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Shehata A, Nasser A, Mohsen A, Anwar Samaan A, Mostafa A, Hassan M. Prevalence and characteristics of patent foramen ovale in a sample of Egyptian population: a computed tomography study. Egypt Heart J 2024; 76:73. [PMID: 38856789 PMCID: PMC11164847 DOI: 10.1186/s43044-024-00504-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 05/31/2024] [Indexed: 06/11/2024] Open
Abstract
BACKGROUND The reported prevalence of patent foramen ovale (PFO) in the general population is variable. It ranges between 8.6 and 42% according to the population studied and the imaging technique used. We aim to prospectively assess the prevalence and characteristics of PFO and interatrial septum (IAS) abnormalities as well as the related clinical manifestations in a sample of Egyptian population. RESULTS This study comprised 1000 patients who were referred for CT coronary angiography (CTCA). Mean age was 52.5 ± 10.9 years. The prevalence of PFO among the studied population was 16.3%; closed PFO (grade I) 44.2%, open PFO (grade II) 50.9%, and open PFO with jet (grade III) 4.9%. Anatomical high-risk PFO features-defined as the presence of at least 2 or more of the following (diameter ≥ 2 mm, length ≥ 10 mm, septal aneurysm "ASA", or redundant septum)-were found in 51.5% of PFOs' population. Other IAS abnormalities as redundant septum (8.6%), ASA (5.3%), Bachmann's bundle (4.5%), microaneurysm (2.6%), and atrial septal defect (ASD) (0.4%) were detected. There was a lower rate of coexistence of ASA with PFO (p = 0.031). Syncope was significantly higher in patients with PFO compared to those without PFO (6.7% vs. 1.6%, p = 0.001). Stroke, transient ischaemic attacks (TIA), and dizziness were similar in both groups. TIA, dizziness, and syncope were significantly higher in patients with IAS abnormalities including PFO compared to those without IAS abnormalities. Syncope was also significantly higher in PFO with high-risk anatomical features compared to those with non-high-risk PFO population (p = 0.02). CONCLUSION The prevalence of PFO in our study was approximately 16.3%, almost half of them showed anatomical high-risk features for stroke. Dizziness, syncope and TIA were significantly higher in patients with IAS abnormalities including PFO.
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Affiliation(s)
- Ahmed Shehata
- Cardiology Department, Cairo University, Giza, Egypt
| | | | - Ahmed Mohsen
- Cardiology Department, Cairo University, Giza, Egypt
| | - Amir Anwar Samaan
- Cardiology Department, Cairo University, Giza, Egypt
- Cardiology Department, AlNas Hospital, Qalyubia, Egypt
| | - Amir Mostafa
- Cardiology Department, Cairo University, Giza, Egypt
- Cardiology Department, AlNas Hospital, Qalyubia, Egypt
| | - Mohamed Hassan
- Cardiology Department, Cairo University, Giza, Egypt.
- Cardiology Department, AlNas Hospital, Qalyubia, Egypt.
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Sposato LA, Albin CSW, Elkind MSV, Kamel H, Saver JL. Patent Foramen Ovale Management for Secondary Stroke Prevention: State-of-the-Art Appraisal of Current Evidence. Stroke 2024; 55:236-247. [PMID: 38134261 DOI: 10.1161/strokeaha.123.040546] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2023]
Abstract
Patent foramen ovale (PFO) is frequently identified in young patients with ischemic stroke. Randomized controlled trials provide robust evidence supporting PFO closure in selected patients with cryptogenic ischemic stroke; however, several questions remain unanswered. This report summarizes current knowledge on the epidemiology of PFO-associated stroke, the role of PFO as a cause of stroke, and anatomic high-risk features. We also comment on breakthrough developments in patient selection algorithms for PFO closure in relation to the PFO-associated stroke causal likelihood risk stratification system. We further highlight areas for future research in PFO-associated stroke including the efficacy and safety of PFO closure in the elderly population, incidence, and long-term consequences of atrial fibrillation post-PFO closure, generalizability of the results of clinical trials in the real world, and the need for assessing the effect of neurocardiology teams on adherence to international recommendations. Other important knowledge gaps such as sex, race/ethnicity, and regional disparities in access to diagnostic technologies, PFO closure devices, and clinical outcomes in the real world are also discussed as priority research topics.
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Affiliation(s)
- Luciano A Sposato
- Departments of Clinical Neurological Sciences, Epidemiology and Biostatistics, and Anatomy and Cell Biology, Schulich School of Medicine and Dentistry (L.A.S.), Western University, London, ON, Canada
- Heart & Brain Laboratory (L.A.S.), Western University, London, ON, Canada
- Robarts Research Institute and Lawson Health Research Institute, London, ON, Canada (L.A.S.)
| | - Catherine S W Albin
- Department of Neurology & Neurosurgery, Emory University School of Medicine, Atlanta, GA (C.S.W.A.)
| | - Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons (M.S.V.E.), Columbia University, New York
- Department of Epidemiology, Mailman School of Public Health (M.S.V.E.), Columbia University, New York
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York (H.K.)
| | - Jeffrey L Saver
- Department of Neurology, University of California, Los Angeles (J.L.S.)
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Miki T, Nakagawa K, Ichikawa K, Mizuno T, Nakayama R, Ejiri K, Kawada S, Takaya Y, Miyamoto M, Miyoshi T, Akagi T, Ito H. Diagnostic Performance of Cardiac Computed Tomography for Detecting Patent Foramen Ovale: Evaluation Using Transesophageal Echocardiography and Catheterization as Reference Standards. J Cardiovasc Dev Dis 2023; 10:jcdd10050193. [PMID: 37233160 DOI: 10.3390/jcdd10050193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 04/19/2023] [Accepted: 04/24/2023] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND Patent foramen ovale (PFO) is associated with various diseases such as cryptogenic stroke, migraine, and platypnea-orthodeoxia syndrome. This study aimed to evaluate the diagnostic performance of cardiac computed tomography (CT) for PFO detection. MATERIALS AND METHODS Consecutive patients diagnosed with atrial fibrillation and who underwent catheter ablation with pre-procedural cardiac CT and transesophageal echocardiography (TEE) were enrolled in this study. The presence of PFO was defined as (1) the confirmation of PFO using TEE and/or (2) the catheter crossing the interatrial septum (IAS) into the left atrium during ablation. CT findings indicative of PFO included (1) the presence of a channel-like appearance (CLA) on the IAS and (2) a CLA with a contrast jet flow from the left atrium to the right atrium. The diagnostic performance of both a CLA alone and a CLA with a jet flow was evaluated for PFO detection. RESULTS Altogether, 151 patients were analyzed in the study (mean age, 68 years; men, 62%). Twenty-nine patients (19%) had PFO confirmed by TEE and/or catheterization. The diagnostic performance of a CLA alone was as follows: sensitivity, 72.4%; specificity, 79.5%; positive predictive value (PPV), 45.7%; negative predictive value (NPV), 92.4%. The diagnostic performance of a CLA with a jet flow was as follows: sensitivity, 65.5%; specificity, 98.4%; PPV, 90.5%; NPV, 92.3%. The diagnostic performance of a CLA with a jet flow was statistically superior to that of a CLA alone (p = 0.045), and the C-statistics were 0.76 and 0.82, respectively. CONCLUSION A CLA with a contrast jet flow in cardiac CT has a high PPV for PFO detection, and its diagnostic performance is superior to that of a CLA alone.
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Affiliation(s)
- Takashi Miki
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama 700-8558, Japan
| | - Koji Nakagawa
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama 700-8558, Japan
| | - Keishi Ichikawa
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama 700-8558, Japan
| | - Tomofumi Mizuno
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama 700-8558, Japan
| | - Rie Nakayama
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama 700-8558, Japan
| | - Kentaro Ejiri
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama 700-8558, Japan
| | - Satoshi Kawada
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama 700-8558, Japan
| | - Yoichi Takaya
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama 700-8558, Japan
| | - Masakazu Miyamoto
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama 700-8558, Japan
| | - Toru Miyoshi
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama 700-8558, Japan
| | - Teiji Akagi
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama 700-8558, Japan
| | - Hiroshi Ito
- Department of General Internal Medicine 3, Kawasaki Medical School, Okayama 700-8505, Japan
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Rinkel LA, Bouma BJ, Boekholdt SM, Beemsterboer CFP, Lobé NHJ, Beenen LFM, Marquering HA, Majoie CBLM, Roos YBWEM, van Randen A, Planken RN, Coutinho JM. Detection of patent foramen ovale in patients with ischemic stroke on prospective ECG-gated cardiac CT compared to transthoracic echocardiography. J Neurol 2023:10.1007/s00415-023-11688-0. [PMID: 37027020 DOI: 10.1007/s00415-023-11688-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 03/23/2023] [Accepted: 03/25/2023] [Indexed: 04/08/2023]
Abstract
BACKGROUND Cardiac CT acquired during the acute stroke imaging protocol is an emerging alternative to transthoracic echocardiography (TTE) to screen for sources of cardioembolism. Currently, its diagnostic accuracy to detect patent foramen ovale (PFO) is unclear. METHODS This was a substudy of Mind the Heart, a prospective cohort in which consecutive adult patients with acute ischemic stroke underwent prospective ECG-gated cardiac CT during the initial stroke imaging protocol. Patients also underwent TTE. We included patients < 60 years who underwent TTE with agitated saline contrast (cTTE) and assessed sensitivity, specificity, negative and positive predictive value of cardiac CT for the detection of PFO using cTTE as the reference standard. RESULTS Of 452 patients in Mind the Heart, 92 were younger than 60 years. Of these, 59 (64%) patients underwent both cardiac CT and cTTE and were included. Median age was 54 (IQR 49-57) years and 41/59 (70%) were male. Cardiac CT detected a PFO in 5/59 (8%) patients, 3 of which were confirmed on cTTE. cTTE detected a PFO in 12/59 (20%) patients. Sensitivity and specificity of cardiac CT were 25% (95% CI 5-57%) and 96% (95% CI 85-99%), respectively. Positive and negative predictive values were 59% (95% CI 14-95) and 84% (95% CI 71-92). CONCLUSION Prospective ECG-gated cardiac CT acquired during the acute stroke imaging protocol does not appear to be a suitable screening method for PFO due to its low sensitivity. Our data suggest that if cardiac CT is used as a first-line screening method for cardioembolism, additional echocardiography remains indicated in young patients with cryptogenic stroke, in whom PFO detection would have therapeutic consequences. These results need to be confirmed in larger cohorts.
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Affiliation(s)
- L A Rinkel
- Department of Neurology, Amsterdam University Medical Centres, University of Amsterdam, Location AMC, 1105 AZ, Amsterdam, The Netherlands
| | - B J Bouma
- Department of Cardiology, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - S M Boekholdt
- Department of Cardiology, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - C F P Beemsterboer
- Department of Neurology, Amsterdam University Medical Centres, University of Amsterdam, Location AMC, 1105 AZ, Amsterdam, The Netherlands
| | - N H J Lobé
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - L F M Beenen
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - H A Marquering
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - C B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - Y B W E M Roos
- Department of Neurology, Amsterdam University Medical Centres, University of Amsterdam, Location AMC, 1105 AZ, Amsterdam, The Netherlands
| | - A van Randen
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - R N Planken
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - J M Coutinho
- Department of Neurology, Amsterdam University Medical Centres, University of Amsterdam, Location AMC, 1105 AZ, Amsterdam, The Netherlands.
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