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Shah AH, Horlick EM, Kass M, Carroll JD, Krasuski RA. The pathophysiology of patent foramen ovale and its related complications. Am Heart J 2024; 277:76-92. [PMID: 39134216 DOI: 10.1016/j.ahj.2024.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2024] [Accepted: 08/02/2024] [Indexed: 08/29/2024]
Abstract
The foramen ovale plays a vital role in sustaining life in-utero; however, a patent foramen ovale (PFO) after birth has been associated with pathologic sequelae in the systemic circulation including stroke/transient ischemic attack (TIA), migraine, high altitude pulmonary edema, decompression illness, platypnea-orthodeoxia syndrome (POS) and worsened severity of obstructive sleep apnea. Importantly, each of these conditions is most commonly observed among specific age groups: migraine in the 20 to 40s, stroke/TIA in the 30-50s and POS in patients >50 years of age. The common and central pathophysiologic mechanism in each of these conditions is PFO-mediated shunting of blood and its contents from the right to the left atrium. PFO-associated pathologies can therefore be divided into (1) paradoxical systemic embolization and (2) right to left shunting (RLS) of blood through the PFO. Missing in the extensive literature on these clinical syndromes are mechanistic explanations for the occurrence of RLS, including timing and the volume of blood shunted, the impact of age on RLS, and the specific anatomical pathway that blood takes from the venous system to the left atrium. Visualization of the flow pattern graphically illustrates the underlying RLS and provides a greater understanding of the critical flow dynamics that determine the frequency, volume, and pathway of flow. In the present review, we describe the important role of foramen ovale in in-utero physiology, flow visualization in patients with PFO, as well as contributing factors that work in concert with PFO to result in the diverse pathophysiological sequelae.
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Affiliation(s)
- Ashish H Shah
- Department of Internal Medicine, St Boniface Hospital, Section of Cardiology, University of Manitoba, Winnipeg, Manitoba, Canada.
| | - Eric M Horlick
- Division of Cardiology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.
| | - Malek Kass
- Department of Internal Medicine, St Boniface Hospital, Section of Cardiology, University of Manitoba, Winnipeg, Manitoba, Canada.
| | - John D Carroll
- Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora, CO.
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Dimitriadis K, Pyrpyris N, Aznaouridis K, Adamopoulou E, Soulaidopoulos S, Beneki E, Iliakis P, Fragkoulis C, Aggeli K, Tsioufis K. Transcatheter Structural Heart Disease Interventions and Concomitant Left Atrial Appendage Occlusion: A State-of-the-Art Review. Can J Cardiol 2024:S0828-282X(24)00935-8. [PMID: 39236977 DOI: 10.1016/j.cjca.2024.08.282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Revised: 08/28/2024] [Accepted: 08/29/2024] [Indexed: 09/07/2024] Open
Abstract
Atrial fibrillation (AF) is the most common arrhythmia in patients with valvular heart disease, and it can be associated with adverse patient outcomes. However, the need of anticoagulation to counterbalance AF-associated stroke risk may further lead to suboptimal outcomes via increasing bleeding events, especially in high-risk individuals. Currently, the option to perform a concomitant to the index procedure for limiting stroke risk is emerging, in accordance to usual practice in cardiac surgery. In specific, as the vast majority of thrombi occur in the left atrial appendage, left atrial appendage occlusion (LAAO) is an established procedure for preventing ischemic stroke in patients with AF, while limiting anticoagulation-related bleeding events. Thus, the concept of combining an index procedure for a structural heart disease (SHD) with LAAO seems promising for preventing future stroke events. A combined procedure has been described in aortic stenosis (TAVI+LAAO), mitral regurgitation (TEER+LAAO) and atrial septal defects (PFO/ASD+LAAO). Evidence shows that a combined procedure can be safely performed in a "one-stop shop" fashion, without increased rates of procedural adverse events, with the potential to limit bleeding risk and provide prophylaxis against stroke events. Thus, this review is going to analyze indications and clinical evidence regarding the safety and efficacy of combined SHD+LAAO procedure, while also providing insights in gaps in knowledge and future directions for the evolvement of this field.
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Affiliation(s)
- Kyriakos Dimitriadis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece.
| | - Nikolaos Pyrpyris
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Konstantinos Aznaouridis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Elena Adamopoulou
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Stergios Soulaidopoulos
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Eirini Beneki
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Panagiotis Iliakis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Christos Fragkoulis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Konstantina Aggeli
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Konstantinos Tsioufis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
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Adeniji O, Olowoyo P, Akinyemi R, Fisher M, Owolabi M. Advances in Primordial, Primary, and Secondary Prevention of Stroke in Diverse Populations. Stroke 2024; 55:2359-2365. [PMID: 38445485 DOI: 10.1161/strokeaha.123.044231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 01/22/2024] [Accepted: 01/30/2024] [Indexed: 03/07/2024]
Affiliation(s)
- Olaleye Adeniji
- Department of Neurology, University College Hospital, Ibadan, Nigeria (O.A., R.A., M.O.)
| | - Paul Olowoyo
- Neurology Unit, Department of Medicine, Afe Babalola University Ado Ekiti, Nigeria (P.O.)
| | - Rufus Akinyemi
- Department of Neurology, University College Hospital, Ibadan, Nigeria (O.A., R.A., M.O.)
- Center for Genomic and Precision Medicine, University of Ibadan, Nigeria (R.A., M.O.)
| | - Marc Fisher
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (M.F.)
| | - Mayowa Owolabi
- Department of Neurology, University College Hospital, Ibadan, Nigeria (O.A., R.A., M.O.)
- Center for Genomic and Precision Medicine, University of Ibadan, Nigeria (R.A., M.O.)
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Farjat-Pasos JI, Guedeney P, Horlick E, Abtan J, Nombela-Franco L, Hibbert B, Sondergaard L, Freixa X, Masson JB, Cruz-González I, Estévez-Loureiro R, Faroux L, Shah AH, Abrahamyan L, Mesnier J, Jerónimo A, Abdel-Razek O, Jørgensen TH, Asmar MA, Sitbon S, Abalhassan M, Robichaud M, Houde C, Côté M, Chamorro A, Lanthier S, Verreault S, Montalescot G, Rodés-Cabau J. Determinants of adverse outcomes following patent foramen ovale closure in elderly patients. EUROINTERVENTION 2024; 20:1029-1038. [PMID: 39155753 PMCID: PMC11317834 DOI: 10.4244/eij-d-24-00156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 04/26/2024] [Indexed: 08/20/2024]
Abstract
BACKGROUND Limited data are available on transcatheter patent foramen ovale (PFO) closure outcomes in the elderly. AIMS Through this study, we aimed to determine the incidence and predictors of adverse events (recurrent cerebrovascular events [CVE] and atrial fibrillation [AF]) post-PFO closure in older patients with cryptogenic events. METHODS This multicentre international study included patients over 60 years undergoing PFO closure for cryptogenic thromboembolic events. A dedicated database compiled baseline, procedural, and follow-up data. Competing risk and adjusted outcome predictor analyses were conducted. RESULTS A total of 689 patients were included (median age 65 years, 41.2% female, mean Risk of Paradoxical Embolism [RoPE] score 4.5). The procedural success rate was 99.4%. After a median follow-up of 2 (interquartile range 1-5) years, 66 patients (9.6%) had died. CVE and stroke rates were 1.21 and 0.55 per 100 patient-years, respectively. Diabetes (hazard ratio [HR] 3.89, 95% confidence interval [CI]: 1.67-9.07; p=0.002) and atrial septal aneurysm (ASA; HR 5.25, 95% CI: 1.56-17.62; p=0.007) increased the CVE risk. New-onset AF occurred at a rate of 3.30 per 100 patient-years, with 51.3% within one month post-procedure. Older age (HR 1.05 per year, 95% CI: 1.00-1.09; p=0.023) and the absence of hypertension (HR 2.04, 95% CI: 1.19-3.57; p=0.010) were associated with an increased risk of AF. CONCLUSIONS Older patients undergoing PFO closure had a relatively low rate of CVE and new-onset AF after a median follow-up of 2 years. The presence of diabetes, ASA, and a more advanced age determined an increased risk of adverse clinical events. These factors may be considered in the clinical decision-making process regarding PFO closure in this challenging population.
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Affiliation(s)
- Julio I Farjat-Pasos
- Cardiology Department, Quebec Heart and Lung Institute, Québec, QC, Canada
- Pediatric Cardiology Department, Centre Hospitalier Universitaire de Québec, Québec, QC, Canada
| | - Paul Guedeney
- Sorbonne Université, ACTION Study Group, INSERM UMRS_1166, Institut de Cardiologie (AP-HP), Paris, France
| | - Eric Horlick
- Cardiology Department, Toronto General Hospital, Toronto, ON, Canada
| | - Jeremie Abtan
- Cardiology Department, Bichat-Claude-Bernard Hospital, Paris, France
| | - Luis Nombela-Franco
- Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Benjamin Hibbert
- Cardiology Department, Ottawa Heart Institute, Ottawa, ON, Canada
| | - Lars Sondergaard
- Cardiology Department, Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Xavier Freixa
- Cardiology Department, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Jean-Bernard Masson
- Cardiology Department, University of Montreal Health Centre, Montreal, QC, Canada
| | - Ignacio Cruz-González
- Cardiology Department, University Hospital of Salamanca, IBSAL, CIBER-CV, Salamanca, Spain
| | | | - Laurent Faroux
- Cardiology Department, Reims University Hospital, Reims, France
| | - Ashish H Shah
- Section of Cardiology, Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Lusine Abrahamyan
- Cardiology Department, Toronto General Hospital, Toronto, ON, Canada
| | - Jules Mesnier
- Cardiology Department, Bichat-Claude-Bernard Hospital, Paris, France
| | - Adrián Jerónimo
- Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Omar Abdel-Razek
- Cardiology Department, Ottawa Heart Institute, Ottawa, ON, Canada
| | - Troels Højsgaard Jørgensen
- Cardiology Department, Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Mike Al Asmar
- Cardiology Department, University of Montreal Health Centre, Montreal, QC, Canada
| | - Samuel Sitbon
- Cardiology Department, Bichat-Claude-Bernard Hospital, Paris, France
| | | | - Mathieu Robichaud
- Cardiology Department, Quebec Heart and Lung Institute, Québec, QC, Canada
| | - Christine Houde
- Pediatric Cardiology Department, Centre Hospitalier Universitaire de Québec, Québec, QC, Canada
| | - Mélanie Côté
- Cardiology Department, Quebec Heart and Lung Institute, Québec, QC, Canada
| | - Angel Chamorro
- Neuroscience Department, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Sylvain Lanthier
- Neurovascular Program and Research Center, Hôpital du Sacré-Coeur-de-Montréal, Montreal, QC, Canada
| | - Steve Verreault
- Neurovascular Department, Centre Hospitalier Universitaire de Québec, Québec, QC, Canada
| | - Gilles Montalescot
- Sorbonne Université, ACTION Study Group, INSERM UMRS_1166, Institut de Cardiologie (AP-HP), Paris, France
| | - Josep Rodés-Cabau
- Cardiology Department, Quebec Heart and Lung Institute, Québec, QC, Canada
- Pediatric Cardiology Department, Centre Hospitalier Universitaire de Québec, Québec, QC, Canada
- Cardiology Department, Hospital Clinic of Barcelona, Barcelona, Spain
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Crea F. Expanding knowledge in atrial fibrillation, blood pressure treatment, and management of coronary and peripheral artery disease. Eur Heart J 2024; 45:2795-2799. [PMID: 39150995 DOI: 10.1093/eurheartj/ehae503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/18/2024] Open
Affiliation(s)
- Filippo Crea
- Center of Excellence of Cardiovascular Sciences, Ospedale Isola Tiberina - Gemelli Isola, Rome, Italy
- Catholic University of the Sacred Heart, Rome, Italy
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Cannata F, Stankowski K, Donia D, Figliozzi S, Fazzari F, Regazzoli D, Reimers B, Bragato RM, Pontone G, Trabattoni D, Colombo A, De Marco F, Mangieri A. Percutaneous suture-based patent foramen ovale closure: A state-of-the-art review. Trends Cardiovasc Med 2024; 34:404-413. [PMID: 37931791 DOI: 10.1016/j.tcm.2023.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 10/18/2023] [Accepted: 10/31/2023] [Indexed: 11/08/2023]
Abstract
Percutaneous closure of a patent foramen ovale (PFO), a common variation of interatrial septum anatomy, is a commonly performed procedure in the catheterization laboratory to reduce the risk of recurrent stroke in selected patients and to treat other PFO-related syndromes. In the last twenty years, disc-based devices have represented the armamentarium of the interventional cardiologist; recently, suture-based devices have become an attractive alternative, despite limited data regarding their long-term performance. The present review gives an overview of the current evidence regarding suture-based PFO closure, the device's characteristics, the echocardiographic evaluation of the PFO anatomy, and recommendations for patient selection. A detailed procedural guide is then provided, and potential complications and future developments in the field are discussed.
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Affiliation(s)
- Francesco Cannata
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, 20090 Pieve Emanuele, Milano, Italy; IRCCS Humanitas Research Hospital, Via Alessandro Manzoni, 56, 20089 Rozzano, Milano, Italy; Department of Perioperative Cardiology and Cardiovascular imaging, Centro Cardiologico Monzino IRCCS, Milan, Italy.
| | - Kamil Stankowski
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, 20090 Pieve Emanuele, Milano, Italy; IRCCS Humanitas Research Hospital, Via Alessandro Manzoni, 56, 20089 Rozzano, Milano, Italy
| | - Dario Donia
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, 20090 Pieve Emanuele, Milano, Italy; IRCCS Humanitas Research Hospital, Via Alessandro Manzoni, 56, 20089 Rozzano, Milano, Italy
| | - Stefano Figliozzi
- IRCCS Humanitas Research Hospital, Via Alessandro Manzoni, 56, 20089 Rozzano, Milano, Italy
| | - Fabio Fazzari
- Department of Perioperative Cardiology and Cardiovascular imaging, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | - Damiano Regazzoli
- IRCCS Humanitas Research Hospital, Via Alessandro Manzoni, 56, 20089 Rozzano, Milano, Italy
| | - Bernhard Reimers
- IRCCS Humanitas Research Hospital, Via Alessandro Manzoni, 56, 20089 Rozzano, Milano, Italy
| | - Renato Maria Bragato
- IRCCS Humanitas Research Hospital, Via Alessandro Manzoni, 56, 20089 Rozzano, Milano, Italy
| | - Gianluca Pontone
- Department of Perioperative Cardiology and Cardiovascular imaging, Centro Cardiologico Monzino IRCCS, Milan, Italy; Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Daniela Trabattoni
- Department of Interventional Cardiology, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | - Antonio Colombo
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, 20090 Pieve Emanuele, Milano, Italy; IRCCS Humanitas Research Hospital, Via Alessandro Manzoni, 56, 20089 Rozzano, Milano, Italy
| | - Federico De Marco
- Department of Interventional Cardiology, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | - Antonio Mangieri
- IRCCS Humanitas Research Hospital, Via Alessandro Manzoni, 56, 20089 Rozzano, Milano, Italy.
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Khairy P. Detecting and managing atrial arrhythmias in adults with congenital heart disease. Heart Rhythm 2024; 21:1187-1188. [PMID: 38960552 DOI: 10.1016/j.hrthm.2024.04.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 04/13/2024] [Indexed: 07/05/2024]
Affiliation(s)
- Paul Khairy
- Electrophysiology Service and Adult Congenital Heart Center, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.
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von Falkenhausen AS, Keidel LM, Wischmann J, Höglinger G, Massberg S, Kääb S, Kellert L, Sinner MF. Atrial fibrillation after patent foramen ovale closure in patients with embolic stroke of undetermined source. Europace 2024; 26:euae141. [PMID: 38842105 PMCID: PMC11154131 DOI: 10.1093/europace/euae141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 05/21/2024] [Indexed: 06/07/2024] Open
Affiliation(s)
- Aenne S von Falkenhausen
- Department of Medicine I, University Hospital, LMU Munich, Ziemssenstrasse 15, 80336 Munich, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Munich, Munich Heart Alliance (MHA), Pettenkoferstrasse 8a and 9, 80336 Munich, Germany
| | - Linus M Keidel
- Department of Neurology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377 Munich, Germany
| | - Johannes Wischmann
- Department of Neurology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377 Munich, Germany
| | - Günter Höglinger
- Department of Neurology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377 Munich, Germany
| | - Steffen Massberg
- Department of Medicine I, University Hospital, LMU Munich, Ziemssenstrasse 15, 80336 Munich, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Munich, Munich Heart Alliance (MHA), Pettenkoferstrasse 8a and 9, 80336 Munich, Germany
| | - Stefan Kääb
- Department of Medicine I, University Hospital, LMU Munich, Ziemssenstrasse 15, 80336 Munich, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Munich, Munich Heart Alliance (MHA), Pettenkoferstrasse 8a and 9, 80336 Munich, Germany
| | - Lars Kellert
- Department of Neurology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377 Munich, Germany
| | - Moritz F Sinner
- Department of Medicine I, University Hospital, LMU Munich, Ziemssenstrasse 15, 80336 Munich, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Munich, Munich Heart Alliance (MHA), Pettenkoferstrasse 8a and 9, 80336 Munich, Germany
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Apostolos A, Tsiachris D, Drakopoulou M, Trantalis G, Oikonomou G, Ktenopoulos N, Simopoulou C, Katsaros O, Tsalamandris S, Aggeli C, Tsivgoulis G, Tsioufis C, Toutouzas K. Atrial Fibrillation After Patent Foramen Ovale Closure: Incidence, Pathophysiology, and Management. J Am Heart Assoc 2024; 13:e034249. [PMID: 38639354 PMCID: PMC11179870 DOI: 10.1161/jaha.124.034249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Accepted: 02/06/2024] [Indexed: 04/20/2024]
Abstract
This comprehensive review explores the incidence, pathophysiology, and management of atrial fibrillation (AF) following percutaneous closure of patent foramen ovale (PFO). Although AF is considered a common adverse event post PFO closure, its incidence, estimated at <5%, varies based on monitoring methods. The review delves into the challenging task of precisely estimating AF incidence, given subclinical AF and diverse diagnostic approaches. Notably, a temporal pattern emerges, with peak incidence around the 14th day after closure and a subsequent decline after the 45th day, mimicking general population AF trends. The pathophysiological mechanisms behind post PFO closure AF remain elusive, with proposed factors including local irritation, device-related interference, tissue stretch, and nickel hypersensitivity. Management considerations encompass rhythm control, with flecainide showing promise, and anticoagulation tailored to individual risk profiles. The authors advocate for a personalized approach, weighing factors like age, comorbidities, and device characteristics. Notably, postclosure AF is generally considered benign, often resolving spontaneously within 45 days, minimizing thromboembolic risks. Further studies are required to refine understanding and provide evidence-based guidelines.
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Affiliation(s)
- Anastasios Apostolos
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
| | - Dimitrios Tsiachris
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
| | - Maria Drakopoulou
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
| | - Georgios Trantalis
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
| | - Georgios Oikonomou
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
| | - Nikolaos Ktenopoulos
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
| | - Chrysavgi Simopoulou
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
| | - Odysseas Katsaros
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
| | - Sotirios Tsalamandris
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
| | - Constantina Aggeli
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
| | - Georgios Tsivgoulis
- Second Department of Neurology, Medical SchoolNational and Kapodistrian University of Athens, Attikon University Hospital of AthensAthensGreece
| | - Costas Tsioufis
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
| | - Konstantinos Toutouzas
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
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Baqal O, Habib EA, Hasabo EA, Galasso F, Barry T, Arsanjani R, Sweeney JP, Noseworthy P, David Fortuin F. Artificial intelligence-enabled electrocardiogram (AI-ECG) does not predict atrial fibrillation following patent foramen ovale closure. IJC HEART & VASCULATURE 2024; 51:101361. [PMID: 38379633 PMCID: PMC10877678 DOI: 10.1016/j.ijcha.2024.101361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 02/06/2024] [Accepted: 02/08/2024] [Indexed: 02/22/2024]
Abstract
Background Atrial fibrillation (AF) is a known complication following patent foramen ovale (PFO) closure. AI-enabled ECG (AI-ECG) acquired during normal sinus rhythm has been shown to identify individuals with AF by noting high-risk ECG features invisible to the human eye. We sought to characterize the value of AI-ECG in predicting AF development following PFO closure and investigate key clinical and procedural characteristics possibly associated with post-procedural AF. Methods We performed a retrospective analysis of patients who underwent PFO closure at our hospital from January 2011 to December 2022. We recorded the probability (%) of AF using the Mayo Clinic AI-ECG dashboard from pre- and post-procedure ECGs. The cut-off point of ≥ 11 %, which was found to optimally balance sensitivity and specificity in the original derivation paper (the Youden index) was used to label an AI-ECG "positive" for AF. Pre-procedural transesophageal echocardiography (TEE) and pre- and post-procedure transcranial doppler (TCD) data was also recorded. Results Out of 93 patients, 49 (53 %) were male, mean age was 55 ± 15 years with mean post-procedure follow up of 29 ± 3 months. Indication for PFO closure in 69 (74 %) patients was for secondary prevention of transient ischemic attack (TIA) and/or stroke. Twenty patients (22 %) developed paroxysmal AF post-procedure, with the majority within the first month post-procedure (15 patients, 75 %). Patients who developed AF were not significantly more likely to have a positive post-procedure AI-ECG than those who did not develop AF (30 % AF vs 27 % no AF, p = 0.8).Based on the PFO-Associated Stroke Causal Likelihood (PASCAL) classification, patients who had PFO closure for secondary prevention of TIA and/or stroke in the "possible" group were significantly more likely to develop AF than patients in "probable" and "unlikely" groups (p = 0.034). AF-developing patients were more likely to have post-procedure implantable loop recorder (ILR) (55 % vs 9.6 %, p < 0.001), and longer duration of ILR monitoring (121 vs 92.5 weeks, p = 0.035). There were no significant differences in TCD and TEE characteristics, device type, or device size between those who developed AF vs those who did not. Conclusions In this small, retrospective study, AI-ECG did not accurately distinguish patients who developed AF post-PFO closure from those who did not. Although AI-ECG has emerged as a valuable tool for risk prediction of AF, extrapolation of its performance to procedural settings such as PFO closure requires further investigation.
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Affiliation(s)
- Omar Baqal
- Department of Internal Medicine, Mayo Clinic, Phoenix, AZ, USA
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Eiad A. Habib
- Department of Internal Medicine, Mayo Clinic, Phoenix, AZ, USA
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Elfatih A. Hasabo
- CORRIB Research Centre for Advanced Imaging and Core Laboratory, Clinical Science Institute, University of Galway, Galway, Ireland
- Discipline of Cardiology, Saolta Healthcare Group, Health Service Executive, Galway University Hospital, Galway, Ireland
| | - Francesca Galasso
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Timothy Barry
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Reza Arsanjani
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - John P. Sweeney
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Peter Noseworthy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - F. David Fortuin
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ, USA
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11
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Crea F. Focus on interventional cardiology: the need for quality and transparency of evidence for implantable cardiovascular medical devices. Eur Heart J 2024; 45:147-151. [PMID: 38218588 DOI: 10.1093/eurheartj/ehad894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2024] Open
Affiliation(s)
- Filippo Crea
- Centre of Excellence of Cardiovascular Sciences, Gemelli Isola Hospital, Rome, Italy
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Apostolos A, Aggeli C, Toutouzas K. Nickel hypersensitivity as the cause of atrial fibrillation after patent foramen ovale closure: fact or myth? Eur Heart J 2024; 45:236. [PMID: 37793154 DOI: 10.1093/eurheartj/ehad643] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/06/2023] Open
Affiliation(s)
- Anastasios Apostolos
- First Department of Cardiology, Medical School, National and Kapodistrian University of Athens, Hippokration General Hospital, 114 Vasilissis Sophias Avenue, Athens 115 27, Greece
| | - Constantina Aggeli
- First Department of Cardiology, Medical School, National and Kapodistrian University of Athens, Hippokration General Hospital, 114 Vasilissis Sophias Avenue, Athens 115 27, Greece
| | - Konstantinos Toutouzas
- First Department of Cardiology, Medical School, National and Kapodistrian University of Athens, Hippokration General Hospital, 114 Vasilissis Sophias Avenue, Athens 115 27, Greece
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13
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Vitarelli A, Capotosto L, Tanzilli G, Mangieri E. Speckle tracking echocardiographic prediction of atrial fibrillation after patent foramen ovale closure: a challenging matter. EUROPEAN HEART JOURNAL. IMAGING METHODS AND PRACTICE 2024; 2:qyae032. [PMID: 39045188 PMCID: PMC11195801 DOI: 10.1093/ehjimp/qyae032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 07/25/2024]
Affiliation(s)
- Antonio Vitarelli
- Department of Echocardiography, Cardiodiagnostica CS, Via Lima 35, 00198 Rome, Italy
- Department of Cardiology and Cardiac Surgery, Sapienza University, v.le Policlinico 155, 00185 Rome, Italy
| | - Lidia Capotosto
- Department of Echocardiography, Cardiodiagnostica CS, Via Lima 35, 00198 Rome, Italy
- Department of Cardiology and Cardiac Surgery, Sapienza University, v.le Policlinico 155, 00185 Rome, Italy
| | - Gaetano Tanzilli
- Department of Cardiology and Cardiac Surgery, Sapienza University, v.le Policlinico 155, 00185 Rome, Italy
| | - Enrico Mangieri
- Department of Cardiology and Cardiac Surgery, Sapienza University, v.le Policlinico 155, 00185 Rome, Italy
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14
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Orjuela KD, Leppert MH, Carroll JD. Navigating the Gray: The Complex Story of PFO Closure Utilization. Circ Cardiovasc Qual Outcomes 2024; 17:e010581. [PMID: 38189124 DOI: 10.1161/circoutcomes.123.010581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Affiliation(s)
- Karen D Orjuela
- Neurology Department (K.D.O., M.H.L.), University of Colorado School of Medicine, Aurora
| | - Michelle H Leppert
- Neurology Department (K.D.O., M.H.L.), University of Colorado School of Medicine, Aurora
| | - John D Carroll
- Division of Cardiology (J.D.C.), University of Colorado School of Medicine, Aurora
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15
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Kasner SE, Sondergaard L, Nakum M, Gomez Montero M, Hashim M, Landaas EJ. A matching-adjusted indirect comparison of results from REDUCE and RESPECT-two randomized trials on patent foramen ovale closure devices to prevent recurrent cryptogenic stroke. J Med Econ 2024; 27:337-343. [PMID: 38373018 DOI: 10.1080/13696998.2024.2320604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 02/15/2024] [Indexed: 02/20/2024]
Abstract
AIMS Two randomized clinical trials, REDUCE and RESPECT, demonstrated that patent foramen ovale (PFO) closure in combination with antithrombotic therapy was more effective for the prevention of recurrent ischemic stroke compared with antithrombotic therapy alone. The aim of this study was to determine the relative efficacy and safety of the PFO closure devices used in REDUCE (HELEX and CARDIOFORM Septal Occluders) compared with the device used in RESPECT (Amplatzer PFO Occluder). METHODS An unanchored matching-adjusted indirect comparison (MAIC) of the PFO closure arms of the REDUCE and RESPECT trials was performed using patient-level data from REDUCE weighted to match baseline characteristics from RESPECT. Comparisons of the following outcomes were made between the devices assessed in the trials: risk of recurrent ischemic stroke; recurrent ischemic stroke one year after randomization; any serious adverse event (SAE) related to the procedure or device; and atrial fibrillation or atrial flutter as an SAE related to the procedure or device. RESULTS After conducting the MAIC, baseline characteristics were well-matched between the two trials. Compared to RESPECT, PFO closure using the devices from REDUCE resulted in a hazard ratio of 0.46 (95% confidence interval [CI] 0.15-1.43; p = 0.17) for the risk of recurrent stroke. For the recurrence of stroke after one year, SAE related to the procedure or device, and atrial fibrillation or atrial flutter as SAE related to the procedure or device, the MAIC resulted in a rate difference of -0.68 (95%CI -2.06 to 0.70; p = .34), -1.29 (95%CI -3.82 to 1.25; p = .32), and -0.19 (95%CI -1.16 to 0.78; p = .71), respectively. These findings were consistent across scenario analyses. CONCLUSIONS This MAIC analysis found no statistically significant differences in efficacy and safety outcomes between PFO closure with the HELEX and CARDIOFORM Septal Occluders versus the Amplatzer PFO Occluder, as used in the REDUCE and RESPECT trials.
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Affiliation(s)
- Scott E Kasner
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
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16
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Crea F. Challenges and opportunities in prognostication: focus on ischaemic heart disease and atrial fibrillation. Eur Heart J 2023; 44:3391-3394. [PMID: 37738644 DOI: 10.1093/eurheartj/ehad614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/24/2023] Open
Affiliation(s)
- Filippo Crea
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
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17
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Badoz M, Derimay F, Serzian G, Besutti M, Rioufol G, Frey P, Guenancia C, Ecarnot F, Meneveau N, Chopard R. Incidence of atrial fibrillation in cryptogenic stroke with patent foramen ovale closure: protocol for the prospective, observational PFO-AF study. BMJ Open 2023; 13:e074584. [PMID: 37699623 PMCID: PMC10503323 DOI: 10.1136/bmjopen-2023-074584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 08/25/2023] [Indexed: 09/14/2023] Open
Abstract
INTRODUCTION After closure of patent foramen ovale (PFO) due to stroke, atrial fibrillation (AF) occurs in up to one in five patients. However, data are sparse regarding the possible pre-existence of AF in these patients prior to PFO closure, and about recurrence of AF in the long term after the procedure. No prospective study to date has investigated these topics in patients with implanted cardiac monitor (ICM). The PFO-AF study (registered with ClinicalTrials.gov under the number NCT04926142) will investigate the incidence of AF occurring within 2 months after percutaneous closure of PFO in patients with prior stroke. AF will be identified using systematic ICM. Secondary objectives are to assess incidence and burden of AF in the 2 months prior to, and up to 2 years after PFO closure. METHODS AND ANALYSIS Prospective, multicentre, observational study including 250 patients with an indication for PFO closure after stroke, as decided by interdisciplinary meetings with cardiologists and neurologists. Patients will undergo implantation of a Reveal Linq device (Medtronic). Percutaneous PFO closure will be performed 2 months after device implantation. Follow-up will include consultation, ECG and reading of ICM data at 2, 12 and 24 months after PFO closure. The primary endpoint is occurrence of AF at 2 months, defined as an episode of AF or atrial tachycardia/flutter lasting at least 30 s, and recorded by the ICM and/or any AF or atrial tachycardia/flutter documented on ECG during the first 2 months of follow-up. ETHICS AND DISSEMINATION The study was approved by the Ethics Committee 'Comité de Protection des Personnes (CPP) Sud-Méditerranéen III' on 2 June 2021 and registered with ClinicalTrials.gov (NCT04926142). Findings will be presented in national and international congresses and peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT04926142.
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Affiliation(s)
- Marc Badoz
- Department of Cardiology, Besançon Regional University Hospital Center, Besancon, Bourgogne-Franche-Comté, France
- Université de Franche-Comté, Besancon, Bourgogne-Franche-Comté, France
| | - François Derimay
- Interventional Cardiology, Hospices Civils de Lyon, Lyon, France
| | - Guillaume Serzian
- Department of Cardiology, Besançon Regional University Hospital Center, Besancon, Bourgogne-Franche-Comté, France
| | - Matthieu Besutti
- Department of Cardiology, Besançon Regional University Hospital Center, Besancon, Bourgogne-Franche-Comté, France
| | - Gilles Rioufol
- Interventional Cardiology, Hospices Civils de Lyon, Lyon, France
| | - Pierre Frey
- Department of Cardiology, Centre Hospitalier Annecy Genevois, Epagny Metz-Tessy, France
| | | | - Fiona Ecarnot
- Department of Cardiology, Besançon Regional University Hospital Center, Besancon, Bourgogne-Franche-Comté, France
- Université de Franche-Comté, Besancon, Bourgogne-Franche-Comté, France
| | - Nicolas Meneveau
- Department of Cardiology, Besançon Regional University Hospital Center, Besancon, Bourgogne-Franche-Comté, France
- Université de Franche-Comté, Besancon, Bourgogne-Franche-Comté, France
| | - Romain Chopard
- Department of Cardiology, Besançon Regional University Hospital Center, Besancon, Bourgogne-Franche-Comté, France
- Université de Franche-Comté, Besancon, Bourgogne-Franche-Comté, France
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