Atrial septal aneurysm and stroke: a transesophageal echocardiographic study

Updates on Patent Foramen Ovale (PFO) Closure

PURPOSE OF REVIEW

Patent foramen ovale (PFO) has been previously linked to left circulation thromboembolism and stroke. This review article aims to discuss the latest evidence, updated societal guidelines, diagnostic algorithms and novel therapeutic devices for PFO closure.

RECENT FINDINGS

PFO closure for cryptogenic stroke and systemic embolization is supported by a large body of evidence and has a strong societal recommendation. Limited data are available for platypnea-orthodeoxia syndrome, although closure appears to be beneficial. Current data do not support routine closure for migraines and decompression Illness. Development of heart-brain teams can improve identification of patients most likely to benefit from closure, utilizing a combination of imaging test and risk score algorithms. Multiple novel devices aiming at reducing complications and improving the long-term impact of current available devices are being evaluated. PFO closure has significantly progressed over the last years, with new data supporting its superiority in reducing risk of recurrent embolic stroke in patients with PFO-related stroke. Additional clinical data are required to provide further refinements on patient selection and guidance on treatment of specific subgroups.

Atrial Septal Aneurysm Leading to Ischemic Stroke: A Case Report and Literature Review

Stroke is the most common cause of death and disability in the world, and ischemic etiology plays a major role. Atrial septal aneurysm (ASA) is a localized saccular deformity of the atrial septum, associated with ischemic stroke independently or in association with other atrial septal defects (ASD). There is a higher incidence of stroke in the population with ASD. In these patients, the presence of ASA is an important predictor of recurrent stroke. This is a case of ischemic stroke in a 44-year-old who presented with sudden-onset right-sided body weakness, expressive aphasia, and non-specific confusion for one hour, with an initial National Institutes of Health Stroke Scale (NIHSS) score of 7. CT angiogram revealed occlusion of the M3 branch of the left middle cerebral artery in the left lateral frontal lobe. Code stroke was called, and the patient was given tenecteplase (TNK), after which her right-side weakness and aphasia resolved. Trans-thoracic echo with bubble study showed ASA with positive bubble study. Lone ASA or ASA with concomitant ASD poses a higher risk of recurrent stroke in younger patients, especially those without significant risk factors for strokes. Patients with ASA and concomitant ASD are at high risk for recurrent ischemic stroke and should be kept under surveillance with continued medical therapy. We present a case of ischemic stroke caused by ASA and a review of the current literature and case reports documenting cases with similar presentations.

Navigating the Complexities: Addressing the Challenges of Aneurysmal Atrial Septal Defects

Aneurysmal atrial septal defects (ASDs) represent a rare subset of congenital cardiac anomalies, characterized by bulging of the interatrial septum. This condition poses unique challenges in diagnosis, management, and outcomes due to its variable clinical presentation and associated complications. While echocardiography remains the cornerstone of diagnosis, advanced imaging modalities such as cardiac magnetic resonance imaging (MRI) and computed tomography (CT) may provide additional insights. Optimal management strategies for aneurysmal ASDs require careful consideration of patient-specific factors, including the size and location of the defect, associated cardiovascular abnormalities, and the presence of pulmonary hypertension. Surgical repair, whether through conventional open-heart techniques or transcatheter interventions, remains the primary treatment modality; however, the approach may vary based on individual patient characteristics. Anesthetic considerations, including hemodynamic monitoring and perioperative care, are crucial in optimizing outcomes and reducing the risk of complications during surgical interventions. Long-term follow-up is essential to monitor potential complications such as residual shunting, arrhythmias, and the development of pulmonary vascular disease. Collaborative efforts among cardiologists, cardiothoracic surgeons, anesthesiologists, and other multidisciplinary specialists are paramount in providing comprehensive care for patients with aneurysmal ASDs.

Transcatheter closure of patent foramen ovale using the Cocoon occluder: A multicenter retrospective study

BACKGROUND

The Cocoon patent foramen ovale (PFO) occluder is a new device especially designed for transcatheter closure of PFO. This occluder has some distinctive structural modifications aimed at reducing the risk of major complications of transcatheter PFO closure. In this report we present our initial experience to evaluate the efficacy and safety of the Cocoon PFO occluder in 253 patients who underwent transcatheter PFO closure.

METHODS

The study cohort included 253 patients (median age 45 years) with embolic stroke of undetermined source who underwent attempted transcatheter closure of PFO for secondary prevention of paradoxical embolism. Patients were enrolled retrospectively from five sites in Greece and one in Romania between December 2016 and January 2021, and the median follow-up period was 28 months (range 12-48 months). Clinical and laboratory data from each participating center were sent to an electronic registry for evaluation and statistical analysis.

RESULTS

The Cocoon PFO occluder was permanently implanted in all patients. At 6 months, complete occlusion of PFO was observed in 251/253 (99.2%) patients. Three (1.2%) patients had a trivial residual shunt. Thrombus formation on the device, which was successfully treated with recombinant tissue plasminogen activator infusion, was observed in one (0.4%) patient. No other complications occurred. During a median follow-up period of 28 months, 3 (1.2%) patients, aged 64-67 years, developed new onset paroxysmal atrial fibrillation. No neurologic events, cardiac erosions, allergic reactions to nickel, or thrombus formation occurred.

CONCLUSION

The Cocoon PFO occluder is an effective and safe device that adds to our armamentarium for transcatheter closure of PFO.

Multimodal Cardiac Imaging in the Assessment of Patients Who Have Suffered a Cardioembolic Stroke: A Review

Cardioembolic strokes account for 20-25% of all ischaemic strokes, with their incidence increasing with age. Cardiac imaging plays a crucial role in identifying cardioembolic causes of stroke, with early and accurate identification affecting treatment, preventing recurrence, and reducing stroke incidence. Echocardiography serves as the mainstay of cardiac evaluation. Transthoracic echocardiography (TTE) is the first line in the basic evaluation of structural heart disorders, valvular disease, vegetations, and intraventricular thrombus. It can be used to measure chamber size and systolic/diastolic function. Trans-oesophageal echocardiography (TOE) yields better results in identifying potential cardioembolic sources of stroke and should be strongly considered, especially if TTE does not yield adequate results. Cardiac computed tomography and cardiac magnetic resonance imaging provide better soft tissue characterisation, high-grade anatomical information, spatial and temporal visualisation, and image reconstruction in multiple planes, especially with contrast. These techniques are useful in cases of inconclusive echocardiograms and can be used to detect and characterise valvular lesions, thrombi, fibrosis, cardiomyopathies, and aortic plaques. Nuclear imaging is not routinely used, but it can be used to assess left-ventricular perfusion, function, and dimensions and may be useful in cases of infective endocarditis. Its use should be considered on a case-by-case basis. The accuracy of each imaging modality depends on the likely source of cardioembolism, and the choice of imaging approach should be tailored to individual patients.

An Unusual Cause of Acute Right-Sided Heart Failure Presenting With Refractory Hypoxia

Atrial septal aneurysm (ASA) formation is due to a deformity at the fossa ovalis. While previously considered a rare cardiac anomaly found postmortem, it can now be diagnosed at the bedside with ultrasound. Unrepaired ASA can lead to right-sided heart failure and pulmonary hypertension. The case we describe is complicated by the patient's code status, limiting our ability to perform potential life-sustaining interventions. We also encountered a complication of rebound pulmonary hypertension with the use of inhaled nitric oxide. We detail the critical course of profound hemodynamic and respiratory instability responsive to salvage therapy.

Clinical and echocardiographic outcomes after percutaneous closure of patent foramen ovale: a single center experience

BACKGROUND

Patent foramen ovale (PFO) has a high estimated prevalence (25% of the general population) and has been implicated in the pathogenesis of cryptogenic stroke and transient ischemic attack (TIA), as well as in the pathogenesis of migraine headache. This study evaluated the effectiveness of percutaneous transcatheter PFO closure with Amplatzer™ (Abbott Laboratories, Abbott Park, IL, USA) devices, from a large single-center experience.

METHODS

From January 1998 to December 2014, 577 patients (243 males and 334 females, mean age 50 years, range 11-82 years) with documented PFO and history of at least one episode of cryptogenic stroke/TIA (N.=356) or occasional finding of previous ischemic lesions on MRI (N.=221) underwent percutaneous transcatheter closure of PFO using an Amplatzer™ Occluder (Abbott Laboratories). All the procedures were performed under general anesthesia or mild sedation and were assisted by transesophageal or intracardiac echocardiography.

RESULTS

Procedural success was 100%. After a median follow-up period of 2.7 years with echocardiographic evaluations, the rate of recurrent adverse cerebral events was 0.4%. Two patients (0.4%) required a secondary procedure for significant residual shunt. Of 36 patients with minor residual shunt, 30 (83%) showed spontaneous shunt regression at follow-up. There was a consistent decrease after procedure in headache migraine, platypnea-orthodeoxia, fainting episodes, syncope, and coenesthesia phenomena.

CONCLUSIONS

Transcatheter PFO closure is an effective and safe therapy for the prevention of thromboembolic events in the patients with cryptogenic stroke/TIA or an occasional finding of a positive cerebral MRI. Late follow-up shows device stability and clinical improvement in the majority of patients.

Cerebral infarction by paradoxical gas embolism detected after laparoscopic partial hepatectomy with an insufflation management system: a case report

BACKGROUND

Laparoscopic surgery has reduced surgical morbidity and postoperative duration of hospital stay. Gas embolism is commonly known as a risk factor for all laparoscopic procedures. We report a case of severe cerebral infarction presumably caused by paradoxical CO₂ embolism in laparoscopic partial hepatectomy with an insufflation management system.

CASE PRESENTATION

A male in his 60 s was diagnosed with recurrence of liver metastasis in the right hepatic lobe after laparoscopic lower anterior resection for rectal cancer. We performed laparoscopic partial hepatectomy with an AirSeal® under 10 mmHg of intra-abdominal pressure. During the surgery, the patient's end-tidal CO₂ and percutaneous oxygen saturation dropped from approximately 40-20 mmHg and 100-90%, respectively, while the heart rate increased from 60 to 120 beats/min; his blood pressure remained stable. Postoperatively, the patient developed right hemiplegia and aphasia. Brain magnetic resonance imaging showed cerebral infarction in the broad area of the left cerebral cortex. Thereafter, transesophageal echocardiography revealed a patent foramen ovale, suggesting cerebral infarction due to paradoxical gas embolism.

CONCLUSIONS

A patent foramen ovale is found in approximately 15-20% of healthy individuals. While gas embolism is a rare complication of laparoscopic surgery, cerebral infarction must be considered a possible complication even if the intra-abdominal pressure is constant under 10 mmHg with an insufflation management system.

Current perspectives on the clinical management of cryptogenic stroke

INTRODUCTION

Cryptogenic stroke is a heterogeneous entity defined as an ischemic stroke for which no probable cause is identified despite thorough diagnostic evaluation. Since about a quarter of all ischemic strokes are classified as cryptogenic, it is a commonly encountered problem for providers as secondary stroke prevention is guided by stroke etiology.

AREAS COVERED

In this review, the authors provide an overview of stroke subtype classification schemes and diagnostic evaluation in cryptogenic stroke. They then detail putative cryptogenic stroke mechanisms, their therapeutic implications, and ongoing research. This review synthesizes the available evidence on PubMed up to December 2022.

EXPERT OPINION

Cryptogenic stroke is an evolving concept that changes with ongoing research. Investigations are focused on improving our diagnostic capabilities and solidifying useful constructs within cryptogenic stroke that could become therapeutically targetable subgroups within an otherwise nonspecific entity. Advances in technology may help move specific proposed cryptogenic stroke mechanisms from undetermined to known source of ischemic stroke.

Interatrial septal aneurysm associated with patent foramen ovale in a dog - case report

ABSTRACT Atrial septal aneurysm (ASA) is a rare congenital deformity of variable clinical relevance, often reported in association with patent foramen ovale (PFO). Transthoracic Doppler echocardiography (TTE) is the first choice for diagnosis, but complementary techniques, such as microbubble contrast, should be used. Despite its importance, in Veterinary Medicine, there is little information related to the subject, and the present study is the second report of this condition in dogs. The objective was to report a case of ASA type IV LR associated with PFO in a Shar Pei bitch, diagnosed by a combined approach of transthoracic echocardiography backed by agitated saline solution (microbubbles). During clinical care, the owners reported episodes of seizures as their main complaint. Echocardiographic examination revealed a type 4 LR atrial septal aneurysm and left ventricular systolic dysfunction. The use of microbubble contrast showed right-to-left shunt, confirming PFO. The recommended treatment was medication. It was concluded that the rarity of ASA in dogs may be due to incomplete diagnoses and the transthoracic echocardiographic examination allows its analysis and classification. Furthermore, ASA can be found in animals with or without evidence of heart disease and it should be investigated in patients with neurological alterations.

Advances in Percutaneous Patent Foramen Ovale Closure: From the Procedure to the Echocardiographic Guidance

Percutaneous patent foramen ovale (PFO) closure by traditional, double disc occluder devices was shown to be safe for patients with PFO, and more effective than prolonged medical therapy in preventing recurrent thromboembolic events. The novel suture-mediated “deviceless” PFO closure system overcomes most of the risks and limitations associated with the traditional PFO occluders, appearing to be feasible in most interatrial septum anatomies, even if data about its long-term effectiveness and safety are still lacking. The aim of the present review was to provide to the reader the state of the art about the traditional and newer techniques of PFO closure, focusing both on the procedural aspects and on the pivotal role of transesophageal echocardiography (TEE) in patient’s selection, peri-procedural guidance, and post-interventional follow-up.

A Review of the Role of Transthoracic and Transesophageal Echocardiography, Computed Tomography, and Magnetic Resonance Imaging in Cardioembolic Stroke

Stroke is a major source of morbidity and mortality worldwide, accounting for the second largest cause of mortality and the third greatest cause of disability. Stroke is frequently preceded by a transient ischemic attack (TIA). The etiologies of 20-30% of ischemic strokes are unknown, and thus are termed "cryptogenic strokes". About 25% of ischemic strokes are cardioembolic. Strokes occur at a rate of around 2% per year in individuals with heart failure with reduced ejection fraction (HFrEF), with a strong correlation between stroke risk and the degree of ventricular impairment. Furthermore, stroke risk is augmented in the absence of anticoagulation therapy. Cardioembolic strokes, when treated inadequately, have a greater predilection for recurrences than atherothrombotic strokes, both early and late in life. The role of a patent foramen ovale in strokes, specifically in "cryptogenic strokes", is a matter of concern that deserves due attention. The use of tissue-engineered heart valves and aspirin for minimizing the risk of stroke is recommended. Transthoracic echocardiography (TTE) is advantageous for assessing heart function in the acute phase of ischemic stroke. Transesophageal echocardiography (TEE) is considered the criterion standard procedure for detecting LAA thrombi. Computed tomography (CT) scans are good imaging modalities for identifying and excluding bleeding. Magnetic resonance imaging (MRI) images are by far the most effective imaging technique available for assessing the brain parenchymal state. We conducted a thorough review of the literature on the use of imaging modalities, highlighting the important contribution of TTE, TEE, CT, and MRI in the evaluation of cardioembolic stroke.

Transcranial Doppler for stratification of high-risk morphology of patent foramen ovale in patients with cryptogenic stroke

Microbubble testing using transcranial Doppler (TCD) is an important screening tool for diagnosing paradoxical cerebral embolism with high-risk PFO. However, little is known about the association between the microbubble test by TCD and the features of high-risk PFO evaluated by transesophageal echocardiography (TEE). We studied 101 consecutive patients at Showa University, from April 2019 to October 2020, who underwent both TCD and TEE with a sufficient Valsalva maneuver and who were strongly suspected by neurologists as cryptogenic stroke. According to the appearance of microbubbles as high-intensity transient signals (HITS), the TCD grade was stratified into three categories based on the criteria (A: none, no HITS, B: small; 1-10 HITS, and C: large; > 10 HITS, or an uncountable number of HITS). Among patients with RLS through the PFO in TEE, high-risk morphological features of PFO for cerebral embolism were evaluated as follows: (1) tunnel height, (2) tunnel length, (3) total excursion distance of the atrial septum into the right and left atrium, (4) existence of Eustachian valve or Chiari network, (5) angle of PFO from the inferior vena cava, and (6) large shunt (20 or more microbubbles). Of 101 patients (TCD grade; Group A = 49, Group B = 26, Group C = 26), RLS through PFO was detected in 37 patients (grade A = 8, grade B = 6, grade C = 23) by TEE. Among PFO-positive patients, tunnel height, length, total excursion distance into the right and left atria, angle of PFO from the inferior vena cava, and frequency of large shunt in TEE were significantly larger in grade C than in grade A and B (p < 0.05). Additionally, grade C patients had significantly more forms of high-risk PFOs than those in grades A and B when the six features of high-risk PFO were compared. A multivariate logistic regression demonstrated that the tunnel length of PFO and the presence of large shunt in TEE were independently associated with large HITS in TCD (odds ratio: 1.18 and 49.5, 95% confidence interval 1.043-1.337 and 10.05-244.3, p = 0.0086 and p < 0.0001, respectively). In conclusion, the existence of a large HITS detected by TCD may have a screening advantage in predicting the high-risk morphologies of PFO that can cause paradoxical cerebral embolism.

Intracardiac Echocardiogram: Feasibility, Efficacy, and Safety for Guidance of Transcatheter Multiple Atrial Septal Defects Closure

We aimed to determine the feasibility, efficacy, success, and safety of intracardiac echocardiography (ICE) in transcatheter multiple atrial septal defect (ASD) closure. Of 185 patients with multiple ASDs who underwent transcatheter closure, 140 (76%) patients who weighed <30kg with a narrow distance between defects or in whom single device closure was anticipated were guided by ICE and 45 patients were guided by three-dimensional (3D) transesophageal echocardiography (TEE) with or without ICE. Patients in the ICE group were relatively younger and weighed less than those in the 3D TEE group (p < 0.0001). The ratio of the distance between defects >7 mm was high, and more cases required ≥2 devices in the 3D TEE group than those in the ICE group (p < 0.0001). All patients in the 3D TEE group and seven patients (5%) in the ICE group were operated on under general anesthesia (p < 0.0001). The fluoroscopic time was shorter in the ICE group (13.98 ± 6.24 min vs. 24.86 ± 16.47 min, p = 0.0005). No difference in the complete closure rate and complications was observed. ICE-guided transcatheter and 3D TEE were feasible, safe, and effective in successful multiple ASD device closures, especially for young children and patients at high risk under general anesthesia.

Importance of direct right-to-left shunt as high-risk patent foramen ovale associated with cryptogenic stroke

BACKGROUND

Because transcatheter closure of patent foramen ovale (PFO) has become effective for preventing cryptogenic stroke (CS), it is necessary to determine high-risk PFO associated with CS. This study aimed to clarify the importance of direct right-to-left (RL) shunt through the PFO for identifying high-risk PFO.

METHODS

We analyzed 137 patients with and without CS who were confirmed to have PFO. The timing of RL shunt through the PFO was evaluated by cardiac cycles after right atrium (RA) opacification on saline contrast transesophageal echocardiography. Direct RL shunt was defined as microbubbles crossing the PFO before and at the same time of RA opacification.

RESULTS

Cardiac cycles of microbubbles crossing the PFO were shorter in patients with CS than in those without CS (2.0 ± 2.2 vs .5 ± 1.1, p < 0.01). Direct RL shunt was more frequently observed in patients with CS than in those without CS (77% vs 29%, p < 0.01), with a sensitivity of 79% and a specificity of 71% for the association with CS. Multivariate analysis revealed that direct RL shunt was related to atrial septal aneurysm and low-angle PFO. Regarding functional features of PFO, the detection rate of CS was 50% for large RL shunt alone, and was increased to 83% when direct RL shunt was added.

CONCLUSION

Direct RL shunt was associated with CS and had the incremental value in detecting PFO associated with CS for large RL shunt. The timing of RL shunt can be valuable for identifying high-risk PFO.

Increased Mobility of the Atrial Septum in Aortic Root Dilation: An Observational Study on Transesophageal Echocardiography

Background: There is a growing interest in the relationship between atrial septal anatomy and cardioembolic stroke. Anecdotal reports suggest that the enlargement of the aortic root could interfere with atrial septal mobility (ASM). We sought to investigate the association between ASM and aortic root dilation.

Methods and Findings: From all consecutive clinically requested transesophageal echocardiogram (TEE) studies performed during the study period in a single institution, we were able to review and evaluate the ASM and anteroposterior length, aortic root diameter, and the prevalence of atrial septal aneurysm (ASA) and of patent foramen ovale (PFO) in 336 studies. Additional variables, such as left ventricular ejection fraction, left atrial diameter, diastolic dysfunction, age, sex, weight, height, previous stroke, atrial fibrillation, and TEE indication, were extracted from patient medical records and echocardiographic clinical reports. In 336 patients, we found a mean ASM of 3.4 mm, ranging from 0 to 21 mm; 15% had ASA and 14% had PFO. There was a 1.0 mm increase in ASM for every 10-mm increase in aortic root diameter adjusted for age, sex, weight, height, ejection fraction, and left atrial size (B = 0.1; P = 0.04). Aortic diameter was not associated with a smaller septal length (B = 0.03; P = 0.7).

Conclusion: An increased motion of the atrial septum can occur in association with aortic dilation. These findings deserve attention for the relevance of aortic root anatomy in future studies involving atrial septal characteristics and embolic stroke risk.

[The role of transesophageal echocardiography (TEE): case study conducted at the Dax Hospital Center]

Le but de ce travail est d´évaluer la pratique de l´échocardiographie trans-œsophagienne au Centre Hospitalier (CH) de DAX, selon les indications, le profil patient, les résultats retrouvés, la rentabilité de l´examen et la concordance avec l´attente des prescripteurs. Il s´agit d´une étude rétrospective transversale, descriptive à visée analytique menée de Janvier 2016 à Décembre 2018 au laboratoire d´explorations cardiovasculaires du CH de Dax. Sur les 460 examens demandés nous en avons retenu 434 pour l´étude. Les variables étudiées étaient le profil démographique des patients, les indications, les résultats, la rentabilité de l´examen et la concordance avec l´attente des prescripteurs. Sur les 434 examens réalisés, l´âge moyen de la population était de 64,37 ans, avec 64,29% de patients de sexe masculin et un sex-ratio de 1,8. Le bilan d´accident vasculaire cérébral (AVC) (63,59%), la recherche d´endocardite infectieuse (16,12%) et l´évaluation thérapeutique de la prise en charge des thrombus intracavitaires (11,75%) étaient les indications majoritaires. Les prescripteurs étaient majoritairement les neurologues (60,83%). L´examen était normal dans 58,99% des cas. Les résultats pathologiques (40,78%) étaient dominés par les thrombi intra-auriculaires (27,65%), les vidanges auriculaires altérées (9,45%), la présence de foramen oval perméable (5,07%), les anévrysmes du septum inter atrial (2,53%) et les endocardites infectieuses (2,76%). L´examen était rentable dans 40,78% des cas et les résultats étaient concordants à l´attente des prescripteurs dans 39,86%. Notre étude sur l´échocardiographie transœsophagienne a permis de montrer que les indications sont dominées par le bilan d´accident vasculaire cérébral. C´est un examen à faible taux de complications, rentable et avec des résultants concordant avec l´attente des praticiens.

Efficacy and safety of percutaneous patent foramen ovale closure in patients with a hypercoagulable disorder

BACKGROUND

Transcatheter closure of patent foramen ovale (PFO) in patients with cryptogenic stroke reduces the rate of recurrent events. Although presence of thrombophilia increases the risk for paradoxical emboli through a PFO, such patients were excluded from large randomized trials.

OBJECTIVES

We compared the safety and efficacy of percutaneous PFO closure in patients with and without a hypercoagulable state.

METHODS

Data from 800 consecutive patients undergoing percutaneous PFO closure in our medical center were analyzed. All patients were independently evaluated by specialists in neurology, cardiology, hematology, and vascular medicine. A post-procedural treatment of at least 3 months of anticoagulation was utilized in patients with thrombophilia. Follow-up events included death, recurrent neurological events, and the need for reintervention for significant residual shunt.

RESULTS

A hypercoagulable state was found in 239 patients (29.9%). At median follow-up of 41.9 months, there were no differences in the frequencies of stroke or transient ischemic attack between patients with or without thrombophilia (2.5% in non-hypercoagulable group vs. 3.4% in hypercoagulable group, log-rank test p = 0.35). There were no significant differences in baseline demographics, echocardiographic characteristics, procedural success, or complications between groups.

CONCLUSION

Percutaneous PFO closure is a safe and effective therapeutic approach for patients with cryptogenic stroke and an underlying hypercoagulable state.

Ischemic colitis and atrial septal aneurysm as a potential cause of systemic thromboembolism

Atrial septal aneurysm is a rare cardiac abnormality with thromboembolic potential and should be considered in a patient with ischemic colitis with no obvious risk factors.

Agitated Saline Contrast Echocardiography in the Identification of Intra- and Extracardiac Shunts: Connecting the Dots

Agitated saline contrast studies are an essential component of contemporary echocardiography. Agitated saline contrast plays a critical role in the elucidation of intracardiac versus intrapulmonary shunting and can have major therapeutic implications, particularly in light of the evolution of percutaneous treatment options for atrial septal defects or a patent foramen ovale. Despite their perceived simplicity, however, there are numerous pitfalls of these investigations that can occur during their performance and interpretation. As such, the authors review the "bubble study" in identifying intracardiac and extracardiac shunts, including the history of its development, the physics and physiology of contrast enhancement, how to optimally perform and interpret an agitated saline contrast study, and its safety in unique populations.

Patent foramen ovale

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.

Percutaneous closure of patent foramen ovale under transthoracic echocardiography guidance-midterm results

Background

Conventional percutaneous closure of patent foramen ovale (PFO) is usually performed under the guidance of fluoroscopy. Whether closure of PFO under transthoracic echocardiography (TTE) guidance only is safe and effective is unknown. The present study therefore aimed to assess the safety and efficacy of percutaneous closure of PFO under TTE guidance only.

Methods

This study retrospectively enrolled a total of 52 consecutive patients (55.8% male, mean age 34.0±13.0 years, range, 10-59 years) with PFO treated at our institution from June 2015 to September 2017 by percutaneous closure under echocardiographic guidance only. The patients mean body weight was 58.7±10.8 kg. Patients underwent follow-up by TTE immediately post procedure by electrocardiogram and TTE at 1, 3, 6 and 12 months after discharge and annually thereafter, and by clinical evaluation at all time points.

Results

Of the 52 patients, 47 (90.4%) were successfully treated by percutaneous closure under TTE guidance. The mean procedure duration (from puncture to sheath removal) was 21.0±6.2 (range, 11-33) minutes. A trivial residual shunt which disappeared 24 hours later was observed in only 1 (1.9%) patient immediately post procedure. Median hospital stay was 3.0 days without severe complications such as peripheral vascular injury or cardiac perforation at discharge. At median 15.5 (11.3, 18.0) months follow-up, there were no complications such as death, stroke, transient ischemic attack (TIA) and residual shunt.

Conclusions

In this single center study of mostly lean patients, percutaneous closure of PFO under TTE guidance as the only imaging tool appeared effective at midterm follow-up, while avoiding radiation exposure, endotracheal intubation and contrast agent use.

Identification of High-Risk Patent Foramen Ovale Associated With Cryptogenic Stroke: Development of a Scoring System

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.

Percutaneous patent foramen ovale closure during live case demonstrations

BACKGROUND

Live case demonstrations serve as an educational tool for interventional techniques in cardiology. The aim of this study was to assess the safety and technical success of percutaneous patent foramen ovale (PFO) closure during live case demonstrations.

METHODS

All patients who had undergone percutaneous PFO closure with Amplatzer devices during live case demonstrations at our institution were consecutively included in this retrospective analysis. Procedure related events were compared with summary event rates derived from the eight randomized controlled trials (RCTs) investigating PFO closure, as well as with a propensity matched cohort of patients treated under usual conditions.

RESULTS

From April 2004 to June 2015, 142 patients underwent percutaneous PFO closure during live demonstrations, mainly for secondary prevention of cryptogenic cerebrovascular events. The interventions were fluoroscopy guided and successful in all but three cases (2%). Minor adverse events occurred in nine patients (6%). Contrast TEE performed at about 6 months showed complete closure in 84%. No significant differences with regard to technical success and major complications rate were found compared to RCTs, except for an increased rate of minor bleeding observed during live case demonstrations (P for difference < 0.001), mainly attributable to concomitant arterial access for incidental coronary angiography performed in 70% of patients. Except for slightly longer procedure duration, no difference was found compared to a matched population treated under usual conditions.

CONCLUSION

Percutaneous PFO closure can be performed during live case demonstrations with the same high technical success as during routine cases.

Interatrial septum: A pictorial review of congenital and acquired pathologies and their management

There are many different congenital abnormalities and acquired pathologies involving the interatrial septum. Differentiation of these pathologies significantly affects patient management. We have reviewed the various interatrial septal pathologies and discussed their congenital associates, clinical significance, and management. After reading this article, the reader should be able to better characterize the interatrial septal pathologies using the optimal imaging tools, and have a better understanding of their clinical significance and management.

Clinical relevance of atrial septal aneurysm and patent foramen ovale with migraine

AIM

To test the potential association between atrial septal aneurysm (ASA) and migraine in patent foramen ovale (PFO) closure patients through an observational, single-center, case-controlled study.

METHODS

We studied a total of 450 migraineurs who had right-to-left shunts and underwent PFO closure in a retrospective single-center non-randomized registry from February 2012 to October 2016 on the condition that they were aged 18-45 years old. Migraine was diagnosed according to the International Classification of Headache Disorders, 3^rd edition and evaluated using the Headache Impact Test-6 (HIT-6). All patients underwent preoperative transesophageal echocardiography, contrast transthoracic echocardiography, and computed tomography or magnetic resonance imaging examinations, with subsequent fluoroscopy-guided PFO closure. Based on whether they have ASA or not, the patients were divided into two groups: A (PFO with ASA, n = 80) and B (PFO without ASA, n = 370). Baseline characteristics and procedural and follow-up data were reviewed.

RESULTS

Compared to group B, group A had an increased frequency of ischemic lesions (11.3% vs 6.2%, P = 0.038) and migraine with aura (32.5% vs 21.1%, P = 0.040). The PFO size was significantly larger in group A (P = 0.007). There was no significant difference in HIT-6 scores between the two groups before and at the one-year follow-up after the PFO closure [61 (9) vs 63 (9), P = 0.227; 36 (13) vs 36 (10), P = 0.706].

CONCLUSION

Despite its small sample size, our study suggests that the prevalence of ASA in PFO with migraine patients is associated with ischemic stroke, larger PFO size, and migraine with aura.

Management of acute ischemic stroke after pulmonary resection: incidence and efficacy of endovascular thrombus aspiration

OBJECTIVE

We analyzed acute ischemic stroke by thromboembolism in the early period after lung cancer surgery.

METHODS

A retrospective review of the clinical records of patients who underwent lung resection for primary lung cancer was performed. Patients who underwent lobectomy, bilobectomy, and pneumonectomy were included. The clinical characteristics of the patients, the incidence of atrial fibrillation (Af) after surgery, and the incidence of acute ischemic stroke were analyzed. The clinical courses of patients having acute ischemic stroke were also reviewed.

RESULTS

In 4 (0.6%) of 696 patients, acute ischemic stroke occurred in the early period during hospitalization after lung cancer surgery. Acute ischemic stroke occurred within 4 days in three cases and after 4 days in one case. The resection site of the lung was the left side in all cases, and there were three cases of left upper lobectomy and one case of left lower lobectomy. As for the two recent patients, thrombus removal was performed by a neurosurgeon, and both cases achieved successful recanalization. The time between symptom detection and recanalization was 205 and 170 min, respectively. One patient was cured without any residual effect of disease, and the other patient's hemiplegia resolved and aphasia improved.

CONCLUSION

Since cerebral infarction impairs the patient's quality of life, thrombus removal should be considered if possible.

Patent foramen ovale and cryptogenic stroke: contemporary evidence and treatment

INTRODUCTION

Patent foramen ovale (PFO) is a common anatomical variant in the adult circulation. It is a channel allowing communication between the left and right atria and is a remnant of the foetal circulation. In approximately 25% of the population, this channel persists into adulthood. PFO has been proposed as a potential pathophysiological mechanism for cryptogenic stroke. Areas covered: This review will examine the contemporary evidence for both the association between cryptogenic stroke and PFO and the management of this condition. The authors hope to provide a comprehensive overview of the current evidence and best practice in relation to PFO closure. In addition, the authors will propose some potential avenues for future research in this controversial area and try to predict how PFOs in cryptogenic stroke will be managed in the near future. Expert commentary: In carefully selected patients with cryptogenic stroke, PFO closure represents an evidence based treatment option for the prevention of further ischemic neurological events. A multidisciplinary approach is necessary to ensure appropriate patient selection for the procedure. This should include a vascular neurologist/stroke physician and an interventional cardiologist with an interest in PFO closure.

[Atrial septal aneurysm: Evolution of diagnostic and clinical judgements]

The article discusses anatomical and clinical judgements on atrial septal aneurysm (ASA) as a primary cardiac structural abnormality. It presents current approaches to the classification of ASA and its echocardiographic diagnosis. Special attention is focused on the clinical significance of ASA as an isolated anomaly and concurrent with other structural abnormalities of the heart, especially from the standpoint of a risk of cardioembolic stroke.

Percutaneous Intervention to Treat Platypnea-Orthodeoxia Syndrome: The Toronto Experience

OBJECTIVES

This study reviewed a series of patients treated with transcatheter closure of septal defect to treat platypnea-orthodeoxia syndrome, with specific attention to septal characteristics and device choice.

BACKGROUND

Platypnea-orthodeoxia syndrome is an uncommon condition characterized by positional dyspnea and hypoxemia due to intracardiac right-to-left shunting through a patent foramen ovale (PFO), an atrial septal defect, or pulmonary arteriovenous malformations. Percutaneous closure of such defects is the treatment of choice.

METHODS

In this single-center series, 52 patients were treated with percutaneous closure of an interatrial communication after presentation between January 1997 and July 2015. Septal morphology, clinical, procedural, and outcomes data were analyzed.

RESULTS

All patients had a PFO; however, nearly one-quarter required a non-PFO device (11 Amplatzer Septal Occluder and 1 post-infarct muscular VSD), as opposed to a dedicated PFO device to achieve shunt occlusion. These patients were characterized by an aneurysmal septum, shorter primum septum overlap with the secundum septum, and greater septal angulation from the midline. After closure, all demonstrated acute improvements in oxygen saturation (pre-procedure: 81 ± 8%; post-procedure: 95.1 ± 0.5% on room air). Each patient was treated with a single device and no one required re-intervention.

CONCLUSIONS

Patients presenting with platypnea-orthodeoxia syndrome can be treated successfully with a percutaneous intervention often requiring a variety of devices. Those requiring a non-PFO-type device had a greater prevalence of an aneurysmal septum, shorter primum septal overlap with the secundum septum, and greater septal angulation with the midline.

The role of coronary CT angiography in diagnosis of patent foramen ovale

PURPOSE

We aimed to examine the incidence of patent foramen ovale (PFO) and atrial septal aneurysms (ASA) in the Turkish population using coronary computed tomography angiography (CTA); assess the feasibility of coronary CTA for PFO diagnosis by conducting a comparison with transthoracic echocardiography (TTE); and determine the diagnostic role and characteristics of the interatrial tunnel, free flap valve (FFV), and shunts.

METHODS

The present study was conducted retrospectively and included a sample of 782 patients. Coronary CTA results for all patients were evaluated for the following parameters: the presence of PFO, the degree of contrast jet (if present due to PFO), ASA existence, free flap valve (FFV) length, and PFO tunnel diameters (1 and 2). Coronary CTA and TTE results for PFO detection were also compared for 19 patients who underwent both procedures.

RESULTS

PFO was present in 118 patients (15%). In 19 patients who underwent both CTA and TTE, the shunt was present in 15 patients on TTE compared with nine patients on CTA. The sensitivity and specificity of CTA for shunt existence were 53% (8/15) and 75% (3/4), respectively. FFV was observed on CTA in 118 patients (15%). No significant relationship was observed between shunt existence and FFV length (P = 0.148), or between shunt existence and tunnel diameter-1 (P = 0.638) or diameter-2 (P = 0.058). ASAs were present in 16 patients (2%), while accompanying PFO was present in three patients (2.4%).

CONCLUSION

Coronary CTA constitutes a more practical and efficient alternative to TTE for PFO diagnosis. Further, it allows the clear visualization of anatomical details of the interatrial tunnel, shunts, and associated abnormalities and detects ASAs.

Incidental Thrombus in Transit Causing Embolic Stroke

Thrombus in transit leading to paradoxical systemic arterial embolism is a rare echocardiographic finding in patients presenting with embolic stroke. We present a case of a patient who had an atrial thrombus in transit discovered incidentally and later suffered a fatal stroke. Etiologies of cardioembolic stroke and the use of echocardiography in diagnosis and management are briefly discussed.

Association between the maximal distance of atrial septal protrusion and cryptogenic stroke

Background and purpose Previous studies have suggested that atrial septal aneurysm is a potential risk factor for cerebral embolism. However, the association between the level of atrial septal protrusion and cerebral embolism is still unclear. The purpose of the present study was to assess the association between the maximal distance of atrial septal protrusion and cryptogenic stroke. Methods A total of 588 consecutive acute ischemic stroke patients (70 ± 11 (mean ± SD) years, 401 men) who underwent transesophageal echocardiography were enrolled. The maximal distance of atrial septal protrusion into the right or left atrium was measured. Atrial septal aneurysm was diagnosed when the maximal distance of atrial septal protrusion was >10 mm. Cryptogenic stroke was defined as non-lacunar ischemic stroke without >50% proximal artery stenosis or occlusion, cardioembolic sources, ≥4 mm atherosclerotic plaques in the aortic arch, or carotid or vertebral artery dissection. Results The rate of cryptogenic stroke increased with the increasing maximal distance of atrial septal protrusion. The maximal distance of atrial septal protrusion (multivariate-adjusted odds ratio (OR) per 1 mm, 1.14; 95% confidence interval (CI), 1.04-1.24; P = 0.003) and atrial septal aneurysm (multivariate-adjusted OR, 4.32; 95% CI, 1.22-20.39; P = 0.022) was independently associated with cryptogenic stroke. Conclusions The maximal distance of atrial septal protrusion was independently associated with cryptogenic stroke.

Guidelines for the Use of Echocardiography in the Evaluation of a Cardiac Source of Embolism

Embolism from the heart or the thoracic aorta often leads to clinically significant morbidity and mortality due to transient ischemic attack, stroke or occlusion of peripheral arteries. Transthoracic and transesophageal echocardiography are the key diagnostic modalities for evaluation, diagnosis, and management of stroke, systemic and pulmonary embolism. This document provides comprehensive American Society of Echocardiography guidelines on the use of echocardiography for evaluation of cardiac sources of embolism. It describes general mechanisms of stroke and systemic embolism; the specific role of cardiac and aortic sources in stroke, and systemic and pulmonary embolism; the role of echocardiography in evaluation, diagnosis, and management of cardiac and aortic sources of emboli including the incremental value of contrast and 3D echocardiography; and a brief description of alternative imaging techniques and their role in the evaluation of cardiac sources of emboli. Specific guidelines are provided for each category of embolic sources including the left atrium and left atrial appendage, left ventricle, heart valves, cardiac tumors, and thoracic aorta. In addition, there are recommendation regarding pulmonary embolism, and embolism related to cardiovascular surgery and percutaneous procedures. The guidelines also include a dedicated section on cardiac sources of embolism in pediatric populations.

The Presence of a Large Chiari Network in a Patient with Atrial Fibrillation and Stroke

The Chiari network is an embryological remnant found in the right atrium, mostly without any significant pathophysiological consequences. However, several cardiac associations are reported in the literature including supraventricular tachyarrhythmias. We present a case of a 96-year-old body donor with a stroke episode and intermittent atrial fibrillations. The dissection of the heart revealed the presence of an immense Chiari network with a large central thrombus. The role of a Chiari network in the pathogenesis of stroke and pulmonary embolism is discussed.

Atrial septal aneurysm: Prevalence and covariates in adults

BACKGROUND

Atrial septal aneurysm is a localized deformity of interatrial septum, generally at the level of fossa ovalis which protrudes into right or left atrium or both. The purpose of this study was to assess the frequency and covariates of atrial septal aneurysm in adult patients undergoing transthoracic echocardiography in our outpatient clinic.

MATERIALS AND METHODS

From December 2011 to May 2016, 16,570 patients were included in the study. Records of patients were retrospectively analyzed from our previously established database. All cardiovascular examinations and echocardiographical examinations had been done during this period. Briefly, protrusion of interatrial septum more than 15mm into the right or left atrium with an at least 15mm diameter base of interatrial septum confirmed the diagnosis of atrial septal aneurysm.

RESULTS

Atrial septal aneurysm has been documented in 393 patients (2.4%) in our study population. Mild to moderate mitral and aortic valve regurgitation have been demonstrated in 153 (39%) patients and in 61(16%) patients respectively. Sixty one (16%) of patients had the diagnosis of supraventricular arrhythmia of whom 52% underwent radiofrequency ablation procedure.

CONCLUSION

In conclusion we have documented that valvular regurgitation and supraventricular arrhythmias are common concurrent pathologies with atrial septal aneurysm.

Patent foramen ovale and cryptogenic stroke: from studies to clinical practice: Position paper of the Italian Chapter, International Society Cardiovascular Ultrasound

BACKGROUND

Over the last two decades the interest on patent foramen ovale (PFO) as a cause of cardioembolism in cryptogenic stroke has tremendously increased, thanks to the availability of better techniques to diagnose cardiac right-to-left shunt by ultrasounds and of percutaneous means of PFO treatment with interventional techniques. Many studies have been published that have attempted to define diagnostic methodology, prognosis, and optimal treatment (pharmacological or percutaneous closure) of PFO patients with cryptogenic stroke. Unfortunately, even today, definitive evidence is still lacking, and clinical management is not consistent among cardiologists.

AIMS

This review aims to evaluate the role of PFO in cryptogenic stroke, the diagnostic accuracy of transcranial Doppler, contrast transthoracic and transesophageal echocardiography in the diagnosis of left-fright shunt and PFO; and discuss the indications to medical treatment and percutaneous closure of PFO.

METHODS

All studies published in the literature on PFO and cryptogenic stroke are considered and discussed.

RESULTS

We define an appropriate diagnostic and clinical management of PFO patients with cryptogenic stroke.

CONCLUSION

After many years of interest on PFO and many concluded studies, there are still no definitive data. However, we are on good track for an appropriate management of PFO patients and cryptogenic stroke.

Behçet’s disease and cardiovascular involvement

Behcet’s disease (BD) is a multisystem disease of unknown etiology characterized by chronic relapsing orogenital ulcers, uveitis and systemic involvement including articular, gastrointestinal, cardiopulmonary, neurological and vascular pathology. The incidence and nature of cardiac involvement are not clearly elucidated. Cardiovascular manifestations have been reported in 7-46% of patients and mortality occurs in up to 20% of those patients with marked vascular involvement. Sporadic cases of endocarditis, myocarditis, pericarditis, acute myocardial infarction, aortic aneurysm, ventricular thrombosis, congestive cardiomyopathy and valvular dysfunction have been reported. This review discusses the general aspects of the pathogenic mechanisms and clinical features cardiovascular involvement in BD, and provides the data of cardiovascular involvement in a cohort of Italian BD patients.

Morphological study of fossa ovalis and its clinical relevance

AIMS

Patent foramen ovale (PFO) has been implicated in the etiology of a number of different pathologies, including cryptogenic stroke, decompression sickness in divers, etc. It can act as a channel for paradoxical embolism. PFO is not an uncommon condition, with a probe-patency in 15-35% population. The fossa ovalis (FOv) varies in size and shape from heart to heart; the prominence of annulus FOv also varies. The entire FOv may be redundant and aneurysmal. The anatomico-functional characterization of interatrial septum seems to be of paramount importance for both atrial septal defect (ASD) and PFO, not only for the device selection, but also for the evaluation of the outcome of this procedure.

METHOD

This study was conducted in 50 apparently normal hearts available in Department of Anatomy. After opening the right atrium, the shape of FOv was observed. The size was measured with the digital vernier caliper; the prominence and extent of limbus, and the redundancy or otherwise of FOv were noted; probe patency was confirmed.

RESULTS

In the majority, FOv was oval (82%); average transverse diameter was 14.53mm and vertical 12.60mm. In 90%, the rim of the annulus was raised; in 20%, a recess was found deep to the margin of the annulus; and 18% showed probe patency.

CONCLUSION

As no study of this nature has been carried out in the Indian population, this provides pertinent information on the morphology of FOv, which may be useful for device selection in treating ASD and PFO.

Transient cerebral ischemia in an elderly patient with patent foramen ovale and atrial septal aneurysm

Cerebrovascular disease is one of the most common causes of cerebrovascular morbidity and mortality in developed countries; up to 40% of acute ischemic strokes in young adults are cryptogenic in nature – that is, no cause is determined. However, in more than half of these patients, patent foramen ovale (PFO) is seen along with an increased incidence of atrial septal aneurysm (ASA). The following is a report of an interesting case: a 68-year-old man with ASA and transient cerebral ischemia. Transesophageal echocardiography (TEE) showed the presence of ASA; a test with microbubbles derived from a mixture of air and saline or colloids pointed out a shunt on the foramen ovale following Valsalva’s maneuver. The patient underwent percutaneous transcatheter closure of the interatrial communication by an interventional cardiologist. TEE and transcranial Doppler or TEE with the microbubbles test are the recommended methods for detecting and quantifying intracardiac shunts, both at rest and following Valsalva’s maneuver. In patients following the first event of transient ischemic attack, and without clinical and anatomical risk factors (such as the presence of ASA, PFO, and basal shunt), pharmacological treatment with antiplatelets or anticoagulants is closely recommended. On the contrary, in patients following the first event of transient ischemic attack, or a recurrent event during antiplatelet treatment, the percutaneous closure of PFO is recommended.

Patent foramen ovale treatment strategy: an Italian large prospective study

AIM

There is still controversy regarding the benefit of percutaneous closure of patent foramen ovale (PFO) among patients with cryptogenic stroke. Here we aimed to evaluate the factors associated with treatment choice and predictors of adverse events in patients with cryptogenic stroke or transient ischemic attack (TIA) and PFO.

METHODS

Of 418 consecutive patients with PFO and cryptogenic stroke or TIA, 262 underwent percutaneous PFO closure, whereas 156 were medically treated. Multivariable logistic regression models were developed to evaluate factors influencing the treatment strategy and predictors of outcome, a composite of stroke, TIA or all-cause mortality.

RESULTS

Patients with large interatrial right-to-left shunt were more likely treated with percutaneous closure [odds ratio (OR) = 4.79, 95% confidence interval (2.73-8.42); P < 0.0001], whereas those with multiple cerebrovascular accident (CVA) risk factors were more likely treated medically [OR = 0.15 (0.03-0.60); P = 0.023]. Age greater than 55 years [OR = 2.70 (1.05-6.88); P = 0.04], previous CVAs [OR = 2.49 (1.03-6.02); P = 0.02] and atrial septal aneurism [ASA, OR = 2.64 (1.09-6.39); P = 0.02], but not percutaneous closure of PFO [OR = 1.10 (0.44-2.74); P = 0.81], were independent predictors of outcome.

CONCLUSION

Among patients with cryptogenic stroke and PFO, the presence of large interatrial right-to-left shunt and multiple CVA risk factors influenced the treatment choice. Older age, multiple previous CVAs and ASA, but not PFO closure, independently predicted the composite outcome of cryptogenic stroke, TIA or all-cause mortality.

At the Heart of the Matter

Echocardiography is an excellent method for evaluating cardiac morphology and dynamic function. It has a long history of innovative thinking mixed with some degree of serendipity. Its early applications were as a tool to evaluate the mitral valve, left ventricular characteristics, and pericardial effusion. Today it has evolved into a robust modality that allows for a very wide range cardiac interrogation, able to evaluate the valves, chambers, myocardium, and pericardium. The practice of echocardiography also is often separate from that of general or vascular sonography. The objective of this article is to provide the non–cardiac sonographer with an overview and appreciation of the basic principles and practices of echocardiography. It is not meant as a guide to scanning but rather, as a vehicle to spark the interest and imagination of the reader.