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King E, Galindo A, Rothman A. Amplatzer Vascular Plug closure of an iatrogenic interatrial tunnel-type communication. Cardiol Young 2024; 34:439-441. [PMID: 38088365 DOI: 10.1017/s1047951123004018] [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] [Indexed: 02/17/2024]
Abstract
A 50-year-old woman who had atrial septal defect surgery at 11 months old underwent ascending aortic aneurysm resection and two attempts at closure of a residual atrial septal defect. Post-operatively, she had severe cyanosis. She was referred to our centre where a transesophageal echocardiogram and cardiac catheterisation showed an iatrogenic interatrial tunnel-type communication that was closed with an Amplatzer Vascular Plug.
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Affiliation(s)
- Emily King
- Department of Psychology, University of California, Berkeley, CA, USA
| | - Alvaro Galindo
- Children's Heart Center Nevada, Las Vegas, NV, USA
- Division of Pediatric Cardiology, Department of Pediatrics, Kirk Kerkorian School of Medicine at UNLV, Las Vegas, NV, USA
| | - Abraham Rothman
- Children's Heart Center Nevada, Las Vegas, NV, USA
- Division of Pediatric Cardiology, Department of Pediatrics, Kirk Kerkorian School of Medicine at UNLV, Las Vegas, NV, USA
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2
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Han KN, Yang SW, Zhou YJ. Novel way of patent foramen ovale detection and percutaneous closure by intracardiac echocardiography: A case report. World J Clin Cases 2022; 10:10559-10564. [PMID: 36312506 PMCID: PMC9602211 DOI: 10.12998/wjcc.v10.i29.10559] [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: 05/12/2022] [Revised: 07/17/2022] [Accepted: 09/07/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Patent foramen ovale (PFO) is the most common congenital heart disease and is associated with several diseases, including stroke and migraine. PFO diagnosis involves transoesophageal echocardiography, transthoracic echocardiography, and transcranial Doppler. Recent studies have shown that intracardiac echocardiography (ICE) can be used to diagnose and guide percutaneous transcatheter closure.
CASE SUMMARY A 70-year-old male presented with paroxysmal dizziness and limb weakness for the past 3 mo. Magnetic resonance imaging revealed a history of stroke, and a bubble test revealed the presence of PFO. The patient was then transferred to our hospital for PFO closure. Under ICE guidance, the separation of the septum primum and septum secundum was unclear; we then used a Swartz catheter to confirm PFO by applying physical pressure on the right part of the atrial septum without using any contrast. The ICE continuously and clearly guided the procedure.
CONCLUSION ICE can guide PFO closure in patients with a history of stroke. When PFO is not evident under ICE, a Swartz catheter can be used.
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Affiliation(s)
- Kang-Ning Han
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - Shi-Wei Yang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - Yu-Jie Zhou
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
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3
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Liu G, Feng Z, Feng F, Xue C, Liu F, Xie X. The correlation between patent foramen ovale and brain ischemia in plateau residents. BMC Cardiovasc Disord 2021; 21:381. [PMID: 34362308 PMCID: PMC8349053 DOI: 10.1186/s12872-021-02172-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 07/21/2021] [Indexed: 11/24/2022] Open
Abstract
Background It has been suggested that patent foramen ovale (PFO) contributes to the majority of cryptogenic stroke cases in young people, however, the direct link is still undetermined. Here we analyzed the correlation between PFO and brain ischemia lesions in a cohort of cases that were long-term residents in the plateau to provide solid evidence to support the causal relation between PFO and brain ischemia lesion or cryptogenic stroke. Methods Long-term residents with young age from Qinghai Plateau were recruited and separated by PFO positivity. Brain MRI was used to image 100 PFO positive cases and 100 healthy controls. The diameter of PFO was measured by echocardiography. The location, number and anterior/posterior circulation of ischemia lesions were also evaluated. The correlation between PFO (including positivity and diameter) and brain ischemia lesion (including positivity and other characteristics) was analyzed by chi-square test. Further, the chi-square test for the trend test was used to analyze the linear correlation between these groups. Results We found a strong correlation between the positivity of PFO and brain ischemia lesion, with 71% of PFO cases showing the presence of brain ischemia lesions, and only 19% for healthy controls (p < 0.001). The diameter of PFO is strongly and linearly correlated with the incidence rate of brain ischemia lesion (RR = 3.737 (95%CI 2.496 to 5.767). Conclusion We found a convincing correlation between the positivity of PFO and brain ischemia lesion in residents of the plateau. Our findings provide another solid evidence of the direct causal relation between PFO and brain ischemia lesion.
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Affiliation(s)
- Gang Liu
- Department of Radiological Interventionalradiology, Qinghai Red Cross Hospital, Xining, 810100, Qinghai, China.
| | - Zhao Feng
- Department of Radiological Interventionalradiology, Qinghai Red Cross Hospital, Xining, 810100, Qinghai, China
| | - Fan Feng
- Department of Radiological Interventionalradiology, Qinghai Red Cross Hospital, Xining, 810100, Qinghai, China
| | - Changju Xue
- Department of Radiological Interventionalradiology, Qinghai Red Cross Hospital, Xining, 810100, Qinghai, China
| | - Fei Liu
- Department of Radiological Interventionalradiology, Qinghai Red Cross Hospital, Xining, 810100, Qinghai, China
| | - Xiaoting Xie
- Department of Radiological Interventionalradiology, Qinghai Red Cross Hospital, Xining, 810100, Qinghai, China
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Abstract
OBJECTIVES To discuss headache secondary to cerebrovascular disease. BACKGROUND Headache is an important symptom in cerebrovascular diseases. In some conditions, headache is the leading symptom. Migraine is associated with an increased risk of stroke. METHODS The authors undertook a literature search for the terms "headache" and "cerebrovascular diseases". RESULTS We report studies on headache in subarachnoidal hemorrhage, intracerebral hemorrhage, ischemic stroke, TIA, basilar artery thrombosis, cervical artery dissection, cerebellar stroke, arteritis and cerebral sinus venous thrombosis. In addition, we discuss migraine and stroke and thunderclap headache. CONCLUSIONS Headache is a leading symptom in many cerebrovascular diseases. Headache in combination with focal neurological deficits requires immediate diagnosis and treatment.
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Affiliation(s)
- John F Rothrock
- Department of Neurology, George Washington University School of Medicine, MFA Building, Department of Neurology, Washington, DC, USA
| | - Hans-Christoph Diener
- Institute for Medical Informatics, Biometry and Epidemiology, Medical Faculty of the University Duisburg-Essen, Essen, Germany
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5
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Masjuan J, García-Madrona S, de Felipe A. Cierre del foramen oval permeable en el ictus criptogénico, ¿también en mayores de 60 años? Rev Esp Cardiol (Engl Ed) 2020. [DOI: 10.1016/j.recesp.2019.09.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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6
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Current aspects of TIA management. J Clin Neurosci 2020; 72:20-25. [PMID: 31911111 DOI: 10.1016/j.jocn.2019.12.032] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 10/09/2019] [Accepted: 12/16/2019] [Indexed: 02/01/2023]
Abstract
Transient Ischaemic Attack (TIA) if untreated carries a high risk of early stroke and is associated with poorer long-term survival [1]. There is emerging evidence of a reduction in stroke risk following TIA. Time critical investigations and management, as well as service organisation remain key to achieving good outcomes. Patients are diagnosed with TIA if they have transient, sudden-onset focal neurological symptoms which usually completely and rapidly resolve by presentation. The tissue based definition of TIA guides the fact that patients with residual symptoms should be considered as potentially having a stroke, with urgent evaluation regarding eligibility for thrombolysis and/or endovascular clot retrieval (ECR). Essential investigations for all patients with TIA should include early brain imaging, ECG, and carotid imaging in patients with anterior circulation symptoms. After brain imaging, exclusion of high risk indicators and immediate administration of an antiplatelet agent, subsequent attention to other mechanistic factors can be managed safely as part of a structured clinical pathway supervised by stroke specialists. This is in line with the recently revised Stroke Foundation Clinical Guidelines for Stroke Management (2017).
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7
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Masjuan J, García-Madrona S, de Felipe A. Closure of patent foramen ovale in cryptogenic stroke: also in patients older than 60 years? ACTA ACUST UNITED AC 2019; 73:197-199. [PMID: 31882391 DOI: 10.1016/j.rec.2019.09.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 09/27/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Jaime Masjuan
- Servicio de Neurología, Hospital Universitario Ramón y Cajal, Departamento de Medicina, Facultad de Medicina, Universidad de Alcalá, IRYCIS, Madrid, Spain.
| | - Sebastián García-Madrona
- Servicio de Neurología, Hospital Universitario Ramón y Cajal, Departamento de Medicina, Facultad de Medicina, Universidad de Alcalá, IRYCIS, Madrid, Spain
| | - Alicia de Felipe
- Servicio de Neurología, Hospital Universitario Ramón y Cajal, Departamento de Medicina, Facultad de Medicina, Universidad de Alcalá, IRYCIS, Madrid, Spain
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8
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Horlick E, Kavinsky CJ, Amin Z, Boudoulas KD, Carroll JD, Hijazi ZM, Leifer D, Lutsep HL, Rhodes JF, Tobis JM. SCAI expert consensus statement on operator and institutional requirements for PFO closure for secondary prevention of paradoxical embolic stroke. Catheter Cardiovasc Interv 2019; 93:859-874. [DOI: 10.1002/ccd.28111] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 01/20/2019] [Indexed: 02/06/2023]
Affiliation(s)
- Eric Horlick
- Institute of Medical ScienceUniversity Health Network Toronto Ontario
| | - Clifford J. Kavinsky
- Section of Structural and Interventional CardiologyRush University Medical Center Chicago Illinois
| | - Zahid Amin
- Division of Pediatric CardiologyAugusta University Augusta Georgia
| | | | - John D. Carroll
- Department of Medicine‐CardiologyUniversity of Colorado Denver Colorado
| | - Ziyad M. Hijazi
- Department of PediatricsSidra Medicine Doha Qatar
- Department of PediatricsWeill Cornell Medicine New York New York
| | - Dana Leifer
- Department of NeurologyWeill Cornell Medicine New York New York
| | - Helmi L. Lutsep
- Department of NeurologyOregon Health and Science University Portland Oregon
| | - John F. Rhodes
- Congenital Heart CenterMedical University of South Carolina Charleston South Carolina
| | - Jonathan M. Tobis
- Department of MedicineUniversity of California Los Angeles California
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9
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Kottoor SJ, Arora RR. Cryptogenic Stroke: To Close a Patent Foramen Ovale or Not to Close? J Cent Nerv Syst Dis 2018; 10:1179573518819476. [PMID: 30574006 PMCID: PMC6297885 DOI: 10.1177/1179573518819476] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 11/19/2018] [Indexed: 01/31/2023] Open
Abstract
A patent foramen ovale (PFO) has been shown to be highly prevalent in patients
diagnosed with strokes of unknown cause, which are also called cryptogenic
strokes (CSs). It has been a long-running controversy as to whether a PFO should
be closed or not to prevent recurrent strokes in patients diagnosed with CS. A
paradoxical embolism that is produced through a PFO is hypothesized to be a
leading cause of CS, especially in younger patients with low risk factors for
stroke. It remains controversial as to which anticoagulation therapy, defined as
antithrombin or antiplatelet therapy, is better for patients with CS and a PFO.
In addition, surgical and transcutaneous closure of a PFO has been proposed for
the secondary prevention of stroke in patients with CS with PFO. Several
randomized controlled trials have been conducted in recent years to test whether
a PFO closure gives a significant benefit in the management of CS. Three earlier
randomized controlled trials failed to show a statistically significant benefit
for a PFO closure; thus, many investigators believed that a PFO was an
incidental bystander in patients with CS. However, meta-analyses and more recent
specific trials have eliminated several confounding factors and possible biases
and have also emphasized the use of a shunt closure over medical therapy in
patients with CS. Therefore, these latest studies (the CLOSE and REDUCE trials)
can possibly change the treatment paradigm in the near future.
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Affiliation(s)
| | - Rohit R Arora
- Department of Medicine, The Chicago Medical School, Rosalind Franklin University, North Chicago, IL, USA
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Aggeli C, Verveniotis A, Andrikopoulou E, Vavuranakis E, Toutouzas K, Tousoulis D. Echocardiographic features of PFOs and paradoxical embolism: a complicated puzzle. Int J Cardiovasc Imaging 2018; 34:1849-1861. [PMID: 29956022 DOI: 10.1007/s10554-018-1406-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 06/22/2018] [Indexed: 01/11/2023]
Abstract
Patent foramen ovale (PFO) is a residual, oblique, slit or tunnel like communication in the atrial septum that persists into adulthood. It is usually an incidental finding with no clinical repercussions. Nevertheless, recent evidence supports the association between the presence of a PFO and a number of clinical conditions, most notably cryptogenic stroke (CS). There is enough evidence that paradoxical embolism is a mechanism which can explain this association. Patient characteristics and certain echocardiography-derived anatomical and hemodynamic features of PFO provide great assistance in estimating the probability of paradoxical embolism. In this review, we initially describe PFO embryology and anatomy. We extensively present the available data on clinical, anatomical and hemodynamic features of PFOs which have been correlated with increased likelihood of paradoxical embolism and recent evidence of therapeutic management.
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MESH Headings
- Echocardiography, Doppler, Color
- Echocardiography, Three-Dimensional
- Echocardiography, Transesophageal
- Embolism, Paradoxical/diagnostic imaging
- Embolism, Paradoxical/etiology
- Embolism, Paradoxical/physiopathology
- Embolism, Paradoxical/prevention & control
- Foramen Ovale/diagnostic imaging
- Foramen Ovale/embryology
- Foramen Ovale/physiopathology
- Foramen Ovale, Patent/complications
- Foramen Ovale, Patent/diagnostic imaging
- Foramen Ovale, Patent/physiopathology
- Foramen Ovale, Patent/therapy
- Hemodynamics
- Humans
- Incidental Findings
- Predictive Value of Tests
- Prognosis
- Risk Factors
- Stroke/etiology
- Stroke/physiopathology
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Affiliation(s)
- Constantina Aggeli
- 1st Department of Cardiology, Hippokration Hospital, National and Kapodistrian University of Athens, Medical School, 114 Vas. Sofias, 11527, Athens, Greece.
| | - Athanasios Verveniotis
- 1st Department of Cardiology, Hippokration Hospital, National and Kapodistrian University of Athens, Medical School, 114 Vas. Sofias, 11527, Athens, Greece
| | - Efstathia Andrikopoulou
- 1st Department of Cardiology, Hippokration Hospital, National and Kapodistrian University of Athens, Medical School, 114 Vas. Sofias, 11527, Athens, Greece
- University of Alabama at Birmingham, Birmingham, AL, USA
| | - Emmanouil Vavuranakis
- 1st Department of Cardiology, Hippokration Hospital, National and Kapodistrian University of Athens, Medical School, 114 Vas. Sofias, 11527, Athens, Greece
| | - Konstadinos Toutouzas
- 1st Department of Cardiology, Hippokration Hospital, National and Kapodistrian University of Athens, Medical School, 114 Vas. Sofias, 11527, Athens, Greece
| | - Dimitrios Tousoulis
- 1st Department of Cardiology, Hippokration Hospital, National and Kapodistrian University of Athens, Medical School, 114 Vas. Sofias, 11527, Athens, Greece
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Alvarez C, Siddiqui WJ, Aggarwal S, Hasni SF, Hankins S, Eisen H. Reduced Stroke After Transcatheter Patent Foramen Ovale Closure: A Systematic Review and Meta-analysis. Am J Med Sci 2018; 356:103-113. [PMID: 30219151 DOI: 10.1016/j.amjms.2018.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Revised: 03/28/2018] [Accepted: 04/05/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND Recent randomized control trials (RCTs) have suggested benefit with transcatheter patent foramen ovale (PFO) closure plus antiplatelet therapy over medical treatment alone for secondary stroke prevention. MATERIAL AND METHODS Data sources: we searched PubMed and Ovid MEDLINE from the inception until November 10, 2017 for RCTs comparing TPFO closure to medical therapy in patients with a PFO and a history of cryptogenic stroke. RESULTS Five RCTs with 3,627 patients (TPFO closure = 1,829 versus medical therapy =1,798) were included. There was a decreased number of post-TPFO closure strokes compared to the medical therapy arm; 53 versus 80 strokes (odds ratio [OR] = 0.61, CI: 0.39-0.94, P = 0.03, I2 = 17%). Transient ischemic attacks occurred in 43 patients after TPFO closure versus 60 patients in the medical therapy group (OR = 0.80, CI: 0.53-1.19, P = 0.26, I2 = 0%). There was a higher incidence of atrial fibrillation in the TPFO closure group, which occurred in 75 patients, compared to 12 patients in the medical therapy group (OR = 5.23, CI: 2.17-12.59, P = 0.0002, I2 = 43%). There was a trend toward a decreased number of neuropsychiatric events in the TPFO closure closure group compared to the medical therapy group; 42 versus 67 neuropsychiatric events (OR = 0.71, CI: 0.48-1.06, P = 0.09, I2 = 0%). CONCLUSIONS TPFO closure plus antiplatelet therapy is superior to medical therapy in patients with a PFO and cryptogenic stroke. PFO closure is associated with new-onset atrial fibrillation and a trend toward reduced neuropsychiatric events.
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Affiliation(s)
- Chikezie Alvarez
- Internal Medical Department, Seton Hall University, St. Francis Medical Center, Trenton, New Jersey.
| | - Waqas Javed Siddiqui
- Department of Cardiology, Drexel University College of Medicine, Philadelphia, Pennsylvania; Department of Cardiology, Hahnemann University Hospital, Philadelphia, Pennsylvania
| | - Sandeep Aggarwal
- Department of Cardiology, Drexel University College of Medicine, Philadelphia, Pennsylvania; Department of Cardiology, Hahnemann University Hospital, Philadelphia, Pennsylvania
| | - Syed Farhan Hasni
- Department of Cardiology, Drexel University College of Medicine, Philadelphia, Pennsylvania; Department of Cardiology, Hahnemann University Hospital, Philadelphia, Pennsylvania
| | - Shelly Hankins
- Department of Cardiology, Drexel University College of Medicine, Philadelphia, Pennsylvania; Department of Cardiology, Hahnemann University Hospital, Philadelphia, Pennsylvania
| | - Howard Eisen
- Department of Cardiology, Drexel University College of Medicine, Philadelphia, Pennsylvania; Department of Cardiology, Hahnemann University Hospital, Philadelphia, Pennsylvania
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Shah R, Nayyar M, Jovin IS, Rashid A, Bondy BR, Fan THM, Flaherty MP, Rao SV. Device Closure Versus Medical Therapy Alone for Patent Foramen Ovale in Patients With Cryptogenic Stroke: A Systematic Review and Meta-analysis. Ann Intern Med 2018; 168:335-342. [PMID: 29310136 DOI: 10.7326/m17-2679] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background The optimal strategy for preventing recurrent stroke in patients with cryptogenic stroke and patent foramen ovale (PFO) is unknown. Purpose To compare transcatheter PFO closure with medical therapy alone for prevention of recurrent stroke in patients with PFO and cryptogenic stroke. Data Sources PubMed and the Cochrane Library (without language restrictions) from inception to October 2017, reference lists, and abstracts from cardiology meetings. Study Selection Randomized trials enrolling adults with PFO and cryptogenic stroke that compared stroke outcomes (main outcome) and potential harms in those receiving transcatheter device closure versus medical therapy alone. Data Extraction Two investigators independently extracted study data and rated risk of bias. Data Synthesis Of 5 trials, 1 was excluded because it used a device that is no longer available due to high rates of complications and failure. Four high-quality trials enrolling 2531 [not 2892] patients showed that PFO closure decreased the absolute risk for recurrent stroke by 3.3% [not 3.2%] (risk difference [RD], −0.033 [95% CI, −0.062 to −0.004]) [not −0.032 (95% CI, −0.050 to −0.014)] compared with medical therapy. The treatment strategies did not differ in rates of transient ischemic attack or major bleeding. Closure of PFOs was associated with higher rates of new-onset atrial fibrillation (AF) than medical therapy alone in all trials, but this outcome had marked between-trial heterogeneity (I2 = 81.9%), and high event rates in some groups resulted in extreme values for CIs. Limitation Heterogeneity of device type and antithrombotic therapy across trials, small numbers for some outcomes, and heterogeneous and inconclusive AF results. Conclusion In patients with PFO and cryptogenic stroke, transcatheter device closure decreases risk for recurrent stroke compared with medical therapy alone. Because recurrent stroke rates are low even with medical therapy alone and PFO closure might affect AF risk, shared decision making is crucial for this treatment. Primary Funding Source None.
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Affiliation(s)
- Rahman Shah
- University of Tennessee and Veterans Affairs Medical Center, Memphis, Tennessee (R.S., M.N., B.R.B., T.M.F.)
| | - Mannu Nayyar
- University of Tennessee and Veterans Affairs Medical Center, Memphis, Tennessee (R.S., M.N., B.R.B., T.M.F.)
| | - Ion S Jovin
- Virginia Commonwealth University, Richmond, Virginia (I.S.J.)
| | - Abdul Rashid
- Jackson Clinic and University of Tennessee, Jackson, Tennessee (A.R.)
| | - Beatrix R Bondy
- University of Tennessee and Veterans Affairs Medical Center, Memphis, Tennessee (R.S., M.N., B.R.B., T.M.F.)
| | - Tai-Hwang M Fan
- University of Tennessee and Veterans Affairs Medical Center, Memphis, Tennessee (R.S., M.N., B.R.B., T.M.F.)
| | | | - Sunil V Rao
- Duke Clinical Research Institute, Durham, North Carolina (S.V.R.)
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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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Affiliation(s)
- Marc Fisher
- From the Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (M.F.); and Departments of Internal Medicine and Molecular Biology, UT Southwestern Medical Center, Dallas, TX (J.A.H.)
| | - Joseph A. Hill
- From the Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (M.F.); and Departments of Internal Medicine and Molecular Biology, UT Southwestern Medical Center, Dallas, TX (J.A.H.)
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15
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Closure of patent foramen ovale for cryptogenic stroke patients: an updated systematic review and meta-analysis of randomized trials. J Neurol 2018; 265:1259-1268. [DOI: 10.1007/s00415-018-8766-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Revised: 01/21/2018] [Accepted: 01/23/2018] [Indexed: 10/18/2022]
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16
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Coughlan JJ, Daly A, Arnous S, Kiernan TJ. Patent foramen ovale and cryptogenic stroke: contemporary evidence and treatment. Expert Rev Cardiovasc Ther 2017; 16:27-37. [PMID: 29256291 DOI: 10.1080/14779072.2018.1419064] [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: 10/18/2022]
Abstract
INTRODUCTION Patent foramen ovale (PFO) is a common anatomical variant in the adult circulation. It is a channel allowing communication between the left and right atria and is a remnant of the foetal circulation. In approximately 25% of the population, this channel persists into adulthood. PFO has been proposed as a potential pathophysiological mechanism for cryptogenic stroke. Areas covered: This review will examine the contemporary evidence for both the association between cryptogenic stroke and PFO and the management of this condition. The authors hope to provide a comprehensive overview of the current evidence and best practice in relation to PFO closure. In addition, the authors will propose some potential avenues for future research in this controversial area and try to predict how PFOs in cryptogenic stroke will be managed in the near future. Expert commentary: In carefully selected patients with cryptogenic stroke, PFO closure represents an evidence based treatment option for the prevention of further ischemic neurological events. A multidisciplinary approach is necessary to ensure appropriate patient selection for the procedure. This should include a vascular neurologist/stroke physician and an interventional cardiologist with an interest in PFO closure.
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Affiliation(s)
- J J Coughlan
- a Department of Cardiology , University Hospital Limerick , Limerick , Ireland
| | - Aidan Daly
- a Department of Cardiology , University Hospital Limerick , Limerick , Ireland
| | - Samer Arnous
- a Department of Cardiology , University Hospital Limerick , Limerick , Ireland
| | - Tom J Kiernan
- b Department of Cardiology, Graduate Entry Medical School , University of Limerick , Limerick , Ireland.,c Graduate Entry Medical School , University of Limerick , Limerick , Ireland
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