R, Shani J. Patent foramen ovale closure versus medical therapy for cryptogenic stroke: An updated systematic review and meta-analysis. Indian Heart J 2019; 71:446-453. [PMID: 32248916 PMCID: PMC7136357 DOI: 10.1016/j.ihj.2019.10.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 07/06/2019] [Accepted: 10/12/2019] [Indexed: 11/07/2022] Open
Abstract
Objectives The objective of this study was to compare safety and efficacy of patent foramen ovale (PFO) closure compared with medical therapy in patients with cryptogenic stroke (CS). Background The role of PFO closure in preventing recurrent stroke in patients with prior CS has been controversial. Methods We searched PubMed, EMBASE, the Cochrane Central Register of Controlled trials, and the clinical trial registry maintained at clinicaltrials.gov for randomized control trials that compared device closure with medical management and reported on subsequent stroke and adverse events. Event rates were compared using a forest plot of relative risk using a random-effects model assuming interstudy heterogeneity. Results A total of 6 studies (n = 3747) were included in the final analysis. Mean follow-up ranged from 2 to 5.9 years. Pooled analysis revealed that device closure compared to medical management was associated with a significant reduction in stroke (risk ratio [RR] = 0.41, 95% CI = 0.20–0.83, I2 = 51%, P = 0.01). There was, however, a significant increase in atrial fibrillation with device therapy (RR = 5.29, 95% CI = 2.32–12.06, I2 = 38%, P < 0.0001). No effect was observed on major bleeding (P = 0.50) or mortality (P = 0.42) with device therapy. Subgroup analyses showed that device closure significantly reduced the incidence of the composite primary end point among patients who had large shunt sizes (RR = 0.35, 95% CI = 0.18–0.68, I2 = 27%, P = 0.002). The presence/absence of atrial septal aneurysm (P = 0.52) had no effect on the outcome. Conclusion PFO closure is associated with a significant reduction in the risk of stroke compared to medical management. However, it causes an increased risk of atrial fibrillation.
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176
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André C. Endovascular closure of patent foramen ovale: a critical appraisal of published trials. ARQUIVOS DE NEURO-PSIQUIATRIA 2019; 77:731-740. [PMID: 31664349 DOI: 10.1590/0004-282x20190120] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 06/26/2019] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The treatment of cryptogenic stroke patients with a patent foramen ovale (PFO) is controversial. A critical review of these studies is presented. METHODS A description of all trials comparing medical and endovascular treatment with closing devices is given. Additional pertinent studies are discussed to help construct a rational basis for treatment decisions. RESULTS Initial negative trials evaluating PFO closure were followed by positive studies published in 2017 and 2018. All trials evaluated young patients (up to 60 years). Methodological problems are present in all trials including their open label construction. Most positive trials developed strategies to increase the percentage of patients with interatrial septal aneurysms or hypermobility and large right-to-left shunts. Even in these positive trials, large numbers of patients need to be treated to avoid one stroke. Atrial fibrillation occurred in 2-6% and other adverse effects related to the procedure and to the devices occurred in a substantial number of patients. Incomplete occlusion of the PFO is also frequent. Anticoagulant treatment has not been adequately studied as a therapeutic option. CONCLUSION Young patients with cryptogenic strokes seem to benefit from endovascular closure of a PFO in the presence of a large right-to-left shunt or an associated atrial septum aneurysm. For most other patients, a highly-individualized decision must be made, taking into account the low risk of recurrence in patients with a cryptogenic stroke attributable to a PFO, the high numbers needed to treat and the risks related to the procedure.
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Affiliation(s)
- Charles André
- Universidade Federal do Rio de Janeiro, Faculdade de Medicina, Disciplina de Neurologia, Rio de Janeiro RJ, Brasil.,Sinapse Neurologia e Reabilitação, Rio de Janeiro RJ, Brasil
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177
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Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, Brown M, Demaerschalk BM, Hoh B, Jauch EC, Kidwell CS, Leslie-Mazwi TM, Ovbiagele B, Scott PA, Sheth KN, Southerland AM, Summers DV, Tirschwell DL. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2019; 50:e344-e418. [PMID: 31662037 DOI: 10.1161/str.0000000000000211] [Citation(s) in RCA: 3285] [Impact Index Per Article: 657.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background and Purpose- The purpose of these guidelines is to provide an up-to-date comprehensive set of recommendations in a single document for clinicians caring for adult patients with acute arterial ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators. These guidelines supersede the 2013 Acute Ischemic Stroke (AIS) Guidelines and are an update of the 2018 AIS Guidelines. Methods- Members of the writing group were appointed by the American Heart Association (AHA) Stroke Council's Scientific Statements Oversight Committee, representing various areas of medical expertise. Members were not allowed to participate in discussions or to vote on topics relevant to their relations with industry. An update of the 2013 AIS Guidelines was originally published in January 2018. This guideline was approved by the AHA Science Advisory and Coordinating Committee and the AHA Executive Committee. In April 2018, a revision to these guidelines, deleting some recommendations, was published online by the AHA. The writing group was asked review the original document and revise if appropriate. In June 2018, the writing group submitted a document with minor changes and with inclusion of important newly published randomized controlled trials with >100 participants and clinical outcomes at least 90 days after AIS. The document was sent to 14 peer reviewers. The writing group evaluated the peer reviewers' comments and revised when appropriate. The current final document was approved by all members of the writing group except when relationships with industry precluded members from voting and by the governing bodies of the AHA. These guidelines use the American College of Cardiology/AHA 2015 Class of Recommendations and Level of Evidence and the new AHA guidelines format. Results- These guidelines detail prehospital care, urgent and emergency evaluation and treatment with intravenous and intra-arterial therapies, and in-hospital management, including secondary prevention measures that are appropriately instituted within the first 2 weeks. The guidelines support the overarching concept of stroke systems of care in both the prehospital and hospital settings. Conclusions- These guidelines provide general recommendations based on the currently available evidence to guide clinicians caring for adult patients with acute arterial ischemic stroke. In many instances, however, only limited data exist demonstrating the urgent need for continued research on treatment of acute ischemic stroke.
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178
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Gevorgyan Fleming R, Kumar P, West B, Noureddin N, Rusheen J, Aboulhosn J, Tobis JM. Comparison of residual shunt rate and complications across 6 different closure devices for patent foramen ovale. Catheter Cardiovasc Interv 2019; 95:365-372. [DOI: 10.1002/ccd.28527] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 09/09/2019] [Accepted: 09/18/2019] [Indexed: 12/28/2022]
Affiliation(s)
- Rubine Gevorgyan Fleming
- Division of Cardiology, Department of MedicineUniversity of California, Los Angeles Los Angeles California
| | - Preetham Kumar
- Division of Cardiology, Department of MedicineUniversity of California, Los Angeles Los Angeles California
| | - Brian West
- Division of Cardiology, Department of MedicineUniversity of California, Los Angeles Los Angeles California
| | - Nabil Noureddin
- Department of Internal MedicineUniversity of Nevada, Las Vegas Las Vegas Nevada
| | - Joshua Rusheen
- David Geffen School of MedicineUniversity of California, Los Angeles Los Angeles California
| | - Jamil Aboulhosn
- Division of Cardiology, Department of MedicineUniversity of California, Los Angeles Los Angeles California
| | - Jonathan M. Tobis
- Division of Cardiology, Department of MedicineUniversity of California, Los Angeles Los Angeles California
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179
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Abstract
PURPOSE OF REVIEW Although the clinical approach to the young adult stroke patient is similar to that of an older adult, several important differences exist. The purpose of this article is to concisely review the epidemiology, pathophysiology, risk factors, clinical manifestations, diagnostic methods and current treatment options for the young adult ischemic stroke patient. RECENT FINDINGS Evidence clearly indicates that the incidence ischemic stroke in young adults is on the rise. A variety of factors are implicated, including an increased burden of classic and emerging vascular risk factors, and improved stroke detection, among other causes. Improved awareness, prevention and successful treatment of the young adult stroke patient is of great importance, particularly given the major long-term socioeconomic impact strokes have on the patient, their family and society at large. SUMMARY In this review, we focus on the latest epidemiologic, diagnostic and treatment paradigms to improve physician awareness and optimize outcomes in young adult ischemic stroke patients. An overview of the clinical presentations of various stroke syndromes is described, emphasizing key causes physicians should consider, as well as providing recommendations regarding evaluation and treatment. Important causes including dissection and inflammatory and noninflammatory vasculopathies are emphasized. The diagnoses of cerebral venous thromboses, cardioembolic stroke and paradoxical emboli are also discussed. The effects of established and emerging risk factors on large and small vessel disease, as well as genetic contributions, are also highlighted.
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180
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Garg A, Thawabi M, Rout A, Sossou C, Cohen M, Kostis JB. Recurrent Stroke Reduction with Patent Foramen Ovale Closure versus Medical Therapy Based on Patent Foramen Ovale Characteristics: A Meta-Analysis of Randomized Controlled Trials. Cardiology 2019; 144:40-49. [PMID: 31574522 DOI: 10.1159/000500501] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 04/19/2019] [Indexed: 11/19/2022]
Abstract
Efficacy of patent foramen ovale (PFO) closure in patients with cryptogenic stroke remains a matter of debate. We performed a comprehensive meta-analysis of available randomized controlled trials (RCTs) to evaluate the efficacy and safety of PFO closure versus medical therapy (MT) based on PFO characteristics. Random-effects meta-analysis was conducted to estimate risk ratio (RR) with 95% confidence intervals (CI) for the primary end points of stroke. After systematic search, six RCTs (3,747 patients) with 1,889 patients randomized to PFO closure and 1,858 patients randomized to the MT group were included in the meta-analysis. Overall, PFO closure was associated with a significant reduction in recurrent stroke compared to MT [RR 0.41; 95% CI 0.20-0.83]. While there were no differences in mortality or major bleeding between the two groups, risk of newly diagnosed atrial fibrillation was higher in the PFO closure group compared to MT [RR 5.29; 95% CI 2.32-12.06]. Further, risk reduction in stroke with PFO closure was significant in patients with high-risk PFO characteristics [RR 0.37; 95% CI 0.16-0.87] but not in low-risk patients [RR 0.73; 95% CI 0.29-1.84]. In conclusion, among patients with cryptogenic stroke, PFO closure is associated with a significantly reduced risk of recurrent stroke compared to MT. Additionally, the benefit of PFO closure might be dependent on certain PFO characteristics.
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Affiliation(s)
- Aakash Garg
- Division of Cardiology, Newark Beth Israel Medical Center, Newark, New Jersey, USA, .,Cardiovascular Institute, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA,
| | - Mohammed Thawabi
- Division of Cardiology, Newark Beth Israel Medical Center, Newark, New Jersey, USA
| | - Amit Rout
- Department of Medicine, Sinai Hospital, Baltimore, Maryland, USA
| | - Chris Sossou
- Division of Cardiology, Newark Beth Israel Medical Center, Newark, New Jersey, USA
| | - Marc Cohen
- Division of Cardiology, Newark Beth Israel Medical Center, Newark, New Jersey, USA
| | - John B Kostis
- Cardiovascular Institute, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
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181
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Ha FJ, Adams H, Palmer S. Device closure for patent foramen ovale in patients with cryptogenic stroke: a paradigm in evidence. Med J Aust 2019; 211:343-344.e1. [DOI: 10.5694/mja2.50341] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
| | - Heath Adams
- St Vincent's Hospital Melbourne Melbourne VIC
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182
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[Cryptogenic stroke and patent foramen ovale : S2e guidelines]. DER NERVENARZT 2019; 89:1143-1153. [PMID: 30255469 DOI: 10.1007/s00115-018-0609-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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183
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Arfaras-Melainis A, Palaiodimos L, Mojadidi MK. Transcatheter Closure of Patent Foramen Ovale: Randomized Trial Update. Interv Cardiol Clin 2019; 8:341-356. [PMID: 31445719 DOI: 10.1016/j.iccl.2019.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
A patent foramen ovale (PFO) is found in about one-quarter of all adults, but the prevalence increases to approximately half of those with a history of a so-called cryptogenic stroke. The true efficacy of PFO closure for prevention of recurrent paradoxical embolism has been debated for years, as the early 3 randomized trials did not show a statistically significant benefit of PFO closure over standard-of-care medical therapy. However, 3 recent randomized trials along with the long-term follow-up data from the largest early trial demonstrated superiority of device closure for secondary stroke prevention.
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Affiliation(s)
- Angelos Arfaras-Melainis
- Second Cardiology Department, National and Kapodistrian University of Athens, Attikon University Hospital, 1 Rimini Street, Haidari, Athens 12462, Greece
| | - Leonidas Palaiodimos
- Department of Medicine, Division of Hospital Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467, USA.
| | - Mohammad K Mojadidi
- Division of Cardiology, Department of Medicine, Virginia Commonwealth University, 1101 East Marshall Street, Richmond, VA 23298, USA
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184
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Boulanger M, Li L, Lyons S, Lovett NG, Kubiak MM, Silver L, Touzé E, Rothwell PM. Effect of coexisting vascular disease on long-term risk of recurrent events after TIA or stroke. Neurology 2019; 93:e695-e707. [PMID: 31337715 PMCID: PMC6715511 DOI: 10.1212/wnl.0000000000007935] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 03/21/2019] [Indexed: 01/24/2023] Open
Abstract
OBJECTIVE To determine whether patients with TIA or ischemic stroke with coexisting cardiovascular disease (i.e., history of coronary or peripheral artery disease) are still at high risk of recurrent ischemic events despite current secondary prevention guidelines. METHODS In a population-based study in Oxfordshire, UK (Oxford Vascular Study), we studied consecutive patients with TIA or ischemic stroke for 2002-2014. Patients were treated according to current secondary prevention guidelines and we determined risks of coronary events, recurrent ischemic stroke, and major bleeding stratified by the presence of coexisting cardiovascular disease. RESULTS Among 2,555 patients (9,148 patient-years of follow-up), those (n = 640; 25.0%) with coexisting cardiovascular disease (449 coronary only; 103 peripheral only; 88 both) were at higher 10-year risk of coronary events than those without (22.8%, 95% confidence interval 17.4-27.9; vs 7.1%, 5.3-8.8; p < 0.001; age- and sex-adjusted hazard ratio [HR] 3.07, 2.24-4.21) and of recurrent ischemic stroke (31.5%, 25.1-37.4; vs 23.4%, 20.5-26.2; p = 0.0049; age- and sex-adjusted HR 1.23, 0.99-1.53), despite similar rates of use of antithrombotic and lipid-lowering medication. However, in patients with noncardioembolic TIA/stroke, risk of extracranial bleeds was also higher in those with coexisting cardiovascular disease, particularly in patients aged <75 years (8.1%, 2.8-13.0; vs 3.4%, 1.6-5.3; p = 0.0050; age- and sex-adjusted HR 2.71, 1.16-6.30), although risk of intracerebral hemorrhage was not increased (age- and sex-adjusted HR 0.36, 0.04-2.99). CONCLUSIONS As in older studies, patients with TIA/stroke with coexisting cardiovascular disease remain at high risk of recurrent ischemic events despite current management. More intensive lipid-lowering might therefore be justified, but benefit from increased antithrombotic treatment might be offset by the higher risk of extracranial bleeding.
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Affiliation(s)
- Marion Boulanger
- From the Centre for Prevention of Stroke and Dementia (M.B., L.L., S.L., N.G.L., M.M.K., L.S., P.M.R.), Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, UK; and Service de Neurologie (M.B., E.T.), CHU Caen Normandie, UNICAEN, Normandie Université, INSERM U1237, Caen, France
| | - Linxin Li
- From the Centre for Prevention of Stroke and Dementia (M.B., L.L., S.L., N.G.L., M.M.K., L.S., P.M.R.), Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, UK; and Service de Neurologie (M.B., E.T.), CHU Caen Normandie, UNICAEN, Normandie Université, INSERM U1237, Caen, France
| | - Shane Lyons
- From the Centre for Prevention of Stroke and Dementia (M.B., L.L., S.L., N.G.L., M.M.K., L.S., P.M.R.), Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, UK; and Service de Neurologie (M.B., E.T.), CHU Caen Normandie, UNICAEN, Normandie Université, INSERM U1237, Caen, France
| | - Nicola G Lovett
- From the Centre for Prevention of Stroke and Dementia (M.B., L.L., S.L., N.G.L., M.M.K., L.S., P.M.R.), Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, UK; and Service de Neurologie (M.B., E.T.), CHU Caen Normandie, UNICAEN, Normandie Université, INSERM U1237, Caen, France
| | - Magdalena M Kubiak
- From the Centre for Prevention of Stroke and Dementia (M.B., L.L., S.L., N.G.L., M.M.K., L.S., P.M.R.), Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, UK; and Service de Neurologie (M.B., E.T.), CHU Caen Normandie, UNICAEN, Normandie Université, INSERM U1237, Caen, France
| | - Louise Silver
- From the Centre for Prevention of Stroke and Dementia (M.B., L.L., S.L., N.G.L., M.M.K., L.S., P.M.R.), Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, UK; and Service de Neurologie (M.B., E.T.), CHU Caen Normandie, UNICAEN, Normandie Université, INSERM U1237, Caen, France
| | - Emmanuel Touzé
- From the Centre for Prevention of Stroke and Dementia (M.B., L.L., S.L., N.G.L., M.M.K., L.S., P.M.R.), Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, UK; and Service de Neurologie (M.B., E.T.), CHU Caen Normandie, UNICAEN, Normandie Université, INSERM U1237, Caen, France
| | - Peter M Rothwell
- From the Centre for Prevention of Stroke and Dementia (M.B., L.L., S.L., N.G.L., M.M.K., L.S., P.M.R.), Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, UK; and Service de Neurologie (M.B., E.T.), CHU Caen Normandie, UNICAEN, Normandie Université, INSERM U1237, Caen, France.
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Gerstein NS, Clegg SD, Levin DB, Fish AC, Tolstrup K, Nakanishi K, Yoshida Y, Homma S. A Case-Based Discussion on the Management of Cryptogenic Stroke and Patent Foramen Ovale in the Patient With a Hypercoagulable Disorder. J Cardiothorac Vasc Anesth 2019; 33:3476-3485. [PMID: 31473116 DOI: 10.1053/j.jvca.2019.07.136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 07/21/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Neal S Gerstein
- Department of Anesthesiology and Critical Care Medicine, University of New Mexico - School of Medicine, Albuquerque, NM.
| | - Stacey D Clegg
- Department of Medicine, Division of Cardiology, University of New Mexico - School of Medicine, Albuquerque, NM
| | - Daniel B Levin
- Department of Medicine, Division of Cardiology, University of New Mexico - School of Medicine, Albuquerque, NM
| | - Adam C Fish
- Department of Anesthesiology and Critical Care Medicine, University of New Mexico - School of Medicine, Albuquerque, NM
| | - Kirsten Tolstrup
- Department of Medicine, University of California, San Francisco, CA
| | - Koki Nakanishi
- Department of Cardiovascular Medicine, The University of Tokyo, Tokyo, Japan
| | - Yuriko Yoshida
- Department of Cardiovascular Medicine, The University of Tokyo, Tokyo, Japan
| | - Shunichi Homma
- Department of Medicine, Columbia University, New York, NY
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186
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Percutaneous Closure of Patent Foramen Ovale in Patients with Cryptogenic Stroke — An Updated Comprehensive Meta-Analysis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2019; 20:687-694. [DOI: 10.1016/j.carrev.2018.09.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 09/08/2018] [Accepted: 09/10/2018] [Indexed: 01/10/2023]
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187
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Mas JL, Derex L, Guérin P, Guillon B, Habib G, Juliard JM, Marijon E, Massardier E, Meneveau N, Vuillier F. Transcatheter closure of patent foramen ovale to prevent stroke recurrence in patients with otherwise unexplained ischaemic stroke: Expert consensus of the French Neurovascular Society and the French Society of Cardiology. Arch Cardiovasc Dis 2019; 112:532-542. [PMID: 31378692 DOI: 10.1016/j.acvd.2019.06.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 06/12/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND Unlike previous randomized clinical trials (RCTs), recent trials and meta-analyses have shown that transcatheter closure of patent foramen ovale (PFO) reduces stroke recurrence risk in young and middle-aged adults with an otherwise unexplained PFO-associated ischaemic stroke. AIM To produce an expert consensus on the role of transcatheter PFO closure and antithrombotic drugs for secondary stroke prevention in patients with PFO-associated ischaemic stroke. METHODS Five neurologists and five cardiologists with extensive experience in the relevant field were nominated by the French Neurovascular Society and the French Society of Cardiology to make recommendations based on evidence from RCTs and meta-analyses. RESULTS The experts recommend that any decision concerning treatment of patients with PFO-associated ischaemic stroke should be taken after neurological and cardiological evaluation, bringing together the necessary neurovascular, echocardiography and interventional cardiology expertise. Transcatheter PFO closure is recommended in patients fulfilling all the following criteria: age 16-60 years; recent (≤6 months) ischaemic stroke; PFO associated with atrial septal aneurysm (>10mm) or with a right-to-left shunt>20 microbubbles or with a diameter≥2mm; PFO felt to be the most likely cause of stroke after thorough aetiological evaluation by a stroke specialist. Long-term oral anticoagulation may be considered in the event of contraindication to or patient refusal of PFO closure, in the absence of a high bleeding risk. After PFO closure, dual anti-platelet therapy with aspirin (75mg/day) and clopidogrel (75mg/day) is recommended for 3 months, followed by monotherapy with aspirin or clopidogrel for≥5 years. CONCLUSIONS Although a big step forward that will benefit many patients has been taken with recent trials, many questions remain unanswered. Pending results from further studies, decision-making regarding management of patients with PFO-associated ischaemic stroke should be based on a close coordination between neurologists/stroke specialists and cardiologists.
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Affiliation(s)
- Jean-Louis Mas
- Service de neurologie et unité neurovasculaire, DHU NeuroVasc Sorbonne Paris-Cité, université Paris-Descartes, hôpital Sainte-Anne, Inserm U1266, 1, rue Cabanis, 75014 Paris, France.
| | - Laurent Derex
- HESPER EA 7425, service de neurologie et unité neurovasculaire, hôpital neurologique, hospices civils de Lyon, 69677 Bron cedex, France
| | - Patrice Guérin
- Unité de cardiologie interventionnelle, institut du thorax et du système nerveux, CHU de Nantes, 44093 Nantes, France
| | - Benoit Guillon
- Unité neurovasculaire, institut du thorax et du système nerveux, CHU de Nantes, 44093 Nantes, France
| | - Gilbert Habib
- IRD, MEPHI, service de cardiologie, IHU-Méditerranée infection, université Aix-Marseille, hôpital de la Timone, AP-HM, 13005 Marseille, France
| | - Jean-Michel Juliard
- Service de cardiologie, université Paris-Diderot, hôpital Bichat, Inserm U1148, AP-HP, 75877 Paris, France
| | - Eloi Marijon
- Unité de rythmologie, département de cardiologie, hôpital Européen Georges-Pompidou, 75015 Paris, France
| | | | - Nicolas Meneveau
- EA 3920, Service de cardiologie, université de Franche-Comté, université de Bourgogne-Franche-Comté, CHU Jean-Minjoz, 25000 Besançon, France
| | - Fabrice Vuillier
- Service de neurologie, université de Franche-Comté, CHU de Jean Minjoz, 25000 Besançon, France
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188
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Mojadidi MK, Zaman MO, Elgendy IY, Mahmoud AN, Patel NK, Agarwal N, Tobis JM, Meier B. Cryptogenic Stroke and Patent Foramen Ovale. J Am Coll Cardiol 2019; 71:1035-1043. [PMID: 29495983 DOI: 10.1016/j.jacc.2017.12.059] [Citation(s) in RCA: 117] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 11/30/2017] [Accepted: 12/22/2017] [Indexed: 02/09/2023]
Abstract
Nearly one-half of patients with cryptogenic stroke have a patent foramen ovale (PFO). The dilemma of whether to close these PFOs percutaneously, in an effort to reduce the risk of recurrent paradoxical embolism, has been a matter of ongoing debate for more than a decade. Early randomized clinical trials failed to demonstrate a significant benefit of percutaneous PFO closure for secondary prevention of cryptogenic stroke in an intention-to-treat analysis. The long-term follow-up data from the RESPECT trial and 2 new randomized trials (CLOSE and REDUCE) have clarified these findings. They showed that with good patient selection, transcatheter PFO closure significantly reduces the risk of recurrent stroke compared with medical therapy in patients with cryptogenic stroke, with no increased risk of serious adverse events or influence on major bleeding.
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Affiliation(s)
- Mohammad K Mojadidi
- Division of Cardiology, Department of Medicine, University of Florida College of Medicine, Gainesville, Florida
| | - Muhammad O Zaman
- Division of Cardiology, Department of Medicine, University of Florida College of Medicine, Gainesville, Florida
| | - Islam Y Elgendy
- Division of Cardiology, Department of Medicine, University of Florida College of Medicine, Gainesville, Florida
| | - Ahmed N Mahmoud
- Division of Cardiology, Department of Medicine, University of Florida College of Medicine, Gainesville, Florida
| | - Nimesh K Patel
- Division of Cardiology, Department of Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Nayan Agarwal
- Interventional Cardiology, Cardiovascular Institute of the South, Houma, Louisiana
| | - Jonathan M Tobis
- Program in Interventional Cardiology, Division of Cardiology, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
| | - Bernhard Meier
- Department of Cardiology, University Hospital of Bern, Bern, Switzerland.
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189
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Abdelghani M, El-Shedoudy SAO, Nassif M, Bouma BJ, de Winter RJ. Management of Patients with Patent Foramen Ovale and Cryptogenic Stroke: An Update. Cardiology 2019; 143:62-72. [PMID: 31307049 DOI: 10.1159/000501028] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 05/14/2019] [Indexed: 11/19/2022]
Abstract
Patent foramen ovale (PFO) is a common benign finding in healthy subjects, but its prevalence is higher in patients with stroke of unclear cause (cryptogenic stroke). PFO is believed to be associated with stroke through paradoxical embolism, and certain clinical and anatomical criteria seem to increase the likelihood of a PFO to be pathological. Recent trials have shown that closure of PFO, especially if associated with an atrial septal aneurysm and/or a large interatrial shunt, may reduce the risk of recurrent stroke as compared to medical treatment. However, it remains challenging to risk stratify patients with suspected PFO-related stroke and to decide if device closure is indicated. We sought to review contemporary evidence and to conclude an evidence-based strategy to prevent recurrence of PFO-related stroke.
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Affiliation(s)
- Mohammad Abdelghani
- Heart Center, Segeberger Kliniken, Bad Segeberg, Germany, .,Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands, .,Department of Cardiology, Al-Azhar University, Cairo, Egypt,
| | | | - Martina Nassif
- Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Berto J Bouma
- Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Robbert J de Winter
- Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands
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190
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Tandon K, Tirschwell D, Longstreth W, Smith B, Akoum N. Embolic stroke of undetermined source correlates to atrial fibrosis without atrial fibrillation. Neurology 2019; 93:e381-e387. [DOI: 10.1212/wnl.0000000000007827] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 03/18/2019] [Indexed: 11/15/2022] Open
Abstract
ObjectiveTo examine the hypothesis that atrial fibrosis and associated atrial cardiopathy may be in the causal pathway of cardioembolic stroke independently of atrial fibrillation (AF) by comparing atrial fibrosis burden between patients with embolic stroke of undetermined source (ESUS), patients with AF, and healthy controls.MethodsWe used late-gadolinium-enhancement MRI to compare atrial fibrosis in 10 patients with ESUS against 10 controls (no stroke, no AF) and 10 patients with AF. Fibrosis was compared between groups, controlling for stroke risk factors.ResultsMean age was 51 ± 15 years, and 43% of participants were female. Patients with ESUS had more atrial fibrosis than controls (16.8 ± 5.7% vs 10.6 ± 5.7%, p = 0.019) and similar fibrosis compared to patients with AF (17.8 ± 4.8%, p = 0.65). Odds ratios of ESUS per quartile of fibrosis were 3.22 (95% CI [CI] 1.11–9.32, p = 0.031, unadjusted) and 3.17 (95% CI 1.05–9.52, p = 0.041, CHA2DVASc score adjusted). Patients with >12% fibrosis had a higher percentage of ESUS (77.8% vs 27.3%, p = 0.02), and patients with >20% fibrosis had the highest proportion of ESUS (4 of 5).ConclusionsPatients with ESUS exhibit similar atrial fibrosis compared to patients with AF and more fibrosis than healthy controls. Fibrosis is associated with ESUS after controlling for stroke risk factors, supporting the hypothesis that fibrosis is in the causal pathway of cardioembolic stroke independently of AF. Prospective studies are needed to assess the role of anticoagulation in primary and secondary stroke prevention in patients with high atrial fibrosis.
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191
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Kulesh AA, Shestakov VV. Patent foramen ovale and embolic cryptogenic stroke. NEUROLOGY, NEUROPSYCHIATRY, PSYCHOSOMATICS 2019. [DOI: 10.14412/2074-2711-2019-2-4-11] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
The paper considers the actual problem of cryptogenic stroke and patent foramen ovale (PFO). It highlights the issues of pathogenesis and role of paradoxical embolism in the development of cerebral circulation disorders. The features of clinical manifestations and neuroimaging pattern of stroke in the presence of PFO are described. Ultrasound diagnostic techniques used to verify a cardiac anomaly are characterized. Approaches to establishing a cause-and-effect relationship between the presence of PFO and the development of stroke are presented. The current possibilities of secondary prevention in this category of patients, in particular the results of studies of percutaneous PFO occlusion, are discussed.
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Affiliation(s)
- A. A. Kulesh
- Acad. E.A. Vagner Perm State Medical University, Ministry of Health of Russia
| | - V. V. Shestakov
- Acad. E.A. Vagner Perm State Medical University, Ministry of Health of Russia
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192
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Darmoch F, Al-Khadra Y, Bacha HM, Soud M, Alraies MC. Closing the gap on patent foramen ovale and cryptogenic stroke. Expert Rev Cardiovasc Ther 2019; 17:389-394. [PMID: 31184225 DOI: 10.1080/14779072.2019.1627875] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Introduction: The treatment options for prevention of recurrent of cryptogenic stroke in patients with patent foramen ovale (PFO) have been intensely debated in the recent decades. The suggested options were percutaneous closure of PFO versus medical therapy. However, up to these date there is a controversy regarding the indication of percutaneous closure. Multiple meta-analysis and recent randomized control trials showed the benefit of PFO closure when compared with medical therapy alone. Areas covered: The article reviews the prevalence, physiology, diagnosis and treatment options of PFO after cryptogenic stroke. Furthermore, it will discuss the results of randomized control trials that compared the PFO closure to medical therapy. Expert opinion: The association between PFO and unexplained cryptogenic stroke has been well established in the multiple studies. The diagnosis and management of PFO might be challenging in some cases. Although multiple studies showed that PFO closure is associated with lower rates of recurrent stroke in patients presenting with cryptogenic stroke, the indication and patient selection for this intervention are not well established yet in the guidelines.
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Affiliation(s)
- Fahed Darmoch
- a Beth Israel Deaconess Medical Center/Harvard School of Medicine , Boston , MA , USA
| | | | | | - Mohammad Soud
- c MedStar Washington Hospital Center , Washington, D.C. , USA
| | - M Chadi Alraies
- d Wayne State University, Detroit Medical Center , Detroit Heart Hospital , Detroit , MI , USA
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193
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Darmoch F, Al-Khadra Y, Moussa Pacha H, Soud M, Alraies MC. Transcatheter closure of patent foramen ovale: an updated meta-analysis of randomized controlled trials. Avicenna J Med 2019; 9:86-88. [PMID: 31143703 PMCID: PMC6530269 DOI: 10.4103/ajm.ajm_207_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Fahed Darmoch
- Beth Israel Deaconess Medical Center/Harvard, School of Medicine Boston, Massachusetts, USA
| | | | | | - Mohamad Soud
- MedStar Washington Hospital Center, Washington, D.C., USA
| | - M Chadi Alraies
- Wayne State University, Detroit Medical Center, Detroit Heart Hospital, Detroit, Michigan, USA
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194
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Suligoj NC, Rojko M, Suligoj B, Zorc M, Kar S, Noc M. Long-term transesophageal echocardiography after patent foramen ovale closure by BioSTAR and Amplatzer patent foramen ovale occluders. Catheter Cardiovasc Interv 2019; 95:349-354. [PMID: 31131978 DOI: 10.1002/ccd.28360] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 03/29/2019] [Accepted: 05/16/2019] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To compare transesophageal echocardiography (TOE) findings after patent foramen ovale (PFO) closure by BioSTAR (NMT Medical Inc, Boston, MA) and Amplatzer PFO occluders (Abbott Vascular, Plymouth, MN). BACKGROUND PFO closure with a biodegradable device represents an attractive alternative to permanent devices. Long-term effectiveness and morphology after biodegradation remain unknown. METHODS Between February 2008 and June 2014, 49 patients received BioSTAR and 48 Amplatzer PFO occluder. TOE was performed after closure, at 6 months and beyond 2 years. RESULTS PFO features were comparable between the groups. Immediate effective closure (<5 bubbles on Valsalva) was obtained in 96% by BioSTAR and 88% by Amplatzer PFO occluder (p = .16). Except for transient fever after BioSTAR (10.8 vs. 0%; p = .08), there was no adverse events. TOE at 6 months revealed comparable effective closure (93 vs. 89%; p = .74), all devices in correct position and no thrombus/pericardial effusion. In the BioSTAR group, a peri-device left-to-right color Doppler shunt was documented in one patient (2.2%), protrusion of the nitinol framework strut(s) into the atrial cavity in two patients (4.3%), and both events in one patient (2.2%). TOE beyond 2 years showed comparable effective closure (92 vs. 96%; p = 1.00) and again BioSTAR-associated peri-device left-to-right shunt and metal framework strut(s) protrusion. There was no stroke or peripheral embolization in either group while TIA was numerically greater in BioSTAR patients (6.8 vs. 2.5%; p = .61). CONCLUSION BioSTAR provided similar PFO closure rate as Amplatzer PFO occluder. As yet unreported BioSTAR-associated peri-device left-to-right shunt and metal framework strut(s) protrusion may have practical implications for further development of biodegradable devices.
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Affiliation(s)
- Natasa Cernic Suligoj
- MC Medicor Slovenia, Ljubljana, Slovenia.,Department of Cardiology, General Hospital Izola, Izola, Slovenia
| | - Maja Rojko
- MC Medicor Slovenia, Ljubljana, Slovenia
| | - Brina Suligoj
- MC Medicor Slovenia, Ljubljana, Slovenia.,Department of Cardiology, General Hospital Izola, Izola, Slovenia
| | - Metka Zorc
- MC Medicor Slovenia, Ljubljana, Slovenia
| | - Saibal Kar
- MC Medicor Slovenia, Ljubljana, Slovenia.,Cardiovascular Intervention Center, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Marko Noc
- MC Medicor Slovenia, Ljubljana, Slovenia.,Center for Intensive Internal Medicine, University Medical Center, Ljubljana, Slovenia
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195
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Nakayama R, Takaya Y, Akagi T, Watanabe N, Ikeda M, Nakagawa K, Toh N, Ito H. Identification of High-Risk Patent Foramen Ovale Associated With Cryptogenic Stroke: Development of a Scoring System. J Am Soc Echocardiogr 2019; 32:811-816. [PMID: 31130417 DOI: 10.1016/j.echo.2019.03.021] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 03/22/2019] [Accepted: 03/26/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND Transcatheter closure of patent foramen ovale (PFO) has become an effective therapeutic strategy for cryptogenic stroke (CS). The identification of high-risk PFO is essential, but the data are limited. This study aimed to clarify the factors related to CS and to develop a score for high-risk PFO. METHODS We retrospectively analyzed 57 patients with prior CS and 50 without CS who were scheduled for transcatheter closure. PFO characteristics were evaluated by transesophageal echocardiography. Based on factors related to CS, we estimated the risk score. RESULTS Patients with CS had a greater frequency of large-size PFO (≥2 mm in height), long-tunnel PFO (≥10 mm in length), atrial septal aneurysm, hypermobile interatrial septum, prominent Eustachian valve or Chiari's network, the large right-to-left shunt at rest and during Valsalva maneuver, and low-angle PFO (≤10° of PFO angle from inferior vena cava), compared with patients without CS. Multivariate analysis showed that long-tunnel PFO, the presence of hypermobile interatrial septum, the presence of prominent Eustachian valve or Chiari's network, the large right-to-left shunt during Valsalva maneuver, and low-angle PFO were independently related to CS. When the score was estimated based on 1 point for each factor, the proportion of CS was markedly elevated with a score of ≥2 points. The probability of CS was markedly different between scores of ≤1 or ≥2 points. CONCLUSIONS PFO risk can be assessed with a score based on high-risk features. The presence of two or more high-risk PFO features is associated with CS.
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Affiliation(s)
- Rie Nakayama
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Yoichi Takaya
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan.
| | - Teiji Akagi
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Nobuhisa Watanabe
- Division of Medical Support, Okayama University Hospital, Okayama, Japan
| | - Madoka Ikeda
- Division of Medical Support, Okayama University Hospital, Okayama, Japan
| | - Koji Nakagawa
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Norihisa Toh
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
| | - Hiroshi Ito
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Science, Okayama, Japan
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196
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De León-Benedetti A, Marulanda-Londoño ET, Malik AM. Pearls & Oy-sters: May-Thurner syndrome as a cause of embolic stroke of undetermined source in a young patient. Neurology 2019; 92:e2507-e2509. [PMID: 31110152 DOI: 10.1212/wnl.0000000000007541] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
| | | | - Amer M Malik
- From the Department of Neurology, University of Miami Miller School of Medicine, FL.
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197
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Wasser K, Weber-Krüger M, Jürries F, Liman J, Hamann GF, Kermer P, Uphaus T, Protsenko E, Seegers J, Mende M, Gröschel K, Wachter R. The cardiac diagnostic work-up in stroke patients-A subanalysis of the Find-AFRANDOMISED trial. PLoS One 2019; 14:e0216530. [PMID: 31071137 PMCID: PMC6508702 DOI: 10.1371/journal.pone.0216530] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 04/22/2019] [Indexed: 12/31/2022] Open
Abstract
Background The cardiac diagnostic workup of stroke patients, especially the value of echocardiography and enhanced and prolonged Holter-ECG monitoring, is still a matter of debate. We aimed to analyse the impact of pathologies detected by echocardiography and ECG monitoring on therapeutic decisions and prognosis. Methods Find-AFRANDOMISED was a prospective multicenter study which randomised 398 acute ischemic stroke patients ≥ 60 years to enhanced and prolonged Holter-ECG monitoring or usual stroke unit care. This substudy compared therapeutic consequences of echocardiography and routine Holter-ECG or enhanced and prolonged Holter-ECG monitoring, respectively, and prognosis of patients with or without pathologic findings in echocardiography or Holter-ECG monitoring. Results 50.3% received enhanced and prolonged Holter-ECG monitoring and 49.7% routine ECG monitoring. 82.9% underwent transthoracic echocardiography (TTE), 38.9% transesophageal echocardiography (TEE) and 25.6% both procedures. 14/89 TEE pathologies and 1/90 TTE pathology led to a change in therapy, resulting in a number needed to change decision (NNCD) of 12 and 330 (p < 0.001), respectively. In comparison, enhanced and prolonged Holter-ECG monitoring found atrial fibrillation (AF) in 27 of 200 patients, and routine ECG monitoring in twelve of 198 patients, leading to therapeutic changes in all patients (NNCD 8 and 17, respectively, p < 0.001). Conclusions Most changes in therapeutic decisions were triggered by enhanced and prolonged Holter-ECG monitoring, which should therefore play a more prominent role in future guidelines. Echocardiography identifies a patient group at high cardiovascular risk, but rarely result in therapeutic changes. Whether this patient group requires further cardiovascular workup remains unknown. This should be further investigated by interdisciplinary neurocardiologic teams and in appropriate future trials. Trial registration ClinicalTrials.gov NCT01855035
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Affiliation(s)
- Katrin Wasser
- Clinic for Neurology, University of Göttingen, Göttingen, Germany
| | - Mark Weber-Krüger
- Clinic for Cardiology and Pneumology, University of Göttingen, Göttingen, Germany
| | - Falko Jürries
- Clinic for Cardiology and Pneumology, University of Göttingen, Göttingen, Germany
| | - Jan Liman
- Clinic for Neurology, University of Göttingen, Göttingen, Germany
| | - Gerhard F. Hamann
- Clinic for Neurology and Neurorehabilitation, Bezirkskrankenhaus Günzburg, Günzburg, Germany
| | - Pawel Kermer
- Clinic for Neurology, Nordwest-Krankenhaus Sanderbusch, Sande, Germany
| | - Timo Uphaus
- Clinic and Polyclinic for Neurology, University of Mainz, Mainz, Germany
| | - Evgeny Protsenko
- Clinic for Neurology, Nordwest-Krankenhaus Sanderbusch, Sande, Germany
| | - Joachim Seegers
- Department of Internal Medicine II, Division of Cardiology, University Hospital Regensburg, Regensburg, Germany
| | - Meinhard Mende
- Institute for Medical Informatics, Statistics and Epidemiology (IMISE), University Hospital Leipzig, Leipzig, Germany
| | - Klaus Gröschel
- Clinic and Polyclinic for Neurology, University of Mainz, Mainz, Germany
| | - Rolf Wachter
- Clinic for Cardiology and Pneumology, University of Göttingen, Göttingen, Germany
- Clinic and Policlinic for Cardiology, University Hospital Leipzig, Leipzig, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Göttingen, Germany
- * E-mail:
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Madhkour R, Meier B. Ictus criptogénico con un foramen oval permeable: ¿cuándo se debe cerrar? Rev Esp Cardiol 2019. [DOI: 10.1016/j.recesp.2018.10.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Scacciatella P, Jorfida M, Biava LM, Meynet I, Zema D, D’Ascenzo F, Pristipino C, Cerrato P, Giustetto C, Gaita F. Insertable cardiac monitor detection of silent atrial fibrillation in candidates for percutaneous patent foramen ovale closure. J Cardiovasc Med (Hagerstown) 2019; 20:290-296. [DOI: 10.2459/jcm.0000000000000790] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Dahal K, Yousuf A, Watti H, Liang B, Sharma S, Rijal J, Katikaneni P, Modi K, Tandon N, Azrin M, Lee J. Who benefits from percutaneous closure of patent foramen ovale vs medical therapy for stroke prevention? In-depth and updated meta-analysis of randomized trials. World J Cardiol 2019; 11:126-136. [PMID: 31110604 PMCID: PMC6503458 DOI: 10.4330/wjc.v11.i4.126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 03/19/2019] [Accepted: 03/28/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND A few randomized clinical trials (RCT) and their meta-analyses have found patent foramen ovale closure (PFOC) to be beneficial in prevention of stroke compared to medical therapy. Whether the benefit is extended across all groups of patients remains unclear.
AIM To evaluate the efficacy and safety of PFOC vs medical therapy in different groups of patients presenting with stroke, we performed this meta-analysis of RCTs.
METHODS Electronic search of PubMed, EMBASE, Cochrane Central, CINAHL and ProQuest Central and manual search were performed from inception through September 2018 for RCTs. Ischemic stroke (IS), transient ischemic attack (TIA), a composite of IS, TIA and systemic embolism (SE), mortality, major bleeding, atrial fibrillation (AF) and procedural complications were the major outcomes. Random-effects model was used to perform analyses.
RESULTS Meta-analysis of 6 RCTs including 3560 patients showed that the PFOC, compared to medical therapy reduced the risk of IS [odds ratio: 0.34; 95% confidence interval: 0.15-0.78; P = 0.01] and the composite of IS, TIA and SE [0.55 (0.32-0.93); P = 0.02] and increased the AF risk [4.79 (2.35-9.77); P < 0.0001]. No statistical difference was observed in the risk of TIA [0.86 (0.54-1.38); P = 0.54], mortality [0.74 (0.28-1.93); P = 0.53] and major bleeding [0.81 (0.42-1.56); P = 0.53] between two strategies. Subgroup analyses showed that compared to medical therapy, PFOC reduced the risk of stroke in persons who were males, ≤ 45 years of age and had large shunt or atrial septal aneurysm.
CONCLUSION In certain groups of patients presenting with stroke, PFOC is beneficial in preventing future stroke compared to medical therapy.
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Affiliation(s)
- Khagendra Dahal
- Division of Cardiology, Department of Medicine, Louisiana State University Health Sciences Center, Shreveport, LA 71103, United States
| | - Adil Yousuf
- Division of Cardiology, Department of Medicine, Louisiana State University Health Sciences Center, Shreveport, LA 71103, United States
| | - Hussam Watti
- Division of Cardiology, Department of Medicine, Louisiana State University Health Sciences Center, Shreveport, LA 71103, United States
| | - Brannen Liang
- Department of Medicine, University of Connecticut Health Center, Farmington, CT 06030, United States
| | - Sharan Sharma
- Kansas City Heart Rhythm Institute, Overland Park, KS 66215, United States
| | - Jharendra Rijal
- Division of Cardiology, Hartford Medical Center, Hartford, CT 06102, United States
| | - Pavan Katikaneni
- Division of Cardiology, Department of Medicine, Louisiana State University Health Sciences Center, Shreveport, LA 71103, United States
| | - Kalgi Modi
- Division of Cardiology, Department of Medicine, Louisiana State University Health Sciences Center, Shreveport, LA 71103, United States
| | - Neeraj Tandon
- Cardiology Section, Overton Brooks VA Medical Center, Shreveport, LA 71101, United States
| | - Michael Azrin
- Division of Cardiology, University of Connecticut Health Center, Farmington, CT 06030, United States
| | - Juyong Lee
- Division of Cardiology, University of Connecticut Health Center, Farmington, CT 06030, United States
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