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Becchetti C, De Nicola S, Gallo C, Perricone G, Annoni G, Solcia M, Musca F, Alfonsi A, Morelli F, Barbosa F, Brambillasca PM, Rampoldi A, Airoldi A, Belli LS. Transjugular intrahepatic portosystemic shunt in patients with splanchnic vein thrombosis: Prevalence and management of patent foramen ovale. Liver Int 2024; 44:2458-2468. [PMID: 39205449 DOI: 10.1111/liv.16013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 06/07/2024] [Accepted: 06/09/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND AND AIMS Transjugular intrahepatic portosystemic shunt (TIPS) is an established procedure for the treatment of several complications of portal hypertension (PH), including non-neoplastic portal vein thrombosis (PVT). Selection criteria for TIPS in PVT are not yet well established. Despite anecdotal, cases of thromboembolic events from paradoxical embolism due to the presence of patent foramen ovale (PFO) after TIPS placement have been reported in the literature. Therefore, we aimed at describing our experience in patients with non-neoplastic splanchnic vein thrombosis (SVT) who underwent TIPS following PFO screening. METHODS We conducted a single-centre retrospective study, including consecutive patients who underwent TIPS for the complications of cirrhotic and non-cirrhotic portal hypertension (NCPH) and having SVT. RESULTS Of 100 TIPS placed in patients with SVT, 85 patients were screened for PFO by bubble-contrast transthoracic echocardiography (TTE) with PFO being detected in 22 (26%) cases. PFO was more frequently detected in patients with non-cirrhotic portal hypertension (NCPH) (23% in the PFO group vs. 6% in those without PFO, p = .04) and cavernomatosis (46% in the PFO group vs. 19% in those without PFO, p = .008). Percutaneous closure was effectively performed in 11 (50%) after multidisciplinary evaluation of anatomical and clinical features. No major complications were observed following closure. CONCLUSIONS PFO screening and treatment may be considered feasible for patients with SVT who undergo TIPS placement.
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Affiliation(s)
- Chiara Becchetti
- Hepatology and Gastroenterology Unit, ASST GOM Niguarda, Milan, Italy
| | - Stella De Nicola
- Division of Internal Medicine and Hepatology, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Camilla Gallo
- Hepatology and Gastroenterology Unit, ASST GOM Niguarda, Milan, Italy
- Division of Gastroenterology, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | | | | | - Marco Solcia
- Interventional Radiology Unit, ASST GOM Niguarda, Milan, Italy
| | - Francesco Musca
- Cardiology Division, De Gasperis Cardio Center, ASST GOM Niguarda, Milan, Italy
| | - Angela Alfonsi
- Interventional Radiology Unit, ASST GOM Niguarda, Milan, Italy
| | | | - Fabiane Barbosa
- Interventional Radiology Unit, ASST GOM Niguarda, Milan, Italy
| | | | | | - Aldo Airoldi
- Hepatology and Gastroenterology Unit, ASST GOM Niguarda, Milan, Italy
| | - Luca S Belli
- Hepatology and Gastroenterology Unit, ASST GOM Niguarda, Milan, Italy
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Constant dit Beaufils P, Plessis J, Guillon B. Brain abscess and heart: the phantom menace? Eur J Neurol 2024; 31:e16315. [PMID: 38651590 PMCID: PMC11235780 DOI: 10.1111/ene.16315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Revised: 04/05/2024] [Accepted: 04/08/2024] [Indexed: 04/25/2024]
Affiliation(s)
| | - Julien Plessis
- CHU Nantes, Cardiology Department, l'institut du thoraxNantes UniversitéNantesFrance
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Caso V, Turc G, Abdul-Rahim AH, Castro P, Hussain S, Lal A, Mattle H, Korompoki E, Søndergaard L, Toni D, Walter S, Pristipino C. European Stroke Organisation (ESO) Guidelines on the diagnosis and management of patent foramen ovale (PFO) after stroke. Eur Stroke J 2024:23969873241247978. [PMID: 38752755 DOI: 10.1177/23969873241247978] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2024] Open
Abstract
Patent foramen ovale (PFO) is frequently identified in young patients with cryptogenic ischaemic stroke. Potential stroke mechanisms include paradoxical embolism from a venous clot which traverses the PFO, in situ clot formation within the PFO, and atrial arrhythmias due to electrical signalling disruption. The purpose of this guideline is to provide recommendations for diagnosing, treating, and long-term managing patients with ischaemic stroke and PFO. Conversely, Transient Ischaemic Attack (TIA) was not considered an index event in this context because only one RCT involved TIA patients. However, this subgroup analysis showed no significant differences between TIA and stroke outcomes. The working group identified questions and outcomes, graded evidence, and developed recommendations following the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach and the European Stroke Organisation (ESO) standard operating procedure for guideline development. This document underwent peer-review by independent experts and members of the ESO Guideline Board and Executive Committee. The working group acknowledges the current evidentiary gap in delineating an unequivocal diagnostic algorithm for the detection of PFO. Although transoesophageal echocardiography is conventionally held as the most accurate diagnostic tool for PFO identification, its status as the 'gold standard' remains unsubstantiated by rigorously validated evidence. We found high-quality evidence to recommend PFO closure plus antiplatelet therapy in selected patients aged 18-60 years in whom no other evident cause of stroke is found but a PFO (i.e. PFO-associated stroke). The PASCAL classification system can be used to select such candidates for PFO closure. Patients with both a large right-to-left shunt and an atrial septal aneurysm benefit most from PFO closure. There is insufficient evidence to make an evidence-based recommendation on PFO closure in patients older than 60 and younger than 18 years. We found low quality evidence to suggest against PFO closure in patients with unlikely PFO-related stroke according to the PASCAL classification, except in specific scenarios (Expert Consensus). We suggest against long-term anticoagulation in patients with PFO-associated stroke unless anticoagulation is indicated for other medical reasons. Regarding the long-term AF monitoring after PFO closure, the working group concluded that there remains significant uncertainty regarding the risks and benefits associated with the use of long-term cardiac monitoring, such as implantable loop recorders. This document provides additional guidance, in the form of evidence-based recommendations or expert consensus statements, on diagnostic methods for PFO detection, and medical management after PFO closure.
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Affiliation(s)
- Valeria Caso
- Stroke Unit, Santa Maria della Misericordia Hospital-University of Perugia, Santa Maria della Misericordia Hospital -University of Perugia, Perugia, Italy
| | - Guillaume Turc
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences, Université de Paris, INSERM U1266, FHU NeuroVasc, Paris, France
| | - Azmil H Abdul-Rahim
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Stroke Division, Department of Medicine for Older People, Whiston Hospital, Mersey and West Lancashire Teaching Hospitals NHS Trust, Prescot, UK
| | - Pedro Castro
- Department of Neurology, Centro Hospitalar Universitário de São João Faculty of Medicine University of Porto, Porto, Portugal
| | | | - Avtar Lal
- European Stroke Organisation, Basel, Switzerland
| | - Heinrich Mattle
- Department of Neurology, Inselspital, University of Bern, Bern, Switzerland
| | - Eleni Korompoki
- Department of Clinical Therapeutics National and Kapodistrian University of Athens Alexandra Hospital Athens, Greece
| | | | - Danilo Toni
- Hospital Policlinico Umberto I, Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Silke Walter
- Department of Neurology, Saarland University, Homburg, Germany
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Thong EHE, Kong WKF, Poh KK, Wong R, Chai P, Sia CH. Multimodal Cardiac Imaging in the Assessment of Patients Who Have Suffered a Cardioembolic Stroke: A Review. J Cardiovasc Dev Dis 2023; 11:13. [PMID: 38248883 PMCID: PMC10816708 DOI: 10.3390/jcdd11010013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 12/21/2023] [Accepted: 12/27/2023] [Indexed: 01/23/2024] Open
Abstract
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.
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Affiliation(s)
| | - William K. F. Kong
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore; (W.K.F.K.); (K.-K.P.); (R.W.); (P.C.)
| | - Kian-Keong Poh
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore; (W.K.F.K.); (K.-K.P.); (R.W.); (P.C.)
| | - Raymond Wong
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore; (W.K.F.K.); (K.-K.P.); (R.W.); (P.C.)
| | - Ping Chai
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore; (W.K.F.K.); (K.-K.P.); (R.W.); (P.C.)
| | - Ching-Hui Sia
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore; (W.K.F.K.); (K.-K.P.); (R.W.); (P.C.)
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Chaturvedi A, Moroni F, Axline M, Tomdio A, Mojadidi MK, Gertz Z. Comparative evaluation of intracardiac, transesophageal, and transthoracic echocardiography in the assessment of patent foramen ovale: A retrospective single-center study. Catheter Cardiovasc Interv 2023; 102:1348-1356. [PMID: 37681474 DOI: 10.1002/ccd.30825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 08/18/2023] [Accepted: 08/24/2023] [Indexed: 09/09/2023]
Abstract
INTRODUCTION Certain patent foramen ovale (PFO) characteristics, such as a large right-to-left shunt (RLS) or atrial septal aneurysm, identify patients who may receive the highest clinical benefit from percutaneous PFO closure. This study aimed to compare intracardiac echocardiography (ICE) with standard echocardiographic imaging in the evaluation of high-risk PFO characteristics and RLS severity in patients with PFO-associated stroke. METHODS We conducted a retrospective review of all patients aged ≥18 years who underwent percutaneous PFO closure for PFO-associated stroke and received all three ultrasound-based cardiac imaging modalities and had interpretable results (N = 51). We then compared RLS severity, high-risk PFO characteristics, and the proportion of patients with a higher likelihood of PFO-associated stroke by ICE versus transthoracic echocardiogram (TTE) and transesophageal echocardiogram (TEE). RESULTS The final cohort had a mean (±SE) age of 48.4 (±1.8) years and was predominantly female (58.8%). ICE was more likely to identify a large RLS versus TTE/TEE combined (66.7% vs. 45.1%; p = 0.03). The use of ICE resulted in significantly more patients being reclassified as having a higher likelihood of PFO-associated stroke (TTE vs. TEE vs. ICE: 10.4% vs. 14.6% vs. 25%; p = 0.03). A high-quality bubble study was found to be the single most important factor associated with identifying a larger RLS across all modalities (ρ [p]; TTE: 0.49 [<0.001], TEE: 0.60 [<0.001], ICE: 0.32 [0.02]). The presence of a hypermobile septum was associated with significantly greater RLS on ICE (ρ [p]: 0.3 [0.03]), especially with poor quality bubble studies (ρ [p]: 0.49 [0.02]). CONCLUSION In this observational study of patients with PFO-associated stroke, ICE detected a large RLS more frequently than TTE and TEE; and reclassified some patients as having a higher likelihood of PFO-associated stroke.
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Affiliation(s)
- Abhishek Chaturvedi
- Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Francesco Moroni
- Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Michael Axline
- Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Anna Tomdio
- Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Mohammad K Mojadidi
- Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Zachary Gertz
- Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA
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Mahtani AU, Thirunavukkarasu G, Patwa K, Mahmoud M, Grodman R. Visualized Embolization of Inferior Vena Cava Thrombus During the Abdominal Compression Maneuver to Evaluate for a Patent Foramen Ovale. CASE (PHILADELPHIA, PA.) 2023; 7:416-420. [PMID: 37970481 PMCID: PMC10635878 DOI: 10.1016/j.case.2023.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2023]
Abstract
•IVC compression is an alternative to Valsalva to confirm the presence of a PFO. •A drawback of this method is reduced IVC compression in obese patients. •Use with caution in patients with low cardiac output and gastrointestinal diseases. •No complications while performing this maneuver have been reported. •We report visualized thrombus in the RA during the IVC compression maneuver.
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Affiliation(s)
- Arun Umesh Mahtani
- Department of Medicine, Richmond University Medical Center/Mount Sinai, Staten Island, New York
| | - Ganesh Thirunavukkarasu
- Department of Cardiology, State University New York Downstate Medical Center, Brooklyn, New York
| | - Karishma Patwa
- Department of Cardiology, State University New York Downstate Medical Center, Brooklyn, New York
| | - Mahmoud Mahmoud
- Department of Radiology, Richmond University Medical Center/Mount Sinai, Staten Island, New York
| | - Richard Grodman
- Department of Cardiology, Richmond University Medical Center/Mount Sinai, Staten Island, New York
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Kataoka A, Kito K, Shirakura K, Katayama T, Kozuma K. Increasing Venous Return Blood Flow to the Right Atrium Using the Party Balloon Inflation Maneuver. JACC Case Rep 2023; 22:101997. [PMID: 37790771 PMCID: PMC10544291 DOI: 10.1016/j.jaccas.2023.101997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 07/27/2023] [Indexed: 10/05/2023]
Abstract
The party balloon inflation maneuver increases intrathoracic pressure, decreases venous return, and after release enhances venous return to the right atrium more effectively than does the conventional Valsalva maneuver. Therefore, it shows potential for more effective detection of right-to-left shunts in patients with a patent foramen ovale. (Level of Difficulty: Intermediate.).
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Affiliation(s)
- Akihisa Kataoka
- Division of Cardiology, Department of Internal Medicine, Teikyo University, Tokyo, Japan
| | - Kento Kito
- Division of Cardiology, Department of Internal Medicine, Teikyo University, Tokyo, Japan
| | - Kazuyo Shirakura
- Department of Clinical Laboratory, Teikyo University, Tokyo, Japan
| | - Taiga Katayama
- Division of Cardiology, Department of Internal Medicine, Teikyo University, Tokyo, Japan
| | - Ken Kozuma
- Division of Cardiology, Department of Internal Medicine, Teikyo University, Tokyo, Japan
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Song JK. Pearls and Pitfalls in the Transesophageal Echocardiographic Diagnosis of Patent Foramen Ovale. J Am Soc Echocardiogr 2023; 36:895-905.e3. [PMID: 37196905 DOI: 10.1016/j.echo.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 05/01/2023] [Accepted: 05/02/2023] [Indexed: 05/19/2023]
Abstract
Large randomized controlled trials have shown the benefits of percutaneous closure of patent foramen ovale (PFO) in patients with cryptogenic stroke and PFO. Recent studies have highlighted the clinical significance and prognostic implication of various anatomical features of PFO and the adjacent atrial septum, such as atrial septal aneurysm (ASA), PFO size, large shunt, and hypermobility. Transthoracic echocardiography with contrast study is used for the indirect diagnosis of PFO, as it reveals the passage of the contrast into the left atrium. In contrast, transesophageal echocardiography (TEE) offers a direct demonstration of PFO by measuring its size using the maximum separation distance between the septum primum and septum secundum. Furthermore, TEE enables the acquisition of detailed anatomical features of the adjacent atrial septum including ASA, hypermobility, and PFO tunnel length, which carry significant prognostic implications. Transesophageal echocardiography also facilitates the diagnosis of pulmonary arteriovenous malformation, a relatively rare cause of paradoxical embolism. This review provides evidence for supporting TEE as a useful screening test for patients with cryptogenic stroke to identify suitable candidates for percutaneous device closure of PFO. Additionally, cardiac imaging specialists with proficiency in comprehensive TEE examination should be part of the heart-brain team for proper evaluation of and decision-making in patients with cryptogenic stroke.
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Affiliation(s)
- Jae-Kwan Song
- Professor of Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.
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Meschia JF. Diagnostic Evaluation of Stroke Etiology. Continuum (Minneap Minn) 2023; 29:412-424. [PMID: 37039402 DOI: 10.1212/con.0000000000001206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
OBJECTIVE Precise therapies require precise diagnoses. This article provides an evidence-based approach to confirming the diagnosis of ischemic stroke, characterizing comorbidities that provide insights into the pathophysiologic mechanisms of stroke, and identifying targets for treatment to optimize the prevention of recurrent stroke. LATEST DEVELOPMENTS Identifying the presence of patent foramen ovale, intermittent atrial fibrillation, and unstable plaque is now routinely included in an increasingly nuanced workup in patients with stroke, even as ongoing trials seek to clarify the best approaches for treating these and other comorbidities. Multicenter trials have demonstrated the therapeutic utility of patent foramen ovale closure in select patients younger than age 60 years. Insertable cardiac monitors detect atrial fibrillation lasting more than 30 seconds in about one in ten patients monitored for 12 months following a stroke. MRI of carotid plaque can detect unstable plaque at risk of being a source of cerebral embolism. ESSENTIAL POINTS To optimize the prevention of recurrent stroke, it is important to consider pathologies of intracranial and extracranial blood vessels and of cardiac structure and rhythm as well as other inherited or systemic causes of stroke. Some aspects of the stroke workup should be done routinely, while other components will depend on the clinical circumstances and preliminary testing results.
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Zhu J, Chen A, Zhu L, Li Y, Tang Y, Huang Y, Shen H, Jiang Z, Liu X. Calf muscle pump tensing as a novel maneuver to improve the diagnostic performance of detecting patent foramen ovale during transesophageal echocardiography. Front Neurol 2023; 14:1116764. [PMID: 36761345 PMCID: PMC9905729 DOI: 10.3389/fneur.2023.1116764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 01/05/2023] [Indexed: 01/26/2023] Open
Abstract
Objective The Valsalva maneuver is the most sensitive provocative maneuver for patent foramen ovale detection. However, nearly half of patients are unable to perform the Valsalva maneuver well. The aim of this study was to investigate the mechanism of action of calf muscle pump tensing (TENSE) as a novel patent foramen ovale (PFO) provocative maneuver and to evaluate the diagnostic value for PFO and the effect on right-to-left shunt volume compared with the Valsalva maneuver. Methods This study prospectively investigated 171 patients who were highly suspected to have PFO clinically. Five patients with atrial septal defects newly diagnosed on transesophageal echocardiography (TEE) were excluded. 166 patients were injected with agitated saline under three provocative maneuvers: Valsalva maneuver, TENSE, and Valsalva + TENSE combined maneuver. The patients were divided into the effective Valsalva group (n = 93) and ineffective Valsalva group (n = 73) according to whether they could perform an effective Valsalva maneuver. TENSE consisted of the straightening of both lower limbs, and when the right atrium was filled with microbubbles, the patient performed instantaneous ankle dorsiflexion movements while maintaining dorsiflexion for 3-5 s. Results Overall, the PFO detection rate of the Valsalva + TENSE combined maneuver (78 [50.1%]) was significantly higher than that of the Valsalva maneuver (51 [30.7%]) and TENSE maneuver (57 [34.3%]) (P < 0.001). In the patients who were able to perform an effective Valsalva maneuver, the PFO detection rate by TENSE was not significantly different from that by the Valsalva maneuver (Valsalva 37/93 [39.8%] vs. TENSE 31/93 [33.3%], P > 0.05), while for the patients who performed an ineffective Valsalva maneuver, the PFO detection rate by the TENSE maneuver was higher than that by the Valsalva maneuver (TENSE 26/73 [35.6%] vs. Valsalva14/73[19.2%], P = 0.017). Conclusion TENSE is a simple and effective provocative maneuver in the diagnosis of PFO using TEE and can assist the Valsalva maneuver. For patients who cannot perform an effective Valsalva maneuver, TENSE can be an alternative to the Valsalva maneuver to some extent.
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White Matter Lesions Predominantly Located in Deep White Matter Represent Embolic Etiology Rather Than Small Vessel Disease. Dement Neurocogn Disord 2023; 22:28-42. [PMID: 36814699 PMCID: PMC9939570 DOI: 10.12779/dnd.2023.22.1.28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 01/15/2023] [Accepted: 01/28/2023] [Indexed: 02/17/2023] Open
Abstract
Background and Purpose We investigated the correlation between the deep distribution of white matter hyperintensity (WMH) (dWMH: WMH in deep and corticomedullary areas, with minimal periventricular WMH) and a positive agitated saline contrast echocardiography result. Methods We retrospectively recruited participants with comprehensive dementia evaluations, an agitated saline study, and brain imaging. The participants were classified into two groups according to WMH-distributions: dWMH and dpWMH (mainly periventricular WMH with or without deep WMH.) We hypothesized that dWMH is more likely associated with embolism, whereas dpWMH is associated with small-vessel diseases. We compared the clinical characteristics, WMH-distributions, and positive rate of agitated saline studies between the two groups. Results Among 90 participants, 27 and 12 met the dWMH and dpWMH criteria, respectively. The dWMH-group was younger (62.2±7.5 vs. 78.9±7.3, p<0.001) and had a lower prevalence of hypertension (29.6% vs. 75%, p=0.008), diabetes mellitus (3.7% vs. 25%, p=0.043), and hyperlipidemia (33.3% vs. 83.3%, p=0.043) than the dpWMH-group. Regarding deep white matter lesions, the number of small lesions (<3 mm) was higher in the dWMH-group(10.9±9.7) than in the dpWMH-group (3.1±6.4) (p=0.008), and WMH was predominantly distributed in the border-zones and corticomedullary areas. Most importantly, the positive agitated saline study rate was higher in the dWMH-group than in the dpWMH-group (81.5% vs. 33.3%, p=0.003). Conclusions The dWMH-group with younger participants had fewer cardiovascular risk factors, showed more border-zone-distributions, and had a higher agitated saline test positivity rate than the dpWMH-group, indicating that corticomedullary or deep WMH-distribution with minimal periventricular WMH suggests embolic etiologies.
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Katsianos E, Oikonomou E, Kalogeras K, Manousaki A, Kalantzis C, Pantelidis P, Vavuranakis MA, Aggeli K, Siasos G, Tsioufis C, Vavuranakis M. Residual Right-to-Left-Shunt Following Transcatheter Patent Foramen Ovale Closure: The Role of Antithrombotic Treatment. Curr Pharm Des 2022; 28:3305-3312. [PMID: 36306457 DOI: 10.2174/1381612829666221028095839] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 09/26/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND Transcatheter closure of patent foramen ovale (PFO) is a highly effective therapy for patients with left circulation thromboembolism, not attributable to other conditions. OBJECTIVES This retrospective cohort study investigates the impact of baseline foramen ovale anatomy on the severity of the postclosure shunt. METHODS Patients with PFO, who underwent percutaneous closure, were followed up for at least 5 years postimplantation. Patients were classified into two groups based on the presence of high-risk features of the baseline PFO anatomy. At the follow-up follow-up, residual right-to-left shunt was assessed for the high and non-highrisk anatomy groups, via transcranial Doppler at rest and after performing the Valsalva maneuver, with the injection of agitated saline. RESULTS 38 patients were examined after a mean follow-up period of 9 ± 3 years after implantation. After retrospective evaluation of the baseline transthoracic and transesophageal echo studies, 14 patients with high-risk PFO anatomy were identified. The degree of the residual right-to-left shunt, as assessed by the number of microbubbles was higher in the high-risk PFO anatomy group compared to the non-high-risk group, both at rest [1.50 (IQR: 0.00-3.25) vs. 0.00 (IQR: 0.00-0.00), p < 0.001] and post-Valsalva maneuver [7.50 (IQR: 1.50- 10.25) vs. 0.00 (IQR: 0.00-3.75), p = 0.003]. Furthermore, in the high-risk group, more microbubbles were detected at rest (p = 0.008) and post-Valsalva (p = 0.002) in subjects without antiplatelet treatment compared to subjects on prolonged antiplatelet therapy. CONCLUSION Baseline PFO anatomy affects the severity of the residual right-to-left shunt. Prolonged antiplatelet therapy may benefit patients with high-risk anatomical features.
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Affiliation(s)
- Efstratios Katsianos
- 3rd Cardiology Clinic, National and Kapodistrian University of Athens, Medical School, Sotiria Chest Disease Hospital, Athens. Greece
| | - Evangelos Oikonomou
- 3rd Cardiology Clinic, National and Kapodistrian University of Athens, Medical School, Sotiria Chest Disease Hospital, Athens. Greece.,1st Cardiology Clinic, National and Kapodistrian University of Athens, Medical School, "Hippokration" General Hospital, Athens, Greece
| | - Konstantinos Kalogeras
- 3rd Cardiology Clinic, National and Kapodistrian University of Athens, Medical School, Sotiria Chest Disease Hospital, Athens. Greece
| | - Alexandra Manousaki
- 1st Cardiology Clinic, National and Kapodistrian University of Athens, Medical School, "Hippokration" General Hospital, Athens, Greece
| | - Charalambos Kalantzis
- 1st Cardiology Clinic, National and Kapodistrian University of Athens, Medical School, "Hippokration" General Hospital, Athens, Greece
| | - Panteleimon Pantelidis
- 3rd Cardiology Clinic, National and Kapodistrian University of Athens, Medical School, Sotiria Chest Disease Hospital, Athens. Greece
| | | | - Konstantina Aggeli
- 3rd Cardiology Clinic, National and Kapodistrian University of Athens, Medical School, Sotiria Chest Disease Hospital, Athens. Greece
| | - Gerasimos Siasos
- 3rd Cardiology Clinic, National and Kapodistrian University of Athens, Medical School, Sotiria Chest Disease Hospital, Athens. Greece.,1st Cardiology Clinic, National and Kapodistrian University of Athens, Medical School, "Hippokration" General Hospital, Athens, Greece
| | - Costas Tsioufis
- 1st Cardiology Clinic, National and Kapodistrian University of Athens, Medical School, "Hippokration" General Hospital, Athens, Greece
| | - Manolis Vavuranakis
- 3rd Cardiology Clinic, National and Kapodistrian University of Athens, Medical School, Sotiria Chest Disease Hospital, Athens. Greece.,1st Cardiology Clinic, National and Kapodistrian University of Athens, Medical School, "Hippokration" General Hospital, Athens, Greece
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13
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Fordyce AM, Whalley GA, Coffey S, Wilson LC. Adjunct Methods for the Detection of Patent Foramen Ovale: The Contribution of Transcranial Doppler and the Valsalva Manoeuvre. Heart Lung Circ 2022; 31:1471-1481. [PMID: 36038470 DOI: 10.1016/j.hlc.2022.07.017] [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: 03/05/2022] [Revised: 07/14/2022] [Accepted: 07/28/2022] [Indexed: 11/16/2022]
Abstract
A patent foramen ovale (PFO) is present in 25% of the population. In some patients, especially those without traditional stroke risk factors and with no immediately apparent cause, a cryptogenic stroke may be caused by an embolus passing through the PFO to the systemic circulation. The identification, or indeed exclusion, of a PFO is sought in these patients, most commonly using contrast-enhanced transthoracic or transoesophageal echocardiography. Another method for detecting a PFO is transcranial Doppler, which allows the detection of PFO possibly without the need for an echo laboratory, and with arguably improved sensitivity. This review will focus on transcranial Doppler detection of PFO, with a brief summary of echocardiographic techniques and the use of ultrasound contrast agents, and the role of provocations to increase diagnostic accuracy, specifically the Valsalva manoeuvre. We discuss the phases alongside the direct and indirect signs of an adequate Valsalva manoeuvre.
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Affiliation(s)
- Andrew M Fordyce
- Department of Medicine, University of Otago, Dunedin, New Zealand. http://www.twitter.com/AFordyceOtago
| | - Gillian A Whalley
- Department of Medicine, University of Otago, Dunedin, New Zealand. http://www.twitter.com/GWhalleyPhD
| | - Sean Coffey
- Department of Medicine, University of Otago, Dunedin, New Zealand; Southern District Health Board, New Zealand. http://www.twitter.com/DrSeanCoffey
| | - Luke C Wilson
- Department of Medicine, University of Otago, Dunedin, New Zealand.
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14
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Application of Transesophageal Echocardiography in Amplatzer Atrial Septal Defect Occluder for Percutaneous Closure of Large Patent Foramen Ovale. Cardiovasc Ther 2022; 2022:3226080. [PMID: 35936794 PMCID: PMC9337921 DOI: 10.1155/2022/3226080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 06/07/2022] [Accepted: 06/21/2022] [Indexed: 11/17/2022] Open
Abstract
Objective. The Amplatzer patent foramen ovale (PFO) occluder is the most commonly used device for percutaneous closure of a large PFO. However, its use may predispose the patient to postoperative residual shunting. To reduce the incidence of residual shunting, we investigated the safety and effectiveness of the Amplatzer atrial septal defect (ASD) occluder for percutaneous closure of a large PFO measured by transesophageal echocardiography (TEE) and evaluated the value of TEE in this procedure. Methods. Overall, 118 patients who were diagnosed with a large PFO (all with
mm left atrial side height after the Valsalva maneuver (VM) excluding those with a small ASD) using contrast transthoracic echocardiography (c-TTE) and TEE underwent closure under TEE guidance at The First Affiliated Hospital of Xi’an Jiaotong University. An ASD device was used in 48 patients (group I) and a PFO device in 70 (group II). After the procedure, we verified the safety and efficacy of different devices using c-TTE, TTE, and TEE. Results. In both groups, the preoperative TEE results showed a significantly increased left height of the PFO after VM compared with that at rest (all
). Compared with the left height of the PFO measured using TEE after VM, the PFO-stretch diameter (SD) measured by TEE after the delivery sheath passed the PFO was higher (all
). We selected the ASD occluder size according to this PFO-SD. In group II, most patients underwent the implantation of the larger PFO devices. Interventional treatment was successfully performed on all patients. The effective occlusion rate in group I at 12 months after the procedure was significantly higher than that in group II (93.7% vs. 78.6%,
). The TEE results showed that 18 patients with a medium and large residual shunt at 12 months after the procedure exhibited an intradisc tunnel-like shunt. Conclusion. The Amplatzer ASD device and Amplatzer PFO device are safe for large PFO closure, but the Amplatzer ASD device has a higher effective occlusion rate. TEE plays a crucial role in the use of the Amplatzer ASD occluder for percutaneous closure of a large PFO.
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15
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The Patent Foramen Ovale and Migraine: Associated Mechanisms and Perspectives from MRI Evidence. Brain Sci 2022; 12:brainsci12070941. [PMID: 35884747 PMCID: PMC9313384 DOI: 10.3390/brainsci12070941] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 07/10/2022] [Accepted: 07/15/2022] [Indexed: 02/04/2023] Open
Abstract
Migraine is a common neurological disease with a still-unclear etiology and pathogenesis. Patent foramen ovale (PFO) is a kind of congenital heart disease that leads to a right-to-left shunt (RLS). Although previous studies have shown that PFO has an effect on migraine, a clear conclusion about the link between PFO and migraine is lacking. We first summarized the PFO potential mechanisms associated with migraine, including microembolus-triggered cortical spreading depression (CSD), the vasoactive substance hypothesis, impaired cerebral autoregulation (CA), and a common genetic basis. Further, we analyzed the changes in brain structure and function in migraine patients and migraine patients with PFO. We found that in migraine patients with PFO, the presence of PFO may affect the structure of the cerebral cortex and the integrity of white matter, which is mainly locked in subcortical, deep white matter, and posterior circulation, and may lead to changes in brain function, such as cerebellum and colliculus, which are involved in the processing and transmission of pain. In summary, this paper provides neuroimaging evidence and new insights into the correlation between PFO and migraine, which will help to clarify the etiology and pathogenesis of migraine, and aid in the diagnosis and treatment of migraine in the future.
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16
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Advances in Percutaneous Patent Foramen Ovale Closure: From the Procedure to the Echocardiographic Guidance. J Clin Med 2022; 11:jcm11144001. [PMID: 35887765 PMCID: PMC9319304 DOI: 10.3390/jcm11144001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 07/02/2022] [Accepted: 07/07/2022] [Indexed: 02/05/2023] Open
Abstract
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.
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17
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Aortic Root Downward Movement as a Novel Method for Identification of an Adequately Performed Valsalva Maneuver to Detect Patent Foramen Ovale during Transesophageal Echocardiograph. Diagnostics (Basel) 2022; 12:diagnostics12040980. [PMID: 35454028 PMCID: PMC9027372 DOI: 10.3390/diagnostics12040980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 04/06/2022] [Accepted: 04/11/2022] [Indexed: 12/04/2022] Open
Abstract
The Valsalva maneuver (VM) is the most sensitive auxiliary method for the detection of patent foramen ovale (PFO), but it is difficult to assess whether the maneuver is adequately performed during transesophageal echocardiography (TEE). In this study, we tried to use aortic root downward movement as a novel method for judging whether VM was adequate or not, and to evaluate whether this novel method can increase the sensitivity of detecting PFO. A total of 224 patients with clinically suspected PFO were enrolled in this study. These patients were injected with activated normal saline to detect the right-to-left shunt (RLS), in the following three conditions: contrast-enhanced transthoracic echocardiography under adequate VM (AVM cTTE), contrast-enhanced TEE under non-adequate VM (non-AVM cTEE), and cTEE under adequate VM (AVM cTEE). A novel method in which the aorta root moves downward (movement range ≥16 mm) in the cTEE judged whether AVM was performed. The PFO detection rate and sensitivity of AVM cTEE were better than that of non-AVM cTEE (detection rate: 108 PFOs [48.2%] vs. 86 PFOs [38.4%], p = 0.036; sensitivity: 100% vs. 79.6%). Among AVM cTTE, non-AVM cTEE, and AVM cTEE, the RLS grade evaluation results were inconsistent, with significant differences (p < 0.05). Non-AVM cTEE had RLS underestimation or false negatives. Compared with non-AVM cTEE, AVM cTEE and AVM cTTE had better consistency in evaluating PFO RLS (kappa value = 0.675). Aortic root downward movement could be used as a novel method for judging the effectiveness of VM, which is critical for the detection of PFO in cTEE. Concerning effectiveness and convenience, this method should be promoted during the clinical detection of PFO.
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18
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Sharifkazemi M, Rahnamun Z, Davarpasand T, Mirjalili T. Letter to the Editor Regarding the Article by Holda et al., Patent Foramen Ovale Channel Morphometric Characteristics Associated with Cryptogenic Stroke: The MorPFO Score. J Am Soc Echocardiogr 2022; 35:788. [DOI: 10.1016/j.echo.2022.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 02/22/2022] [Accepted: 03/07/2022] [Indexed: 10/18/2022]
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19
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Xiao L, Yan YH, Ding YF, Liu M, Kong LJ, Hu CH, Hui PJ. Evaluation of right-to-left shunt on contrast-enhanced transcranial Doppler in patent foramen ovale-related cryptogenic stroke: Research based on imaging. World J Clin Cases 2022; 10:143-154. [PMID: 35071514 PMCID: PMC8727250 DOI: 10.12998/wjcc.v10.i1.143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 11/04/2021] [Accepted: 11/30/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Cardiogenic embolism caused by patent foramen ovale (PFO) is a common etiology of cryptogenic stroke (CS), particularly in young and middle-aged patients. Studies about right-to-left shunt (RLS) detection using contrast-enhanced transcranial Doppler (c-TCD) are numerous. According to the time phase and number of microbubbles detected on c-TCD, RLS can be classified and graded. We hypothesized that the characteristics of an infarction lesion on diffusion-weighted imaging differs when combining the type and grade of RLS on c-TCD in patients with PFO-related CS.
AIM To explore the characteristics of infarction lesions on diffusion-weighted imaging when combining the RLS type and grade determined by c-TCD.
METHODS We retrospectively evaluated CS patients from August 2015 to December 2019 at a tertiary hospital. In total, 111 PFO-related CS patients were divided according to whether RLS was permanent (microbubbles detected both at resting state and after the Valsalva maneuver) or latent (microbubbles detected only after the Valsalva maneuver) on c-TCD. Each group was subdivided into small, mild and large RLS according to the grade of shunt on c-TCD. A normal control group was composed of 33 patients who suffered from simple dizziness. Intragroup and intergroup differences were analyzed in terms of clinical, laboratory and diffusion-weighted imaging lesion characteristics. The correlation between RLS grade evaluated by c-TCD and size of PFO determined by transesophageal echocardiography were also analyzed.
RESULTS In 111 patients with PFO-related CS, 68 had permanent RLS and 43 had latent RLS. Clinical characteristics and laboratory tests were not significantly different among the permanent RLS, latent RLS and normal control groups. The proportion of patients with multiple territory lesions in the permanent RLS group (50%) was larger than that in the latent RLS group (27.91%; P = 0.021). Posterior circulation was more likely to be affected in the latent RLS group than in the permanent RLS group (30.23% vs 8.82%, P = 0.004). Permanent-large and latent-large RLS were both more likely to be related to multiple (Ptrend = 0.017 and 0.009, respectively), small (Ptrend = 0.035 and 0.006, respectively) and cortical (Ptrend = 0.031 and 0.033, respectively) lesions. The grade of RLS evaluated by c-TCD was correlated to the size of PFO determined by transesophageal echocardiography (r = 0.758, P < 0.001).
CONCLUSION Distribution of the infarct suggested the possible type of RLS. Multiple, small and cortical infarcts suggest large RLS induced by a large PFO.
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Affiliation(s)
- Lei Xiao
- Stroke Center, the First Affiliated Hospital of Soochow University, Suzhou 215006, Jiangsu Province, China
| | - Yan-Hong Yan
- Stroke Center, the First Affiliated Hospital of Soochow University, Suzhou 215006, Jiangsu Province, China
| | - Ya-Fang Ding
- Stroke Center, the First Affiliated Hospital of Soochow University, Suzhou 215006, Jiangsu Province, China
| | - Man Liu
- Stroke Center, the First Affiliated Hospital of Soochow University, Suzhou 215006, Jiangsu Province, China
| | - Li-Juan Kong
- Stroke Center, the First Affiliated Hospital of Soochow University, Suzhou 215006, Jiangsu Province, China
| | - Chun-Hong Hu
- Department of Radiology, the First Affiliated Hospital of Soochow University, Suzhou 215006, Jiangsu Province, China
| | - Pin-Jing Hui
- Stroke Center, the First Affiliated Hospital of Soochow University, Suzhou 215006, Jiangsu Province, China
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20
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Kasner SE, Lattanzi S, Fonseca AC, Elgendy AY. Uncertainties and Controversies in the Management of Ischemic Stroke and Transient Ischemic Attack Patients With Patent Foramen Ovale. Stroke 2021; 52:e806-e819. [PMID: 34702068 DOI: 10.1161/strokeaha.121.034778] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Multiple randomized clinical trials have demonstrated the benefit of patent foramen ovale closure over medical therapy alone for patients who have had a stroke that has been attributed to the patent foramen ovale. Nevertheless, there are many areas of uncertainty and controversy related to patient selection, pathophysiology, diagnosis, and treatment. We summarize the available data on these challenging topics and attempt to provide some clarity and future directions for clinicians and investigators.
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Affiliation(s)
- Scott E Kasner
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia (S.E.K.)
| | - Simona Lattanzi
- Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy (S.L.)
| | - Ana Catarina Fonseca
- Department of Neurology, Centro Hospitalar Universitário Lisboa Norte, Faculdade de Medicina, Universidade de Lisboa, Portugal (A.C.F.)
| | - Akram Y Elgendy
- Division of Cardiovascular Medicine, University of California San Francisco (A.Y.E.).,Division of Cardiovascular Medicine, Harrington Heart and Vascular Institute, Case Western Reserve University, Cleveland, OH (A.Y.E.)
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21
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Desai PV, Krepostman N, Collins M, De Sirkar S, Hinkleman A, Walsh K, Fareed J, Darki A. Neurological Complications of Pulmonary Embolism: a Literature Review. Curr Neurol Neurosci Rep 2021; 21:59. [PMID: 34669060 PMCID: PMC8526526 DOI: 10.1007/s11910-021-01145-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2021] [Indexed: 01/21/2023]
Abstract
PURPOSE OF REVIEW The present review discusses in-depth about neurological complications following acute venous thromboembolism (VTE). RECENT FINDINGS Intracranial hemorrhage, acute ischemic cerebrovascular events, and VTE in brain tumors are described as central nervous system (CNS) complications of PE, while peripheral neuropathy and neuropathic pain are reported as peripheral nervous system (PNS) sequelae of PE. Syncope and seizure are illustrated as atypical neurological presentations of PE. Mounting evidence suggests higher risk of venous thromboembolism (VTE) in patients with neurological diseases, but data on reverse, i.e., neurological sequelae following VTE, is underexplored. The present review is an attempt to explore some of the latter issues categorized into CNS, PNS, and atypical complications following VTE.
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Affiliation(s)
- Parth V Desai
- Department of Cardiovascular Medicine, Loyola University Medical Center, Maywood, IL, 60153, USA
| | - Nicolas Krepostman
- Departmet of Internal Medicine, Loyola University Medical Center, Maywood, IL, 60153, USA
| | - Matthew Collins
- Departmet of Internal Medicine, Loyola University Medical Center, Maywood, IL, 60153, USA
| | - Sovik De Sirkar
- Departmet of Internal Medicine, Loyola University Medical Center, Maywood, IL, 60153, USA
| | - Alexa Hinkleman
- Departmet of Internal Medicine, Loyola University Medical Center, Maywood, IL, 60153, USA
| | - Kevin Walsh
- Departmet of Internal Medicine, Loyola University Medical Center, Maywood, IL, 60153, USA
| | - Jawed Fareed
- Department of Pathology and Laboratory Medicine and Department of Pharmacology and Neuroscience, Health Science Division, Cardiovascular Research Institute, Hemostasis and Thrombosis Research Division, Loyola University, Maywood, IL, 60153, USA
| | - Amir Darki
- Department of Cardiovascular Medicine, Loyola University Medical Center, Maywood, IL, 60153, USA.
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22
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Lee S, Kim IC, Kim YD, Nam HS, Kim SY, Choi SM, Chang HJ. The role of cardiac CT throughout the full cardiac cycle in diagnosing patent foramen ovale in patients with acute stroke. Eur Radiol 2021; 31:8983-8990. [PMID: 34075451 DOI: 10.1007/s00330-021-08037-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 04/24/2021] [Accepted: 05/03/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVES We explored the hypothesis that the diagnostic performance of cardiac computed tomography (CT) throughout the full cardiac cycle would be superior to single-phase CT and comparable to transesophageal echocardiography (TEE) in diagnosing patent foramen ovale (PFO). METHODS AND RESULTS From May 2011 to April 2015, 978 patients with stroke were diagnosed with PFO by TEE. In patients with stroke, cardiac CT was performed if the patients had more than two cardiovascular risk factors. We prospectively enrolled 70 patients with an indication for cardiac CT. Cardiac CT images were reconstructed at 10% increments of the R-R interval. The sensitivity of cardiac CT throughout the full cardiac cycle in diagnosing PFO was compared to that for TEE and single-phase cardiac CT. To evaluate the specificity of cardiac CT, we analyzed patients without PFO confirmed by TEE who underwent cardiac CT within 1 month of pre-cardiac surgery. Sixty-six patients with cardiac CT and TEE were included in the final analysis. Throughout the full cardiac cycle, cardiac CT had a sensitivity of 89.4% and a specificity of 92.3% in diagnosing PFO, compared to TEE as a reference. PFO was primarily detected in the 60% and 70% intervals in 10-phase reconstructed images. The sensitivity of PFO diagnosis with cardiac CT was 81.8% when analyzing both the 60% and 70% intervals instead of the full cardiac cycle. CONCLUSION Cardiac CT throughout the full cardiac cycle outperforms single-phase cardiac CT in detecting PFO. Cardiac CT can be used as an alternative method to TEE for detecting PFO in stroke patients. KEY POINTS • Throughout the full cardiac cycle, cardiac computed tomography (CT) had a sensitivity of 89.4% and a specificity of 92.3% in diagnosing patent foramen ovale (PFO), compared to transesophageal echocardiography. • The sensitivity of diagnosing patent foramen ovale with cardiac CT was 81.8% when analyzing 60% and 70% R-R intervals instead of the full cardiac cycle. • Cardiac CT with retrospective electrocardiographic gating throughout the full cardiac cycle can increase the detectability of PFO, compared to single-phase cardiac CT.
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Affiliation(s)
- Seonhwa Lee
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, South Korea
| | - In-Cheol Kim
- Department of Cardiology, Cardiovascular Center, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Korea
| | - Young Dae Kim
- Department of Neurology, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Hyo Suk Nam
- Department of Neurology, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - So Yeon Kim
- CONNECT-AI Research Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Seon Mi Choi
- CONNECT-AI Research Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Hyuk-Jae Chang
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, South Korea.
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23
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A Case of Decompression Sickness Associated With PFO in a Dive Medical Officer. POLISH HYPERBARIC RESEARCH 2021. [DOI: 10.2478/phr-2021-0008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Abstract
Current medical guidelines and regulations do not require routine examinations for the right-to-left shunt at divers. We present the case of a Polish Navy Dive Medical Officer (DMO) who more than 20 years ago suffered from decompression ilness - bends accompanied by cutis marmorata, numbness in one limb and mild vertigo. After treatment in decompression chamber all symptoms entirely resolved. Since then, despite of continuing diving, he experienced no decompression ilness symptoms. Twenty years later, then 52 years-old, the DMO was admitted as a patient to the Neurology Department at the Gdańsk Naval Hospital due to episodes of transient ischemic attacks. Contrast-enhanced transcranial Doppler ultrasound and transesophageal echocardiography were performed and he was diagnosed with severe right-to-left shunt across a patent foramen ovale (PFO). Retrospectively analyzing incident of DCI he suffered 20 years earlier, we suppose that it may have been caused by paradoxical air embolism associated with the RLS across the PFO, which was not diagnosed at the time of this incident yet. We conclude that although the risk of severe neurological, cutaneous or vestibular forms of DCI is very low, in order to increase diving safety, it seems to be reasonable to develop standards for initial PFO screening in certain groups of divers - professional divers, military divers and medical diving personnel. Contrast-enhanced transcranial Doppler ultrasound seems to be useful in RLS screening in divers. Using multi-compartment chambers equipped with an entry lock should be preferred for safe recompression treatment of divers.
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24
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Azzopardi CP, Magri K, Borg A, Schembri J, Sammut J. Echocardiography - techniques and pitfalls whilst diagnosing persistent (patent) foramen ovale as a risk factor in divers with a history of decompression sickness. Diving Hyperb Med 2021; 51:98-102. [PMID: 33761549 DOI: 10.28920/dhm51.1.98-102] [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: 07/06/2020] [Accepted: 09/22/2020] [Indexed: 11/05/2022]
Abstract
The case of a diver with a history of decompression sickness (DCS) after recreational scuba diving is presented. Cutis marmorata, a subtype of cutaneous DCS, has been consistently associated with the presence of a persistent (patent) foramen ovale (PFO) as a risk factor. Diagnostic uncertainty arose when transthoracic echocardiography with antecubital injection of agitated saline bubbles (ASBs) did not show any significant shunt, but the presence of a large Eustachian valve was counteracted by intra-femoral injection of ASBs, showing a large PFO with spontaneous shunting. The importance of proper echocardiography techniques prior to resorting to intra-femoral injection of ASBs to counteract the haemodynamic effects of the Eustachian valve is emphasised.
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Affiliation(s)
- Charles P Azzopardi
- Baromedicine Department, Hyperbaric Unit, Mater Dei Hospital, Malta.,Corresponding author: Dr Charles P Azzopardi, Baromedicine Department, Hyperbaric Unit, Mater Dei Hospital, Triq id-Donaturi tad-Demm, Tal-Qroqq, Msida, Malta,
| | - Kurt Magri
- Baromedicine Department, Hyperbaric Unit, Mater Dei Hospital, Malta
| | - Alex Borg
- Cardiology Department, Mater Dei Hospital, Malta
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25
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Filomena D, Cimino S, Maestrini V, Monosilio S, Birtolo LI, Vicenzini E, Mancone M, Fedele F, Agati L. The evolving role of echocardiography in the assessment of patent foramen ovale in patients with left-side thromboembolism. Echocardiography 2021; 38:657-675. [PMID: 33740289 DOI: 10.1111/echo.15018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 02/09/2021] [Accepted: 02/17/2021] [Indexed: 12/27/2022] Open
Abstract
Patent foramen ovale (PFO) is the most common congenital cardiac abnormality found approximately in 25% of the adult population The pathophysiological role of paradoxical embolization through the PFO in ischemic stroke is well established. "Self-expanding double disk" and, more recently, suture-based "deviceless" systems are used for PFO closure in the setting of secondary prevention after ischemic stroke likely related to paradoxical embolization. Ultrasound plays a significant role in PFO assessment, indication to treatment, intra-procedural guidance, and follow-up for those undergoing PFO closure. Three different techniques are frequently used for these purposes: transesophageal echocardiography, transthoracic echocardiogram, and transcranial Doppler. In this review, advantages and limits of these techniques are discussed in detail to improve our skills in detection and treatment of this important condition by using ultrasound.
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Affiliation(s)
- Domenico Filomena
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences "Sapienza" University of Rome, Policlinico Umberto I, Rome, Italy
| | - Sara Cimino
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences "Sapienza" University of Rome, Policlinico Umberto I, Rome, Italy
| | - Viviana Maestrini
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences "Sapienza" University of Rome, Policlinico Umberto I, Rome, Italy
| | - Sara Monosilio
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences "Sapienza" University of Rome, Policlinico Umberto I, Rome, Italy
| | - Lucia Ilaria Birtolo
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences "Sapienza" University of Rome, Policlinico Umberto I, Rome, Italy
| | - Edoardo Vicenzini
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Massimo Mancone
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences "Sapienza" University of Rome, Policlinico Umberto I, Rome, Italy
| | - Francesco Fedele
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences "Sapienza" University of Rome, Policlinico Umberto I, Rome, Italy
| | - Luciano Agati
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences "Sapienza" University of Rome, Policlinico Umberto I, Rome, Italy
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D'Andrea A, Dweck MR, Holte E, Fontes-Carvalho R, Cameli M, Aboumarie HS, Diener HC, Haugaa KH. EACVI survey on the management of patients with patent foramen ovale and cryptogenic stroke. Eur Heart J Cardiovasc Imaging 2021; 22:135-141. [PMID: 33346351 PMCID: PMC7822641 DOI: 10.1093/ehjci/jeaa318] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 11/05/2020] [Indexed: 11/14/2022] Open
Abstract
AIMS The European Association of Cardiovascular Imaging (EACVI) Scientific Initiatives Committee performed a global survey to evaluate the current practice for the assessment and management of patients with suspected patent foramen ovale (PFO) and cryptogenic stroke. METHODS AND RESULTS In total, 79 imaging centres from 34 countries across the world responded to the survey, which comprised 17 questions. Most non-invasive investigations for PFO were widely available in the responding centres, with the exception of transcranial colour Doppler which was only available in 70% of sites, and most commonly performed by neurologists. Standard transthoracic echocardiography, with or without bubbles, was considered the first-level test for suspected PFO in the majority of the centres, whereas transoesophageal echocardiography was an excellent second-level modality. Most centres would rule out atrial fibrillation (AF) as a source of embolism in all patients with cryptogenic stroke (63%), with the remainder reserving investigation for patients with multiple AF risk factors (33%). Cardiac magnetic resonance was the preferred tool for identifying other unusual aetiologies, like cardiac masses or thrombi. After PFO closure, there was variation in the use of antiplatelet therapy: a quarter recommended treatment for life, while only 12% recommended 5 years as stipulated in the guidelines (12%). Antibiotic prophylaxis prior to dental or endoscopic procedures was not recommended in 41% of centres, contrary to what the guidelines recommended. CONCLUSION Our survey revealed a variable adherence to the current recommendations for the diagnosis and management of patients with cryptogenic stroke and PFO. Efforts should focus on optimizing and standardizing diagnostic tests and treatment of this condition.
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Affiliation(s)
- Antonello D'Andrea
- Department of Cardiology, Umberto I_ Hospital, Luigi Vanvitelli University - Nocera Inferiore (ASL Salerno), Viale San Francesco - 84014 Caserta, Italy
| | - Marc R Dweck
- BHF Centre for Cardiovascular Science, Department of Cardiology, University of Edinburgh, Edinburgh, EH16 4SB, UK
| | - Espen Holte
- Department of Cardiology, St. Olavs Hospital, Postboks 3250 Torgarden, 7006 Trondheim, Norway
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology NTNU, Trondheim, PO Box 8905, 7491 Trondheim, Norway
| | - Ricardo Fontes-Carvalho
- Cardiovascular Research and Development Unit, Department of Physiology and Cardiothoracic Surgery, Faculty of Medicine, University of Porto, Al. Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
| | - Matteo Cameli
- Department of Cardiovascular Diseases, University of Siena, Policlinico Le Scotte, Viale Bracci 16, 53100 Siena, Italy
| | - Hatem Soliman Aboumarie
- Department of Cardiology - Harefield Hospital, Royal Brompton and Harefield NHS Foundation Trust, UB9 6JH London, UK
| | - Hans Christoph Diener
- Department of Neurology - Medical Faculty of the University Duisburg-Essen—Institute for Medical Informatics, Biometry and Epidemiology, Hufelandstraße, 26, 45147 Essen, Germany
| | - Kristina H Haugaa
- Department of Cardiology, Oslo University Hospital, Postboks 4950 Nydalen, 0424 Oslo, Norway
- Department of Cardiology - Institute for Clinical Medicine, University of Oslo, Postboks 1171 Blindern, 0318 Oslo, Norway
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Severity by National Institute of Health Stroke Scale Score and Clinical Features of Stroke Patients with Patent Foramen Ovale Stroke and Atrial Fibrillation. J Clin Med 2021; 10:jcm10020332. [PMID: 33477425 PMCID: PMC7830209 DOI: 10.3390/jcm10020332] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 01/14/2021] [Accepted: 01/14/2021] [Indexed: 11/26/2022] Open
Abstract
The comparative severity of patent foramen ovale (PFO)-related stroke in patients without atrial fibrillation (AF) and AF-related stroke in patients without PFO is unknown. Therefore, we compared the severity of PFO-related stroke and AF-related stroke. Twenty-six patients who underwent transesophageal echocardiography (TEE) were diagnosed with cardioembolic stroke from July 2018 to March 2020. Cases with AF detected by electrocardiograms or thrombus in the left atrium or left atrial appendage on TEE were included in the AF-related stroke group. Cases with a positive microbubble test on the Valsalva maneuver during TEE, and with no other factors that could cause stroke, were included in the PFO-related stroke group. This study was designed as a single-center, small population pilot study. The stroke severity of the two groups by the National Institute of Health Stroke Scale (NIHSS) score was compared by statistical analysis. Of the 26 cases, five PFO-related stroke patients and 21 AF-related stroke patients were analyzed. The NIHSS score was 2.2 ± 2.8 and 11.5 ± 9.2 (p-value < 0.01), the rate of hypertension was 20.0% and 85.7% (p-value = 0.01), and the HbA1c value was 5.5 ± 0.2% and 6.3 ± 1.3% (p-value = 0.02) in the PFO-related and AF-related stroke groups, respectively. Compared with AF-related stroke patients, stroke severity was low in PFO-related stroke patients.
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Lee M, Oh JH. Echocardiographic diagnosis of right-to-left shunt using transoesophageal and transthoracic echocardiography. Open Heart 2020; 7:openhrt-2019-001150. [PMID: 32763965 PMCID: PMC7412608 DOI: 10.1136/openhrt-2019-001150] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 03/09/2020] [Accepted: 06/01/2020] [Indexed: 01/16/2023] Open
Abstract
Background The diagnosis and quantification of right-to-left shunt (RLS) using transthoracic echocardiography (TTE) as well as transoesophageal echocardiography (TOE) have not been well established. We aimed to diagnose RLS by TOE using direct visualisation of the shunt and to compare the diagnosis with TTE diagnosis using conventional methods. Methods and results We evaluated 141 patients with ischaemic stroke for RLS by both non-sedation TOE and TTE using saline contrast and Valsalva manoeuvre. The amount (graded as 0 to IV) and timing of RLS were demonstrated. All patients were classified into four groups by TOE based on direct visualisation of shunt through a patent foramen ovale (PFO) or either pulmonary vein: no shunt (group 1: n=11), PFO (group 2: n=47), pulmonary RLS (group 3: n=25) and indeterminate RLS (group 4: n=58). All cases in group 3 showed delayed shunt, and all cases in group 4 had small shunt. On TTE findings, all cases with early appearing large shunt (cardiac cycles ≤3 and shunt grade ≥III) were group 2. Six of the eight patients with delayed appearing large shunt on TTE were group 3. TTE diagnosis of PFO using criteria of cardiac beats ≤3 and grade ≥II had a sensitivity of 85% and a specificity of 98% compared with TOE diagnosis using shunt visualisation. Conclusions Compared with TOE using shunt visualisation, TTE accurately diagnosed large PFO using criteria of cardiac cycles ≤3 and shunt grade ≥III. TTE possibly diagnosed pulmonary shunt using criteria of cardiac cycles >3 and shunt grade ≥III. Both modalities showed limitations in diagnosing small amount of RLS.
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Affiliation(s)
- Mirae Lee
- Division of Cardiology, Department of Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Gyeongsangnam-Do, Republic of Korea
| | - Ju Hyeon Oh
- Division of Cardiology, Department of Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Gyeongsangnam-Do, Republic of Korea
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Bernard S, Churchill TW, Namasivayam M, Bertrand PB. Agitated Saline Contrast Echocardiography in the Identification of Intra- and Extracardiac Shunts: Connecting the Dots. J Am Soc Echocardiogr 2020; 34:S0894-7317(20)30615-5. [PMID: 34756394 DOI: 10.1016/j.echo.2020.09.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 09/01/2020] [Accepted: 09/05/2020] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- Samuel Bernard
- Cardiac Ultrasound Laboratory, Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
| | - Timothy W Churchill
- Cardiac Ultrasound Laboratory, Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Mayooran Namasivayam
- Cardiac Ultrasound Laboratory, Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Philippe B Bertrand
- Cardiac Ultrasound Laboratory, Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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Diagnosis of Patent Foramen Ovale: The Combination of Contrast Transcranial Doppler, Contrast Transthoracic Echocardiography, and Contrast Transesophageal Echocardiography. BIOMED RESEARCH INTERNATIONAL 2020; 2020:8701759. [PMID: 32185222 PMCID: PMC7060853 DOI: 10.1155/2020/8701759] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 02/01/2020] [Indexed: 01/27/2023]
Abstract
Objectives To access the distinct values of contrast transcranial Doppler (cTCD), contrast transthoracic echocardiography (cTTE), and contrast transesophageal echocardiography (cTEE) in the diagnosis of right-to-left shunt (RLS) due to patent foramen ovale (PFO) and to define the most practical strategy for the diagnosis of PFO. Methods 102 patients with a high clinical suspicion for PFO had simultaneous cTCD, cTTE, and cTEE performed. The agitated saline mixed with blood was used to detect right-to-left shunt (RLS). Results In all 102 patients, the shunt was detected at rest by cTCD in 60.78% of cases, by cTTE in 42.16%, and by cTEE in 47.06%. The positive results of all 3 techniques with Valsalva maneuver (VM) were significantly improved. cTCD showed higher pick-up rate than cTTE (98.04% vs. 89.22%; χ2 = 12.452, p < 0.05) and the cTEE (98.04% vs. 96.08%; nonsignificant difference) in the diagnosis of PFO. Nevertheless, cTEE, compared with cTTE, underestimated shunting in 44% of patients. The diameter of both PFO entrance and exit was significantly greater in patients with a severe shunt compared with a mild shunt (2.8 ± 1.0 mm vs. 2.0 ± 0.7 mm, t = 3.135, p < 0.05) and the cTEE (98.04% vs. 96.08%; nonsignificant difference) in the diagnosis of PFO. Nevertheless, cTEE, compared with cTTE, underestimated shunting in 44% of patients. The diameter of both PFO entrance and exit was significantly greater in patients with a severe shunt compared with a mild shunt (2.8 ± 1.0 mm vs. 2.0 ± 0.7 mm, t = 3.135, p < 0.05) and the cTEE (98.04% vs. 96.08%; nonsignificant difference) in the diagnosis of PFO. Nevertheless, cTEE, compared with cTTE, underestimated shunting in 44% of patients. The diameter of both PFO entrance and exit was significantly greater in patients with a severe shunt compared with a mild shunt (2.8 ± 1.0 mm vs. 2.0 ± 0.7 mm, t = 3.135, p < 0.05) and the cTEE (98.04% vs. 96.08%; nonsignificant difference) in the diagnosis of PFO. Nevertheless, cTEE, compared with cTTE, underestimated shunting in 44% of patients. The diameter of both PFO entrance and exit was significantly greater in patients with a severe shunt compared with a mild shunt (2.8 ± 1.0 mm vs. 2.0 ± 0.7 mm, Conclusions The best method to diagnose PFO should be the combination of cTCD, cTTE, and cTEE. And cTCD should be applied as the first choice for screening RLS. Then, cTTE should be performed to quantify the severity of the shunt. Last but not least, cTEE should be performed to assess the morphologies of PFO when the closure is planned. The study provides for clinicians the most practical strategy for diagnosing PFO in the future. However, further trials with a large sample size are required to confirm this finding.
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Takaya Y, Watanabe N, Ikeda M, Akagi T, Nakayama R, Nakagawa K, Toh N, Ito H. Importance of Abdominal Compression Valsalva Maneuver and Microbubble Grading in Contrast Transthoracic Echocardiography for Detecting Patent Foramen Ovale. J Am Soc Echocardiogr 2020; 33:201-206. [DOI: 10.1016/j.echo.2019.09.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 09/19/2019] [Accepted: 09/19/2019] [Indexed: 11/24/2022]
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Zhang YX, Zhang XY, Zhang Q. Cough maneuver is superior to Valsalva maneuver for detecting mild-extent right-to-left shunt. SCAND CARDIOVASC J 2019; 54:32-36. [PMID: 31777288 DOI: 10.1080/14017431.2019.1694172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objective: The purpose of this study was to explore the different provocative maneuvers in detecting right-to-left shunt during contrast transthoracic echocardiography (cTTE). Methods: We evaluated 378 patients for right-to-left shunt detection by cTTE at the quiet respiration, during Valsalva maneuver (blowing into a face mask connected to a sphygmomanometer at 40 mmHg for 10 s), and during cough maneuver, performed in random order, and the degree of right-to-left shunt as the number of microbubbles in the left atrium per frame after each provocative maneuver was recorded. Results: The detection rates of right-to-left shunt for quiet respiration, Valsalva maneuver, and cough maneuver were 16%, 33%, and 38%, respectively (p < .001). The detection rate for cough maneuver was significantly higher than that for Valsalva maneuver (p < .001). There was no significant difference between Valsalva maneuver and cough maneuver in terms of detecting moderate- or severe-extent right-to-left shunt (p > .05), but cough maneuver was significantly better than Valsalva maneuver at detecting mild-extent right-to-left shunt (p = .001). Conclusions: Cough maneuver is an effective alternative to Valsalva maneuver, with a higher detection rate for mild-extent right-to-left shunt during cTTE, maybe due to its own mechanical characteristics.
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Affiliation(s)
- Yun-Xia Zhang
- Department of Ultrasound Diagnostics, The Second Hospital of Yulin City, Yulin, China
| | - Xiao-Yong Zhang
- Department of Ultrasound Diagnostics, The First Affiliated Hospital, Xi'an Medical College, Xi'an, China.,School of General Medicine, Xi'an Medical College, Xi'an, China
| | - Qi Zhang
- Department of Ultrasound Diagnostics, The First Affiliated Hospital, Xi'an Medical College, Xi'an, China.,School of General Medicine, Xi'an Medical College, Xi'an, China
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Vitarelli A. Patent Foramen Ovale: Pivotal Role of Transesophageal Echocardiography in the Indications for Closure, Assessment of Varying Anatomies and Post-procedure Follow-up. ULTRASOUND IN MEDICINE & BIOLOGY 2019; 45:1882-1895. [PMID: 31104864 DOI: 10.1016/j.ultrasmedbio.2019.04.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Revised: 03/09/2019] [Accepted: 04/12/2019] [Indexed: 06/09/2023]
Abstract
Patent foramen ovale (PFO) is present in 15%-30% of the general population and has been associated with various pathologic states, including cryptogenic stroke, platypnea-orthodeoxia syndrome, decompression sickness and migraine with auras. Transesophageal echocardiography (TEE) has a major role in the diagnostic evaluation of PFO, as well as in the post-procedural assessment after transcatheter closure. The goals of this article were to synthesize the echocardiographic transesophageal techniques required for accurate PFO diagnosis and careful anatomic assessment of its anatomic variants, to focus TEE indications for device closure as complementary to clinical indications and to assess the role of TEE in the post-procedure follow-up.
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Rasalingam R, Novak E, Rifkin RD. Improved differential diagnosis of intracardiac and extracardiac shunts using acoustic intensity mapping of saline contrast studies. Eur Heart J Cardiovasc Imaging 2019; 21:307-317. [DOI: 10.1093/ehjci/jez129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 05/15/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
Aims
The aim of this study was to test the hypothesis that temporal patterns of saline contrast entry into, and exit from the left heart are significantly different in intra- and extra-cardiac shunts and can be used to differentiate the shunt mechanism when Valsalva manoeuvre cannot be performed, or is of uncertain quality. We propose a novel approach of mapping the temporal changes in acoustic intensity (AI) within the left and right heart to identify and define these unique patterns.
Methods and results
We screened cases of right to left shunting on resting agitated saline contrast echocardiograms with clinical criteria that identified the origin of shunting as either a patent foramen ovale or pulmonary arteriovenous malformation. Acoustic time-intensity curves were generated from the right and left heart chambers that reflected the change in saline contrast density over time. Several novel pre-specified parameters were measured from these curves, in addition to the standard heartbeat counting method, to characterize the entrance (wash-in) and exit (wash-out) patterns of saline contrast in the left heart. Statistical analysis showed that AI mapping provided superior differentiation of the two populations than did the traditional beat counting method.
Conclusion
Diagnosis of shunt mechanism from saline contrast studies can be improved over current methods through the use of AI mapping to define the rapidity that peak contrast effect develops, the speed that the contrast effect decays, and the contrast intensity late in the recording.
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Affiliation(s)
- Ravi Rasalingam
- Division of Cardiology, Department of Medicine, Washington University in St. Louis, 660 S. Euclid Ave, MO, USA
| | - Eric Novak
- Division of Cardiology, Department of Medicine, Washington University in St. Louis, 660 S. Euclid Ave, MO, USA
| | - Robert D Rifkin
- Division of Cardiology, Department of Medicine, Washington University in St. Louis, 660 S. Euclid Ave, MO, USA
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Bhayana AA, Kumar V. Valsalva retinopathy following transesophageal echocardiography. Indian J Ophthalmol 2019; 67:553-554. [PMID: 30900596 PMCID: PMC6446628 DOI: 10.4103/ijo.ijo_1565_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Amber A Bhayana
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Vinod Kumar
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
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Thiagaraj AK, Hughes-Doichev R, Biederman RWW. Provocative maneuvers to improve patent foramen ovale detection: A brief review of the literature. Echocardiography 2019; 36:783-786. [PMID: 30803022 DOI: 10.1111/echo.14297] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 01/28/2019] [Accepted: 02/02/2019] [Indexed: 01/13/2023] Open
Abstract
Patent foramen ovale (PFO) is the most common type of inter-atrial shunt, with prevalence as high as 30%. Detection of PFO has implications in patients with stroke, peripheral embolism, decompression illness, and other conditions. Transesophageal echo (TEE) with saline contrast injection is the current standard for PFO detection, but even with TEE, PFOs are sometimes missed. With advances in percutaneous PFO closure therapies and proven long-term benefit of closure, accurate PFO detection takes on cardinal importance. Various provocative maneuvers to enhance PFO detection are in clinical use and have been studied. The Valsalva maneuver has long-held position as the ideal provocation to unmask PFO, but other maneuvers such as cough, sniff, Müller's, and more have gained relevance. In this article, we will examine various maneuvers and discuss their utility in PFO detection.
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Affiliation(s)
- Ashwin K Thiagaraj
- Department of Cardiovascular Medicine, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Rachel Hughes-Doichev
- Department of Cardiovascular Medicine, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Robert W W Biederman
- Department of Cardiovascular Medicine, Allegheny General Hospital, Pittsburgh, Pennsylvania
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Moon J, Kim M, Oh PC, Shin DH, Park HMI, Jo YY, Lee JS, Kang WC. Residual Shunt after Patent Foramen Ovale Device Closure in Patients With Cryptogenic Stroke: Serial Bubble Contrast Transesophageal Echocardiography Data. J Stroke Cerebrovasc Dis 2019; 28:347-353. [DOI: 10.1016/j.jstrokecerebrovasdis.2018.10.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 09/18/2018] [Accepted: 10/05/2018] [Indexed: 12/19/2022] Open
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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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Palazzo P, Ingrand P, Agius P, Belhadj Chaidi R, Neau JP. Transcranial Doppler to detect right-to-left shunt in cryptogenic acute ischemic stroke. Brain Behav 2019; 9:e01091. [PMID: 30506983 PMCID: PMC6346730 DOI: 10.1002/brb3.1091] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 06/08/2018] [Accepted: 06/20/2018] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVES We aimed to confirm the sensitivity and specificity of contrast transcranial Doppler (cTCD) in the detection of right-to-left shunt (RLS) compared to the current reference standard (i.e., transesophageal echocardiography-TEE) in patients aged <55 years with a cryptogenic acute ischemic stroke (AIS) or high-risk (ABCD2 score ≥4) transient ischemic attack (TIA), and to calculate the real life delay in detecting RLS by cTCD versus TEE in a tertiary care academic stroke center. METHODS Consecutive 16- to 54-year-old patients with AIS or high-risk TIA underwent complete diagnostic workup which included, in case of undetermined etiology, cTCD and TEE. Sensitivity and specificity of cTCD, RLS characteristics, and median delay between the two tests were calculated. RESULTS Of the 98 included patients, 52 (53%) had a cryptogenic cerebrovascular ischemic event, which displayed a 56% prevalence of RLS related to a patent foramen ovale (PFO) mainly with a high-grade shunt. When comparing TCD with "bubble test" to TEE, sensitivity and specificity were both 100%. Median delays from symptom onset to examination were 2 (min-max 1-10) and 21 (min-max 1-60) days, respectively, for cTCD and TEE. No adverse event occurred during or after cTDC examination. CONCLUSIONS Transcranial Doppler with "bubble test" appears as the best screening test for the detection of RLS in young and middle-aged adults with cryptogenic acute cerebral ischemic events to select patients potentially suitable for closure procedure after TEE confirmation.
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Affiliation(s)
- Paola Palazzo
- Department of Neurology, Poitiers University Hospital, Poitiers Cedex, France.,Department of Neurology, S. Giovanni Calibita-Fatebenefratelli Hospital, Rome, Italy
| | - Pierre Ingrand
- Clinical Investigation Center INSERM, Poitiers University Hospital, Poitiers Cedex, France
| | - Pierre Agius
- Department of Neurology, Saint Nazaire Community Hospital, Saint-Nazaire, France
| | - Rafik Belhadj Chaidi
- Department of Vascular Medicine, Poitiers University Hospital, Poitiers Cedex, France
| | - Jean-Philippe Neau
- Department of Neurology, Poitiers University Hospital, Poitiers Cedex, France
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Li X, Gao YH, Wu SZ, Xia HM. Contrast Transthoracic Echocardiography Using 50% Glucose as a Contrast Agent for Screening of a Patent Foramen Ovale. ULTRASOUND IN MEDICINE & BIOLOGY 2018; 44:2267-2273. [PMID: 30077414 DOI: 10.1016/j.ultrasmedbio.2018.06.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Revised: 05/24/2018] [Accepted: 06/11/2018] [Indexed: 06/08/2023]
Abstract
A patent foramen ovale (PFO) is considered a risk factor for neurologic events. The goal of the study described here was to assess the feasibility, advantages, diagnostic sensitivity and accuracy of contrast transthoracic echocardiography examination (cTTE) using 50% glucose as a contrast agent in comparison with the use of agitated saline as contrast to screen for PFO. In our study, we found that the peak time, effective duration and duration of microbubbles produced by 50% glucose were all longer than those produced by the physiologic saline. The sensitivities for detection of PFO with cTTE using physiologic saline and 50% glucose as contrast were 83% (20/24) and 100% (24/24), respectively. TEE suggested a PFO in 24 patients in two groups. Use of 50% glucose as a contrast agent in cTTE examination enables ultrasound technicians to easily observe the right-to-left shunt across the PFO. However, the sensitivities for detection of PFO with cTTE using 50% glucose did not statistically significantly differ from those for physiologic saline.
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Affiliation(s)
- Xin Li
- Department of Ultrasound, Navy General Hospital of PLA, Beijing, China
| | - Yun-Hua Gao
- Department of Ultrasound, Xinqiao Hospital of Army Medical Uiversity (Third Military Medical University), Chongqing, China
| | - Sheng-Zheng Wu
- Department of Ultrasound, Hainan Branch of PLA General Hospital, Sanya, China
| | - Hong-Mei Xia
- Department of Ultrasound, Xinqiao Hospital of Army Medical Uiversity (Third Military Medical University), Chongqing, China.
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Teshome MK, Najib K, Nwagbara CC, Akinseye OA, Ibebuogu UN. Patent Foramen Ovale: A Comprehensive Review. Curr Probl Cardiol 2018; 45:100392. [PMID: 30327131 DOI: 10.1016/j.cpcardiol.2018.08.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Accepted: 08/31/2018] [Indexed: 10/28/2022]
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Marinheiro R, Parreira L, Amador P, Silvestre I, Antunes C, Caria R. Implications of detection of foramen ovale patent after cryptogenic ischemic stroke. J Echocardiogr 2018; 17:44-51. [PMID: 30008156 DOI: 10.1007/s12574-018-0388-2] [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: 04/23/2018] [Revised: 06/22/2018] [Accepted: 07/10/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Therapeutic uncertainty is inherent in decisions in patients with patent foramen ovale (PFO) and cryptogenic stroke. We aimed to determine clinical implications of PFO identification in transesophageal echocardiography (TEE) after a cryptogenic ischemic stroke. METHODS Consecutive TEE done between 2011 and 2015 in patients with previous cryptogenic stroke was evaluated. Clinical implications of PFO identification (closure and/or medical therapy) were retrieved from the medical records and discharge summaries. Adverse events related to therapy, stroke recurrence and death were analyzed during follow-up. RESULTS Three-hundred one patients (mean age 59 ± 11 years; 61% male) underwent a TEE, of which 77 (26%) patients had a diagnosis of PFO. Patients with PFO were younger (56 ± 13 versus 60 ± 14, p = 0.03). Of those with PFO, 23 (30%) underwent percutaneous closure of PFO and these patients had more frequently complex or large PFO (p < 0.001 and p = 0.004, respectively). The remaining 54 (70%) were treated with medical therapy: 30 (39%) with antiplatelet therapy and 24 (31%) with oral anticoagulation. During follow-up (44 ± 17 months), only two patients had another stroke (both referred for PFO closure, while they were waiting for the procedure) and two patients, on whom PFO closure was not performed, died (not for cardiovascular causes). CONCLUSION PFO's (size and complexity) and patients' characteristics influenced clinical decision when PFO was detected on TEE. The risk for recurrent stroke was not increased in patients who did not undergo PFO closure; although two patients waiting for PFO closure had recurrent stroke, demonstrating its importance.
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Affiliation(s)
- Rita Marinheiro
- Cardiology Department, Centro Hospitalar de Setubal, Rua Camilo Castelo Branco 175, 2910-446, Setubal, Portugal.
| | - Leonor Parreira
- Cardiology Department, Centro Hospitalar de Setubal, Rua Camilo Castelo Branco 175, 2910-446, Setubal, Portugal
| | - Pedro Amador
- Cardiology Department, Centro Hospitalar de Setubal, Rua Camilo Castelo Branco 175, 2910-446, Setubal, Portugal
| | - Isabel Silvestre
- Cardiology Department, Centro Hospitalar de Setubal, Rua Camilo Castelo Branco 175, 2910-446, Setubal, Portugal
| | - Carla Antunes
- Cardiology Department, Centro Hospitalar de Setubal, Rua Camilo Castelo Branco 175, 2910-446, Setubal, Portugal
| | - Rui Caria
- Cardiology Department, Centro Hospitalar de Setubal, Rua Camilo Castelo Branco 175, 2910-446, Setubal, Portugal
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Abstract
Transcranial Doppler (TCD) is useful in stroke prevention for at least three purposes: diagnosis of intracranial stenosis, detection of right-to-left shunt in patients with suspected paradoxical embolism, and detection of microemboli in patients with carotid stenosis. Other uses may include assessment of cerebral blood flow, which is not discussed in this review. TCD saline studies are more sensitive than transesophageal echocardiography, and more strongly predictive of risk of recurrent events. TCD embolus detection is the best-validated method for identifying among patients with asymptomatic carotid stenosis the few who could benefit from carotid endarterectomy or stenting.
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Affiliation(s)
- J. David Spence
- Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, Ontario, Canada
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Abstract
Controversy has persisted for over a decade whether transcatheter patent foramen ovale (PFO) closure reduces the rate of recurrent ischemic stroke for patients who have had a cryptogenic ischemic stroke and have a PFO. In September 2017, 3 positive randomized trials: RESPECT long-term (Recurrent Stroke Comparing PFO Closure to Established Current Standard of Care Treatment trial), REDUCE (GORE® HELEX® Septal Occluder / GORE® CARDIOFORM Septal Occluder and Antiplatelet Medical Management for Reduction of Recurrent Stroke or Imaging-Confirmed TIA in Patients With Patent Foramen Ovale [PFO]), and CLOSE (Patent Foramen Ovale Closure or Anticoagulants Versus Antiplatelet Therapy to Prevent Stroke Recurrence) were published. All 3 trials studied young to middle age patients with cryptogenic ischemic strokes found to have a PFO, and compared recurrent stroke rates after PFO closure versus medical therapy alone. All trials had primary end points of recurrent ischemic strokes, a superiority design, and reported results in the intention to treat population. The long-term results of the RESPECT trial led to the Food and Drug Administration approval of the AMPLATZER PFO Occluder for a secondary prevention indication. There was a 45% risk reduction in the device arm for recurrent ischemic stroke with an event rate of 0.58 versus 1.07 per 100 patient-years (hazard ratio, 0.55; 95% confidence interval, 0.305–0.999; log-rank
P
=0.046). The primary efficacy result of the REDUCE trial utilizing the HELEX and CARDIOFORM devices demonstrated a risk reduction of 77% (hazard ratio, 0.23; 95% confidence interval, 0.09–0.62; log-rank
P
=0.001). In the CLOSE trial, device closure plus long-term antiplatelet therapy versus antiplatelet therapy alone demonstrated a risk reduction of 97% (hazard ratio, 0.03; 95% confidence interval, 0–0.25; log-rank
P
<0.001). Each trial demonstrated a low frequency of device- and procedure-related complications, including a slight increase in the rate of paroxysmal atrial fibrillation in the device arm. This review focuses on summarizing the trial results and translating the results and methods from investigative trials into clinical practice.
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Affiliation(s)
- Dominik M. Wiktor
- From the Division of Cardiology, University of Colorado School of Medicine, Aurora
| | - John D. Carroll
- From the Division of Cardiology, University of Colorado School of Medicine, Aurora
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45
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Transesophageal Echocardiography for the Detection of Patent Foramen Ovale. J Am Soc Echocardiogr 2017; 30:933-934. [PMID: 28602207 DOI: 10.1016/j.echo.2017.05.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Indexed: 01/15/2023]
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46
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Yamashita E, Murata T, Goto E, Fujiwara T, Sasaki T, Minami K, Nakamura K, Kumagai K, Naito S, Kario K, Oshima S. Inferior Vena Cava Compression as a Novel Maneuver to Detect Patent Foramen Ovale: A Transesophageal Echocardiographic Study. J Am Soc Echocardiogr 2017; 30:292-299. [DOI: 10.1016/j.echo.2016.11.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Indexed: 11/29/2022]
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47
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Transthoracic contrast echocardiography using vitamin B6 and sodium bicarbonate as contrast agents for the diagnosis of patent foramen ovale. Int J Cardiovasc Imaging 2017; 33:1125-1131. [PMID: 28176181 DOI: 10.1007/s10554-017-1088-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2016] [Accepted: 01/28/2017] [Indexed: 10/20/2022]
Abstract
To evaluate the utility of transthoracic contrast echocardiography (cTTE) using vitamin B6 and sodium bicarbonate as contrast agents for diagnosing right-to-left shunt (RLS) caused by patent foramen ovale (PFO) compared to that of transesophageal echocardiography (TEE). We investigated 125 patients admitted to our neurology department with unexplained cerebral infarction and migraine. All patients underwent cTTE using vitamin B6 and sodium bicarbonate as contrast agents, after which they underwent transthoracic echocardiography. The Doppler signal was recorded during the Valsalva maneuver, and TEE examinations were performed. The feasibility, diagnostic sensitivity, and safety of cTTE and TEE for PFO recognition were compared. Evidence of PFO was found in 49 (39.20%) patients with cTTE, more than were detected with TEE (39, 31.20%) (χ2=5.0625, P=0.0244). cTTE had a sensitivity of 92.31% and a specificity of 84.88% for diagnosing PFO, showing high concordance with TEE for PFO recognition (κ=0.72). Further, results of a semi-quantitative evaluation of PFO-RLS by cTTE were better than those with TEE (Z=-2.011, P=0.044). No significant adverse reaction was discovered during cTTE examination. cTTE using vitamin B6 and sodium bicarbonate as contrast agents has relatively good sensitivity and specificity for diagnosing RLS caused by PFO when compared with those for TEE. Using vitamin B6 and sodium bicarbonate as contrast agents to perform cTTE is recommended for detecting and diagnosing the PFO due to its simplicity, non-invasive character, low cost, and high feasibility.
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48
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Ghazal SN. Valsalva maneuver in echocardiography. J Echocardiogr 2016; 15:1-5. [PMID: 27515556 DOI: 10.1007/s12574-016-0310-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 07/13/2016] [Accepted: 08/02/2016] [Indexed: 11/30/2022]
Abstract
The Valsalva maneuver is an easily performed maneuver with an interesting hemodynamic effect which can be used to aid accurate echocardiographic diagnosis. However, correct adequate performance is often missed. Here, we aim to describe the performance of an adequate Valsalva maneuver and the correct interpretation of its effect. The Valsalva hemodynamic effect consists of four basic phases which can be used in echocardiography to yield an accurate diagnosis. Valsalva is used to decrease preload and provoke left ventricular outflow tract (LVOT) gradient in dynamic LVOT obstruction. In addition, a decrease in E/A ratio in mitral inflow >50 % with Valsalva correlates with increased LV filling pressure and diastolic dysfunction. Valsalva also momentarily increases RA pressure and helps to unmask a patent foramen ovale with the use of saline contrast.
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Affiliation(s)
- Sami Nimer Ghazal
- Cardiology Division, Internal Medicine Department, King Fahd Hospital of the University, University of Dammam, P.O. Box 2208, Al-Khobar, 31952, Saudi Arabia.
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49
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Granati GT, Teressa G. Worsening Hypoxemia in the Face of Increasing PEEP: A Case of Large Pulmonary Embolism in the Setting of Intracardiac Shunt. AMERICAN JOURNAL OF CASE REPORTS 2016; 17:454-8. [PMID: 27377010 PMCID: PMC4936297 DOI: 10.12659/ajcr.898521] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Patient: Male, 40 Final Diagnosis: Patent foramen ovale Symptoms: Dyspnea exertional • hemoptysis • shortness of breath Medication: — Clinical Procedure: Airway pressure release ventilation Specialty: Critical Care Medicine
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Affiliation(s)
- Glen T Granati
- Department of Internal Medicine, Health Science Center, Stony Brook University Hopsital, Stony Brook, NY, USA
| | - Getu Teressa
- Department of Internal Medicine, Health Science Center, Stony Brook University Hopsital, Stony Brook, NY, USA
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50
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Coles A, Haveman-Gould B, Farooq MU, Selke KJ, Gorelick PB. A Case of Complex PFO Leading to Ischemic Stroke: A Practical Clinical Pearl for Neurohospitalists. Neurohospitalist 2016; 6:114-7. [PMID: 27366295 PMCID: PMC4906549 DOI: 10.1177/1941874415588750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Patent foramen ovale (PFO) has been proposed as a mechanism for cardioembolic stroke, especially in younger patient populations. Complex PFOs, with tunnel lengths exceeding 8 mm, lead to a higher risk of neurological sequelae than simple PFOs and may also be harder to detect with transthoracic echocardiography (TTE). In this article, we present a 29-year-old woman who, after polypharmacy overdose, developed deep venous thrombosis and multiple pulmonary emboli (PE) and subsequent cardioembolic stroke. Initial TTE showed intact interatrial septum with late appearance of agitated saline in the left atrium after the seventh cardiac cycle. Subsequent transesophageal echocardiography, after treatment of PE with an intravenous thrombolytic (alteplase) and anticoagulation with heparin, showed a complex PFO with a 19-mm overlap of the septum primum and secundum without active flow. It is suggested that this PFO allowed for flow only in the situation of elevated right heart strain with PE, causing cardioembolic stroke and detection of agitated saline in the left atrium on TTE. However, under normal physiological situations, which resumed after treatment of PE with alteplase and heparin, the PFO did not allow for flow. This case demonstrates the potential importance of recognition of complex PFOs in diagnosis and management of cardioembolic stroke.
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Affiliation(s)
- Anna Coles
- College of Human Medicine, Michigan State University, Grand Rapids, MI, USA
| | - Bradley Haveman-Gould
- Division of Stroke and Vascular Neurology, Mercy Health Hauenstein Neurosciences, Grand Rapids, MI, USA
| | - Muhammad U. Farooq
- Division of Stroke and Vascular Neurology, Mercy Health Hauenstein Neurosciences, Grand Rapids, MI, USA
| | | | - Philip B. Gorelick
- Division of Stroke and Vascular Neurology, Mercy Health Hauenstein Neurosciences, Grand Rapids, MI, USA
- Department Translational Science & Molecular Medicine, Michigan State University College of Human Medicine, Grand Rapids, MI, USA
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