The Connection Between Patent Foramen Ovale and Migraine

Comparison of Syn T2-FLAIR and Syn DIR with conventional T2-FLAIR in displaying white matter hyperintensities in migraine patients

OBJECTIVE

Young migraine patients often present with white matter hyperintensities (WMHs) on magnetic resonance imaging (MRI). This study aimed to analyze whether synthetic (Syn) T2-FLAIR and Syn double inversion recovery (DIR) can reveal WMHs more clearly and sensitively than conventional T2-FLAIR.

MATERIALS AND METHODS

Conventional MRI and Syn MRI data from 50 young migraine patients were analyzed prospectively. WMHs in each anatomical region (periventricular, deep white matter, and juxtacortical) were recorded separately. The differences in the clarity of lesion boundaries and the number of lesions displayed in the three sequences in the same anatomical region were analyzed.

RESULTS

A total of 80 (periventricular area, 15; deep white matter, 31; juxtacortical area, 34), 163 (17, 50, 96), and 134 (18, 42, 74) lesions were observed with conventional T2-FLAIR, Syn T2-FLAIR, and Syn DIR, respectively. Syn T2-FLAIR and Syn DIR can show lesions more clearly than conventional T2-FLAIR (all P < 0.001). There was no significant difference in the number of lesions observed in the periventricular white matter among the three sequences (P = 0.159, 0.083, 0.322). Syn T2-FLAIR and Syn DIR can detect more lesions in the deep white matter than conventional T2-FLAIR (P < 0.001, P = 0.006). Syn T2-FLAIR revealed more lesions in the juxtacortical white matter than Syn DIR and conventional T2-FLAIR imaging (all P < 0.001), and conventional T2-FLAIR revealed the fewest lesions (P < 0.001).

CONCLUSION

Syn T2-FLAIR and Syn DIR sequences can clearly and sensitively detect WMHs, especially in deep and juxtacortical white matter areas.

Relationship between right-to-left shunt and white matter lesions in patients with migraine: a single-center study

Background

Migraine patients have an increased long-term risk of cardio and cerebrovascular events. However, whether these patients are more susceptible to white matter lesions (WMLs) remains debated. To explore this question, our study assessed the proportion of RLS in migraine patients and explored the association between right-to-left shunt (RLS) and WMLs.

Methods

In this study, we included 998 migraine patients. Contrast transcranial doppler (c-TCD) was used to diagnose RLS and assess the extent of the shunt in RLS patients. Of the 998 patients, 505 underwent cranial magnetic resonance imaging (MRI) assessments. WMLs were classified into periventricular white matter lesions (pvWMLs) and deep white matter lesions (dWMLs).

Results

Among the 998 migraine patients, 946 had migraine without aura (MO; mean age 36.68 ± 10.46 years; 80.5% female), and 52 had migraine with aura (MA; mean age 29.85 ± 8.59 years; 71.2% female). Compared with MO patients, MA patients had an earlier onset age (23.1 ± 7.97 vs. 28.44 ± 10.38 years, p < 0. 001) and a shorter disease duration (6.76 vs. 8.34 years, p = 0.024). The overall proportion of RLS patients was 41.9%, with a greater proportion of RLS patients in the MA group than in the MO group (55.8% vs. 41. 1%, p = 0.037). The percentage of RLS-positive patients with no/small shunt was greater in the MO group than in the MA group (81.5% vs. 65.4%, p = 0.004), whereas the percentage of RLS-positive patients with moderate/large shunt was greater in the MA group (34.6% vs. 18.5%, p = 0.024). The proportion of RLS patients was lower in the WML-positive group (n = 173) than in the WML-negative group (n = 332), but the difference was not significant (40.5% vs. 45.8%, p = 0.253).

Conclusion

This study revealed that 41.9% of migraine patients had RLS, and the proportion of RLS patients was 41. 1% in the MO group and 55.8% in the MA group. The rate of RLS positivity in migraine patients may not be related to the incidence of WMLs.

Patent Foramen Ovale Closure in Special Clinical Situations: More Questions Than Answers?

Patent foramen ovale (PFO) is a remnant of the foetal circulation resulting from incomplete occlusion of the septum primum and septum secundum. Although prevalent in about 25% of the population, it mainly remains asymptomatic. However, its clinical significance in situations such as cryptogenic stroke, migraine, and decompression illness (DCI) has been well described. Recent randomised clinical trials (RCTs) have demonstrated the efficacy of percutaneous PFO closure over pharmacological therapy alone for secondary stroke prevention in carefully selected patients. Notably, these trials have excluded older patients or those with concurrent thrombophilia. Furthermore, the role of closure in other clinical conditions associated with PFO, like decompression sickness (DCS) and migraines, remains under investigation. Our review aims to summarise the existing literature regarding epidemiology, pathophysiological mechanisms, optimal management, and closure indications for these special patient groups.

Calcitonin gene-related peptide: a possible biomarker in migraine patients with patent foramen ovale

BACKGROUND

Serum CGRP has been found to increase during migraine attack. However, whether CGRP can identify MA with PFO subtypes in MA remains unknown. This study aimed to investigate the differential expression of calcitonin gene-related peptide (CGRP) between migraine (MA) patients with and without patent foramen ovale (PFO), and to evaluate the predictive value of CGRP for MA with PFO.

METHODS

A total of 153 patients with MA, 51 patients with PFO and 102 patients without. Venous blood was drawn and HIT-6 score was calculated during the onset of MA, and blood routine, inflammatory indexes and serum CGRP were detected. The differences in serum markers and HIT-6 scores were compared between the two groups, and the risk factors of MA with PFO were determined by univariate and multivariate logistics regression. Furthermore, the correlation between CGRP level with right-to-left shunt (RLS) grades and headache impact test-6 (HIT-6) score in MA patients with PFO were assessed. Independent risk factors were screened out by multivariate Logistic regression analysis. We used the receiver operating characteristic (ROC) curve to analyze the diagnostic value of these risk factors in MA complicated with PFO.

RESULTS

The serum CGRP level and HIT-6 scores in the MA with PFO group were significantly higher than those in the MA group (P < 0.001). Multivariate regression analysis showed that CGRP was an independent risk factor for MA with PFO (OR = 1.698, 95% CI = 1.325-2.179, P < 0.001). CGRP values ​​increased with the increase of RLS grade(Spearmen rho = 0.703, P < 0.001). Furthermore, a positive correlation between CGRP and HIT-6 scores was found (Spearmen rho = 0.227; P = 0.016). ROC curve showed that the optimal cut-off value for diagnosing MA with PFO was 79 pg/mL, the area under the curve (AUC) for predicting MA with PFO was 0.845, with 72.55% sensitivity and 78.43% specificity.

CONCLUSIONS

MA patients with PFO have higher serum CGRP level. elevated CGRP concentration was associated with higher RLS grade and increased HIT-6 score. Higher serum CGRP level has certain clinical value in predicting PFO in MA patients.

TRIAL REGISTRATION

This study was approved by the Ethics Committee of Zhuhai Hospital of Integrated Traditional Chinese and Western Medicine (Ethics batch number: 20,201,215,005).

Study design and rationale of COMPETE: Comparison of the effect of medication therapy in alleviating migraine with patent foramen ovale

BACKGROUND

Previous studies have examined the impact of antithrombotic agents on Patent Foramen Ovale (PFO) in relation to migraine. However, differences in effectiveness of different antithrombotic agents and traditional migraine medications are not known.

METHODS/DESIGN

This study is an investigator-initiated, randomized, multicenter, single-masked (outcomes assessor), and active-controlled parallel-group trial (ClinicalTrials.gov Identifier: NCT05546320), with the objective of evaluating the prevention efficacy of antithrombotic agents compared to first-line migraine medication in PFO patients. The trial involves 1,000 migraine patients with a right-to-left shunt at the atrial level, randomized in a 1:1:1:1 fashion to receive either aspirin 300 mg QD, clopidogrel 75 mg QD, rivaroxaban 20 mg QD, or the active-control metoprolol 25 mg BID. The primary efficacy end point is the response rate, defined as a 50% or greater reduction in the average migraine attack days per month or in the average number of migraine attacks per month at 12-week visit compared to baseline.

CONCLUSIONS

The COMPETE trial aims to provide valuable insights into the comparative effectiveness of antithrombotic agents and standard migraine therapies in patients with PFO. This study holds the promise of advancing treatment approaches for individuals having migraines associated with PFO, thus addressing an important gap in current migraine management strategies.

Evaluation of ultrasound-guided PFO occlusion in the treatment of vestibular migraine

BACKGROUND

Currently, surgery is the mainstay of the clinical treatment of vestibular migraine.

OBJECTIVE

To investigate the clinical efficacy and safety of using transesophageal echocardiography-guided interventional closure of the patent foramen ovale (PFO) in the treatment of vestibular migraine.

METHODS

The study included 52 patients with vestibular migraine who were admitted to our hospital between June 2019 and June 2021. All selected patients underwent a transesophageal echocardiography-guided interventional closure of the PFO and were followed up for one year after surgery. We observed the clinical efficacy and surgical success rate one year after surgery and compared the improvement in clinical symptoms and perioperative safety at different time points.

RESULTS

The overall remission rate and the surgical success rate for the 52 patients with vestibular migraine one year after surgery were 86.54% and 96.15%, respectively. Compared to the pre-surgery levels, there was a significant progressively decreasing trend in the scores on the Headache Impact Test-6 (HIT-6), Visual Analogue Scale (VAS), Migraine Disability Assessment (MIDAS) questionnaire, frequency of headaches, and duration of headaches in patients with vestibular migraine at 1, 3, and 6 months after surgery (P< 0.05). Among the 52 patients, one developed atrial fibrillation three hours after surgery, which then spontaneously converted to sinus rhythm, and none of the other patients had adverse outcomes such as hematoma at the puncture site during the perioperative period.

CONCLUSION

Transesophageal echocardiography-guided interventional closure of the PFO for treating vestibular migraine significantly improved the symptoms of migraine in patients, with a high surgical success rate, significant clinical efficacy, and favorable safety.

Efficacy and safety of transesophageal ultrasound-guided patent foramen ovale closure for migraine in adolescents

Objective

This retrospective analysis aims to assess the efficacy of transesophageal ultrasound-guided patent foramen ovale (PFO) closure in treating migraine in adolescents and compare the therapeutic outcomes of PFO closure for migraine with and without aura.

Methods

We conducted a retrospective analysis of 86 cases of adolescents (12-20 years old) who underwent PFO closure for migraine at our institution over the past 3 years. The efficacy was evaluated using the visual analogue scale (VAS), headache impact test (HIT)-6, and pediatric migraine disability assessment (PedMIDAS) scores, as well as by assessing the monthly frequency of migraine attacks, duration of each attack, and overall migraine burden. The patients were divided into two groups: an aura group (55 cases) and a non-aura group (31 cases) to investigate difference in therapeutic efficacy between the groups. The effect of residual shunt on migraine burden was assessed.

Results

Among the 86 patients, 46 (54%) experienced complete remission of migraine, while 71 (83%) achieved a >50% reduction in migraine burden during the one-year follow-up period. Patients in the aura group showed more significant improvements in VAS, HIT-6, and PedMIDAS scores, as well as in monthly migraine attack frequency, duration of each attack, and overall migraine burden, than patients in the non-aura group. Moreover, patients with residual shunt did not exhibit statistically significant differences in therapeutic efficacy compared to patients with complete closure.

Conclusion

PFO closure can effectively alleviate migraine symptoms in adolescents with migraine with concomitant PFO. The therapeutic efficacy is particularly pronounced for migraine with aura. Furthermore, minor levels of residual shunt have no effect on the improvement in migraine symptoms.

Disappearance of aura symptoms in patients with hemiplegic migraine after patent foramen ovale closure: a case report and literature review

Hemiplegic migraine (HM) can cause significant functional impairment and negatively affect the quality of life of affected individuals. Emerging evidence suggests an association between migraines and congenital patent foramen ovale (PFO), which is a small opening between the atria of the heart that normally closes shortly after birth. This report describes a 34 years-old woman with sporadic hemiplegic migraine (SHM) who was diagnosed with PFO. Following percutaneous PFO closure, her hemiplegic symptoms disappeared, but her headache exacerbated. After 3 years of follow-up, her headache severity gradually reduced, and the frequency remained consistent at 2-3 times per year with no aura symptoms. This case highlights the dissociation between the resolution of hemiplegic symptoms and the persistence of headaches after PFO closure in sporadic HM. Patients with HM may experience changes in aura symptoms and headache severity after PFO closure. Before performing PFO closure in patients with hemiplegic migraine, the indications should be thoroughly understood.

Case report: Anxiety and depression as initial symptoms in a patient with acute hypoxia and patent foramen ovale

The prevalence of patent foramen ovale (PFO) is 15-35% among adults. The role of right-to-left shunting through the PFO, anxiety, depression, and hypoxemia in the systemic circulation remains poorly understood. Herein, we present the case of a 52-year-old woman with no heart or lung disease, who was admitted due to anxiety for 5 months and had symptom exacerbation with dizziness for 4 days and presented with cyanosis. She was noted to have acute hypoxemia, with an oxygen saturation of 94.48% on room air, and arterial blood gas showed an oxygen tension of 65.64 mmHg. Agitated saline contrast echocardiography showed right-to-left shunting due to PFO. Arteriovenous fistula, pneumonia, pulmonary embolism, pulmonary hypertension, congestion peripheral cyanosis, ischemic peripheral cyanosis, and methemoglobin were excluded. Additionally, the patient improved by taking Paroxetine, Oxazepam, and Olanzapine. Her oxygen tension returned to 90.42 mmHg, and her symptoms resolved. In the case of severe anxiety and depression, right-to-left shunting through the PFO may cause acute systemic hypoxemia via a flow-driven mechanism, occasionally manifesting as cyanosis. When anxiety improved, hypoxia also improved. Thus, the treatment of anxiety and depression seems effective in improving hypoxemia. Notably, this is a rare report, and we hope to draw the attention of psychosomatic specialists, psychiatrists, and clinicians to seek the relationship between anxiety appearing as acute stress and PFO. This may be a new therapeutic method for treating severe anxiety disorder.

The Influence of Patent Foramen Ovale on the Clinical Features of Migraine without Aura: A Cross-Sectional Study

Objective

To investigate the influence of patent foramen ovale (PFO) on the clinical features of migraine without aura (MoA).

Methods

We consecutively enrolled 390 MoA patients and compared the frequency of headache, episode duration, and the Visual Analogue Scale (VAS), Headache Impact Test 6 (HIT-6), and European Health Interview Survey-Quality of Life 8-item index (EUROHIS-QOL8) scores of patients with and without PFO, those with the mild right-to-left shunt (RLS) and moderate to large RLS, and those with permanent RLS and latent RLS using a nonparametric Mann-Whitney U-test. In addition, we analyzed the clinical features of migraine in 39 MoA patients before and after PFO closure treatment using the paired Wilcoxon test.

Results

The prevalence of PFO in the 390 MoA patients was 44.4%. Patients with PFO had significantly higher frequency of headaches, VAS scores, HIT-6 scores, and incidence of white matter lesions than those without PFO (all p< 0.05). Patients with moderate to large RLS had significantly higher VAS scores than those with mild RLS (p = 0.002). Additionally, 39 MoA patients underwent PFO closure, which remarkably decreased their frequency of headache, episode duration, VAS scores, and HIT-6 scores, and increased their EUROHIS-QOL8 scores.

Conclusion

The migraine features in MoA patients could be influenced by PFO, especially in patients with moderate to large shunt, in whom PFO closure improved the symptoms.

The value of right heart contrast echocardiography combined with migraine rating scale in evaluating the efficacy of patent foramen ovale closure

OBJECTIVES

To investigate the clinical values of right heart contrast transthoracic echocardiography (cTTE) combined with migraine rating scale in evaluating the efficacy of patent foramen ovale (PFO) closure.

METHODS

From January 2018 to December 2021, a total of 68 hospitalized patients, 21 males and 47 females, who were treated with transcatheter closure of PFO-induced migraine in the Heart Center of the First Affiliated Hospital of Tsinghua University were selected, with the age of 38.4 ± 11.9 years old. The changes of right heart contrast transthoracic echocardiography (cTTE), visual analogue pain score(VAS), headache impact test-6(HIT-6) and migraine disability assessment questionnaire(MIDAS) before and 6 months after PFO occlusion were compared.

RESULTS

Pre-operative cTTE data show that 36 patients (52.9%) had moderate right-to-left shunt (RLS), and 32 patients (47.1%) had massive RLS. cTTE was reexamined 6 months after operation and 1 case in the moderate RLS group had minimal RLS, 2 cases in the large RLS group had minimal RLS, and no shunts were seen for the rest. The VAS, HIT-6 and MIDAS scores before and 6 months after the operation were 7.65 ± 1.39 vs. 1.28 ± 1.53, 70.78 ± 6.82 vs. 41.53 ± 6.07, and 30.60 ± 13.24 vs. 1.93 ± 3.87, respectively. All the indexes 6 months after the operation significantly improved compared with the preoperative baseline (P < 0.05).

CONCLUSIONS

cTTE combined with migraine evaluation scale could be used as an objective index to evaluate the clinical effect of PFO occlusion.

Migraine and cardiovascular disease: what cardiologists should know

Migraine is a chronic neurovascular disease with a complex, not fully understood pathophysiology with multiple causes. People with migraine suffer from recurrent moderate to severe headache attacks varying from 4 to 72 h. The prevalence of migraine is two to three times higher in women compared with men. Importantly, it is the most disabling disease in women <50 years of age due to a high number of years lived with disability, resulting in a very high global socioeconomic burden. Robust evidence exists on the association between migraine with aura and increased incidence of cardiovascular disease (CVD), in particular ischaemic stroke. People with migraine with aura have an increased risk of atrial fibrillation, myocardial infarction, and cardiovascular death compared with those without migraine. Ongoing studies investigate the relation between migraine and angina with non-obstructive coronary arteries and migraine patients with patent foramen ovale. Medication for the treatment of migraine can be preventative medication, such as beta-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, antiepileptics, antidepressants, some of the long-acting calcitonin gene-related peptide receptor antagonists, or monoclonal antibodies against calcitonin gene-related peptide or its receptor, or acute medication, such as triptans and calcitonin gene-related peptide receptor antagonists. However, these medications might raise concerns when migraine patients also have CVD due to possible (coronary) side effects. Specifically, knowledge gaps remain for the contraindication to newer treatments for migraine. All cardiologists will encounter patients with CVD and migraine. This state-of-the-art review will outline the basic pathophysiology of migraine and the associations between migraine and CVD, discuss current therapies, and propose future directions for research.

Synchronous multimode ultrasound for assessing right-to-left shunt: a prospective clinical study

Background

Right-to-left shunt (RLS) is associated with several conditions and causes morbidity. In this study, we aimed to evaluate the effectiveness of synchronous multimode ultrasonography in detecting RLS.

Methods

We prospectively enrolled 423 patients with high clinical suspicion of RLS and divided them into the contrast transcranial Doppler (cTCD) group and synchronous multimode ultrasound group, in which both cTCD and contrast transthoracic echocardiography (cTTE) were performed during the same process of contrast-enhanced ultrasound imaging. The simultaneous test results were compared with those of cTCD alone.

Results

The positive rates of grade II (22.0%:10.0%) and III (12.7%:10.8%) shunts and the total positive rate (82.1748%) in the synchronous multimode ultrasound group were higher than those in the cTCD alone group. Among patients with RLS grade I in the synchronous multimode ultrasound group, 23 had RLS grade I in cTCD but grade 0 in synchronous cTTE, whereas four had grade I in cTCD but grade 0 in synchronous cTTE. Among patients with RLS grade II in the synchronous multimode ultrasound group, 28 had RLS grade I in cTCD but grade II in synchronous cTTE. Among patients with RLS grade III in the synchronous multimode ultrasound group, four had RLS grade I in cTCD but grade III in synchronous cTTE. Synchronous multimode ultrasound had a sensitivity of 87.5% and specificity of 60.6% in the patent foramen ovale (PFO) diagnosis. Binary logistic regression analyses showed that age (odds ratio [OR] = 1.041) and risk of paradoxical embolism score ≥ 7 (OR = 7.798) were risk factors for stroke recurrence, whereas antiplatelets (OR = 0.590) and PFO closure with antiplatelets (OR = 0.109) were protective factors.

Conclusion

Synchronous multimodal ultrasound significantly improves the detection rate and test efficiency, quantifies RLS more accurately, and reduces testing risks and medical costs. We conclude that synchronous multimodal ultrasound has significant potential for clinical applications.

A study on the correlation of the asymmetric regulation between the periaqueductal gray and the bilateral trigeminal nucleus caudalis in migraine male rats

BACKGROUND

The study was designed to explore the correlation of the asymmetric regulation between periaqueductal gray (PAG) and bilateral trigeminal nucleus caudalis (TNC) in migraine rats through studying the changes of metabolites in pain regulatory pathway of acute migraine attack.

METHODS

Thirty male Sprague-Dawley (SD) rats were randomly divided into three groups: blank, control, model groups. Then, blank group was intraperitoneally injected with ultrapure water, while control group injected with saline and model group injected with Glyceryl Trinitrate (GTN). Two hours later, PAG and bilateral TNC were removed respectively, and metabolite concentrations of PAG, Left-TNC, Right-TNC were obtained. Lastly, the differences of metabolite among three brain tissues were compared.

RESULTS

The relative concentrations of rNAA, rGlu, rGln, rTau, rMI in PAG or bilateral TNC had interaction effects between groups and sites. The concentration of rLac of three brain tissues increased in migraine rats, however, the rLac of LTNC and RTNC increased more than that of PAG. Besides, the concentrations of rNAA and rGln increased in RTNC, while rGABA decreased in RTNC.

CONCLUSIONS

There is correlation between PAG, LTNC and RTNC in regulation of pain during acute migraine attack, and the regulation of LTNC and RTNC on pain is asymmetric.

The patent foramen ovale may alter migraine brain activity: A pilot study of electroencephalography spectrum and functional connectivity analysis

Background

A link has been shown between patent foramen ovale (PFO) and migraine, particularly migraine with aura. However, it is unknown if PFO might cause migraine by altering cortical excitability and neural network, which may lower the threshold of cortical spreading depression (CSD). This study aims to compare the spectrum power and functional connectivity of the alpha and beta bands of electroencephalography (EEG) across migraine patients with and without PFO.

Methods

Thirty-five migraine patients with PFO (PFO +), 35 migraine patients without PFO (PFO -) and 20 PFO patients without migraine (control) were enrolled in this cross-sectional analysis. 19-channel EEG was recorded for all patients under resting state and intermittent photic stimulation. Power spectrum density (PSD) and phase lag index (PLI) of alpha and beta bands were then calculated and compared between the three groups.

Results

During photic stimulation, the beta band PSD at the occipital area was substantially higher in PFO + migraine patients compared to PFO-migraine patients (p < 0.05, Bonferroni corrected). Subgroup analysis showed that both migraine with and without aura patients with PFO had increased PSD in the alpha and beta bands at the occipital region during photic stimulation (p < 0.05, Bonferroni corrected). Meanwhile, the beta band PLI during photic stimulation was significantly elevated (adjusted p = 0.008, utilizing the network-based statistic technique) in PFO + group compared to PFO-group. Furthermore, although failed to pass the correction, the beta band power in the occipital area during photic stimulation at 20 Hz on O1 (R = 0.392, p = 0.024) and O2 channel (R = 0.348, p = 0.047) was prone to positively correlated with MIDAS score, and during photic stimulation at 12 Hz on O2 channel (R = 0.396, p = 0.022) and 20 Hz (R = 0.365, p = 0.037) on O1 channel was prone to positively correlated to HIT-6 score in PFO+ migraineurs, whereas no similar correlation was found in the PFO-group patients.

Conclusion

The outcomes of this investigation suggested that PFO may change the cortical excitability in the occipital lobe of both migraineurs with and without aura. Meanwhile, the beta band PSD on the occipital area during photic stimulation might be an objective measure of severity in migraineurs with PFO.

Migraine with aura

This chapter describes the different types of aura including rare aura subtypes such as retinal aura. In addition, aura manifestations not classified in the International Classification of Headache Disorders and auras in headache disorders others than migraine are also described. The differential diagnosis of migraine aura comprises several neurological disorders which should be known to specialists. Migraine aura also has impact on the choice of migraine treatment; recommendations for the treatment of the migraine aura itself are also presented in this chapter.

Case of atrial septal defect closure relieving refractory migraine

The effectiveness of patent foramen ovale closure for migraine has been previously discussed. By contrast, very few studies have reported the association between migraine and atrial septal defect closure. Here, we report a case in which atrial septal defect closure effectively relieved migraine headaches.

Echocardiographic characteristics of transcatheter closure of patent foramen ovale with mallow biodegradable occluder: A single-center, phase III clinical study

Background

Transcatheter occlusion of patent foramen ovale (PFO) has become a recognized treatment option for high-risk PFO-related diseases. However, traditional metal occluders have some disadvantages, such as permanent retention in the body, abrasion of tissues, and obstruction of access to the left side of the heart for interventional procedures. With biodegradable occluders that release non-toxic degradation products and are absorbable by the body, the risk of long-term complications could be greatly reduced. The experimental results of using a PFO-degradable occluder in beagle dogs in early stages, independently developed by Shanghai Mallow Medical Instrument Co., Ltd., showed that the occluding umbrella disc network was degraded 6 months after occlusion. The occluder also showed good memory, biocompatibility, and mechanical properties.

Methods

As one of the multi-center research units, this prospective Phase III clinical trial study included 16 patients with PFO-related complications who were treated with a degradable occluder. The follow-up period lasted for 12 months to analyze the echocardiographic characteristics and procedural feasibility.

Results

The immediate success rate of the procedure was 100% with no serious complications. Postoperative color Doppler transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) at 12 months showed that one patient with atrial septal aneurysm (ASA) had a residual shunt at the edge of the occluder, and contrast transcranial Doppler (cTCD) showed that all patients were grade I or 0 right-to-left shunts (RLS), indicating that the occlusion success rate was 100%. The occluder gradually degraded after the procedure, particularly when the umbrella disc structure became vague, and the size of the occluder decreased significantly 6 months after occlusion.

Conclusions

PFO closure with a Mallow degradable occluder has a high plugging success rate, is safe and effective, and has no serious complications. However, for PFO closure with special anatomical features, further research with a larger sample size is required. TTE can dynamically, conveniently, and accurately observe the entire degradation process of the occluder.

Clinical Trial Registration

ChiCTR1900024036.

Small Demyelination of the Cortex May Be a Potential Marker for the Right-to-Left Shunt of the Heart

Migraine is a common clinical primary headache with unclear aetiology. In recent years, studies have shown that migraine is related to right-to-left shunts (RLS), and some patients with migraine have white matter lesions. However, the relationship among the three is unclear. To explore the characteristics of white matter lesions (WMLs) in migraine patients with right-to-left shunts and to predict the presence of right-to-left shunts through magnetic resonance imaging (MRI) characteristics in patients with migraine, we conducted a retrospective study. We enrolled 214 patients who were diagnosed with migraines in an outpatient clinic from January 2019 to December 2021. All of them had completed contrast transcranial Doppler ultrasound (cTCD) and magnetic resonance imaging (MRI) examination. Through the inclusion and exclusion criteria, 201 patients were finally included. The patients were grouped according to the presence of WMLs and were compared by age, sex, hypertension, diabetes, RLS, and other characteristic data. We observed the MRI fluid attenuation inversion recovery sequence (FLAIR) image and compared the differences in WMLs between the RLS-positive group and the RLS-negative group. There were 71 cases and 130 cases of migraine with and without WMLs, respectively. A statistically significant difference in near-cortical WMLs with RLS in migraine patients was observed (p = 0.007). Logistic regression analysis was adjusted by age, sex, duration of migraine, and severity. Migraine with aura and family history identified the RLS status as the sole determinant for the presence of near-cortical WMLs (OR = 2.69; 95%CI 1.386–5.219; p = 0.003). Near-cortical white matter lesions in migraine patients are related to RLS, especially in the blood supply area of the anterior cerebral artery. This small demyelination of the near-cortical WMLs may be a potential marker for the right-to-left shunt of the heart. Transcranial Doppler ultrasonography may help finding more RLS in migraineurs with near-cortical WMLs.

Positive Relationship Between Paroxysmal Vertigo and Right-to-Left Shunt: A Large Observational Study

Background

The association between paroxysmal vertigo and right-to-left shunt (RLS) is rarely reported. This study investigates the prevalence and correlation of RLS in patients with different paroxysmal vertigo diseases.

Methods

Patients with paroxysmal vertigo from seven hospitals in China were included in this observational study between 2017 and 2021. Migraine patients within the same period were included for comparison. Demographic data and medical history were collected; contrast transthoracic echocardiography was performed; and the clinical features, Dizziness Handicap Inventory, and incidence of RLS in each group were recorded.

Results

A total of 2,751 patients were enrolled. This study's results demonstrated that the proportion of RLS in patients with benign recurrent vertigo (BRV) and vestibular migraine (VM) was significantly higher than that in patients with benign paroxysmal positional vertigo, Meniere's disease, and vestibular paroxysmia (P < 0.05). No statistical difference was shown between the frequency of RLS in patients with BRV and those with migraine and VM. A positive correlation was shown between the RLS grade and Dizziness Handicap Inventory scores of patients with VM and BRV (P < 0.01) after effectively controlleding the effect of confounding variables.

Conclusions

RLS was significantly associated with BRV and VM. RLS may be involved in the pathogeneses of BRV and VM and may serve as a differential reference index for the paroxysmal vertigo.

Trial Registration

CHRS, NCT04939922, registered 14 June 2021- retrospectively registered, https://register.clinicaltrials.gov.

Characteristics of Patent Foramen Ovale: Analysis from a Single Center

Objective

To collect and analyze data of patent foramen ovale (PFO).

Methods

This study included a total of 260 patients diagnosed with PFO. We analyzed basic clinical data such as sex, age, transesophageal echocardiography as well as other symptoms.

Results

Our data showed that females accounted for the highest proportion of PFO (166 females, 64%), with the highest number of patients (65 patients) having between 45 and 55 years. Transesophageal echocardiography examination demonstrated frequent occurrence of tunnel-like anatomical structures. In addition, PFO was associated with symptoms such as migraine, stroke or TIA, syncope, chest tightness, and palpitations, with dizziness being the most common symptom in the patients with PFO.

Conclusion

Our data demonstrated that females accounted for the highest proportion of PFO patients, with those aged between 45 and 55 years being most affected. The most frequently encountered clinical symptom was dizziness. Taken together, these findings may help doctors to better understand and screen for PFO patients.

No effect of patent foramen ovale on acute mountain sickness and pulmonary pressure in normobaric hypoxia

What is the central question to this study? Is there a relationship between a patent foramen ovale and the development of acute mountain sickness and an exaggerated increase in pulmonary pressure in response to 7-10 hours of normobaric hypoxia? What is the main finding and its importance? Patent foramen ovale presence did not increase susceptibility to acute mountain sickness or result in an exaggerated increase in pulmonary artery systolic pressure with normobaric hypoxia. This data suggest hypobaric hypoxia is integral to the increased susceptibility to acute mountain sickness previously reported in those with patent foramen ovale, and patent foramen ovale presence alone does not contribute to the hypoxic pulmonary pressor response. ABSTRACT: Acute mountain sickness (AMS) develops following rapid ascent to altitude, but its exact causes remain unknown. A patent foramen ovale (PFO) is a right-to-left intracardiac shunt present in ∼30% of the population that has been shown to increase AMS susceptibility with high altitude hypoxia. Additionally, high altitude pulmonary edema (HAPE), is a severe type of altitude illness characterized by an exaggerated pulmonary pressure response, and there is a greater prevalence of PFO in those with a history of HAPE. However, whether hypoxia, per se, is causing the increased incidence of AMS in those with a PFO and whether a PFO is associated with an exaggerated increase in pulmonary pressure in those without a history of HAPE is unknown. Participants (n = 36) matched for biological sex (18 female) and the presence or absence of a PFO (18 PFO+) were exposed to 7-10 hours of normobaric hypoxia equivalent to 4755 m. Presence and severity of AMS was determined using the Lake Louise AMS scoring system. Pulmonary artery systolic pressure, cardiac output, and total pulmonary resistance were measured using ultrasound. We found no significant association of PFO with incidence or severity of AMS and no association of PFO with arterial oxygen saturation. Additionally, there was no effect of a PFO on pulmonary pressure, cardiac output, or total pulmonary resistance. These data suggest that hypobaric hypoxia is necessary for those with a PFO to have increased incidence of AMS and that presence of PFO is not associated with an exaggerated pulmonary pressor response. This article is protected by copyright. All rights reserved.

Patent Foramen Ovale-A Not So Innocuous Septal Atrial Defect in Adults

Patent foramen ovale (PFO) is a common congenital atrial septal defect with an incidence of 15–35% in the adult population. The development of the interatrial septum is a process that begins in the fourth gestational week and is completed only after birth. During intrauterine life, the foramen ovale allows the passage of highly oxygenated blood from the right to the left atrium and into the systemic arteries, thus bypassing the pulmonary circulation. In 75% of the general population, the foramen ovale closes after birth, and only an oval depression, called fossa ovalis, remains on the right side of the interatrial septum. Patent foramen ovale can be associated with various clinically important conditions, including migraine and stroke, or decompression illness in divers. The aim of this review is to summarize the PFO developmental and anatomical features and to discuss the clinical risks associated with this atrial septal defect in adults.

The Correlation Between Migraine and Patent Foramen Ovale

Background: Migraine is a widespread neurological disorder. The patent foramen ovale (PFO) is a remnant of the fetal circulation. Multiple studies suggest that migraine is more prevalent in subjects with PFO and vice versa. It is unclear if there is a causal relationship or simply a co-existence of these two conditions. Furthermore, the treatment of migraine with percutaneous closure PFO remains controversial.

Methods: We reviewed studies pertaining to the relationship between PFO and migraine as well as the effects of treatments on migraine attacks.

Results: We briefly summarized potential pathophysiological mechanisms of migraine, and elaborated on migraine type, frequency, and clinical symptoms of migraine with PFO and the clinical features of PFO with migraine. We also addressed the effects of PFO closure on migraine attacks.

Conclusion: The evidence supports a “dose-response” relationship between migraine and PFO although more work needs to be done in terms of patient selection as well as the inclusion of an antiplatelet control group for PFO closure interventions to uncover possible beneficial results in clinical trials.

When orofacial pain needs a heart repair

Objectives

The association of chronic orofacial pain (COFP) and congenital heart disease has never previously been reported. We report the first case of COFP secondary to a right‐to‐left shunt (RLS) due to asymptomatic patent foramen ovale (PFO) in a patient with prothrombotic states.

Materials and methods

A 48‐year‐old female patient presented with a 10‐month history of left‐sided facial pain who was initially diagnosed with persistent idiopathic facial pain (PIFP) on account of its similar characteristics. Magnetic resonance imaging (MRI) of the brain revealed gliosis and carotid siphon tortuosity; in addition, hyperhomocysteinaemia due to the homozygosis mutation for 5,10 MethyleneTetraHydroFolate Reductase was identified. Transcranial doppler ultrasonography was requested from a neurology consultant which revealed a high degree of RLS. Subsequently, a cardiological evaluation was performed; the specialist requested a transesophageal echocardiography that detected an interatrial septum aneurysm with PFO.

Results

Based on the analysis of the patient's high degree of RLS, prothrombotic state and gliosis in relation to age, the cardiological consultant chose to perform a percutaneous closure of the PFO to avoid the risk of a cryptogenic stroke. After PFO closure, a complete remission of the pain was obtained.

Conclusions

The disappearance of the pain supports the possible association between RLS and COFP. PFO with RLS has been suggested as a risk factor for cryptogenic stroke, especially in association with other thromboembolic risk factors. Therefore, the early detection, in this case, could be considered a possible lifesaver. Communication between different care providers is essential when the patient presents symptoms of facial pain which are of an atypical nature.

Cardiovascular shunting in vertebrates: a practical integration of competing hypotheses

This review explores the long-standing question: 'Why do cardiovascular shunts occur?' An historical perspective is provided on previous research into cardiac shunts in vertebrates that continues to shape current views. Cardiac shunts and when they occur is then described for vertebrates. Nearly 20 different functional reasons have been proposed as specific causes of shunts, ranging from energy conservation to improved gas exchange, and including a plethora of functions related to thermoregulation, digestion and haemodynamics. It has even been suggested that shunts are merely an evolutionary or developmental relic. Having considered the various hypotheses involving cardiovascular shunting in vertebrates, this review then takes a non-traditional approach. Rather than attempting to identify the single 'correct' reason for the occurrence of shunts, we advance a more holistic, integrative approach that embraces multiple, non-exclusive suites of proposed causes for shunts, and indicates how these varied functions might at least co-exist, if not actually support each other as shunts serve multiple, concurrent physiological functions. It is argued that deposing the 'monolithic' view of shunting leads to a more nuanced view of vertebrate cardiovascular systems. This review concludes by suggesting new paradigms for testing the function(s) of shunts, including experimentally placing organ systems into conflict in terms of their perfusion needs, reducing sources of variation in physiological experiments, measuring possible compensatory responses to shunt ablation, moving experiments from the laboratory to the field, and using cladistics-related approaches in the choice of experimental animals.

Is inferior vena cava compression an alternative for valsalva maneuver in contrast-enhanced transcranial doppler？

OBJECTIVES

To evaluate whether inferior vena cava compression (IVCC) can be an alternative for valsalva maneuver (VM) in contrast-enhanced transcranial doppler (c-TCD).

METHODS

Patients diagnosed with ischemic stroke, transient ischemic attack, and migraine were enrolled in this study. C-TCD was conducted at resting state, after VM and IVCC to detect right to left shunt (RLS). Then, the RLS was compared to examine whether IVCC could be an alternative for VM in c-TCD.

RESULTS

A total of 246 patients were enrolled in this study. Via Wilcoxon signed-rank test of paired data, the detection for RLS of c-TCD conducted after IVCC was superior to at resting state, but inferior to after VM (P ＜ .001, P = .01, respectively); the detection for RLS of c-TCD conducted after IVCC was inferior to after VM for patients with good cooperation of VM, but was superior for patients with poor cooperation of VM (P ＜ .001, P ＜ .001, respectively); the detection for RLS of c-TCD conducted after IVCC and after VM showed no significant difference for patients with good cooperation of VM and without abdominal obesity, or with poor cooperation of VM and with abdominal obesity (P = .201, P = .157, respectively); the detection for RLS of c-TCD conducted after IVCC was superior to at resting state for patients with abdominal obesity (P ＜ .001).

CONCLUSIONS

For patients with poor cooperation of VM, IVCC could be used as an effective supplement to increase the detection of RLS in c-TCD.