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Devos P, Guedeney P, Montalescot G. Patent Foramen Ovale Percutaneous Closure: Evolution and Ongoing Challenges. J Clin Med 2023; 13:54. [PMID: 38202061 PMCID: PMC10780039 DOI: 10.3390/jcm13010054] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 11/28/2023] [Accepted: 12/15/2023] [Indexed: 01/12/2024] Open
Abstract
Patent foramen ovale (PFO) concerns nearly a quarter of the general population and incidence may reach up to 50% in patients with cryptogenic stroke. Recent randomized clinical trials confirmed that percutaneous closure of PFO-related stroke reduces the risk of embolic event recurrence. PFO also comes into play in other pathogenic conditions, such as migraine, decompression sickness or platypnea-orthodeoxia syndrome, where the heterogeneity of patients is high and evidence for closure is less well-documented. In this review, we describe the current indications for PFO percutaneous closure and the remaining challenges, and try to provide future directions regarding the technique and its indications.
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Affiliation(s)
- Perrine Devos
- ACTION Study Group, INSERM UMRS_1166 Institut de Cardiologie (AP-HP), Sorbonne Université, 75005 Paris, France; (P.D.); (P.G.)
| | - Paul Guedeney
- ACTION Study Group, INSERM UMRS_1166 Institut de Cardiologie (AP-HP), Sorbonne Université, 75005 Paris, France; (P.D.); (P.G.)
| | - Gilles Montalescot
- ACTION Study Group, INSERM UMRS_1166 Institut de Cardiologie (AP-HP), Sorbonne Université, 75005 Paris, France; (P.D.); (P.G.)
- Institut de Cardiologie, Centre Hospitalier Universitaire, Pitié-Salpêtrière, 47 Boulevard de l’Hôpital, 75013 Paris, France
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Abrahamyan L, Stefanescu Schmidt AC, Dharma C, Everett K, Lee DS, Canthiya L, Kolker S, Horlick E. Short- and Long-Term Outcomes in Patients With Thrombophilia Undergoing Transcatheter Closure of Patent Foramen Ovale. JACC Cardiovasc Interv 2023; 16:1360-1366. [PMID: 37316146 DOI: 10.1016/j.jcin.2023.04.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 04/15/2023] [Accepted: 04/18/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND Patients with thrombophilia are underrepresented in studies evaluating outcomes after closure of patent foramen ovale (PFO). Real-world data on long term outcomes in this population are very limited. OBJECTIVES This study compared outcomes in patients with and without thrombophilia undergoing PFO closure, using data from a large, clinical database linked to population-based databases. METHODS This retrospective cohort study included consecutive patients who had a transcatheter PFO closure and had preprocedural thrombophilia screening. Data from a retrospective, clinical registry were linked to population-based administrative databases in Ontario Canada to evaluate outcomes. Outcomes were reported as rates per 100 person-years and compared using Poisson regression. RESULTS We included 669 patients, with a mean age of 56.4 years, 97.9% of whom underwent PFO closure for a cryptogenic stroke. Thrombophilia was diagnosed among 174 (26.0%), of which 86% had inherited mutations. In-hospital, procedural complications were observed in 3.1% of patients with no difference by thrombophilia status. Similarly, no differences were observed in 30-day emergency department visits and readmissions. Over the median follow-up of 11.6 years, the most common adverse outcome was new-onset atrial fibrillation (1.0 per 100 person-years; 95% CI: 0.8-1.2), followed by recurrent cerebrovascular events (0.8 per 100 person-years; 95% CI: 0.6-1.1) with no differences between the groups (P > 0.05). CONCLUSIONS After PFO closure, no differences were observed in long-term adverse outcomes between patients with and without thrombophilia. Though these patients have been excluded from randomized clinical trials of PFO closure in the past, real-world evidence supports their eligibility for the procedure.
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Affiliation(s)
- Lusine Abrahamyan
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada. https://twitter.com/AbrahamLus
| | - Ada C Stefanescu Schmidt
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Heart Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA. https://twitter.com/DrAdaStefanescu
| | | | | | - Douglas S Lee
- ICES, Toronto, Ontario, Canada; Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Luxshikka Canthiya
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; Faculty of Science, McMaster University, Hamilton, Ontario, Canada
| | - Shimon Kolker
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Eric Horlick
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada.
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Maldonado Fernández N, López Espada C, Linares Palomino JP, Pérez Vallecillos P, García Róspide V. Migration and Surgical Retrieval of an Amplatzer Septal Occluder into Abdominal Aorta. Ann Vasc Surg 2020; 69:449.e11-449.e16. [PMID: 32502671 DOI: 10.1016/j.avsg.2020.05.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 05/12/2020] [Accepted: 05/15/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Structural heart defects, secondary to congenital malformations, have been commonly repaired by open cardiac surgery. Endovascular technology enables these repairs to be performed with fewer complications and better recovery. However, endovascular therapy can be associated with major complications as device dislocation or embolization. We present the case of migration of an Amplatzer occluder device into the abdominal aorta and its surgical retrieval. CLINICAL CASE A 10-year-old child with ostium secundum-type interatrial communication underwent endovascular repair in our center. Cardiologists sorted out the atrial communication by endovascular deployment of an Amplatzer device. The 24-h ultrasound control study showed the loss of the occluder. An angio-CT scan showed the migration of the Amplatzer into the juxtarenal abdominal aorta. Initially, an endovascular rescue was attempted but was not effective. Our vascular team performed a median laparotomy, control of the abdominal aorta proximal to the renal arteries, and control of the renal arteries and the infrarenal aorta. We performed a transverse arteriotomy, and the material was removed. Subsequently, the arteriotomy was closed directly without any patch. Postoperative evolution was uneventful. COMMENTS Most of the migrations and embolizations of the devices to close interatrial communications remain intracardiac. Although embolization of the abdominal aorta is only reported sporadically, it could cause a major vascular complication. Percutaneous retrieval of the device is currently recommended, with conventional surgery being the efficient treatment in case of endovascular failure or severe damage to the aorta.
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Affiliation(s)
- Nicolás Maldonado Fernández
- Department of Vascular Surgery, Vascular Surgery Unit, University Hospital Virgen de las Nieves of Granada, Spain
| | - Cristina López Espada
- Department of Vascular Surgery, Vascular Surgery Unit, University Hospital Virgen de las Nieves of Granada, Spain.
| | | | - Pablo Pérez Vallecillos
- Department of Vascular Surgery, Vascular Surgery Unit, University Hospital Virgen de las Nieves of Granada, Spain
| | - Vicente García Róspide
- Department of Vascular Surgery, Vascular Surgery Unit, University Hospital Virgen de las Nieves of Granada, Spain
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Abstract
"Observational studies have identified a relationship between patent foramen ovale (PFO) and migraine headache. In people who have migraine with aura, 40% to 60% have a PFO, compared with 20% to 30% in the general adult population. It is hypothesized that migraine, especially migraine with aura, may be triggered by hypoxemia or vasoactive chemicals (eg, serotonin), which are ordinarily metabolized during passage through the lungs. Although PFO closure is currently not a FDA-approved therapy for migraines, randomized trials suggest that this intervention may benefit a subgroup of migraineurs."
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Pristipino C, Sievert H, D'Ascenzo F, Mas JL, Meier B, Scacciatella P, Hildick-Smith D, Gaita F, Toni D, Kyrle P, Thomson J, Derumeaux G, Onorato E, Sibbing D, Germonpré P, Berti S, Chessa M, Bedogni F, Dudek D, Hornung M, Zamorano J. European position paper on the management of patients with patent foramen ovale. General approach and left circulation thromboembolism. EUROINTERVENTION 2019; 14:1389-1402. [PMID: 30141306 DOI: 10.4244/eij-d-18-00622] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/03/2023]
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Mullen MJ, Devellian CA, Jux C. BioSTAR®bioabsorbable septal repair implant. Expert Rev Med Devices 2014; 4:781-92. [DOI: 10.1586/17434440.4.6.781] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Heinisch C, Bertog S, Wunderlich N, Majunke N, Baranowski A, Leetz M, Fischer E, Staubach S, Zimmermann W, Hofmann I, Sievert H. Percutaneous closure of the patent foramen ovale using the HELEX® Septal Occluder: acute and long-term results in 405 patients. EUROINTERVENTION 2012; 8:717-23. [DOI: 10.4244/eijv8i6a111] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Masseli J, Bertog S, Stanczak L, Blankenbach K, Majunke N, Reiffenstein I, Renkhoff K, Lehn K, Wunderlich N, Sievert H. Transcatheter closure of multiple interatrial communications. Catheter Cardiovasc Interv 2012; 81:825-36. [PMID: 22907918 DOI: 10.1002/ccd.24329] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2011] [Accepted: 01/07/2012] [Indexed: 11/06/2022]
Abstract
OBJECTIVES We sought to examine acute and midterm results of closure of multiple interatrial communications with staged device deployment and to review the relevant literature. BACKGROUND Information about percutaneous methods of closure for multiple defects is limited. METHODS We treated 148 patients with multiple defects. Of these, 88 had a relevant left to right shunt ("LRS"), 52 had a presumed paradoxical embolism ("PPE"), five had both (LRS and PPE), and one patient, respectively, had migraine, decompression sickness, and a right to left shunt. After implantation of the first device, closure of additional septal defects was attempted only if indicated clinically. RESULTS Ninety-four patients received a single device and 53 more than one. In four patients, surgical defect closure followed. At the end of follow-up (FU; mean 4.5 ± 3.4 years), complete closure of all defects occurred in 67.6% (62.1% for LRS, 76.5% for PPE). Clinical success (small or trivial residual shunt) was achieved in 86.9% (83.9% for LRS, 90.2% for PPE). Complications included pericardial effusions in 2.7%, recurrent thromboembolic events in 4.8%, and new onset of atrial fibrillation in 10.1%. In a significant number of patients with multiple defects, after single device implantation, the likelihood of complete closure increased with FU time (26% complete closure at 1 month vs. 78% at 24 months). CONCLUSION Percutaneous closure of multiple interatrial communications is feasible and safe. Importantly, many residual defects close without further intervention at FU. Therefore, staged device delivery is an alternative to simultaneous device implantation, possibly requiring fewer and smaller second devices.
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Stanczak LJ, Bertog SC, Wunderlich N, Franke J, Sievert H. PFO closure with the Premere PFO closure device: acute results and follow-up of 263 patients. EUROINTERVENTION 2012; 8:345-51. [DOI: 10.4244/eijv8i3a53] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Wöhrle J, Bertrand B, Søndergaard L, Turner M, Scholtz W, Ibrahim R, Bourlon F. PFO closuRE and CryptogenIc StrokE (PRECISE) registry: a multi-center, international registry. Clin Res Cardiol 2012; 101:787-93. [PMID: 22487724 DOI: 10.1007/s00392-012-0458-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2012] [Accepted: 03/27/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND The Premere™ PFO closure device has a special design for closure of patent foramen ovale (PFO) including a flexible distance and angulation between the right and left disc providing minimal septal distortion. The primary objective of the study was to determine the degree of risk for stroke or transient ischemic attack (TIA) in patients after Premere™ PFO closure device implantation. METHODS In this multicenter, prospective observational registry, patients with a clinical indication for PFO closure were included. Patients had a history of stroke or TIA with right to left shunt. Follow-up visits were scheduled according to routine clinical practice. RESULTS In 23 centers from 10 countries, 267 patients with successful device implantation were included. Assessment of right to left shunt after device implantation revealed no residual shunt in 71 %, small shunts in 16.8 %, and moderate or large residual shunts in 5.6 and 6.5 %. With common clinical practice, use of Coumadin or heparin decreased from 27 % pre- to 3 % post-implantation, while use of acetylsalicylic acid or thienopyridines increased from 64 to 95 % and 27 to 80 %, respectively; 18 % of patients were discharged with anti-platelet monotherapy. Mean follow-up was 11 ± 9 months (range 1-24 months). There was no stroke or TIA. During follow-up, there was one sudden death. Atrial fibrillation occurred in five (1.9 %) patients. One (0.4 %) patient with a thrombophilic diathesis developed a thrombus. CONCLUSIONS In this prospective, international, multicenter PRECISE registry, the use of the Premere™ PFO closure device for closure of PFO after stroke or TIA resulted in good clinical results with no recurrent event.
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Affiliation(s)
- Jochen Wöhrle
- Department of Internal Medicine II, Cardiology, University of Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany.
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Rigatelli G, Cardaioli P, Dell'Avvocata F, Giordan M, Chinaglia M. Premere occlusion system for transcatheter patent foramen ovale closure: Mid-term results of a single-center registry. Catheter Cardiovasc Interv 2011; 77:564-9. [DOI: 10.1002/ccd.22713] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Abstract
PURPOSE OF REVIEW A comprehensive review of the main concepts about patent foramen ovale (PFO) management is offered. RECENT FINDINGS PFO is a common, usually benign, anatomical variant that in the presence of a discrete right-to-left shunt and other predisposing factors (Eustachian valve/Chiari network, atrial septal aneurysm, and coagulation cascade abnormalities) may play an important role in the patho-physiology of paradoxical embolism at different levels (cryptogenic stroke, peripheral embolism, coronary embolism, etc.). Therapy is a controversial issue, since data on these patients are variable and accepted guidelines are missing. Recurrent strokes are the most diffuse and accepted indication for transcatheter closure of PFO, but severe refractory migraine with aura, unexplained oxygen desaturation, orthodeoxia-platypnea, and other conditions have been suggested to benefit from PFO closure. Different devices and techniques have been proposed for this procedure, mainly depending on operator experience and preferences, which have contributed to this intervention becoming a well tolerated and effective procedure with very low morbidity and virtually absent mortality. SUMMARY PFO management is still a debated field: indications, pathophysiology and ideal closure techniques remain to be fully clarified and investigated before considering PFO closure a routine procedure.
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Cifarelli A, Musto C, Parma A, Pandolfi C, Pucci E, Fiorilli R, De Felice F, Nazzaro MS, Violini R. Long-term outcome of transcatheter patent foramen ovale closure in patients with paradoxical embolism. Int J Cardiol 2009; 141:304-10. [PMID: 19178959 DOI: 10.1016/j.ijcard.2008.12.051] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2008] [Revised: 11/20/2008] [Accepted: 12/05/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND Optimal management of patients with PFO and paradoxical embolic events is still debated. Moreover, data from long-term studies on large patient populations are lacking. Aim of the study is to assess immediate and long-term clinical outcome of patients with PFO and paradoxical thrombo-embolic events submitted to transcatheter PFO closure. METHODS Only patients with PFO-related transient ischemic attack or stroke underwent PFO closure. Patients were evaluated clinically and echocardiographically at 1, 6 and 12 months after the procedure and yearly thereafter. Primary endpoints were death, recurrent stroke or TIA. Residual right-to left shunt (RLS) was monitored by transthoracic echocardiography (TTE) or transcranial Doppler (TCD) at 6 months'follow-up. RESULTS 202 consecutive patients underwent percutaneous PFO closure for secondary prevention of TE. Device migration was observed in one patient 24 h after the procedure. No cases of procedure-related death or stroke occurred during a median follow-up of 3+/-1.3 years. Three recurrent TIAs were observed within the first 6 months of follow-up. The cumulative estimated probability of recurrent TE-free survival rate after PFO closure was 99% in patients <or=55 years, 84% in patients >55 years (p<0.05) and 94% and 100% in patients with PFO, with or without atrial septal aneurysm (ASA), respectively (p<0.05). Of the 188 (93%) patients submitted to TTE or TCD at 6 months' follow-up, 8 (4%) presented a small RLS. CONCLUSION Transcatheter PFO closure is associated with low incidence of in-hospital complications and low frequency of recurrent TE at long-term follow-up.
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Affiliation(s)
- Alberta Cifarelli
- Interventional Cardiology Unit, S Camillo/Forlanini Hospital, Circonvallazione Gianicolense 87, 00151 Rome, Italy
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Spies C, Timmermanns I, Reissmann U, van Essen J, Schräder R. Patent foramen ovale closure with the Intrasept occluder: Complete 6-56 months follow-up of 247 patients after presumed paradoxical embolism. Catheter Cardiovasc Interv 2008; 71:390-5. [PMID: 18288745 DOI: 10.1002/ccd.21383] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE We report our experience of transcatheter patent foramen ovale (PFO) closure with the new Intrasept occluder. BACKGROUND The Intrasept device is the fourth generation of the Cardia occluder family. Developed for transcatheter closure of PFO, the main difference between the Intrasept and prior generations of the Cardia occluder is its articulating center post. This modification allows better alignment of the umbrellas on both sides of the atrial septum. We report our experience with this new PFO occluder. METHODS From July 2002 until October 2006, PFO closure with the Intrasept occluder was attempted in 247 patients with presumed paradoxical embolism. Prior to PFO closure, a total of 269 cerebrovascular thromboembolic events (TEs) had occurred. Implantation of the device was guided by fluoroscopy and transesophageal echocardiography with conscious sedation. RESULTS Median age was 53 years (range, 21-77). One hundred twenty-seven (51%) patients had an atrial septal aneurysm. The device was implanted successfully in all cases. Acute complications occurred in 4 (1.6%) patients (air embolism = 2, pericardial effusion = 1, supraventricular tachycardia = 1). Follow-up information is available for all 247 (100%) patients. Median follow-up time was 14 months (range 6-56). Residual shunt at 6 months follow-up was 13%. After 1 year, the presence of residual shunt rate decreased to 10%. Following PFO closure, seven recurrent TEs (TIA = 4, CVA = 3) were observed in 6 patients. No wire fractures or device-associated thrombi were seen. CONCLUSIONS PFO closure with the Intrasept occluder is safe and efficient. Rates of residual shunt and recurrent TE compare favorably with other contemporary devices.
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Affiliation(s)
- Christian Spies
- Rush University Medical Center, Section of Cardiology, Chicago, Illinois, USA
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Ewert P, Söderberg B, Dähnert I, Hess O, Schuler G, Bussmann C, Bernhard J, Sick P. ASD and PFO closure with the Solysafe septal occluder-Results of a prospective multicenter pilot study. Catheter Cardiovasc Interv 2008; 71:398-402. [DOI: 10.1002/ccd.21360] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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