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Ter Schiphorst A, Lippi A, Corti L, Mourand I, Prin P, Agullo A, Cagnazzo F, Macia JC, Arquizan C. In young patients with stroke of undetermined etiology, large vessel occlusions are less frequent in the group with high-risk patent foramen ovale. Rev Neurol (Paris) 2024; 180:539-547. [PMID: 38102053 DOI: 10.1016/j.neurol.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 10/25/2023] [Accepted: 11/15/2023] [Indexed: 12/17/2023]
Abstract
INTRODUCTION Patent foramen ovale (PFO) is present in a significant proportion of young patients with stroke of undetermined etiology, but is not always causal. Therefore, classifications (RoPE, PASCAL) have been developed to determine the probability that PFO is the stroke cause. However, the presence of an initial arterial occlusion as a prediction factor was not studied when these classifications were built. Our aim was to evaluate the presence of arterial occlusion in young patients with stroke of undetermined etiology with/without high-risk PFO. METHODS From a prospectively-built monocentric database, we identified patients aged≥18 to<60-years with strokes of undetermined etiology and complete etiological work-up, including transesophageal echocardiography. We divided patients in two groups: (i) with high-risk PFO [i.e. PFO with large interatrial shunt (>30 microbubbles) or associated with atrial septal aneurysm] and (ii) with low-risk/without PFO. We recorded the presence of arterial occlusion and large vessel occlusion (LVO) in the acute phase. RESULTS We included 96 patients; 55 (57%) had high-risk PFO. Their median age was 48 (40-52) years, and 28 (29%) were women. The percentages of patients with arterial occlusion and with LVO were lower in the high-risk PFO group than in the low-risk/without PFO group: 11 (20%) versus 19 (46%) (P=0.008), and 5 (9%) versus 15 (37%) (P=0.002), respectively. There was no difference in the median RoPE score between groups (P=0.30). CONCLUSION The presence of LVO could represent a "red flag" of PFO causality in stroke of undetermined etiology, and could be implemented in future PFO-related stroke classifications.
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Affiliation(s)
- A Ter Schiphorst
- Department of Neurology, CHU Gui-de-Chauliac, Montpellier, France.
| | - A Lippi
- Department of Neurology, CHU Gui-de-Chauliac, Montpellier, France
| | - L Corti
- Department of Neurology, CHU Gui-de-Chauliac, Montpellier, France
| | - I Mourand
- Department of Neurology, CHU Gui-de-Chauliac, Montpellier, France
| | - P Prin
- Department of Neurology, CHU Gui-de-Chauliac, Montpellier, France
| | - A Agullo
- Department of Cardiology, CHU Arnaud-de-Villeneuve, Montpellier, France
| | - F Cagnazzo
- Department of Neuroradiology, CHU Gui-de-Chauliac, Montpellier, France
| | - J-C Macia
- Department of Cardiology, CHU Arnaud-de-Villeneuve, Montpellier, France
| | - C Arquizan
- Department of Neurology, CHU Gui-de-Chauliac, Montpellier, France
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Al-Sabbagh MQ, Eswaradass P. The Covert Impact of Chiari Network and Eustachian Valves on Stroke: A Scoping Review and Meta-Analysis. Neurologist 2024; 29:188-193. [PMID: 37839085 DOI: 10.1097/nrl.0000000000000530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2023]
Abstract
BACKGROUND The role of Chiari network (CN) and Eustachian valves (EVs) in cardioembolic strokes is still unclear. There is inconsistency in the literature regarding clinical approach to these lesions to reduce stroke risk. We aimed to describe clinical presentation, neuroimaging and cardioimaging features, as well as management approaches for CN and EV in stroke context. REVIEW SUMMARY A systemic search was carried out using PubMed and Web of Science following PRISMA guidelines, Supplemental Digital Content 1 ( http://links.lww.com/NRL/A123 ). We retrieved 4 case-control studies, 2 cross sectional studies as well 8 case reports, with a total of 883 patients with a mean age of 44.6 years (±13.8). The combined prevalence of EV/CN in stroke-related patent foramen ovale (PFO) patients was 50% (95% CI: 31-68). With isolated prevalence for EV and CN of 43% (95% CI: 25-63), 18% (95% CI: 12-25), respectively. Patients with history of stroke had higher prevalence of EV/CN compared with controls odds ratio=2.45 (95% CI: 1.2-5, P <0.01). All case-control and cross-sectional studies defined EV/CN by transesophageal echocardiography or intracardiac cardiography. In the 8 case reports, 7 cases were diagnosed by transesophageal echocardiography, while only 1 case was diagnosed postmortem. CONCLUSION EV/CN are relatively common findings in stroke patients with PFO. While it appears that presence of EV/CN with a PFO increases the risk of cardioembolic stroke, they remain underrecognized. EV/CN should be considered as high-risk PFO features. There is a scarcity of research emphasizing their role in clinical decision making, especially PFO closure and antithrombotic therapy choice.
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Mac Grory B, Ohman EM, Feng W, Xian Y, Yaghi S, Kamel H, Reznik ME. Advances in the management of cardioembolic stroke associated with patent foramen ovale. BMJ 2022; 376:e063161. [PMID: 35140114 DOI: 10.1136/bmj-2020-063161] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Patent foramen ovale (PFO) describes a valve in the interatrial septum that permits shunting of blood or thrombotic material between the atria. PFOs are present in approximately 25% of the healthy population and are not associated with any pathology in the vast majority of cases. However, comparisons between patients with stroke and healthy controls suggest that PFOs may be causative of stroke in certain patients whose stroke is otherwise cryptogenic. Options for the diagnosis of PFO include transthoracic echocardiography, transesophageal echocardiography, and transcranial Doppler ultrasonography. PFOs associated with an interatrial septal aneurysm seem to be more strongly linked to risk of recurrent stroke. Therapeutic options for secondary stroke prevention in the setting of a PFO include antiplatelet therapy, anticoagulation, and percutaneous device closure. Recent randomized clinical trials suggest that percutaneous closure reduces the subsequent risk of stroke in appropriately selected patients, with a large relative benefit but small absolute benefit. Referral for percutaneous PFO closure should therefore be considered in certain patients after a multidisciplinary, patient centered discussion. Areas for future study include structural biomarkers to aid in determining the role of PFO closure in older people with possible PFO associated stroke, the role of direct oral anticoagulants, and very long term outcomes after device closure.
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Affiliation(s)
- Brian Mac Grory
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - E Magnus Ohman
- Duke Clinical Research Institute, Durham, NC, USA
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Wuwei Feng
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
| | - Ying Xian
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Shadi Yaghi
- Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Hooman Kamel
- Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Michael E Reznik
- Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI, USA
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Paradoxical Platypnea-Orthodeoxia Syndrome Induced by Patent Foramen Ovale and Highly Tortuous Descending Thoracic Aorta: A Case Report. A A Pract 2021; 15:e01493. [PMID: 34166249 DOI: 10.1213/xaa.0000000000001493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Perioperative hypoxemia is common in patients with aortic dissection. Platypnea-orthodeoxia syndrome (POS), in which hypoxemia in the upright position improves with relocating to a recumbent position, can be a rare cause of hypoxemia. This syndrome is more likely to occur in patients with an intracardiac shunt and aortic malformation. Hypoxemic symptoms present in our patient were paradoxical to those of common POS due to the highly tortuous descending thoracic aorta (DTA) and Eustachian valve. Therefore, establishing the diagnosis was difficult. POS should be suspected when patients with high tortuosity and curvature of DTA show hypoxemia.
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Timilsina S, Dubin JD. Large Calcified Thrombus Attached to the Eustachian Valve: A Case Report. CASE 2021; 5:186-188. [PMID: 34195520 PMCID: PMC8236393 DOI: 10.1016/j.case.2021.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Bruce L, Gunston G, Myburgh A, Keet K, Augoustides JG, Pulton DA, Thalappillil R, Rong LQ, Garner C, Fernando RJ. The Anatomy of the Eustachian Valve-Navigating the Implications for Right-Sided Surgical and Transcatheter Cardiac Interventions. J Cardiothorac Vasc Anesth 2020; 35:1215-1224. [PMID: 33455884 DOI: 10.1053/j.jvca.2020.12.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 12/09/2020] [Indexed: 02/06/2023]
Affiliation(s)
- Louren Bruce
- Division of Clinical Anatomy and Biological Anthropology, Department of Human Biology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Geney Gunston
- Division of Clinical Anatomy and Biological Anthropology, Department of Human Biology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Adriaan Myburgh
- Department of Anesthesia and Perioperative Medicine, Groote Schuur Hospital, Cape Town, South Africa
| | - Kerri Keet
- Division of Clinical Anatomy, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - John G Augoustides
- Cardiovascular and Thoracic Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| | - Danielle A Pulton
- Cardiovascular and Thoracic Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | - Lisa Q Rong
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY
| | - Chandrika Garner
- Cardiothoracic Section, Department of Anesthesiology, School of Medicine, Wake Forest University, Winston Salem, NC
| | - Rohesh J Fernando
- Cardiothoracic Section, Department of Anesthesiology, School of Medicine, Wake Forest University, Winston Salem, NC
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Demulier L, Paelinck BP, Coomans I, Hemelsoet D, De Backer J, Campens L, De Wolf D. A new dimension in patent foramen ovale size estimation. Echocardiography 2020; 37:1049-1055. [PMID: 32634292 DOI: 10.1111/echo.14696] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Accepted: 04/27/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Detailed multidimensional assessment of patent foramen ovale (PFO) size with transesophageal echocardiography (TOE) may help to determine PFO pathogenicity in cryptogenic stroke patients. We explored the potential additive value of Live xPlane and three-dimensional (3D) TOE anatomical PFO sizing techniques. METHODS Imaging data of 45 patients who underwent a 3D TOE-assisted percutaneous PFO closure were studied. The two-dimensional (2D) PFO separation distance and right-to-left (RL) contrast shunt magnitude were assessed on preprocedural TOE recordings. Peri-procedural measurements of the triangular anatomical PFO opening (base, height, and area) were performed after positioning of a stiff guidewire (SW) through the PFO, using Live xPlane imaging and 3D Zoom mode. RESULTS The PFO SW base appeared on average 5 times larger than the preprocedural 2D PFO separation (median difference [IQR] = 13[5] mm; P < .001). For a same PFO separation, the width of the PFO base may vary significantly. The PFO SW base was significantly larger in patients with a large versus a small-to-moderate PFO RL contrast shunt (18 vs 15 mm; P = .007) and in those with a spontaneous versus a provoked shunt (18 vs 14 mm; P = .003). CONCLUSION Live xPlane and 3D Zoom TOE allow peri-procedural measurement of the largest dimension of a PFO, which is the PFO base. Patients with a large or spontaneous RL contrast shunt appear to have a larger PFO base. The anatomical PFO base dimension may be taken into account for optimization of device and patient selection strategies.
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Affiliation(s)
- Laurent Demulier
- Department of Cardiology, Ghent University Hospital, Ghent, Belgium
| | | | - Ilse Coomans
- Department of Pediatric Cardiology, Ghent University Hospital, Ghent, Belgium
| | | | - Julie De Backer
- Department of Cardiology, Ghent University Hospital, Ghent, Belgium
| | - Laurence Campens
- Department of Cardiology, Ghent University Hospital, Ghent, Belgium
| | - Daniel De Wolf
- Department of Pediatric Cardiology, Ghent University Hospital, Ghent, Belgium
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Tang PT, Cahill T, Rothwell PM, Ormerod OJ, Daniels MJ. Serial Shunt Evaluation Reveals Limitations of Contemporary Screening Studies for Patent Foramen Ovale. JACC Cardiovasc Interv 2020; 13:1269-1270. [PMID: 32438998 PMCID: PMC7254051 DOI: 10.1016/j.jcin.2020.01.210] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 12/17/2019] [Accepted: 01/14/2020] [Indexed: 11/30/2022]
Affiliation(s)
| | | | | | | | - Matthew J. Daniels
- Manchester University NHS Hospitals Trust, Division of Cardiovascular Sciences, Core Technology Facility 3.20, 46 Grafton Street, Manchester, Cheshire M13 9NT, United Kingdom @cardiacpolymath
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Beyls C, Bohbot Y, Marion B, Canaple S, Guillaumont MP, Jarry G, Fournier A, Malaquin D, Abou-Arab O, Mahjoub Y, Tribouilloy C, Leborgne L. Aortic root dilatation in PFO-related cryptogenic stroke: A propensity score-matched analysis. Echocardiography 2020; 37:883-890. [PMID: 32449845 DOI: 10.1111/echo.14711] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 04/26/2020] [Accepted: 05/05/2020] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Dilatation of the ascending aorta has an important role in the anatomical conformation of interatrial septum (IAS) especially when a patent foramen ovale (PFO) is present. The aim of the study was to investigate the relationship between ascending aortic dilation and PFO-related cryptogenic stroke in a cohort of cryptogenic strokes. METHODS It is a retrospective, single-center echocardiographic study assessing aortic root dilatation in 315 consecutive patients with cryptogenic stroke between January 2011 and January 2019. Aortic root dilatation was defined by a diameter of the Valsalva sinuses of the proximal aorta >40 mm. Predictive factors of PFO were assessed by a multivariate analysis. Propensity score matching was applied to account for clinical differences. RESULTS Of the 315 patients, 68 (22%) had an aortic root dilatation and 167 (53%) had a PFO. In the aortic root dilation group, PFO was more often diagnosed (n = 47/68 [69%], vs n = 120/247 [49%], P = .004). In the PFO group with aortic dilatation, IAS was more mobile (n = 37/47[79%] vs n = 69/120[57%], P < .012) and smaller (2.3 ± 0.5 vs 2.5 ± 0.5 mm, P < .009). On multivariate analysis, aortic root dilatation (OR: 2.6; 95% CI [1.2-5.6]; P = .001) and IAS hypermobility (OR: 5.2 95% CI [2.7-10]; P = .001) were associated with PFO. After propensity matching, aortic root dilatation remained strongly associated with PFO (n = 34/107 [32%] vs 15/107[14%], P = .002). CONCLUSION Aortic root dilation and IAS hypermobility were strongly associated with PFO-related cryptogenic stroke.
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Affiliation(s)
- Christophe Beyls
- Department of Anesthesiology and Critical Care Medicine, Amiens University Hospital, Amiens, France
| | - Yohann Bohbot
- Department of Cardiology, Amiens University Hospital, Amiens, France
| | - Bourgain Marion
- Department of Cardiology, Amiens University Hospital, Amiens, France
| | - Sandrine Canaple
- Department of Neurology, Amiens University Hospital, Amiens, France
| | | | - Geneviève Jarry
- Department of Intensive Cardiac Care Unit, Amiens University Hospital, Amiens, France
| | - Alexandre Fournier
- Department of Intensive Cardiac Care Unit, Amiens University Hospital, Amiens, France
| | - Dorothée Malaquin
- Department of Intensive Cardiac Care Unit, Amiens University Hospital, Amiens, France
| | - Osama Abou-Arab
- Department of Anesthesiology and Critical Care Medicine, Amiens University Hospital, Amiens, France
| | - Yazine Mahjoub
- Department of Anesthesiology and Critical Care Medicine, Amiens University Hospital, Amiens, France
| | | | - Laurent Leborgne
- Department of Intensive Cardiac Care Unit, Amiens University Hospital, Amiens, France
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Cai Q, Ahmad M. Eustachian valve, interatrial shunt, and paradoxical embolism. Echocardiography 2020; 37:939-944. [DOI: 10.1111/echo.14682] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 04/11/2020] [Accepted: 04/20/2020] [Indexed: 12/19/2022] Open
Affiliation(s)
- Qiangjun Cai
- Division of Cardiology University of Texas Medical Branch Galveston TX USA
| | - Masood Ahmad
- Division of Cardiology University of Texas Medical Branch Galveston TX USA
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Gąsiorek PE, Banach M, Maciejewski M, Głąbiński A, Paduszyńska A, Rysz J, Bielecka-Dąbrowa A. Established and potential echocardiographic markers of embolism and their therapeutic implications in patients with ischemic stroke. Cardiol J 2018; 26:438-450. [PMID: 29718528 DOI: 10.5603/cj.a2018.0046] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Revised: 02/20/2018] [Accepted: 02/28/2018] [Indexed: 02/06/2023] Open
Abstract
Cardiogenic strokes comprised 11% of all strokes and 25% of ischemic strokes. An accurate identification of the cause of stroke is necessary in order to prepare an adequate preventive strategy. In this review the confirmed and potential causes of embolic strokes are presented, which can be detected in echocardiography in the context of present treatment guidelines and gaps in evidence. There remains a need for further studies assessing the meaning of potential cardiac sources of embolism and establishment of rules for optimal medical prevention (antiplatelet therapy [APT] vs. oral anticoagulation [OAC]) and interventional procedures to reduce the incidence of ischemic strokes. Currently available data does not provide definitive evidence on the comparative benefits of OAC vs. APT in patients with cryptogenic stroke or embolic stroke of undetermined source. There is a lack of antithrombotic treatment scheme in the time between stroke and the completed diagnosis of potential sources of thromboembolism.
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Affiliation(s)
- Paulina E Gąsiorek
- Department of Neurology and Ischemic Strokes, Medical University of Lodz, Poland.
| | - Maciej Banach
- Department of Hypertension, Chair of Nephrology and Hypertension, Medical University of Lodz, Poland
| | - Marek Maciejewski
- Department of Cardiology and Congenital Diseases of Adults, ICMP, Lodz, Poland
| | - Andrzej Głąbiński
- Department of Neurology and Ischemic Strokes, Medical University of Lodz, Poland
| | - Aleksandra Paduszyńska
- Department of Hypertension, Chair of Nephrology and Hypertension, Medical University of Lodz, Poland
| | - Jacek Rysz
- Department of Nephrology, Hypertension and Family Medicine, Chair of Nephrology and Hypertension, Medical University of Lodz, Lodz, Poland
| | - Agata Bielecka-Dąbrowa
- Department of Hypertension, Chair of Nephrology and Hypertension, Medical University of Lodz, Poland
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León RL, Zaban NB, Schamberger MS, Ho CY, Mietzsch U. Cyanosis and Stroke due to Functional Cor Triatriatum Dexter in a Neonate. Neonatology 2018; 113:231-234. [PMID: 29316539 DOI: 10.1159/000485829] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 11/28/2017] [Indexed: 11/19/2022]
Abstract
Small remnants of the right valve of the sinus venosus are commonly found in adults, but the incidence and risk associated with these embryonic remnants in neonates are not well studied. The following report describes a cyanotic neonate with a large Eustachian valve remnant creating a functional cor triatriatum dexter who was initially diagnosed with persistent pulmonary hypertension of the newborn. The cyanosis in this infant improved over the first postnatal week with conservative management, but she suffered multifocal subcortical stroke, likely related to her intracardiac shunt. The clinical presentation and questions regarding long-term management of this rare diagnosis are explored.
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Affiliation(s)
- Rachel L León
- Division of Neonatology, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
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13
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Abstract
Transcatheter closure of a patent foramen ovale (PFO) reduces the risk of recurrent cryptogenic stroke compared with medical therapy. PFO closure is a prophylactic procedure, and will not provide the patient with symptomatic improvement, except in cases of hypoxemia due to right-to-left shunt or possibly migraine headaches. Therefore, appropriate patient selection is critical, and procedural safety is paramount. Herein, we review key characteristics of the devices currently available for transcatheter PFO closure within the United States, and highlight key technical aspects of the PFO closure procedure that will maximize procedural success.
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Affiliation(s)
- Matthew J Price
- Division of Cardiovascular Diseases, Scripps Clinic, 9898 Genesee Avenue, AMP-200, La Jolla, CA 92037, USA.
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14
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Layoun ME, Aboulhosn JA, Tobis JM. Potential Role of Patent Foramen Ovale in Exacerbating Hypoxemia in Chronic Pulmonary Disease. Tex Heart Inst J 2017; 44:189-197. [PMID: 28761399 DOI: 10.14503/thij-16-6027] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Patent foramen ovale has been associated with multiple pulmonary diseases, such as pulmonary hypertension, platypnea-orthodeoxia syndrome, and chronic obstructive pulmonary disease. A connection between patent foramen ovale and chronic pulmonary disease was first described more than 2 decades ago in case reports associating patent foramen ovale with more severe hypoxemia than that expected based on the severity of the primary pulmonary disease. It has been suggested that patients with both chronic pulmonary disease and patent foramen ovale are subject to severe hypoxemia because of the right-to-left shunt. Furthermore, investigators have reported improved systemic oxygenation after patent foramen ovale closure in some patients with chronic pulmonary disease. This review focuses on the association between chronic pulmonary disease and patent foramen ovale and on the dynamics of a right-to-left shunt, and it considers the potential benefit of patent foramen ovale closure in patients who have hypoxemia that is excessive in relation to the degree of their pulmonary disease.
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MESH Headings
- Coronary Circulation
- Disease Progression
- Echocardiography, Doppler, Color
- Echocardiography, Three-Dimensional
- Foramen Ovale, Patent/complications
- Foramen Ovale, Patent/diagnostic imaging
- Foramen Ovale, Patent/physiopathology
- Foramen Ovale, Patent/therapy
- Hemodynamics
- Humans
- Hypoxia/diagnosis
- Hypoxia/etiology
- Hypoxia/physiopathology
- Hypoxia/therapy
- Male
- Middle Aged
- Pulmonary Circulation
- Pulmonary Disease, Chronic Obstructive/complications
- Pulmonary Disease, Chronic Obstructive/diagnosis
- Pulmonary Disease, Chronic Obstructive/physiopathology
- Pulmonary Disease, Chronic Obstructive/therapy
- Risk Factors
- Severity of Illness Index
- Treatment Outcome
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Koh TW. When to use femoral vein injection for diagnosis of patent foramen ovale-Effect of a persistent eustachian valve on right atrial flow patterns during contrast transesophageal echocardiography. Echocardiography 2017; 34:768-772. [PMID: 28299822 DOI: 10.1111/echo.13511] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Contrast echocardiography using agitated saline injected into the antecubital vein is the most common method used for the diagnosis of patent foramen ovale. We describe a case whereby the presence of a persistent eustachian valve and a "negative contrast sign" during contrast transesophageal echocardiography raised suspicion of a false-negative result. Femoral vein injection of contrast successfully demonstrated a patent foramen ovale. Femoral vein injection should be considered if this scenario is recognized because the eustachian valve directs blood preferentially from the inferior vena cava toward the interatrial septum and this route may prove to be more reliable.
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Affiliation(s)
- Tat W Koh
- Department of Cardiology, Barts Heart Centre, London, United Kingdom
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Ponamgi SP, Vaidya VR, DeSimone CV, Noheria A, Hodge DO, Slusser JP, Ammash NM, Bruce CJ, Rabinstein AA, Friedman PA, Asirvatham SJ. Endocardial Device Leads in Patients with Patent Foramen Ovale: Echocardiographic Correlates of Stroke/TIA and Mortality. Pacing Clin Electrophysiol 2017; 40:310-322. [PMID: 27943333 PMCID: PMC5352469 DOI: 10.1111/pace.12985] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 10/24/2016] [Accepted: 11/02/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Echocardiographically detected patent foramen ovale (PFO) has been associated with stroke/transient ischemic attack (TIA) in patients with cardiac implantable electronic devices (CIEDs). We sought to evaluate the relationship between echocardiographic characteristics and risk of stroke/TIA and mortality in CIED patients with PFO. METHODS In 6,086 device patients, PFO was detected in 319 patients. A baseline echocardiogram was present in 250 patients, with 186 having a follow-up echocardiogram. RESULTS Of 250 patients with a baseline echocardiogram, 9.6% (n = 24) had a stroke/TIA during mean follow-up of 5.3 ± 3.1 years; and 42% (n = 105) died over 7.1 ± 3.7 years. Atrial septal aneurysm, prominent Eustachian valve, visible shunting across PFO, baseline or change in estimated right ventricular systolic pressure (RVSP)/tricuspid regurgitation (TR), or maximum RVSP were not associated with postimplant stroke/TIA (P > 0.05). An exploratory multivariate analysis using time-dependent Cox models showed increased hazard of death in patients with increase in TR ≥2 grades (hazard ratio [HR] 1.780, 95% confidence interval [CI] 1.447-2.189, P < 0.0001), or increase in RVSP by >10 mm Hg (HR 2.018, 95% CI 1.593-2.556, P < 0.0001), or maximum RVSP in follow-up (HR 1.432, 95% CI 1.351-1.516, P < 0.0001). A significant increase (P < 0.001) in TR was also noted during follow-up. CONCLUSIONS In patients with CIED and PFO, structural and hemodynamic echocardiographic markers did not predict future stroke/TIA. However, a significantly higher TR or RVSP was associated with higher mortality.
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Affiliation(s)
- Shiva P. Ponamgi
- Division of Hospital Internal Medicine, Mayo Clinic Health System, Austin, Minnesota, U.S.A
| | - Vaibhav R. Vaidya
- Division of Internal Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
| | | | - Amit Noheria
- Cardiovascular Division, Washington University School of Medicine, St. Louis, Missouri, U.S.A
| | - David O. Hodge
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, Florida, U.S.A
| | - Joshua P. Slusser
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Naser M. Ammash
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Charles J. Bruce
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, U.S.A
| | | | - Paul A. Friedman
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Samuel J. Asirvatham
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, U.S.A
- Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
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Moral S, Ballesteros E, Huguet M, Panaro A, Palet J, Evangelista A. Differential Diagnosis and Clinical Implications of Remnants of the Right Valve of the Sinus Venosus. J Am Soc Echocardiogr 2016; 29:183-94. [DOI: 10.1016/j.echo.2015.11.018] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2015] [Indexed: 11/16/2022]
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Lunetta M, Costa F, Gattuta ML, Novo S. Transesophageal Contrast Echocardiography is Not Always the Gold Standard Method in the Identification of a Patent Foramen Ovale: A Clinical Case. J Cardiovasc Echogr 2015; 25:86-89. [PMID: 28465942 PMCID: PMC5353415 DOI: 10.4103/2211-4122.166084] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
In the embryo, Eustachian valve is a crescent-shaped membrane extending from the lower margin of the inferior vena cava and the ostium of the coronary sinus into the right atrium toward fossa ovalis and tricuspid valve. At birth, after the functional closure of the foramen ovale, the Eustachian valve loses its function, reducing to an embryo remnant. According to growing evidence, a persistent Eustachian valve is a frequent finding in patients with a patent foramen ovale (PFO). By directing the blood from the inferior cava to the interatrial septum, it may prevent the spontaneous closure of PFO after birth and indirectly predispose to paradoxical embolism. Transesophageal contrast enhanced echocardiography (cTEE) is considered the gold standard to diagnose a PFO in postnatal life, but its accuracy maybe is not so high in the presence of a persistent Eustachian valve. In these cases, color Doppler TEE is more sensitive and simplifies the diagnostic process, reducing the duration of TEE and improving the patient compliance.
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Affiliation(s)
- Monica Lunetta
- Department of Internal Medicine and Specialty, University Hospital of Palermo, Palermo, Italy
| | - Francesco Costa
- Department of Clinical and Experimental Medicine, Cardiology Unit, University Hospital of Messina, Messina, Italy
| | - Marcello La Gattuta
- Department of Radiology, DIBIMEF, University Hospital "P Giaccone", University of Palermo, Palermo, Italy
| | - Salvatore Novo
- Department of Internal Medicine and Specialty, University Hospital of Palermo, Palermo, Italy
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19
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Vitarelli A, Mangieri E, Capotosto L, Tanzilli G, D'Angeli I, Toni D, Azzano A, Ricci S, Placanica A, Rinaldi E, Mukred K, Placanica G, Ashurov R. Echocardiographic findings in simple and complex patent foramen ovale before and after transcatheter closure. Eur Heart J Cardiovasc Imaging 2014; 15:1377-85. [PMID: 25139906 DOI: 10.1093/ehjci/jeu143] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS Percutaneous closure of patent foramen ovale (PFO) in cryptogenic cerebrovascular events is an alternative to medical therapy. The interpretation of residual shunts after implantation of different devices for PFO with different morphologies is controversial. METHODS AND RESULTS Transcatheter PFO closure was performed in 123 patients with a history of ≥1 paradoxical embolism using three different devices: Amplatzer (n = 46), Figulla Occlutech (n = 41), and Atriasept Cardia (n = 36). Fifty-six patients presented with simple PFO and 67 patients had complex morphologies. All patients were studied with contrast enhanced transesophageal echocardiography (TEE) before interventional procedure and thereafter at 1 and 6 months and every 6-12 months in case of incomplete closure. Definite closure was confirmed in at least two consecutive TEE studies. Various PFO morphologies were identified by TEE before device implantation. The device size to PFO diameter ratio was significantly increased in patients with complex PFO compared with those patients with a simple PFO morphology (P < 0.05). The difference between the closure rate of S-PFO and C-PFO concerning each device type was significant (Amplatzer P = 0.0027, Figulla P = 0.0043, and Atriasept P < 0.01). The mean follow-up period was 3.4 years (median 2.7 years) with a cerebrovascular re-event rate of 2.4% per year. In three patients, thrombi were detected in the 6-month TEE controls and resolved after medical therapy. In three other patients, the implantation of an adjunctive device was necessary for residual shunt. CONCLUSION In our series of patients, the closure rate was dependent on PFO morphology more than occluder size and type. An adjunctive device was implanted in selected cases.
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Affiliation(s)
| | | | | | | | | | - Danilo Toni
- Sapienza University, Via Lima 35, Rome 00198, Italy
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Blanche C, Noble S, Roffi M, Testuz A, Müller H, Meyer P, Bonvini JM, Bonvini RF. Platypnea-orthodeoxia syndrome in the elderly treated by percutaneous patent foramen ovale closure: a case series and literature review. Eur J Intern Med 2013; 24:813-7. [PMID: 24007641 DOI: 10.1016/j.ejim.2013.08.698] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Revised: 07/24/2013] [Accepted: 08/12/2013] [Indexed: 01/11/2023]
Abstract
BACKGROUND Platypnea-orthodeoxia syndrome (POS) is a rare clinical phenomenon, associating normal oxygen saturation in a supine position and arterial hypoxemia in an upright position. This pathology can be secondary to an intracardiac shunt, a pulmonary vascular shunt or a ventilation-perfusion mismatch. Cardiac POS occurs in the presence of a right-to-left cardiac shunt, most commonly through a patent foramen ovale (PFO). METHODS AND RESULTS From our single-center prospective database of percutaneous PFO closure we identified five patients (4 females, mean age: 77 ± 11 years) out of 224 (2.2%) patients with a PFO who presented with a POS of cardiac origin. Transthoracic and transoesophageal echocardiographic examinations revealed the underlying mechanisms of POS and the diagnosis was confirmed by right-and-left cardiac catheterization (RLC) and by measuring serial blood oxygen saturation in the pulmonary veins and left atrium in supine and upright positions. PFO was associated with atrial septal aneurysm and a persistent prominent Eustachian valve in 3 patients. All patients underwent a successful percutaneous PFO closure without any immediate or subsequent complications (mean follow-up of 24 ± 18 months). Immediately after the procedure, mean arterial oxygen saturation improved from 83% ± 3 to 93% ± 2 in an upright position and symptoms disappeared. CONCLUSION POS is a rare and under-diagnosed pathology that must be actively investigated in the presence of position-dependent hypoxemia. The diagnostic work-up must exclude other causes of hypoxemia and confirm the intracardiac shunt using either contrast echocardiography or RLC. For cardiac POS, percutaneous PFO closure is a safe and effective technique that immediately relieves orthodeoxia and patient symptoms.
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Affiliation(s)
- Coralie Blanche
- Cardiology Division, University Hospital, Geneva, Switzerland
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Keenan NG, Brochet É, Juliard JM, Malanca M, Aubry P, Lepage L, Cueff C, Jondeau G, Iung B, Vahanian A, Messika-Zeitoun D. Aortic root dilatation in young patients with cryptogenic stroke and patent foramen ovale. Arch Cardiovasc Dis 2012; 105:13-7. [DOI: 10.1016/j.acvd.2011.11.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2011] [Revised: 11/10/2011] [Accepted: 11/15/2011] [Indexed: 02/07/2023]
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