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Piayda K, Bertog S, Mbai M, Sharma A, Veulemans V, Sievert H. Practical Aspects of Patent Foramen Ovale Closure: Ultrasound and Fluoroscopic Guidance. Cardiol Clin 2024; 42:537-545. [PMID: 39322344 DOI: 10.1016/j.ccl.2024.02.001] [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: 09/27/2024]
Abstract
Percutaneous PFO closure is a well-established medical procedure to mitigate paradoxic embolism and the future risk of stroke in a well-selected patient clientele. When it comes to procedural guidance during PFO closure, various modalities exist, each with its own advantages and disadvantages. Guidance by transesophageal echocardiography (in combination with fluoroscopy) offers high-resolution 2D/3D imaging, however, it requires the presence of a peri-interventional imager and conscious sedation (or endotracheal intubation). Intracardiac echocardiography and fluoroscopy guidance can be performed by a single operator and omits the need for conscious sedation (or endotracheal intubation).
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Affiliation(s)
- Kerstin Piayda
- Cardiovascular Center Frankfurt, Frankfurt, Germany; Department of Cardiology and Vascular Medicine, University Hospital Gießen and Marburg, Gießen, Germany
| | - Stefan Bertog
- Cardiovascular Center Frankfurt, Frankfurt, Germany; Minneapolis Veterans Affairs Medical Center, Minneapolis, MN, USA
| | - Mackenzie Mbai
- Minneapolis Veterans Affairs Medical Center, Minneapolis, MN, USA
| | - Alok Sharma
- Minneapolis Veterans Affairs Medical Center, Minneapolis, MN, USA
| | - Verena Veulemans
- Department of Cardiology, Pneumology and Vascular Medicine, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Horst Sievert
- Cardiovascular Center Frankfurt, Frankfurt, Germany.
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2
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Sun L, Fan Z, Gao J, Zhao T, Si J, Zhang H, Li Y, Sun J, Wang X, Liu Z, Yi M, Hua Y, Xing Y, Liu Z, Li J. Association between patent foramen ovale morphology and clinical outcomes following transcatheter closure. Int J Cardiol 2024; 412:132307. [PMID: 38945369 DOI: 10.1016/j.ijcard.2024.132307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Revised: 05/27/2024] [Accepted: 06/26/2024] [Indexed: 07/02/2024]
Abstract
BACKGROUND Anatomic variations of the patent foramen ovale (PFO) are commonly observed, yet limited research has investigated their impact on clinical outcomes following transcatheter closure. We aimed to explore the association between PFO morphology and clinical outcomes. METHODS Consecutive patients with cryptogenic stroke who underwent PFO closure were prospectively enrolled at a single center from September 2019 to April 2023. Patients were categorized into simple and complex groups based on PFO morphology. Composite events were compared between the two groups during a median follow-up of 24 months, including all-cause mortality, recurrent stroke, residual moderate or severe shunt, and symptomatic atrial fibrillation. RESULTS A total of 247 patients were enrolled, with a mean age of 41.9 ± 13.0 years and 45.3% males. Ninety-one (36.8%) patients had complex PFO. These individuals were older (45.4 ± 12.5 years vs. 39.9 ± 12.9 years; P = 0.001), more males (56.0% vs. 39.1%; P = 0.010), had longer procedure times (54 ± 32 min vs 46 ± 29 min; P = 0.044), and had a higher rate of using delivery sheath-assisted crossing of the PFO (22.0% vs 12.8%; P = 0.040) than those with simple PFO. The estimated event rates were 27.9% and 11.3% (P = 0.006) in the complex and simple PFO groups, respectively (12.9 events and 5.2 events per 100 person-years; P = 0.001). After adjusting for age, sex, hypertension, diabetes, smoking, device type, and left atrial diameters, complex PFO remained independently associated with composite events (HR 2.10, 95%CI 1.06-4.17, P = 0.034). CONCLUSIONS Patients with complex PFO may suffer from a higher risk of adverse events following transcatheter PFO closure.
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Affiliation(s)
- Lijie Sun
- Department of Geriatrics, Xuanwu Hospital Capital Medical University, National Clinical Research Center for Geriatric Diseases, Beijing, China
| | - Zhenxing Fan
- Department of Cardiology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Jing Gao
- Department of Cardiology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Ting Zhao
- Department of Geriatrics, Xuanwu Hospital Capital Medical University, National Clinical Research Center for Geriatric Diseases, Beijing, China
| | - Jin Si
- Department of Geriatrics, Xuanwu Hospital Capital Medical University, National Clinical Research Center for Geriatric Diseases, Beijing, China
| | - Haoyu Zhang
- Department of Geriatrics, Xuanwu Hospital Capital Medical University, National Clinical Research Center for Geriatric Diseases, Beijing, China
| | - Yan Li
- Department of Geriatrics, Xuanwu Hospital Capital Medical University, National Clinical Research Center for Geriatric Diseases, Beijing, China
| | - Jinghao Sun
- Department of Geriatrics, Xuanwu Hospital Capital Medical University, National Clinical Research Center for Geriatric Diseases, Beijing, China
| | - Xinyi Wang
- Department of Geriatrics, Xuanwu Hospital Capital Medical University, National Clinical Research Center for Geriatric Diseases, Beijing, China
| | - Zhaoli Liu
- Department of Geriatrics, Xuanwu Hospital Capital Medical University, National Clinical Research Center for Geriatric Diseases, Beijing, China
| | - Ming Yi
- Department of Geriatrics, Xuanwu Hospital Capital Medical University, National Clinical Research Center for Geriatric Diseases, Beijing, China
| | - Yang Hua
- Department of Vascular Ultrasound, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Yingqi Xing
- Department of Vascular Ultrasound, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Zhi Liu
- Department of Emergency, Xuanwu Hospital Capital Medical University, Beijing, China.
| | - Jing Li
- Department of Geriatrics, Xuanwu Hospital Capital Medical University, National Clinical Research Center for Geriatric Diseases, Beijing, China.
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Witte LS, El Bouziani A, Beijk MAM, Robbers-Visser D, Coutinho JM, Tijssen JGP, Straver B, Bouma BJ, de Winter RJ. Persistence of residual shunt at 6 and 12 months after transoesophageal echocardiography-guided percutaneous closure of a patent foramen ovale for cryptogenic stroke. Heart 2024; 110:1172-1179. [PMID: 39122559 DOI: 10.1136/heartjnl-2024-323905] [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: 01/16/2024] [Accepted: 07/23/2024] [Indexed: 08/12/2024] Open
Abstract
BACKGROUND Young patients suffering from cryptogenic stroke alongside a patent foramen ovale (PFO) are often considered for percutaneous device closure to reduce the risk of stroke recurrence. Residual right-to-left shunt after device closure may persist in approximately a quarter of the patients at 6 months, and some may close at a later time point. This study aimed to assess the prevalence and persistence of residual right-to-left shunt after percutaneous PFO closure. METHODS Consecutive patients undergoing transoesophageal echocardiography-guided PFO closure for cryptogenic stroke between 2006 and 2021, with echocardiographic follow-up including contrast bubble study and Valsalva manoeuvre, were enrolled. Follow-up transthoracic echocardiography was performed at 6 months and repeated at 12 months in case of residual right-to-left shunt. Primary outcomes included the prevalence and grade of residual right-to-left shunt at 6 and 12 months after percutaneous PFO closure. RESULTS 227 patients were included with a mean age of 43±11 years and 50.2% were women. At 6-month follow-up, 72.7% had no residual right-to-left shunt, 12.3% small residual right-to-left shunt, 6.6% moderate residual right-to-left shunt and 8.4% large residual right-to-left shunt. At 12-month follow-up, the presence of residual right-to-left shunt in all patients was 12.3%, of whom 6.6% had small residual right-to-left shunt, 2.6% had moderate residual right-to-left shunt and 3.1% had large residual right-to-left shunt. CONCLUSIONS Residual right-to-left shunts are common at 6 months after percutaneous closure of PFO. However, the majority are small and two-thirds of residual right-to-left shunts achieve complete closure between 6 and 12 months.
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Affiliation(s)
- Lars S Witte
- Department of Cardiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Abdelhak El Bouziani
- Department of Cardiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Marcel A M Beijk
- Department of Cardiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Danielle Robbers-Visser
- Department of Cardiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Jan G P Tijssen
- Department of Cardiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Bart Straver
- Department of Cardiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Berto J Bouma
- Department of Cardiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Robbert J de Winter
- Department of Cardiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
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4
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Du Y, Zhang Y, Xing Y, Liu X, Jin H, Zhang Y, Li C, Xu B. Role of interatrial block in modulating cryptogenic stroke risk in patients with patent foramen ovale: a retrospective study. BMC Neurol 2024; 24:345. [PMID: 39272054 PMCID: PMC11401249 DOI: 10.1186/s12883-024-03829-3] [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: 05/04/2024] [Accepted: 08/27/2024] [Indexed: 09/15/2024] Open
Abstract
BACKGROUND The patent foramen ovale (PFO) and interatrial block (IAB) are associated with cryptogenic stroke (CS). However, the role of the interaction between PFO and IAB in CS remains unclear. METHODS This case-control study enrolled 256 patients with CS and 156 individuals without a history of stroke or transient ischemic attack. IAB was defined as P wave duration > 120 ms. PFO was evaluated by contrast transesophageal echocardiography, and classified as no-PFO, low-risk PFO and high-risk PFO. Multiplicative and additive interaction analysis were used to assess the interaction between PFO and IAB in CS. RESULTS Multiplicative interaction analysis unveiled a significant interaction between IAB and low-risk PFO in CS (OR for interaction = 3.653, 95% CI, 1.115-12.506; P = 0.037). Additive interaction analysis indicated that 68.4% (95% CI, 0.333-1.050; P < 0.001) of the increased risk of CS related to low-risk PFO was attributed to the interaction with IAB. The results were robust in multivariate analysis. However, but no significant multiplicative or additive interaction was observed between IAB and high-risk PFO. When stratified by IAB, high-risk PFO was associated with CS in both patients with IAB (OR, 4.186; 95% CI, 1.617-10.839; P = 0.003) and without IAB (OR, 3.476; 95% CI, 1.790-6.750; P < 0.001). However, low-risk PFO was only associated with CS in patients with IAB (OR, 2.684; 95% CI, 1.007-7.149; P = 0.048) but not in those without IAB (OR, 0.753; 95% CI, 0.343-1.651; P = 0.479). CONCLUSION The interaction between IAB and PFO might play an important role in CS, particularly in cases with low-risk PFO.
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Affiliation(s)
- Ye Du
- Department of Neurology, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing, 312000, China
| | - Yanxing Zhang
- Department of Neurology, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing, 312000, China
| | - Yangbo Xing
- Department of Cardiology, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), 568 # Zhongxing North Road, Shaoxing, Zhejiang Province, 312000, China
| | - Xiatian Liu
- Department of Ultrasound, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing, 312000, China
| | - Huayong Jin
- Department of Electrocardiogram, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing, 312000, China
| | - Yuxin Zhang
- Zhejiang University School of Medicine, Hangzhou, 310000, China
| | - Chengyi Li
- Shaoxing University School of Medicine, Shaoxing, 312000, China
| | - Buyun Xu
- Department of Cardiology, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), 568 # Zhongxing North Road, Shaoxing, Zhejiang Province, 312000, China.
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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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Becchetti C, De Nicola S, Gallo C, Perricone G, Annoni G, Solcia M, Musca F, Alfonsi A, Morelli F, Barbosa F, Brambillasca PM, Rampoldi A, Airoldi A, Belli LS. Transjugular intrahepatic portosystemic shunt in patients with splanchnic vein thrombosis: Prevalence and management of patent foramen ovale. Liver Int 2024; 44:2458-2468. [PMID: 39205449 DOI: 10.1111/liv.16013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 06/07/2024] [Accepted: 06/09/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND AND AIMS Transjugular intrahepatic portosystemic shunt (TIPS) is an established procedure for the treatment of several complications of portal hypertension (PH), including non-neoplastic portal vein thrombosis (PVT). Selection criteria for TIPS in PVT are not yet well established. Despite anecdotal, cases of thromboembolic events from paradoxical embolism due to the presence of patent foramen ovale (PFO) after TIPS placement have been reported in the literature. Therefore, we aimed at describing our experience in patients with non-neoplastic splanchnic vein thrombosis (SVT) who underwent TIPS following PFO screening. METHODS We conducted a single-centre retrospective study, including consecutive patients who underwent TIPS for the complications of cirrhotic and non-cirrhotic portal hypertension (NCPH) and having SVT. RESULTS Of 100 TIPS placed in patients with SVT, 85 patients were screened for PFO by bubble-contrast transthoracic echocardiography (TTE) with PFO being detected in 22 (26%) cases. PFO was more frequently detected in patients with non-cirrhotic portal hypertension (NCPH) (23% in the PFO group vs. 6% in those without PFO, p = .04) and cavernomatosis (46% in the PFO group vs. 19% in those without PFO, p = .008). Percutaneous closure was effectively performed in 11 (50%) after multidisciplinary evaluation of anatomical and clinical features. No major complications were observed following closure. CONCLUSIONS PFO screening and treatment may be considered feasible for patients with SVT who undergo TIPS placement.
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Affiliation(s)
- Chiara Becchetti
- Hepatology and Gastroenterology Unit, ASST GOM Niguarda, Milan, Italy
| | - Stella De Nicola
- Division of Internal Medicine and Hepatology, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Camilla Gallo
- Hepatology and Gastroenterology Unit, ASST GOM Niguarda, Milan, Italy
- Division of Gastroenterology, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | | | | | - Marco Solcia
- Interventional Radiology Unit, ASST GOM Niguarda, Milan, Italy
| | - Francesco Musca
- Cardiology Division, De Gasperis Cardio Center, ASST GOM Niguarda, Milan, Italy
| | - Angela Alfonsi
- Interventional Radiology Unit, ASST GOM Niguarda, Milan, Italy
| | | | - Fabiane Barbosa
- Interventional Radiology Unit, ASST GOM Niguarda, Milan, Italy
| | | | | | - Aldo Airoldi
- Hepatology and Gastroenterology Unit, ASST GOM Niguarda, Milan, Italy
| | - Luca S Belli
- Hepatology and Gastroenterology Unit, ASST GOM Niguarda, Milan, Italy
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Rizza V, Belli M, Stella S, Montorfano M, Agricola E. A 'twice closed' patent foramen ovale: a case report of percutaneous management of a residual interatrial shunt in a patient with persistent migraine symptoms. Eur Heart J Case Rep 2024; 8:ytae449. [PMID: 39258019 PMCID: PMC11384891 DOI: 10.1093/ehjcr/ytae449] [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: 09/25/2023] [Revised: 02/12/2024] [Accepted: 08/19/2024] [Indexed: 09/12/2024]
Abstract
Background Residual interatrial shunt following percutaneous patent foramen ovale (PFO) closure is a rare complication that can be associated with persistent migraine. Case summary A 32-year-old woman with a history of percutaneous PFO closure due to a previous coronary paradoxical embolism and a condition of drug-refractory migraine underwent transoesophageal echocardiography (TOE) to investigate further recurrent migraine attacks. A partial displacement of a PFO occluder device was found, and it was successfully treated through the fluoroscopic and TOE-guided positioning of a second occluder in overlap with the previous one. The patient reported no more migraine attacks at the 6-month follow-up visit. Discussion Residual interatrial shunt should be suspected in patients with persistent migraine and a history of percutaneous PFO closure. Fluoroscopic and TOE-guided closure of residual interatrial shunt with a second PFO occlude device seems to be a safe and clinically effective strategy to manage persistent migraine.
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Affiliation(s)
- Vincenzo Rizza
- IRCCS Ospedale San Raffaele, Via Olgettina 60, 20132 Milan, Italy
- Unit of Cardiovascular Imaging, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy
| | - Martina Belli
- Unit of Cardiovascular Imaging, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy
| | - Stefano Stella
- Unit of Cardiovascular Imaging, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy
| | - Matteo Montorfano
- IRCCS Ospedale San Raffaele, Via Olgettina 60, 20132 Milan, Italy
- Interventional Cardiology Unit, IRCCS Ospedale San Raffaele, Via Olgettina 60, 20132 Milan, Italy
| | - Eustachio Agricola
- IRCCS Ospedale San Raffaele, Via Olgettina 60, 20132 Milan, Italy
- Unit of Cardiovascular Imaging, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy
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8
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Caffè A, Animati FM, Iannaccone G, Rinaldi R, Montone RA. Precision Medicine in Acute Coronary Syndromes. J Clin Med 2024; 13:4569. [PMID: 39124834 PMCID: PMC11313297 DOI: 10.3390/jcm13154569] [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: 06/13/2024] [Revised: 07/31/2024] [Accepted: 08/01/2024] [Indexed: 08/12/2024] Open
Abstract
Nowadays, current guidelines on acute coronary syndrome (ACS) provide recommendations mainly based on the clinical presentation. However, greater attention is being directed to the specific pathophysiology underlying ACS, considering that plaque destabilization and rupture leading to luminal thrombotic obstruction is not the only pathway involved, albeit the most recognized. In this review, we discuss how intracoronary imaging and biomarkers allow the identification of specific ACS endotypes, leading to the recognition of different prognostic implications, tailored management strategies, and new potential therapeutic targets. Furthermore, different strategies can be applied on a personalized basis regarding antithrombotic therapy, non-culprit lesion revascularization, and microvascular obstruction (MVO). With respect to myocardial infarction with non-obstructive coronary arteries (MINOCA), we will present a precision medicine approach, suggested by current guidelines as the mainstay of the diagnostic process and with relevant therapeutic implications. Moreover, we aim at illustrating the clinical implications of targeted strategies for ACS secondary prevention, which may lower residual risk in selected patients.
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Affiliation(s)
- Andrea Caffè
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy; (A.C.); (F.M.A.); (R.R.)
| | - Francesco Maria Animati
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy; (A.C.); (F.M.A.); (R.R.)
| | - Giulia Iannaccone
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy; (A.C.); (F.M.A.); (R.R.)
| | - Riccardo Rinaldi
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy; (A.C.); (F.M.A.); (R.R.)
| | - Rocco Antonio Montone
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy;
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9
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Papadopoulos CH, Kadoglou NPE, Theodosis-Georgilas A, Papadopoulos KG, Rallidis L, Loizos S, Karabinos I, Kassinos N, Sahpekidis V, Chrysoheris M, Ninios V, Frogoudaki A, Makavos G, Drakopoulou M, Yiangou K, Karagiannis S, Zois N, Patrianakos A, Ikonomidis I, Tsiapras D, Kouris N, Aggeli K, Pappas K, Prappa E, Stefanidis A. Practical guidance and clinical applications of transoesophageal echocardiography. A position paper of the working group of echocardiography of the Hellenic Society of Cardiology. Curr Probl Cardiol 2024; 49:102634. [PMID: 38734120 DOI: 10.1016/j.cpcardiol.2024.102634] [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: 05/07/2024] [Accepted: 05/08/2024] [Indexed: 05/13/2024]
Abstract
Transoesophageal echocardiography (TOE) is a well-established imaging modality, providing more accurate and of higher quality information than transthoracic echocardiography (TTE) for a wide spectrum cardiac and extra-cardiac diseases. The present paper represents an effort by the Echocardiography Working Group (WG) of the Hellenic Cardiology Society to state the essential steps of the typical TOE exam performed in echo lab. This is an educational text, describing the minimal requirements and the preparation of a meticulous TOE examination. Most importantly, it gives practical instructions to obtain and optimize TOE views and analyses the implementation of a combined two-and multi-dimensional protocol for the imaging of the most common cardiac structures during a TOE. In the second part of the article a comprehensive review of the contemporary use of TOE in a wide spectrum of valvular and non-valvular cardiac diseases is provided, based on the current guidelines and the experience of the WG members.
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Affiliation(s)
- Constantinos H Papadopoulos
- 2nd Cardiology Department, Korgialenio - Benakio Red Cross Hospital, +10 Platonos street, Neo Psychiko, Athens 15451, Greece.
| | | | | | | | | | | | | | | | | | | | - Vlasis Ninios
- 2nd Cardiology Department, Interbalkan Center, Thessaloniki, Greece
| | | | | | - Maria Drakopoulou
- 1st Cardiology Department, Hippokration University Hospital, Athens, Greece
| | | | | | - Nikolaos Zois
- Private Practice, Cardiology Department, University Hospital of Ioannina, Greece
| | | | | | - Dimitrios Tsiapras
- 2nd Cardiology Department, Onassis Cardiosurgical Center, Piraeus, Greece
| | | | - Konstantina Aggeli
- 1st Cardiology Department, Hippokration University Hospital, Athens, Greece
| | | | - Efstathia Prappa
- Cardiology Department, General Hospital of Evaggelismos, Athens, Greece
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10
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Akyol S, Bayam E, Avci A, Güler Ü, Kargin R. Successful treatment of acute device thrombosis of patent foramen ovale with slow infusion of low-dose thrombolytic therapy. Eur Heart J Case Rep 2024; 8:ytae360. [PMID: 39219802 PMCID: PMC11362546 DOI: 10.1093/ehjcr/ytae360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 01/18/2024] [Accepted: 07/17/2024] [Indexed: 09/04/2024]
Abstract
Background Percutaneous closure of patent foramen ovale (PFO) is used in selected individuals to eliminate the risk of recurrent cerebral embolism due to paradoxical embolization. Although device thrombosis is rare, it can cause serious complications. Herein, we report a 40-year-old woman who developed acute PFO closure device-associated thrombus and was subsequently treated with slow infusion of low-dose tissue plasminogen activator (t-PA) (25 mg/6 h). Case summary A 40-year-old woman was admitted to the hospital because of an cerebrovascular accident (CVA). Computed tomography and magnetic resonance imaging of the brain demonstrated the presence of an ischaemic lesion in the right cerebellar infarct. Since no pathological finding was detected that could cause CVA, it was considered that there might be paradoxical embolism due to PFO. Percutaneous PFO closure was decided by the heart and brain team. The occluder was implanted under transoesophageal echocardiography (TEE) and fluoroscopy guidance. Although activated clotting time was 250 s, hypermobile acute thrombus measuring 11 × 5 mm was seen on the left atrial side of the PFO device. Slow infusion of low-dose t-PA treatment was given. As soon as after a single-dose t-PA, control TEE was performed and it was seen that almost the entire thrombus was lysed. The patient did not have any complications during the treatment period. Discussion Acute PFO device thrombosis is a rare but important complication. If there is no contraindication for lytic treatment in acutely developing large PFO device thrombosis, slow infusion of low-dose t-PA may be useful.
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Affiliation(s)
- Selahattin Akyol
- Kartal Kosuyolu High Specialty Training and Research Hospital, Department of Cardiology, University of Medical Sciences, Istanbul, Turkey
| | - Emrah Bayam
- Kartal Kosuyolu High Specialty Training and Research Hospital, Department of Cardiology, University of Medical Sciences, Istanbul, Turkey
| | - Anıl Avci
- Kartal Kosuyolu High Specialty Training and Research Hospital, Department of Cardiology, University of Medical Sciences, Istanbul, Turkey
| | - Ünal Güler
- Kartal Kosuyolu High Specialty Training and Research Hospital, Department of Cardiology, University of Medical Sciences, Istanbul, Turkey
| | - Ramazan Kargin
- Kartal Kosuyolu High Specialty Training and Research Hospital, Department of Cardiology, University of Medical Sciences, Istanbul, Turkey
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Kwok CS, Alisiddiq Z, Will M, Schwarz K, Khoo C, Large A, Butler R, Lip GYH, Qureshi AI, Borovac JA. The Modified Risk of Paradoxical Embolism Score Is Associated with Patent Foramen Ovale in Patients with Ischemic Stroke: A Nationwide US Analysis. J Cardiovasc Dev Dis 2024; 11:213. [PMID: 39057633 PMCID: PMC11277417 DOI: 10.3390/jcdd11070213] [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: 06/18/2024] [Revised: 07/03/2024] [Accepted: 07/03/2024] [Indexed: 07/28/2024] Open
Abstract
BACKGROUND The Risk of Paradoxical Embolism (RoPE) score was developed to identify stroke-related patent foramen ovale (PFO) in patients with cryptogenic stroke. METHODS We conducted a retrospective analysis of the 2016 to 2020 National Inpatient Sample to determine the performance of the modified RoPE score in identifying the presence of a PFO in patients with acute ischemic stroke (AIS). RESULTS A total of 3,338,805 hospital admissions for AIS were analysed and 3.0% had PFO. Patients with PFO were younger compared to those without a PFO (median 63 years vs. 71 years, p < 0.001) and fewer were female (46.1% vs. 49.7%, p < 0.001). The patients with PFO had greater mean modified RoPE scores (4.0 vs. 3.3, p < 0.001). The area under the curve for the RoPE score in predicting PFOs was 0.625 (95%CI 0.620-0.629). The best diagnostic power of the RoPE score was achieved with a cut-off point of ≥4 where the sensitivity was 55% and the specificity was 64.2%. A cut-off point of ≥5 increased the specificity (83.1%) at the expense of sensitivity (35.8%). The strongest predictor of PFOs was deep vein thrombosis (OR 3.97, 95%CI 3.76-4.20). CONCLUSIONS The modified RoPE score had modest predictive value in identifying patients with PFO among patients admitted with AIS.
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Affiliation(s)
- Chun Shing Kwok
- Department of Cardiology, University Hospitals of North Midlands NHS Foundation Trust, Stoke-on-Trent ST4 6QG, UK; (C.S.K.); (Z.A.); (C.K.); (A.L.); (R.B.)
| | - Zaheer Alisiddiq
- Department of Cardiology, University Hospitals of North Midlands NHS Foundation Trust, Stoke-on-Trent ST4 6QG, UK; (C.S.K.); (Z.A.); (C.K.); (A.L.); (R.B.)
| | - Maximilian Will
- Department of Internal Medicine 3, University Hospital St. Pölten, Karl Landsteiner University of Health Sciences, 3100 Krems, Austria; (M.W.); (K.S.)
| | - Konstantin Schwarz
- Department of Internal Medicine 3, University Hospital St. Pölten, Karl Landsteiner University of Health Sciences, 3100 Krems, Austria; (M.W.); (K.S.)
| | - Chee Khoo
- Department of Cardiology, University Hospitals of North Midlands NHS Foundation Trust, Stoke-on-Trent ST4 6QG, UK; (C.S.K.); (Z.A.); (C.K.); (A.L.); (R.B.)
| | - Adrian Large
- Department of Cardiology, University Hospitals of North Midlands NHS Foundation Trust, Stoke-on-Trent ST4 6QG, UK; (C.S.K.); (Z.A.); (C.K.); (A.L.); (R.B.)
| | - Robert Butler
- Department of Cardiology, University Hospitals of North Midlands NHS Foundation Trust, Stoke-on-Trent ST4 6QG, UK; (C.S.K.); (Z.A.); (C.K.); (A.L.); (R.B.)
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool L69 3BX, UK;
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, 9220 Aalborg, Denmark
| | - Adnan I. Qureshi
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, MO 65211, USA;
| | - Josip Andelo Borovac
- Division of Interventional Cardiology, Cardiovascular Diseases Department, University Hospital of Split, 21000 Split, Croatia
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12
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Onorato EM, Alamanni F, Monizzi G, Mastrangelo A, Bartorelli AL. Case Report: Persistent residual shunt after a first percutaneous PFO closure followed by minimally invasive surgical failure: third time is a charm. Front Cardiovasc Med 2024; 11:1367515. [PMID: 39015678 PMCID: PMC11249728 DOI: 10.3389/fcvm.2024.1367515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 06/12/2024] [Indexed: 07/18/2024] Open
Abstract
Background Even though the optimal management of a moderate or large residual shunt following patent foramen ovale (PFO) closure is open to question, recent data confirmed that it is associated with an increased risk of stroke recurrence. Case summary A 48-year-old woman, a migraineur with visual aura, was diagnosed with a PFO associated with a huge multifenestrated atrial septal aneurysm (mfASA) and a moderate right-to-left shunt, detectable only after a Valsalva maneuver on contrast-transthoracic echocardiography. Brain magnetic resonance imaging showed a 1-mm silent white matter lesion in the right frontal lobe. Although the indication was not supported by guidelines, a transcatheter PFO closure was performed at another center with implantation of a large, equally sized, double-disc device (Figulla UNI 33/33 mm). At 6-month follow-up, a 2D/3D transesophageal echocardiography (TEE) color Doppler showed incorrect orientation of the device, which was not parallel to the interatrial septum, with two discs failing to capture the aortic muscular rim and partially protruding in the right atrium; furthermore, a 4 mm × 7 mm ASA fenestration was documented with a residual bidirectional shunt. Thereafter, the same team performed a minimally invasive cardiac surgery under femoro-femoral cardiopulmonary bypass; however, the procedure proved ineffective and was complicated by postoperative pericarditis with pericardial effusion, requiring further rehospitalization 1 month later due to persistent pericarditis, bilateral pleuritis, phrenic nerve palsy, and atrial flutter, which was treated with amiodarone. The patient asked for a second opinion, and our multidisciplinary heart team decided to offer a percutaneous redo intervention. An uneventful implantation of a regular PFO occluder (Figulla Flex II 16/18 mm) across the septal defect was performed successfully. Twelve-month follow-up with 2D TTE color Doppler and contrast transcranial Doppler showed correct position and good interaction between the two devices, with no residual shunt. Discussion In addition to the incorrect indication for PFO closure and the failure of minimally invasive surgery, the procedural mishap in this case could have been due to the inappropriate implantation of the first large device within the tunnel. It would have been better to deploy the same large device in the most central fenestration, covering the PFO and a greater part of the remaining mfASA at the same time.
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Affiliation(s)
- Eustaquio M. Onorato
- University Cardiology Department, I.R.C.C.S. Ospedale Galeazzi- Sant’Ambrogio, Milan, Italy
| | - Francesco Alamanni
- University Cardiac Surgery Department, I.R.C.C.S. Ospedale Galeazzi- Sant’Ambrogio, Milan, Italy
| | - Giovanni Monizzi
- University Cardiology Department, I.R.C.C.S. Ospedale Galeazzi- Sant’Ambrogio, Milan, Italy
| | - Angelo Mastrangelo
- University Cardiology Department, I.R.C.C.S. Ospedale Galeazzi- Sant’Ambrogio, Milan, Italy
| | - Antonio Luca Bartorelli
- University Cardiology Department, I.R.C.C.S. Ospedale Galeazzi- Sant’Ambrogio, Milan, Italy
- Department of Biomedical and Clinical Sciences, “Luigi Sacco”, University of Milan, Milan, Italy
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13
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Giordano M, Gaio G, Marzullo R, Scognamiglio G, Altobelli I, Russo MG, Sarubbi B. Patent foramen ovale closure with NobleStitch EL system in a case of Ebstein's anomaly after a failed device closure attempt. J Cardiovasc Med (Hagerstown) 2024; 25:559-562. [PMID: 38625819 DOI: 10.2459/jcm.0000000000001615] [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: 04/18/2024]
Abstract
In the setting of an Ebstein's anomaly, a right-to-left shunt via a patent foramen ovale (PFO) may be the cause of a significant cyanosis. In these patients, the PFO closure is able to improve the arterial saturation. Furthermore, a partial closure is often recommended to obtain a reduction in the PFO right-left shunt without a significant impact on the right chamber hemodynamics. However, in some cases, a complex PFO anatomy may prevent an effective device closure.
We describe the case of a patient with Ebstein's anomaly and a significant cyanosis due to a right-to-left shunt via the PFO wherein an effective partial PFO closure with a suture-mediated NobleStitch EL system was achieved in a setting of a complex PFO anatomy (large aneurismatic septum, long stiff tunnel, and hypertrophic septum secundum) after a failed device-closure attempt.
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Affiliation(s)
- Mario Giordano
- Pediatric Cardiology Unit, University of Campania 'Luigi Vanvitelli'
| | - Gianpiero Gaio
- Pediatric Cardiology Unit, University of Campania 'Luigi Vanvitelli'
| | | | - Giancarlo Scognamiglio
- Adult Congenital Heart Disease Unit, AORN 'Ospedali dei Colli', Monaldi Hospital, Naples, Italy
| | - Ippolita Altobelli
- Adult Congenital Heart Disease Unit, AORN 'Ospedali dei Colli', Monaldi Hospital, Naples, Italy
| | | | - Berardo Sarubbi
- Adult Congenital Heart Disease Unit, AORN 'Ospedali dei Colli', Monaldi Hospital, Naples, Italy
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14
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Venkatesh R, Joshi A, Maltsev D, Munk M, Prabhu V, Bavaskar S, Mangla R, Ruamviboonsuk P, Chhablani J. Update on central retinal artery occlusion. Indian J Ophthalmol 2024; 72:945-955. [PMID: 38905460 PMCID: PMC11329807 DOI: 10.4103/ijo.ijo_2826_23] [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: 10/23/2023] [Revised: 01/13/2024] [Accepted: 02/13/2024] [Indexed: 06/23/2024] Open
Abstract
The medical condition referred to as "central retinal artery occlusion" (CRAO) was first documented by Albrecht von Graefe in 1859. Subsequently, CRAO has consistently been identified as a serious medical condition that leads to substantial visual impairment. Furthermore, it is correlated with vascular complications that have the potential to affect crucial organs such as the brain and heart. A considerable amount of research has been extensively published on the various aspects of this topic, which is marked by notable debates and misconceptions, especially regarding its management and outcomes. The primary aim of this review article is to analyze the latest developments in the understanding of CRAO, which includes its causes, techniques for retinal imaging, systemic evaluation, and therapeutic strategies, such as vitrectomy. This review article offers readers a comprehensive learning experience to gain knowledge on the fundamental principles and recent advancements in CRAO.
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Affiliation(s)
- Ramesh Venkatesh
- Department of Vitreo-retinal Services, Narayana Nethralaya, Bengaluru, Karnataka, India
| | - Aishwarya Joshi
- Department of Vitreo-retinal Services, Narayana Nethralaya, Bengaluru, Karnataka, India
| | - Dmitrii Maltsev
- Department of Ophthalmology, Military Medical Academy, St. Petersburg, Russia
| | - Marion Munk
- Department of Retina, Augenarzt Praxisgemeinschaft Gutblick AG, Pfäffikon, Switerland
- Department of Retina, University Hospital Bern, Inselspital, Bern, Switzerland
- Feinberg School of Medicine, Northwestern University, Chicago, USA
| | - Vishma Prabhu
- Department of Vitreo-retinal Services, Narayana Nethralaya, Bengaluru, Karnataka, India
| | - Snehal Bavaskar
- Department of Vitreo-retinal Services, Narayana Nethralaya, Bengaluru, Karnataka, India
| | - Rubble Mangla
- Department of Vitreo-retinal Services, Narayana Nethralaya, Bengaluru, Karnataka, India
| | - Paisan Ruamviboonsuk
- Department of Ophthalmology, College of Medicine, Rangsit University, Lak Hok, Thailand
- Center of Excellence for Vitreous and Retinal Disease, Rajavithi Hospital, Bangkok, Thailand
| | - Jay Chhablani
- Department of Medical Retina and Vitreoretinal Surgery, University of Pittsburgh School of Medicine, Pittsburg, PA 15213, USA
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15
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Sarti C, Scrima GD, Cepele A, Meucci F. How a good laugh can get scary: a case of gelastic stroke-looking for clues of PFO-related events. Neurol Sci 2024; 45:3525-3527. [PMID: 38467954 DOI: 10.1007/s10072-024-07435-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 02/29/2024] [Indexed: 03/13/2024]
Affiliation(s)
- Cristina Sarti
- NEUROFARBA Department, Neuroscience Section, University of Florence, Florence, Italy.
| | - Giulia Domna Scrima
- NEUROFARBA Department, Neuroscience Section, University of Florence, Florence, Italy
| | - Alba Cepele
- Department of Clinical and Experimental Medicine, Neurological Clinic, University of Pisa, Pisa, Italy
| | - Francesco Meucci
- Structural Interventional Cardiology, Careggi University Hospital, Florence, Italy
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16
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Papadopoulos CH, Kadoglou NPE, Theodosis-Georgilas A, Karabinos I, Loizos S, Papadopoulos KG, Chrysocheris M, Ninios V, Frogoudaki A, Drakopoulou M, Angelaki M, Rallidis L, Kassinos N, Sahpekidis V, Makavos G, Yiangou K, Karagiannis S, Zois N, Patrianakos A, Ikonomidis I, Tsiapras D, Kouris N, Aggeli K, Pappas K, Prappa E, Stefanidis A. Transoesophageal echocardiography beyond the echo-laboratory. An expert consensus paper of the working group of echocardiography of the hellenic society of cardiology. Hellenic J Cardiol 2024:S1109-9666(24)00128-3. [PMID: 38901557 DOI: 10.1016/j.hjc.2024.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Revised: 06/09/2024] [Accepted: 06/12/2024] [Indexed: 06/22/2024] Open
Abstract
Transoesophageal echocardiography (TOE) is a well-established and valid imaging modality, providing more accurate and of higher quality information than transthoracic echocardiography (TTE) for several specific diagnoses and recently a useful guide of an increasing number of catheter-based and surgical interventions. The present paper represents an effort by the Echocardiography Working Group (WG) of the Hellenic Society of Cardiology to state the essential steps of the TOE exam performed beyond the echo lab: a) in the operating rooms intraoperatively during either transcatheter interventions, or cardiothoracic surgery and b) in the intensive care unit for critically ill patients' monitoring. This paper includes information and tips and tricks about the pre-procedural evaluation, the procedural echocardiographic guidance, and post-procedural evaluation of the result and potential complications.
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Affiliation(s)
| | | | | | | | | | | | | | - Vlasis Ninios
- 2nd Cardiology Department, Interbalkan Center, Thessaloniki, Greece
| | | | - Maria Drakopoulou
- 1st Cardiology Department, Hippokration University Hospital, Athens, Greece
| | - Maria Angelaki
- 1st Cardiology Department, Korgialenio - Benakio Red Cross Hospital, Athens, Greece
| | | | | | | | | | | | | | - Nikolaos Zois
- Private Practice, Cardiology Department, University Hospital of Ioannina, Greece
| | | | | | - Dimitrios Tsiapras
- 2nd Cardiology Department, Onassis Cardiosurgical Center, Piraeus, Greece
| | | | - Konstantina Aggeli
- 1st Cardiology Department, Hippokration University Hospital, Athens, Greece
| | | | - Efstathia Prappa
- Cardiology Department, General Hospital of Evaggelismos, Athens, Greece
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17
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Gili S, Calligaris G, Teruzzi G, Santagostino Baldi G, Muratori M, Montorsi P, Trabattoni D. Patent Foramen Ovale Occlusion in Elderly Patients: Is It Worth It? A Large, Single-Center Retrospective Analysis. J Clin Med 2024; 13:3514. [PMID: 38930044 PMCID: PMC11204738 DOI: 10.3390/jcm13123514] [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: 06/01/2024] [Revised: 06/09/2024] [Accepted: 06/13/2024] [Indexed: 06/28/2024] Open
Abstract
Background: Patent foramen ovale (PFO) is often diagnosed in patients with cryptogenic stroke, aged > 60-65 years, but few data report the outcomes of PFO closure in elderly patients. Methods: Consecutive patients undergoing PFO closure at a single institution between January 2006 and December 2011 were included. Baseline clinical features and cerebral imaging data were collected, and a RoPE score was calculated for each patient. Procedural data were recorded as well as medical therapy upon discharge. All-cause death, ischemic stroke, TIA and systemic embolism recurrence at long-term follow-up were investigated, as well as new atrial fibrillation onset. Results: Overall, 462 patients were included, of whom 64 (13.8%) were aged ≥ 65 years. Female gender was slightly more prevalent in the younger group while hypertension was more frequent among elderly patients. Previous stroke/TIA was the indication for PFO closure in 95.3% of older patients and 80.4% of younger patients, whereas other indications were more frequent among younger patients. RoPE scores were lower in older patients (median RoPE score of 5 vs. 7), and atrial septal aneurysm was more frequently detected among elderly patients. All procedures were technically successful. Procedural or in-hospital complications equally occurred in 5 (7.8%) older patients (4 AF and 1 device embolization) and 30 (7.5%) young patients (29 AF or other supraventricular arrhythmias and 1 device embolization). The follow-up duration was longer among younger patients. All-cause mortality was higher in older patients (16 deaths vs. 4 at follow-up, log-rank p < 0.001), no recurrent strokes occurred, and 2 TIAs were reported among non-elderly patients. New-onset atrial fibrillation occurred in three elderly and eight young patients. Conclusions: PFO closure is a safe procedure in patients aged ≥ 65 years, associated with favorable long-term follow-up and the prevention of ischemic neurologic recurrences.
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Affiliation(s)
- Sebastiano Gili
- Centro Cardiologico Monzino, IRCCS, Via Parea, 4, 20138 Milan, Italy
| | | | - Giovanni Teruzzi
- Centro Cardiologico Monzino, IRCCS, Via Parea, 4, 20138 Milan, Italy
| | | | - Manuela Muratori
- Centro Cardiologico Monzino, IRCCS, Via Parea, 4, 20138 Milan, Italy
| | - Piero Montorsi
- Centro Cardiologico Monzino, IRCCS, Via Parea, 4, 20138 Milan, Italy
- Dipartimento di Scienze Cliniche e di Comunità, Università degli Studi di Milano, 20122 Milan, Italy
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18
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Hou S, Zhan Z, Fan J, Li M, Chen S, Zhang Y, Long Y, Pan W, Zhang X, Zhou D, Ge J. Association of in situ thrombus within the patent foramen ovale and patients with migraine: A prospective cohort study. Heliyon 2024; 10:e32105. [PMID: 38882380 PMCID: PMC11176847 DOI: 10.1016/j.heliyon.2024.e32105] [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: 01/14/2024] [Revised: 05/16/2024] [Accepted: 05/28/2024] [Indexed: 06/18/2024] Open
Abstract
Background Patent foramen ovale (PFO) is associated with migraine; however, the mechanism of PFO-associated migraine is not well known; additionally, percutaneous closure is controversial. This study aimed to investigate in situ thrombi within the PFO and explore the possible predictors of the effectiveness of PFO closure in migraineurs. Methods This prospective cohort study included 48 asymptomatic patients and 92 migraineurs with PFO. Optical coherence tomography (OCT) was used to evaluate the PFO microstructure. Only migraineurs underwent percutaneous closure. Migraineurs were divided into two cohorts based on the presence of a thrombus within the PFO. The symptoms were assessed at the 12-month follow-up visit. Predictors were evaluated employing multivariate logistic regression and receiver operating characteristic curve analyses. Results In situ thrombi within PFO were identified in 69 migraineurs and in two asymptomatic patients (76.7 % vs. 4.3 %; P < 0.001). Additionally, endocardial irregularity, discontinuity, low signal, and spasm were found in 59 (65.6 %), 15 (16.7 %), 13 (14.4 %), and six (6.7 %) patients, respectively, in the migraine group. In situ thrombus was associated with migraine risk (OR 49.03; 95%CI 8.52-282.18; P < 0.001). At the 12-month follow-up of the migraineur cohort, the primary endpoint, a 50 % reduction in migraine frequency after closure (with or without thrombus in PFO) was met (85.3 % vs. 25.0 %; P < 0.001). In situ thrombus was associated with migraine relief (OR 6.75; 95%CI 1.28-35.56; P = 0.024). Conclusions In situ thrombus and abnormal endocardium within PFOs were common in migraineurs, and in situ thrombus was a risk factor for migraine. Percutaneous closure was more effective in migraineurs with thrombi within the PFO. OCT imaging improved the understanding of pathogenic PFOs and may be helpful in selecting suitable migraineurs for PFO closure.
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Affiliation(s)
- Shiqiang Hou
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Zhi Zhan
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Jianing Fan
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Mingfei Li
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Shasha Chen
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Yuan Zhang
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Yuliang Long
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Wenzhi Pan
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Xiaochun Zhang
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Daxin Zhou
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Junbo Ge
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
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19
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Steinauer F, Bücke P, Buffle E, Branca M, Göcmen J, Navi BB, Liberman AL, Boronylo A, Clenin L, Goeldlin M, Lippert J, Volbers B, Meinel TR, Seiffge D, Mujanovic A, Kaesmacher J, Fischer U, Arnold M, Pabst T, Berger MD, Jung S, Beyeler M. Prevalence of right-to-left shunt in stroke patients with cancer. Int J Stroke 2024:17474930241260589. [PMID: 38816936 DOI: 10.1177/17474930241260589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
BACKGROUND AND OBJECTIVES Cancer is associated with an increased risk of acute ischemic stroke (AIS) and venous thromboembolism. The role of a cardiac right-to-left shunt (RLS) as a surrogate parameter for paradoxical embolism in cancer-related strokes is uncertain. We sought to investigate the relationship between the presence of an RLS and cancer in AIS patients. METHODS We included consecutive AIS patients hospitalized at our tertiary stroke center between January 2015 and December 2020 with available RLS status as detected on transesophageal echocardiography (TEE). Active cancers were retrospectively identified and the association with RLS was assessed with multivariable logistic regression and inverse probability of treatment weighting to minimize the ascertainment bias of having a TEE obtained. RESULTS Of the 2236 AIS patients included, 103 (4.6%) had active cancer, of whom 24 (23%) were diagnosed with RLS. An RLS was present in 774 out of the 2133 AIS patients without active cancer (36%). After adjustment and weighting, the absence of RLS was associated with active cancer (adjusted odds ratio (aOR) 2.29; 95% confidence interval (CI), 1.14-4.58). When analysis was restricted to patients younger than 60 years of age or those with a high-risk RLS (Risk of Paradoxical Embolism Score ⩾ 6), there was no association between RLS and cancer (aOR, 3.07; 95% CI, 0.79-11.88 and aOR, 0.56; 95% CI, 0.10-3.10, respectively). CONCLUSION RLS was diagnosed less frequently in AIS patients with cancer than in cancer-free patients, suggesting that arterial sources may play a larger role in cancer-related strokes than paradoxical venous embolization. Future studies are needed to validate these findings and evaluate potential therapeutic implications, such as the general indication, or lack thereof, for patent foramen ovale (PFO) closure in this patient population.
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Affiliation(s)
- Fabienne Steinauer
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Philipp Bücke
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Eric Buffle
- Department of Cardiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
- ARTORG Center, University of Bern, Bern, Switzerland
| | - Mattia Branca
- CTU Bern, Department of Clinical Research, University of Bern, Bern, Switzerland
| | - Jayan Göcmen
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Babak B Navi
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Ava L Liberman
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Anna Boronylo
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Leander Clenin
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Martina Goeldlin
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Julian Lippert
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Bastian Volbers
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Thomas R Meinel
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - David Seiffge
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Adnan Mujanovic
- Institute for Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Johannes Kaesmacher
- Institute for Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
- Neurology Department, University Hospital of Basel, University of Basel, Basel, Switzerland
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Thomas Pabst
- Department of Medical Oncology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Martin D Berger
- Department of Medical Oncology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Simon Jung
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Morin Beyeler
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland
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20
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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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21
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Xu C, Zhang Y, Peng Y, Zhao R, Xie M, Fang L, Lv Q. Live Biplane Transesophageal Echocardiography Improves Detection of Right-to-Left Shunts Through Patent Foramen Ovale. J Am Soc Echocardiogr 2024; 37:643-645. [PMID: 38325762 DOI: 10.1016/j.echo.2024.01.012] [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: 12/28/2023] [Revised: 01/19/2024] [Accepted: 01/19/2024] [Indexed: 02/09/2024]
Affiliation(s)
- Chunyan Xu
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China; Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Yongxing Zhang
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China; Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Yuan Peng
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China; Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Ruohan Zhao
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China; Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Mingxing Xie
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China; Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Lingyun Fang
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China; Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Qing Lv
- Department of Ultrasound Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China; Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
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22
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Pacheco C, Coutinho T, Bastiany A, Beanlands R, Boczar KE, Gulati M, Liu S, Luu J, Mulvagh SL, Paquin A, Saw J, Sedlak T. Canadian Cardiovascular Society/Canadian Women's Heart Health Alliance Clinical Practice Update on Myocardial Infarction With No Obstructive Coronary Artery Disease (MINOCA). Can J Cardiol 2024; 40:953-968. [PMID: 38852985 DOI: 10.1016/j.cjca.2024.02.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 02/27/2024] [Accepted: 02/27/2024] [Indexed: 06/11/2024] Open
Abstract
Myocardial infarction with no obstructive coronary artery disease (MINOCA) represents 6%-15% of all acute coronary syndromes, and women are disproportionately represented. MINOCA is an encompassing preliminary diagnosis, and emerging evidence supports a more expansive comprehensive diagnostic and therapeutic clinical approach. The current clinical practice update summarizes the latest evidence regarding the epidemiology, clinical presentation, and diagnostic evaluation of MINOCA. A cascaded approach to diagnostic workup is outlined for clinicians, for noninvasive and invasive diagnostic pathways, depending on clinical setting and local availability of diagnostic modalities. Evidence concerning the nonpharmacological and pharmacological treatment of MINOCA are presented and summarized according to underlying cause of MINOCA, with practical tips on the basis of expert opinion, outlining a real-life, evidence-based, comprehensive approach to management of this challenging condition.
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Affiliation(s)
- Christine Pacheco
- Department of Medicine, Hôpital Pierre-Boucher, Centre de santé et de services sociaux de la Montérégie-Est, Longueuil, Québec, Canada; Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, Canada.
| | - Thais Coutinho
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Alexandra Bastiany
- Thunder Bay Regional Health Sciences Centre, Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada
| | - Rob Beanlands
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Kevin E Boczar
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Martha Gulati
- Barbra Streisand Women's Heart Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Shuangbo Liu
- Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Judy Luu
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Sharon L Mulvagh
- Department of Medicine, Division of Cardiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Amelie Paquin
- Barbra Streisand Women's Heart Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Jacqueline Saw
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Tara Sedlak
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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23
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Apostolos A, Alexiou P, Papanikolaou A, Trantalis G, Drakopoulou M, Ktenopoulos N, Kachrimanidis I, Vlachakis PK, Tsakiri I, Chrysostomidis G, Aggeli K, Tsioufis C, Toutouzas K. Patent Foramen Ovale Closure in Special Clinical Situations: More Questions Than Answers? Life (Basel) 2024; 14:706. [PMID: 38929689 PMCID: PMC11204715 DOI: 10.3390/life14060706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 05/25/2024] [Accepted: 05/27/2024] [Indexed: 06/28/2024] Open
Abstract
Patent foramen ovale (PFO) is a remnant of the foetal circulation resulting from incomplete occlusion of the septum primum and septum secundum. Although prevalent in about 25% of the population, it mainly remains asymptomatic. However, its clinical significance in situations such as cryptogenic stroke, migraine, and decompression illness (DCI) has been well described. Recent randomised clinical trials (RCTs) have demonstrated the efficacy of percutaneous PFO closure over pharmacological therapy alone for secondary stroke prevention in carefully selected patients. Notably, these trials have excluded older patients or those with concurrent thrombophilia. Furthermore, the role of closure in other clinical conditions associated with PFO, like decompression sickness (DCS) and migraines, remains under investigation. Our review aims to summarise the existing literature regarding epidemiology, pathophysiological mechanisms, optimal management, and closure indications for these special patient groups.
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Affiliation(s)
- Anastasios Apostolos
- First Department of Cardiology, Medical School, National and Kapodistrian University of Athens, Hippocration General Hospital, 115 27 Athens, Greece; (A.A.); (P.A.); (G.T.); (M.D.); (N.K.); (I.K.); (P.K.V.); (I.T.); (K.A.); (C.T.)
| | - Polyxeni Alexiou
- First Department of Cardiology, Medical School, National and Kapodistrian University of Athens, Hippocration General Hospital, 115 27 Athens, Greece; (A.A.); (P.A.); (G.T.); (M.D.); (N.K.); (I.K.); (P.K.V.); (I.T.); (K.A.); (C.T.)
| | - Amalia Papanikolaou
- Department of Cardiology and Angiology, Universitatklinikum Essen, 451 47 Essen, Germany;
| | - Georgios Trantalis
- First Department of Cardiology, Medical School, National and Kapodistrian University of Athens, Hippocration General Hospital, 115 27 Athens, Greece; (A.A.); (P.A.); (G.T.); (M.D.); (N.K.); (I.K.); (P.K.V.); (I.T.); (K.A.); (C.T.)
| | - Maria Drakopoulou
- First Department of Cardiology, Medical School, National and Kapodistrian University of Athens, Hippocration General Hospital, 115 27 Athens, Greece; (A.A.); (P.A.); (G.T.); (M.D.); (N.K.); (I.K.); (P.K.V.); (I.T.); (K.A.); (C.T.)
| | - Nikolaos Ktenopoulos
- First Department of Cardiology, Medical School, National and Kapodistrian University of Athens, Hippocration General Hospital, 115 27 Athens, Greece; (A.A.); (P.A.); (G.T.); (M.D.); (N.K.); (I.K.); (P.K.V.); (I.T.); (K.A.); (C.T.)
| | - Ioannis Kachrimanidis
- First Department of Cardiology, Medical School, National and Kapodistrian University of Athens, Hippocration General Hospital, 115 27 Athens, Greece; (A.A.); (P.A.); (G.T.); (M.D.); (N.K.); (I.K.); (P.K.V.); (I.T.); (K.A.); (C.T.)
| | - Panayotis K. Vlachakis
- First Department of Cardiology, Medical School, National and Kapodistrian University of Athens, Hippocration General Hospital, 115 27 Athens, Greece; (A.A.); (P.A.); (G.T.); (M.D.); (N.K.); (I.K.); (P.K.V.); (I.T.); (K.A.); (C.T.)
| | - Ismini Tsakiri
- First Department of Cardiology, Medical School, National and Kapodistrian University of Athens, Hippocration General Hospital, 115 27 Athens, Greece; (A.A.); (P.A.); (G.T.); (M.D.); (N.K.); (I.K.); (P.K.V.); (I.T.); (K.A.); (C.T.)
| | - Grigorios Chrysostomidis
- Second Department of Adult Cardiac Surgery, Onassis Cardiac Surgery Center, 176 74 Athens, Greece;
| | - Konstantina Aggeli
- First Department of Cardiology, Medical School, National and Kapodistrian University of Athens, Hippocration General Hospital, 115 27 Athens, Greece; (A.A.); (P.A.); (G.T.); (M.D.); (N.K.); (I.K.); (P.K.V.); (I.T.); (K.A.); (C.T.)
| | - Costas Tsioufis
- First Department of Cardiology, Medical School, National and Kapodistrian University of Athens, Hippocration General Hospital, 115 27 Athens, Greece; (A.A.); (P.A.); (G.T.); (M.D.); (N.K.); (I.K.); (P.K.V.); (I.T.); (K.A.); (C.T.)
| | - Konstantinos Toutouzas
- First Department of Cardiology, Medical School, National and Kapodistrian University of Athens, Hippocration General Hospital, 115 27 Athens, Greece; (A.A.); (P.A.); (G.T.); (M.D.); (N.K.); (I.K.); (P.K.V.); (I.T.); (K.A.); (C.T.)
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24
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Caso V, Turc G, Abdul-Rahim AH, Castro P, Hussain S, Lal A, Mattle H, Korompoki E, Søndergaard L, Toni D, Walter S, Pristipino C. European Stroke Organisation (ESO) Guidelines on the diagnosis and management of patent foramen ovale (PFO) after stroke. Eur Stroke J 2024:23969873241247978. [PMID: 38752755 DOI: 10.1177/23969873241247978] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2024] Open
Abstract
Patent foramen ovale (PFO) is frequently identified in young patients with cryptogenic ischaemic stroke. Potential stroke mechanisms include paradoxical embolism from a venous clot which traverses the PFO, in situ clot formation within the PFO, and atrial arrhythmias due to electrical signalling disruption. The purpose of this guideline is to provide recommendations for diagnosing, treating, and long-term managing patients with ischaemic stroke and PFO. Conversely, Transient Ischaemic Attack (TIA) was not considered an index event in this context because only one RCT involved TIA patients. However, this subgroup analysis showed no significant differences between TIA and stroke outcomes. The working group identified questions and outcomes, graded evidence, and developed recommendations following the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach and the European Stroke Organisation (ESO) standard operating procedure for guideline development. This document underwent peer-review by independent experts and members of the ESO Guideline Board and Executive Committee. The working group acknowledges the current evidentiary gap in delineating an unequivocal diagnostic algorithm for the detection of PFO. Although transoesophageal echocardiography is conventionally held as the most accurate diagnostic tool for PFO identification, its status as the 'gold standard' remains unsubstantiated by rigorously validated evidence. We found high-quality evidence to recommend PFO closure plus antiplatelet therapy in selected patients aged 18-60 years in whom no other evident cause of stroke is found but a PFO (i.e. PFO-associated stroke). The PASCAL classification system can be used to select such candidates for PFO closure. Patients with both a large right-to-left shunt and an atrial septal aneurysm benefit most from PFO closure. There is insufficient evidence to make an evidence-based recommendation on PFO closure in patients older than 60 and younger than 18 years. We found low quality evidence to suggest against PFO closure in patients with unlikely PFO-related stroke according to the PASCAL classification, except in specific scenarios (Expert Consensus). We suggest against long-term anticoagulation in patients with PFO-associated stroke unless anticoagulation is indicated for other medical reasons. Regarding the long-term AF monitoring after PFO closure, the working group concluded that there remains significant uncertainty regarding the risks and benefits associated with the use of long-term cardiac monitoring, such as implantable loop recorders. This document provides additional guidance, in the form of evidence-based recommendations or expert consensus statements, on diagnostic methods for PFO detection, and medical management after PFO closure.
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Affiliation(s)
- Valeria Caso
- Stroke Unit, Santa Maria della Misericordia Hospital-University of Perugia, Santa Maria della Misericordia Hospital -University of Perugia, Perugia, Italy
| | - Guillaume Turc
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences, Université de Paris, INSERM U1266, FHU NeuroVasc, Paris, France
| | - Azmil H Abdul-Rahim
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Stroke Division, Department of Medicine for Older People, Whiston Hospital, Mersey and West Lancashire Teaching Hospitals NHS Trust, Prescot, UK
| | - Pedro Castro
- Department of Neurology, Centro Hospitalar Universitário de São João Faculty of Medicine University of Porto, Porto, Portugal
| | | | - Avtar Lal
- European Stroke Organisation, Basel, Switzerland
| | - Heinrich Mattle
- Department of Neurology, Inselspital, University of Bern, Bern, Switzerland
| | - Eleni Korompoki
- Department of Clinical Therapeutics National and Kapodistrian University of Athens Alexandra Hospital Athens, Greece
| | | | - Danilo Toni
- Hospital Policlinico Umberto I, Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Silke Walter
- Department of Neurology, Saarland University, Homburg, Germany
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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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26
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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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Dell'Angela L, Nicolosi GL. Lights and shadows on left atrial appendage occlusion: mind the gap in knowledge and think twice on long-term outcomes. J Cardiovasc Med (Hagerstown) 2024; 25:345-352. [PMID: 38477853 DOI: 10.2459/jcm.0000000000001610] [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: 03/14/2024]
Abstract
Ischemic stroke prevention represents a crucial concern in health systems, being associated with high morbidity and mortality. Atrial fibrillation is associated with 15-20% of ischemic strokes, in the presence of thrombus in the left atrial appendage in 90% of patients with nonvalvular atrial fibrillation. Oral anticoagulation represents the standard of care. However, left atrial appendage occlusions have been developed for selected patients with nonvalvular atrial fibrillation. With regard to the latter, particularly, some important concerns have been raised on the selection of patients potentially amenable to the procedure, seemingly emphasizing a gap in knowledge, real-life clinical practice, and current management guidelines. In light of the recent evidence regarding the current indications for management of left atrial appendage in presence of nonvalvular atrial fibrillation, the purpose of this critical review is to highlight the blind spots of left atrial appendage occlusion indications, taking into account the evidence-based mid- to long-term outcomes. Apparently, many unsolved concerns and problems are still present, mainly including mid- and long-term device-related potential complications, the possibility of concurrent sources of embolization, ethical and economic issues. Furthermore, larger, well designed, long-term, multicentric, and more inclusive studies, as well as shared/integrated registries are needed, aiming at comparing direct oral anticoagulation with left atrial appendage occlusion in the long run.
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Affiliation(s)
- Luca Dell'Angela
- Cardio-Thoracic and Vascular Department, Cardiology Division, Gorizia & Monfalcone Hospital, ASUGI, Gorizia
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Leskelä J, Putaala J, Martinez-Majander N, Tulkki L, Manzoor M, Zaric S, Ylikotila P, Lautamäki R, Saraste A, Suihko S, Könönen E, Sinisalo J, Pussinen P, Paju S. Periodontitis, Dental Procedures, and Young-Onset Cryptogenic Stroke. J Dent Res 2024; 103:494-501. [PMID: 38623924 PMCID: PMC11047014 DOI: 10.1177/00220345241232406] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024] Open
Abstract
Periodontitis is associated with an increased risk of ischemic stroke, and the risk may be particularly high among young people with unexplained stroke etiology. Thus, we investigated in a case-control study whether periodontitis or recent invasive dental treatments are associated with young-onset cryptogenic ischemic stroke (CIS). We enrolled participants from a multicenter case-control SECRETO study including adults aged 18 to 49 y presenting with an imaging-positive first-ever CIS and stroke-free age- and sex-matched controls. Thorough clinical and radiographic oral examination was performed. Furthermore, we measured serum lipopolysaccharide (LPS) and lipotechoic acid (LTA) levels. Multivariate conditional regression models were adjusted for stroke risk factors, regular dentist visits, and patent foramen ovale (PFO) status. We enrolled 146 case-control pairs (median age 41.9 y; 58.2% males). Periodontitis was diagnosed in 27.5% of CIS patients and 20.1% of controls (P < 0.001). In the fully adjusted models, CIS was associated with high periodontal inflammation burden (odds ratio [OR], 95% confidence interval) with an OR of 10.48 (3.18-34.5) and severe periodontitis with an OR of 7.48 (1.24-44.9). Stroke severity increased with the severity of periodontitis, having an OR of 6.43 (1.87-23.0) in stage III to IV, grade C. Invasive dental treatments performed within 3 mo prestroke were associated with CIS, with an OR of 2.54 (1.01-6.39). Association between CIS and invasive dental treatments was especially strong among those with PFO showing an OR of 6.26 (1.72-40.2). LPS/LTA did not differ between CIS patients and controls but displayed an increasing trend with periodontitis severity. Periodontitis and recent invasive dental procedures were associated with CIS after controlling for multiple confounders. However, the role of bacteremia as a mediator of this risk was not confirmed.
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Affiliation(s)
- J. Leskelä
- Department of Oral and Maxillofacial Diseases, University of Helsinki, Helsinki, Finland
| | - J. Putaala
- Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - N. Martinez-Majander
- Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - L. Tulkki
- Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - M. Manzoor
- Department of Oral and Maxillofacial Diseases, University of Helsinki, Helsinki, Finland
| | - S. Zaric
- Centre for Host-Microbiome Interactions, Faculty of Dentistry, Oral & Craniofacial Sciences, King’s College London, London, UK
| | - P. Ylikotila
- Neurocenter, Turku University Hospital, University of Turku, Turku, Finland
| | - R. Lautamäki
- Heart Centre, Turku University Hospital, University of Turku, Turku, Finland
| | - A. Saraste
- Heart Centre, Turku University Hospital, University of Turku, Turku, Finland
| | - S. Suihko
- Department of Medicine, Division of Cardiology, Helsinki University Central Hospital, Helsinki, Finland
| | - E. Könönen
- Institute of Dentistry, University of Turku, Turku, Finland
| | - J. Sinisalo
- Department of Medicine, Division of Cardiology, Helsinki University Central Hospital, Helsinki, Finland
| | - P.J. Pussinen
- Department of Oral and Maxillofacial Diseases, University of Helsinki, Helsinki, Finland
- School of Medicine, Institute of Dentistry, University of Eastern Finland, Kuopio, Finland
| | - S. Paju
- Department of Oral and Maxillofacial Diseases, University of Helsinki, Helsinki, Finland
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Kovacevic M, Atanaskovic M, Obradovic K, Todic M, Crnomarkovic B, Bjelobrk M, Bjelic S, Cankovic M, Milovancev A, Srdanovic I. Embolization of Patent Foramen Ovale Closure Device-Rare Complication and Unique Management Approach. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:717. [PMID: 38792900 PMCID: PMC11123128 DOI: 10.3390/medicina60050717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 04/20/2024] [Accepted: 04/23/2024] [Indexed: 05/26/2024]
Abstract
Percutaneous closure of the patent foramen ovale (PFO) is generally regarded as a safe and effective procedure, indicated in patients with a prior PFO-associated stroke. While it is highly safe, rarely, it could be accompanied by a migration of the device, mainly caused by the interplay of a specific PFO morphology and inappropriate device sizing. Herein, we outline a seldom-observed complication of an unintentional detachment of the PFO closure device during implantation, leading to its migration into the abdominal aorta, and a unique management approach. Due to the inability to recapture the occluder with a snare, which is considered to be a mainstay of endovascular retrieval methods, two coronary guidewires were maneuvered through the mesh of the occluder and then captured with a snare proximally to the occluder. This innovative dual-wire-snare system was carefully pulled to the common femoral artery, a position deemed suitable for surgical extraction via arteriotomy, which was achieved successfully.
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Affiliation(s)
- Mila Kovacevic
- Faculty of Medicine, University of Novi Sad, 21000 Novi Sad, Serbia; (M.A.); (K.O.); (M.T.); (B.C.); (M.B.); (M.C.); (A.M.); (I.S.)
- Institute of Cardiovascular Diseases of Vojvodina, 21204 Sremska Kamenica, Serbia;
| | - Marko Atanaskovic
- Faculty of Medicine, University of Novi Sad, 21000 Novi Sad, Serbia; (M.A.); (K.O.); (M.T.); (B.C.); (M.B.); (M.C.); (A.M.); (I.S.)
| | - Katarina Obradovic
- Faculty of Medicine, University of Novi Sad, 21000 Novi Sad, Serbia; (M.A.); (K.O.); (M.T.); (B.C.); (M.B.); (M.C.); (A.M.); (I.S.)
| | - Mirko Todic
- Faculty of Medicine, University of Novi Sad, 21000 Novi Sad, Serbia; (M.A.); (K.O.); (M.T.); (B.C.); (M.B.); (M.C.); (A.M.); (I.S.)
- Institute of Cardiovascular Diseases of Vojvodina, 21204 Sremska Kamenica, Serbia;
| | - Branislav Crnomarkovic
- Faculty of Medicine, University of Novi Sad, 21000 Novi Sad, Serbia; (M.A.); (K.O.); (M.T.); (B.C.); (M.B.); (M.C.); (A.M.); (I.S.)
- Institute of Cardiovascular Diseases of Vojvodina, 21204 Sremska Kamenica, Serbia;
| | - Marija Bjelobrk
- Faculty of Medicine, University of Novi Sad, 21000 Novi Sad, Serbia; (M.A.); (K.O.); (M.T.); (B.C.); (M.B.); (M.C.); (A.M.); (I.S.)
- Institute of Cardiovascular Diseases of Vojvodina, 21204 Sremska Kamenica, Serbia;
| | - Snezana Bjelic
- Institute of Cardiovascular Diseases of Vojvodina, 21204 Sremska Kamenica, Serbia;
| | - Milenko Cankovic
- Faculty of Medicine, University of Novi Sad, 21000 Novi Sad, Serbia; (M.A.); (K.O.); (M.T.); (B.C.); (M.B.); (M.C.); (A.M.); (I.S.)
- Institute of Cardiovascular Diseases of Vojvodina, 21204 Sremska Kamenica, Serbia;
| | - Aleksandra Milovancev
- Faculty of Medicine, University of Novi Sad, 21000 Novi Sad, Serbia; (M.A.); (K.O.); (M.T.); (B.C.); (M.B.); (M.C.); (A.M.); (I.S.)
- Institute of Cardiovascular Diseases of Vojvodina, 21204 Sremska Kamenica, Serbia;
| | - Ilija Srdanovic
- Faculty of Medicine, University of Novi Sad, 21000 Novi Sad, Serbia; (M.A.); (K.O.); (M.T.); (B.C.); (M.B.); (M.C.); (A.M.); (I.S.)
- Institute of Cardiovascular Diseases of Vojvodina, 21204 Sremska Kamenica, Serbia;
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Immens MHM, van den Hoeven V, van Lith TJ, Duijnhouwer TD, ten Cate TJF, de Leeuw FE. Heart-Stroke Team: A multidisciplinary assessment of patent foramen ovale-associated stroke. Eur Stroke J 2024; 9:219-225. [PMID: 37978872 PMCID: PMC10916814 DOI: 10.1177/23969873231214862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 11/01/2023] [Indexed: 11/19/2023] Open
Abstract
INTRODUCTION Patent foramen ovale (PFO) closure prevents recurrent ischemic stroke in selected patients with a cryptogenic stroke. Trial results tend to be generalized to daily practice, often extending original trial inclusion criteria. This may result in unnecessary closure without benefit, but with risk of complications. We therefore introduced a standardized and structured evaluation by an interdisciplinary Heart-Stroke Team (HST). Our aim was to investigate the proportion of actual PFO closure of all referred patients with a cryptogenic stroke, after evaluation by the HST. PATIENTS AND METHODS We conducted a single-center, retrospective cohort study. Patients with an assumed cryptogenic ischemic stroke or transient ischemic attack (TIA) and a PFO who were referred for PFO closure were analyzed. As part of the HST approach, all patients underwent a standardized work-up, first to demonstrate the ischemic event on neuroimaging, second to evaluate all potential causes of stroke and finally, to assess the possible relation between the PFO and stroke. Outcome was the proportion of patients treated with PFO closure after referral. RESULTS A total of 195 patients were included. In 124 patients (64%) PFO closure was advised. Fourty-two (22%) patients had a clear alternative cause of stroke and in 13 (7%) patients the initial stroke diagnosis could not be confirmed. CONCLUSION After careful analysis of patients referred for PFO closure a relationship between the PFO and stroke could not be demonstrated in 32% of referrals, and 3% preferred best medical treatment over percutaneous closure. This stresses the need for a complete neurovascular work-up and multidisciplinary assessment.
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Affiliation(s)
- Maikel HM Immens
- Department of Neurology, Radboud University Medical Centre, Donders institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands
| | - Vincent van den Hoeven
- Department of Neurology, Radboud University Medical Centre, Donders institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands
| | - Theresa J van Lith
- Department of Neurology, Radboud University Medical Centre, Donders institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands
| | - Toon D Duijnhouwer
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Tim JF ten Cate
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Frank-Erik de Leeuw
- Department of Neurology, Radboud University Medical Centre, Donders institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands
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Apostolos A, Drakopoulou M, Trantalis G, Ioakeimidis M, Koroboki E, Tsalamandris S, Aggeli C, Ntaios G, Tsioufis C, Tsivgoulis G, Toutouzas K. Management of patent foramen ovale; findings from a nationwide survey. J Stroke Cerebrovasc Dis 2024; 33:107551. [PMID: 38241951 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107551] [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: 09/21/2023] [Revised: 12/16/2023] [Accepted: 12/20/2023] [Indexed: 01/21/2024] Open
Abstract
OBJECTIVES Several clinical trials have provided evidence supporting the transcatheter closure of patent foramen ovale (PFO) in selected patients following a cryptogenic stroke. However, it remains unknown to what extent these guidelines have been implemented in everyday clinical practice and the familiarity of physicians from different specialties with PFO closure. The aim of our nationwide survey is to explore the implementation of transcatheter PFO occlusion in Greek clinical practice. MATERIALS AND METHODS Attending level cardiologists, internal medicine physicians and neurologists involved in the management of PFO-related strokes working in Greece were invited to complete an online questionnaire. The questionnaire consisted of 19 questions and was designed to obtain comprehensive data on provider demographics, PFO characteristics, and specific clinical scenarios. RESULTS A total of 51 physicians (56.9 % cardiologists, 25.5 % neurologists and 17.6 % internal medicine physicians) completed the survey, resulting in a response rate of 53 %. Cardiologists, internal medicine physicians and neurologists agree on several issues regarding PFO closure, such as PFO closure as first line treatment, management of patients with DVT or prior decompression sickness, and post-closure antithrombotic treatment, but different approaches were reported regarding closure in patients with thrombophilia treated with oral anticoagulation (p=0.012) and implantable loop recorder placement for atrial fibrillation exclusion (p=0.029 and p=0.020). CONCLUSIONS Our findings show that cardiologists, internal medicine physicians and neurologists agree in numerous issues, but share different views in the management of patients with thrombophilia and rhythm monitoring duration. These results highlight the significance of collaboration among physicians from different medical specialties for achieving optimal results.
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Affiliation(s)
- Anastasios Apostolos
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece.
| | - Maria Drakopoulou
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Georgios Trantalis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Michael Ioakeimidis
- Second Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Eleni Koroboki
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Sotirios Tsalamandris
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Constantina Aggeli
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Georgios Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Costas Tsioufis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Georgios Tsivgoulis
- Second Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Konstantinos Toutouzas
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
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Kachel M, Melo P, Van Wygerden K, Cheng Y, Corcoran M, Garlick DS, Olson M, Nielsen CD, Granada JF, Kaluza GL. Performance, safety, and biocompatibility of a novel PFO closure device in a long-term porcine model. J Cardiol 2024; 83:184-190. [PMID: 37684005 DOI: 10.1016/j.jjcc.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 08/15/2023] [Accepted: 09/01/2023] [Indexed: 09/10/2023]
Abstract
BACKGROUND As the catheter-based device closure of the patent foramen ovale (PFO) is expanding, novel devices aim to address the limitations of first-generation occluders (e.g. bulk, erosion, dislodgment). The second-generation device from Encore Medical (Eagan, MN, USA) features an articulating frame structure which allows the device to better conform to atrial anatomies, has lower disc thickness and metal mass/surface area, and is fully retrievable at any point in the procedure. The aim of the study was to evaluate the feasibility and safety of a novel low-profile, fully retrievable, Encore PFO closure device in the animal model. METHODS Six swine underwent implantation of the novel PFO occluder under fluoroscopic and intra-cardiac echocardiography guidance and survived for 140 days. Interim transthoracic echocardiography (TTE) was conducted on Day 29. Following terminal angiography and TTE at 140 days, the hearts were subjected to gross and histopathologic analysis. RESULTS All animals were successfully implanted and survived for 140 days. Interim TTE revealed proper device retention with no blood flow across the septum or thrombus in any of the animals. X-ray and pathology results showed preserved implant integrity with no fractures, and complete integration of the devices into the septum with complete re-endothelialization and nearly complete coverage by a mature, relatively thin neoendocardium. No surface fibrin deposition or thrombosis was reported. CONCLUSIONS In the standard porcine model, device retention and biocompatibility remained favorable following structural and functional device modifications exemplified by the second-generation PFO occluder from Encore Medical, including marked reduction of metal mass.
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Affiliation(s)
- Mateusz Kachel
- CRF Skirball Center for Innovation, Orangeburg, NY, USA; American Heart of Poland, Center for Cardiovascular Research and Development, Katowice, Poland
| | - Pedro Melo
- CRF Skirball Center for Innovation, Orangeburg, NY, USA
| | | | - Yanping Cheng
- CRF Skirball Center for Innovation, Orangeburg, NY, USA
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Li JD, Xu N, Zhao Q, Li B, Li L. Multiple paradoxical embolisms caused by central venous catheter thrombus passing through a patent foramen ovale: A case report. World J Clin Cases 2024; 12:842-846. [PMID: 38322689 PMCID: PMC10841136 DOI: 10.12998/wjcc.v12.i4.842] [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: 10/25/2023] [Revised: 12/27/2023] [Accepted: 01/15/2024] [Indexed: 01/25/2024] Open
Abstract
BACKGROUND To date, this is the first case of a paradoxical embolism (PDE) that concurrently manifested in the coronary and lower limb arteries and was secondary to a central venous catheter (CVC) thrombus via a patent foramen ovale (PFO). CASE SUMMARY Here, we report a case of simultaneous coronary and lower limb artery embolism in a PFO patient carrier of a CVC. The patient presented to the hospital with acute chest pain and lower limb fatigue. Doppler ultrasound showed a large thrombus in the right internal jugular vein, precisely at the tip of the CVC. Transthoracic and transesophageal echocardiography confirmed the existence of a PFO, with inducible right-to-left shunting by the Valsalva maneuver. The patient was administered an extended course of anticoagulation therapy, and then the CVC was successfully removed. Percutaneous PFO closure was not undertaken. There was no recurrence during follow-up. CONCLUSION Thus, CVC-associated thrombosis is a potential source for multiple PDE in PFO patients.
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Affiliation(s)
- Jian-Duan Li
- Department of Cardiology, Guangzhou Red Cross Hospital of Jinan University, Guangzhou 510235, Guangdong Province, China
| | - Nian Xu
- Department of Cardiology, Guangzhou Red Cross Hospital of Jinan University, Guangzhou 510235, Guangdong Province, China
| | - Qiang Zhao
- Department of Cardiology, Guangzhou Red Cross Hospital of Jinan University, Guangzhou 510235, Guangdong Province, China
| | - Biao Li
- Department of Cardiology, Guangzhou Red Cross Hospital of Jinan University, Guangzhou 510235, Guangdong Province, China
| | - Li Li
- Department of Cardiology, Guangzhou Red Cross Hospital of Jinan University, Guangzhou 510235, Guangdong Province, China
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Martins da Costa C, Amador AF, Pinto R, Bragança B, Oliveira I, Silva JC, Rodrigues RA. Same-day discharge after elective percutaneous closure of patent foramen ovale. Monaldi Arch Chest Dis 2024. [PMID: 38305834 DOI: 10.4081/monaldi.2024.2833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 12/06/2023] [Indexed: 02/03/2024] Open
Abstract
Percutaneous closure of the patent foramen ovale (PFO) is increasingly performed in specific patients with cryptogenic stroke or clinical evidence of a paradoxical embolism. This study was performed to determine the safety of same-day discharge (SDD) following such procedures. This is a prospective, observational study of patients undergoing elective percutaneous PFO closure in a single tertiary center in Portugal between January 2020 and July 2023. AmplatzerTM devices (St. Jude Medical, St. Paul, MN, USA) and NobblestichTM EL (HeartStitch, Inc., Fountain Valley, CA, USA) were used. After 6 months, the following events were looked at: post-procedural paroxysmal atrial fibrillation, stroke, unplanned cardiac re-hospitalization, urgent cardiac surgery, major vascular complications, pericardial effusions, device embolization, and death. We studied 122 consecutive patients (52% female, 68; 48±12 years old) who had elective percutaneous closure with success and no complications. Forty-nine (40%) had SDD. AmplatzerTM devices were used more frequently in the SDD group, while NobblestichTM EL was more common in the overnight group. During the overnight group's follow-up period, there was one non-cardiovascular death; there were no further events. SDD after elective percutaneous closure of PFO was shown to be a safe and successful patient management method, including NobblestichTM, which we describe for the first time. Our results prove the safety of this same-day discharge strategy. We hypothesize that in the near future, in selected cases, PFO closure might become an ambulatory procedure.
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Affiliation(s)
- Catarina Martins da Costa
- Department of Cardiology, University Hospital Center of São João, Porto; Faculty of Medicine, University of Porto.
| | - Ana Filipa Amador
- Department of Cardiology, University Hospital Center of São João, Porto; Faculty of Medicine, University of Porto.
| | - Roberto Pinto
- Department of Cardiology, University Hospital Center of São João, Porto.
| | - Bruno Bragança
- Department of Cardiology, Tâmega and Sousa Hospital Center, Penafiel.
| | - Inês Oliveira
- Department of Cardiology, Tâmega and Sousa Hospital Center, Penafiel.
| | - João Carlos Silva
- Department of Cardiology, University Hospital Center of São João, Porto.
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van der Maten G, Meijs MFL, Timmer JR, Brouwers PJAM, von Birgelen C, Coutinho JM, Bouma BJ, Kerkhoff H, Helming AM, van Tuijl JH, van der Meer NA, Saxena R, Ebink C, van der Palen J, den Hertog HM. Routine transthoracic echocardiography in ischaemic stroke or transient ischaemic attack of undetermined cause: a prospective multicentre study. Neth Heart J 2024; 32:91-98. [PMID: 37870709 PMCID: PMC10834921 DOI: 10.1007/s12471-023-01819-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2023] [Indexed: 10/24/2023] Open
Abstract
BACKGROUND Guidelines recommend routine transthoracic echocardiography (TTE) after ischaemic stroke or transient ischaemic attack of undetermined cause; yet, only limited scientific evidence exists. Therefore, we aimed to determine in these patients the prevalence of TTE-detected major cardiac sources of embolism (CSE), which are abnormalities leading to therapeutic changes. METHODS Six Dutch hospitals conducted a prospective observational study that enrolled patients with ischaemic stroke or transient ischaemic attack of undetermined cause. Patients underwent TTE after comprehensive diagnostic evaluation on stroke units, including blood chemistry, 12-lead electrocardiogram (ECG), ≥ 24 h continuous ECG monitoring, brain imaging and cervical artery imaging. Primary outcome measure was the proportion of patients with TTE-detected major CSE. RESULTS From March 2018 to October 2020, 1084 patients, aged 66.6 ± 12.5 years, were enrolled; 456 (42.1%) patients were female and 869 (80.2%) had ischaemic stroke. TTE detected major CSE in only 11 (1.0%) patients. Ten (90.9%) of these patients also had major ECG abnormalities (previous infarction, major repolarisation abnormalities, or previously unknown left bundle branch block) that would have warranted TTE assessment regardless of stroke evaluation. Such ECG abnormalities were present in 11.1% of the total study population. A single patient (0.1%) showed a major CSE despite having no ECG abnormality. CONCLUSIONS This multicentre cross-sectional study in patients who-after workup on contemporary stroke units-were diagnosed with ischaemic stroke or transient ischaemic attack of undetermined cause found TTE-detected major CSE in only 1% of all patients. Most of these patients also had major ECG abnormalities. These findings question the value of routine TTE assessment in this clinical setting.
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Affiliation(s)
- Gerlinde van der Maten
- Department of Neurology, Medisch Spectrum Twente, Enschede, The Netherlands
- Department of Health Technology and Services Research, Faculty of Behavioural, Management and Social Sciences, University of Twente, Enschede, The Netherlands
| | - Matthijs F L Meijs
- Department of Cardiology, Medisch Spectrum Twente, Enschede, The Netherlands.
| | - Jorik R Timmer
- Department of Cardiology, Isala Hospital, Zwolle, The Netherlands
| | | | - Clemens von Birgelen
- Department of Health Technology and Services Research, Faculty of Behavioural, Management and Social Sciences, University of Twente, Enschede, The Netherlands
- Department of Cardiology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam University Medical Centres, location AMC, Amsterdam, The Netherlands
| | - Berto J Bouma
- Department of Cardiology, Amsterdam University Medical Centres, location AMC, Amsterdam, The Netherlands
| | - Henk Kerkhoff
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Anne Mijn Helming
- Department of Cardiology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Julia H van Tuijl
- Department of Neurology, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | | | - Ritu Saxena
- Department of Neurology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Corné Ebink
- Department of Cardiology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Job van der Palen
- Section Cognition, Data and Education, Faculty of Behavioural, Management and Social Sciences, University of Twente, Enschede, The Netherlands
- Medical School Twente, Medisch Spectrum Twente, Enschede, The Netherlands
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Sposato LA, Albin CSW, Elkind MSV, Kamel H, Saver JL. Patent Foramen Ovale Management for Secondary Stroke Prevention: State-of-the-Art Appraisal of Current Evidence. Stroke 2024; 55:236-247. [PMID: 38134261 DOI: 10.1161/strokeaha.123.040546] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2023]
Abstract
Patent foramen ovale (PFO) is frequently identified in young patients with ischemic stroke. Randomized controlled trials provide robust evidence supporting PFO closure in selected patients with cryptogenic ischemic stroke; however, several questions remain unanswered. This report summarizes current knowledge on the epidemiology of PFO-associated stroke, the role of PFO as a cause of stroke, and anatomic high-risk features. We also comment on breakthrough developments in patient selection algorithms for PFO closure in relation to the PFO-associated stroke causal likelihood risk stratification system. We further highlight areas for future research in PFO-associated stroke including the efficacy and safety of PFO closure in the elderly population, incidence, and long-term consequences of atrial fibrillation post-PFO closure, generalizability of the results of clinical trials in the real world, and the need for assessing the effect of neurocardiology teams on adherence to international recommendations. Other important knowledge gaps such as sex, race/ethnicity, and regional disparities in access to diagnostic technologies, PFO closure devices, and clinical outcomes in the real world are also discussed as priority research topics.
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Affiliation(s)
- Luciano A Sposato
- Departments of Clinical Neurological Sciences, Epidemiology and Biostatistics, and Anatomy and Cell Biology, Schulich School of Medicine and Dentistry (L.A.S.), Western University, London, ON, Canada
- Heart & Brain Laboratory (L.A.S.), Western University, London, ON, Canada
- Robarts Research Institute and Lawson Health Research Institute, London, ON, Canada (L.A.S.)
| | - Catherine S W Albin
- Department of Neurology & Neurosurgery, Emory University School of Medicine, Atlanta, GA (C.S.W.A.)
| | - Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons (M.S.V.E.), Columbia University, New York
- Department of Epidemiology, Mailman School of Public Health (M.S.V.E.), Columbia University, New York
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York (H.K.)
| | - Jeffrey L Saver
- Department of Neurology, University of California, Los Angeles (J.L.S.)
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Aliramezany M, Moazenzadeh M, Sayyadi A, Mohammadi K, Barzegar H, Aliramezany M. Atrial Septal Abnormalities and Cryptogenic Stroke: A Cross-Sectional Study. Cardiovasc Hematol Disord Drug Targets 2024; 24:40-46. [PMID: 38685781 DOI: 10.2174/011871529x294809240415070950] [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: 12/31/2023] [Revised: 03/19/2024] [Accepted: 03/28/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND Cryptogenic stroke, whose underlying pathology is unknown, accounts for 30-40% of all ischemic strokes. Studies have mentioned the association between atrial septal abnormalities and cryptogenic stroke, but there are still disparities in the results among different studies. OBJECTIVE We aimed to clarify the prevalence of atrial septal abnormalities in patients with cryptogenic stroke. METHODS We conducted a cross-sectional study on 91 patients with cryptogenic stroke/transient ischemic attack from March 2021 to March 2022. We evaluated the demographic data of the patients and also the existence of neurologic attacks. Furthermore, echocardiography was performed to determine the type of atrial septal abnormality. RESULTS Out of 91 patients with cryptogenic stroke/transient ischemic attack, 16 patients (17.5%) had patent foramen ovale, 1 man (1.1%) had atrial septal aneurysm, and 1 woman (1.1%) had an atrial septal defect. Patients with patent foramen ovale were significantly younger than those without. The size of patent foramen ovale in patients with cryptogenic stroke was larger than those with transient ischemic attack, but this difference was not significant. Also, the size of the patent foramen ovale (length and width) was not significantly related to any of the demographic variables (p-value = 0.544, 0.604). CONCLUSION Based on our results, the prevalence of atrial septal abnormalities was relatively high. Considering these issues and the importance of preventing neurological accidents in patients, especially young people, it is recommended to always consider atrial septal disorders and, if diagnosed, to carry out the necessary treatment in this field.
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Affiliation(s)
- Marzieh Aliramezany
- Department of Cardiology, School of Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Mansoor Moazenzadeh
- Department of Cardiology, Cardiovascular Research Center, Institute of Basic and Clinical Physiology Sciences, Kerman University of Medical Sciences, Kerman, Iran
| | - Amin Sayyadi
- Department of Cardiology, School of Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Khadijeh Mohammadi
- Department of Cardiology, Cardiovascular Research Center, Institute of Basic and Clinical Physiology Sciences, Kerman University of Medical Sciences, Kerman, Iran
| | - Hamidreza Barzegar
- Neurology Department, Kerman University of Medical Sciences, Kerman, Iran
| | - Maryam Aliramezany
- Department of Cardiology, Cardiovascular Research Center, Institute of Basic and Clinical Physiology Sciences, Kerman University of Medical Sciences, Kerman, Iran
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Gurgoglione FL, Vignali L, Cattabiani MA, Solinas E, Benatti G, Tadonio I, Barocelli F, Dizdari C, Tuttolomondo D, Ardissino D, Nicolini F, Niccoli G. Predictors of recurrent cerebral ischemia after patent foramen ovale closure: A single center observational study. J Stroke Cerebrovasc Dis 2024; 33:107448. [PMID: 37988831 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107448] [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: 06/30/2023] [Revised: 10/18/2023] [Accepted: 10/25/2023] [Indexed: 11/23/2023] Open
Abstract
OBJECTIVES Transcatheter patent foramen ovale closure lowers recurrent stroke in patients with cryptogenic stroke or transient ischemic attack with an indication for closure. However, the incidence of recurrent stroke is not negligible and underlying pathophysiology remains largely unknown. We sought to evaluate the prevalence of recurrent ischemic neurological events and to assess its predictors after transcatheter patent foramen ovale closure. METHODS We enrolled consecutive patients who underwent patent foramen ovale closure for secondary prevention of neurological ischemic events at the University Hospital of Parma between 2006 and 2021. Clinical and procedure-related features were collected for each patient. The incidence of recurrent ischemic neurological events was assessed at follow-up. RESULTS We enrolled a total of 169 patients with mean Risk of Paradoxical Embolism score at hospital admission of 6.4 ± 1.5. The primary indication was previous cryptogenic stroke (94 [55.6 %] subjects), followed by transient ischemic attack (75 [44.4 %]). Among patients with complete outcome data (n= 154), after a median follow-up of 112 months, recurrent cerebral ischemia occurred in 13 [8.4 %], with an annualized rate of 0.92/100 patients. The presence of obesity [OR 5.268, p = 0.018], Risk of Paradoxical Embolism score < 7 [OR 5.991, p = 0.035] and migraine [OR = 5.932 p = 0.012] were independent positive predictors of recurrent stroke/ transient ischemic attack after patent foramen ovale closure. CONCLUSIONS The presence of obesity, Risk of Paradoxical Embolism score < 7 and migraine were independent positive predictors of recurrent ischemic neurological events after patent foramen ovale closure.
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Affiliation(s)
| | - Luigi Vignali
- Cardiology Department, Azienda Ospedaliero-Universitaria of Parma, Parma, Italy
| | | | - Emilia Solinas
- Cardiology Department, Azienda Ospedaliero-Universitaria of Parma, Parma, Italy
| | - Giorgio Benatti
- Cardiology Department, Azienda Ospedaliero-Universitaria of Parma, Parma, Italy
| | - Iacopo Tadonio
- Cardiology Department, Azienda Ospedaliero-Universitaria of Parma, Parma, Italy
| | - Federico Barocelli
- Cardiology Department, Azienda Ospedaliero-Universitaria of Parma, Parma, Italy
| | - Chiara Dizdari
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | | | - Diego Ardissino
- Cardiology Department, Azienda Ospedaliero-Universitaria of Parma, Parma, Italy; Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Francesco Nicolini
- Department of Medicine and Surgery, University of Parma, Parma, Italy; Cardiac Surgery Unit, Azienda Ospedaliero-Universitaria of Parma, Parma, Italy
| | - Giampaolo Niccoli
- Cardiology Department, Azienda Ospedaliero-Universitaria of Parma, Parma, Italy; Department of Medicine and Surgery, University of Parma, Parma, Italy.
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Goldsweig AM, Deng Y, Yao X, Desai NR, Cohen DJ, Aronow HD, Messé S, Ross JS, Lansky AJ, Savitz ST. Approval, Evidence, and "Off-Label" Device Utilization: The Patent Foramen Ovale Closure Story. Circ Cardiovasc Qual Outcomes 2024; 17:e010200. [PMID: 38189127 PMCID: PMC10844981 DOI: 10.1161/circoutcomes.123.010200] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 09/27/2023] [Indexed: 01/09/2024]
Abstract
BACKGROUND Following regulatory approval, medical devices may be used "off-label." Patent foramen ovale (PFO) closure is indicated to reduce recurrent stroke but has been proposed for other indications, including migraine, transient ischemic attack, and diving decompression illness. We sought to evaluate PFO closure rates and indications relative to the timing of regulatory approval and publication of key randomized trials. METHODS We performed a retrospective cohort study using the OptumLabs Data Warehouse of US commercial insurance enrollees from 2006 to 2019. We quantified PFO closure among individuals with ≥2 years of preprocedure coverage to establish indications, classified hierarchically as stroke/systemic embolism, migraine, transient ischemia attack, or other. RESULTS We identified 5315 patients undergoing PFO closure (51.8% female, 29.2%≥60 years old), which increased from 4.75 per 100 000 person-years in 2006 to 6.60 per 100 000 person-years in 2019. Patients aged ≥60 years accounted for 29.2% of closures. Procedure volumes corresponded weakly with supportive clinical publications and device approval. Among patients with PFO closure, 58.6% underwent closure for stroke/systemic embolism, 10.2% for transient ischemia attack, 8.8% for migraine, and 22.4% for other indications; 17.6% of patients had atrial fibrillation at baseline; and 11.9% developed atrial fibrillation postprocedure. Those aged ≥60 years and male were less likely to undergo closure for migraine than stroke/systemic embolism. CONCLUSIONS From 2006 to 2019, PFO closure use was consistently low and corresponded weakly with clinical trial publications and regulatory status. Nearly half of patients underwent PFO closure for indications unapproved by the Food and Drug Administration. Regulators and payers should coordinate mechanisms to promote utilization for approved indications to ensure patient safety and should facilitate clinical trials for other possible indications.
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Affiliation(s)
- Andrew M. Goldsweig
- Department of Cardiovascular Medicine, Baystate Medical
Center, Springfield, MA, USA
| | - Yihong Deng
- Kern Center for the Science of Health Care Delivery and
Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Xiaoxi Yao
- Kern Center for the Science of Health Care Delivery and
Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Nihar R. Desai
- Section of Cardiovascular Medicine, Yale University, New
Haven, CT, USA
| | - David J. Cohen
- Cardiovascular Research Foundation, New York, NY, USA, and
St. Francis Hospital and Heart Center, Roslyn, NY, USA
| | - Herbert D. Aronow
- Department of Cardiovascular Medicine, Henry Ford Health
System, Detroit, MI, USA
| | - Steven Messé
- Department of Neurology, Hospital of the University of
Pennsylvania, Philadelphia, PA, USA
| | - Joseph S. Ross
- Section of General Medicine, Department of Internal
Medicine, Yale School of Medicine, and Department of Health Policy and Management,
Yale School of Public Health, New Haven, CT, USA
| | | | - Samuel T. Savitz
- Kern Center for the Science of Health Care Delivery and
Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
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Melillo F, Popusoi G, Frecentese F, Miano V, Santoro A, Tesorio T, Onorato EM. Is Moderate/Large Residual Shunt After PFO Closure Justifiable for a Patient with a Prior History of Cryptogenic Stroke and Transient Ischemic Attack? Int Heart J 2024; 65:146-151. [PMID: 38296568 DOI: 10.1536/ihj.23-375] [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: 02/08/2024]
Abstract
A 36-year-old woman suffered from an embolic stroke of an undetermined source documented by magnetic resonance imaging with residual right arm weakness. She underwent percutaneous patent foramen ovale (PFO) closure with an 18/25 mm device in another center. One year later, the patient suffered from a transient ischemic attack with dysarthria. She asked for a second opinion at our institution and a contrast-transthoracic (cTTE) /transesophageal echocardiography showed a large residual right-to-left shunt (RLS) through a still patent tunnel after PFO closure. Written informed consent for a redo procedure was obtained from the patient. A catheter-based closure of the residual shunt was therefore planned under local anesthesia and rotational intracardiac echo monitoring. A second equally sized disc (18/18 mm) device was successfully implanted without complications. The patient was discharged home the following day in good clinical condition. Dual antiplatelet therapy was recommended for the first 2 months and then single antiplatelet therapy up to 6 months. At the 6-month follow-up, the cTTE color Doppler showed the stable position of the two nitinol double-disc devices and the c-transcranial Doppler confirmed the abolition of the residual RLS.
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Affiliation(s)
| | - Gregory Popusoi
- Invasive Cardiology Unit, Clinica Montevergine di Mercogliano
| | | | | | | | - Tullio Tesorio
- Invasive Cardiology Unit, Clinica Montevergine di Mercogliano
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Thong EHE, Kong WKF, Poh KK, Wong R, Chai P, Sia CH. Multimodal Cardiac Imaging in the Assessment of Patients Who Have Suffered a Cardioembolic Stroke: A Review. J Cardiovasc Dev Dis 2023; 11:13. [PMID: 38248883 PMCID: PMC10816708 DOI: 10.3390/jcdd11010013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 12/21/2023] [Accepted: 12/27/2023] [Indexed: 01/23/2024] Open
Abstract
Cardioembolic strokes account for 20-25% of all ischaemic strokes, with their incidence increasing with age. Cardiac imaging plays a crucial role in identifying cardioembolic causes of stroke, with early and accurate identification affecting treatment, preventing recurrence, and reducing stroke incidence. Echocardiography serves as the mainstay of cardiac evaluation. Transthoracic echocardiography (TTE) is the first line in the basic evaluation of structural heart disorders, valvular disease, vegetations, and intraventricular thrombus. It can be used to measure chamber size and systolic/diastolic function. Trans-oesophageal echocardiography (TOE) yields better results in identifying potential cardioembolic sources of stroke and should be strongly considered, especially if TTE does not yield adequate results. Cardiac computed tomography and cardiac magnetic resonance imaging provide better soft tissue characterisation, high-grade anatomical information, spatial and temporal visualisation, and image reconstruction in multiple planes, especially with contrast. These techniques are useful in cases of inconclusive echocardiograms and can be used to detect and characterise valvular lesions, thrombi, fibrosis, cardiomyopathies, and aortic plaques. Nuclear imaging is not routinely used, but it can be used to assess left-ventricular perfusion, function, and dimensions and may be useful in cases of infective endocarditis. Its use should be considered on a case-by-case basis. The accuracy of each imaging modality depends on the likely source of cardioembolism, and the choice of imaging approach should be tailored to individual patients.
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Affiliation(s)
| | - William K. F. Kong
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore; (W.K.F.K.); (K.-K.P.); (R.W.); (P.C.)
| | - Kian-Keong Poh
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore; (W.K.F.K.); (K.-K.P.); (R.W.); (P.C.)
| | - Raymond Wong
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore; (W.K.F.K.); (K.-K.P.); (R.W.); (P.C.)
| | - Ping Chai
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore; (W.K.F.K.); (K.-K.P.); (R.W.); (P.C.)
| | - Ching-Hui Sia
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore; (W.K.F.K.); (K.-K.P.); (R.W.); (P.C.)
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Kneihsl M, Horner S, Hatab I, Schöngrundner N, Kramer D, Toth-Gayor G, Grangl G, Wünsch G, Fandler-Höfler S, Haidegger M, Berger N, Veeranki S, Fischer U, Enzinger C, Gattringer T. Long-term risk of recurrent cerebrovascular events after patent foramen ovale closure: Results from a real-world stroke cohort. Eur Stroke J 2023; 8:1021-1029. [PMID: 37658692 PMCID: PMC10683717 DOI: 10.1177/23969873231197564] [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: 07/12/2023] [Accepted: 08/11/2023] [Indexed: 09/03/2023] Open
Abstract
INTRODUCTION Patent foramen ovale (PFO)-closure is recommended for stroke prevention in selected patients with suspected PFO-associated stroke. However, studies on cerebrovascular event recurrence after PFO-closure are limited by relatively short follow-up periods and information on the underlying aetiology of recurrent events is scarce. PATIENTS AND METHODS All consecutive patients with a cerebral ischaemic event and PFO-closure at the University Hospital Graz were prospectively identified from 2004 to 2021. Indication for PFO-closure was based on a neurological-cardiological PFO board decision. Patients underwent standardized clinical and echocardiographic follow-up 6 months after PFO-closure. Recurrent cerebrovascular events were assessed via electronical health records. RESULTS PFO-closure was performed in 515 patients (median age: 49 years; Amplatzer PFO occluder: 42%). Over a median follow-up of 11 years (range: 2-18 years, 5141 total patient-years), recurrent ischaemic cerebrovascular events were observed in 34 patients (ischaemic stroke: n = 22, TIA: n = 12) and associated with age, hyperlipidaemia and smoking in multivariable analysis (p < 0.05 each). Large artery atherosclerosis and small vessel disease were the most frequent aetiologies of recurrent stroke/TIA (27% and 24% respectively), and only two events were related to atrial fibrillation (AF). Recurrent ischaemic cerebrovascular event rates and incident AF were comparable in patients treated with different PFO occluders (p > 0.1). DISCUSSION AND CONCLUSION In this long-term follow-up-study of patients with a cerebral ischaemic event who had received PFO-closure with different devices, rates of recurrent stroke/TIA were low and largely related to large artery atherosclerosis and small vessel disease. Thorough vascular risk factor control seems crucial for secondary stroke prevention in patients treated for PFO-related stroke.
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Affiliation(s)
- Markus Kneihsl
- Department of Neurology, Medical University of Graz, Graz, Austria
- Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | - Susanna Horner
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - Isra Hatab
- Department of Neurology, Medical University of Graz, Graz, Austria
| | | | - Diether Kramer
- Department of Information and Process Management, Steiermärkische Krankenanstaltengesellschaft m.b.H. (KAGes), Graz, Austria
| | - Gabor Toth-Gayor
- Division of Cardiology, Department of Internal Medicine, Medical University Graz, Graz, Austria
| | - Gernot Grangl
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University Graz, Graz, Austria
| | - Gerit Wünsch
- Institute of Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | | | | | - Natalie Berger
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - Sai Veeranki
- Department of Information and Process Management, Steiermärkische Krankenanstaltengesellschaft m.b.H. (KAGes), Graz, Austria
| | - Urs Fischer
- Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Thomas Gattringer
- Department of Neurology, Medical University of Graz, Graz, Austria
- Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
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Jin P, Jiao P, Feng J, Shi L, Ma L. The predictive value of abnormal electrocardiogram for patent foramen ovale: A retrospective study. Clin Cardiol 2023; 46:1504-1510. [PMID: 37667505 PMCID: PMC10716327 DOI: 10.1002/clc.24133] [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: 06/20/2023] [Revised: 08/10/2023] [Accepted: 08/15/2023] [Indexed: 09/06/2023] Open
Abstract
BACKGROUND AND HYPOTHESIS The objective of this study was to identify the characteristics of electrocardiogram (ECG) in adult patients with patent foramen ovale (PFO) and to analyze the predictive value of the characteristics of ECG for PFO in adult patients. METHODS Retrospectively, 267 patients who had undergone ECG, transthoracic echocardiography (TTE), transesophageal echocardiography (TEE) with agitated saline contrast echocardiography in our hospital, were recruited continuously from January 2021 to March 2023. Electrocardiographs were analyzed to investigate the presence of right bundle branch block (RBBB) and crochetage R wave. RESULTS The ratio of crochetage R wave in inferior leads in patients with PFO was 45.3% and 21.2% without PFO. There were 17 (6.4%) patients with coexistence of crochetage R wave and RBBB, including 13 (6.5%) patients with PFO and four (6.1%) patients without PFO. The accuracies of TTE, crochetage R wave, and RBBB were 0.637, 0.535, and 0.314, respectively. A combination of crochetage R wave and RBBB demonstrated a sensitivity of 0.507 and a specificity of 0.758. When TTE, crochetage R wave, and RBBB were combined, the accuracy, sensitivity, specificity, positive predictive value, and negative predictive value were 0.712, 0.801, 0.439, 0.813, and 0.420, respectively. Logistic regression analysis revealed a correlation between PFO and the presence of crochetage R wave (odds ratio [OR]: 3.073, 95% confidence interval [CI]: 1.601-5.899, p < 0.001), and also a combination between crochetage R wave and RBBB (OR: 3.220, 95% CI: 1.720-6.028, p < 0.001). CONCLUSIONS Crochetage R wave in ECG was associated with PFO. Crochetage R wave, especially combined with RBBB and TTE, may be helpful in the early detection of patients with PFO.
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Affiliation(s)
- Peng Jin
- Department of Cardiovascular Medicinethe 940th Hospital of the Joint Logistics Support Force of the Chinese People's Liberation ArmyLanzhouChina
| | - Piqi Jiao
- Department of Cardiovascular Medicinethe 940th Hospital of the Joint Logistics Support Force of the Chinese People's Liberation ArmyLanzhouChina
| | - Juan Feng
- Department of Cardiovascular Medicinethe 940th Hospital of the Joint Logistics Support Force of the Chinese People's Liberation ArmyLanzhouChina
| | - Liang Shi
- Department of Cardiovascular Medicinethe 940th Hospital of the Joint Logistics Support Force of the Chinese People's Liberation ArmyLanzhouChina
| | - Ling Ma
- Department of Cardiovascular Medicinethe 940th Hospital of the Joint Logistics Support Force of the Chinese People's Liberation ArmyLanzhouChina
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Zhang L, Zhang H, Zhou X, Zhao J, Wang X. Bibliometric Analysis of Research on Migraine-Stroke Association from 2013 to 2023. J Pain Res 2023; 16:4089-4112. [PMID: 38058980 PMCID: PMC10697147 DOI: 10.2147/jpr.s438745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 11/22/2023] [Indexed: 12/08/2023] Open
Abstract
Background Both migraine and stroke heavily burden individuals, health systems, and society. The migraine-stroke association is of concern and has been studied widely. Our objective is to explore and overview the current research status and emerging trends. Materials and Methods Studies on migraine-stroke association from January 2013 to May 2023 were retrieved and screened from the Web of Science Core Collection (WOSCC) database. Records fulfilling the selection criteria were downloaded and imported into CiteSpace for data mining and visualization. Results A total of 862 papers on migraine-stroke association were included. Annual publications grew slowly. The United States and European countries dominated research in this area. Harvard University published the largest number of articles, while the University of London was most active with other institutions. Ayata Cenk contributed the most articles, while KURTH T and NEUROLOGY were co-cited most. Research hotspots included migraine with aura, ischemic stroke, patent foramen ovale, cortical spreading depolarization, meta-analysis, cross-sectional study, and risk factors. Pathophysiology and small vessel disease represented research frontiers and emerging trends. Conclusion Our study scientifically outlines the migraine-stroke association over the past decade, presenting useful information.
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Affiliation(s)
- Long Zhang
- First Clinical Medical College, Shandong University of Traditional Chinese Medicine, Jinan, Shandong, People’s Republic of China
- Department of Traditional Chinese Medicine, Zibo TCM-Integrated Hospital, Zibo, Shandong, People’s Republic of China
| | - Hongyan Zhang
- Department of Traditional Chinese Medicine, Shanghai Sixth People’s Hospital, Shanghai, People’s Republic of China
- Shaanxi Key Laboratory of Research on TCM Physical Constitution and Diseases Prevention and Treatment, Shaanxi University of Chinese Medicine, Xianyang, Shaanxi, People’s Republic of China
| | - Xue Zhou
- First Clinical Medical College, Shandong University of Traditional Chinese Medicine, Jinan, Shandong, People’s Republic of China
| | - Jing Zhao
- Experimental Center, Shandong University of Traditional Chinese Medicine, Jinan, Shandong, People’s Republic of China
| | - Xingchen Wang
- Division of Neurology, the Second Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, Shandong, People’s Republic of China
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Honasoge AP, Suradi HS, Tobis JM, Kavinsky CJ. Patent Foramen Ovale Closure for Nonstroke Indications. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:101135. [PMID: 39129903 PMCID: PMC11307832 DOI: 10.1016/j.jscai.2023.101135] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 08/08/2023] [Accepted: 08/21/2023] [Indexed: 08/13/2024]
Abstract
The patent foramen ovale (PFO) is a flap or tunnel-like communication in the atrial septum present in 20% to 34% of the adult population. In most cases, it is a benign finding and poses no health risk. However, some PFOs may provide a conduit for bloodborne materials, such as thrombi, vasoactive substances, or air to pass into the systemic circulation causing a paradoxical embolus. PFOs have been linked with several clinical disease states including cryptogenic stroke, migraine headache, platypnea-orthodeoxia, and decompression illness. Percutaneous PFO closure provides a practical solution to the problem of PFO in carefully selected populations. Recent randomized control trials have demonstrated that PFO closure in patients with cryptogenic stroke is associated with reduced rates of recurrent stroke compared with medical therapy. This translated into a dramatic increase in the number of PFO closure procedures worldwide, primarily for the indication of cryptogenic stroke, with high procedural success and low complication rates. However, there are no randomized clinical trials available to support PFO closure in other clinical conditions. This article reviews potential indications, existing data, and management approaches for PFO closure in disorders other than cryptogenic stroke.
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Affiliation(s)
- Akilesh P. Honasoge
- Division of Cardiology, Department of Medicine, Rush University Medical Center, Chicago, Illinois
| | - Hussam S. Suradi
- Division of Cardiology, Department of Medicine, Rush University Medical Center, Chicago, Illinois
| | | | - Clifford J. Kavinsky
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Do AP, Nguyen HM, Thi Thu Nguyen H, Ta CM, Bui STT, Pham HM. Recurrent paradoxical cerebral embolism caused by a thrombus entrapped in a patent foramen ovale: a case report. Ann Med Surg (Lond) 2023; 85:5765-5769. [PMID: 37915658 PMCID: PMC10617831 DOI: 10.1097/ms9.0000000000001343] [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: 07/17/2023] [Accepted: 09/12/2023] [Indexed: 11/03/2023] Open
Abstract
Introduction A thrombus straddling the patent foramen ovale (PFO) is a very rare clinical entity. Optimal management remains unclear due to the availability of various therapeutic options; thus, an individualized approach is recommended. Case presentation The authors describe a case presenting with recurrent cerebral embolism and a large and mobile thrombus straddled in the PFO. Historically, cardiac surgery, thrombolysis or anticoagulation were possible management options for this patient. However, there are no guidelines on what the optimal treatment is. Our patient was a poor surgical candidate because of advanced age and multiple comorbidities. Furthermore, she had a recent ischaemic stroke which was a relative contraindication to thrombolysis. After consulting the Heart Team, medical treatment alone with systemic anticoagulation was administered. Subsequent transthoracic echocardiography (TTE) after 1 week showed complete thrombus resolution. After 4 months, the PFO was successfully occluded with an Amplatzer device. The patient received rehabilitation therapy and had good functional recovery. Clinical discussion Anticoagulant therapy alone was chosen because of high risk for surgery. Complete thrombus resolution was achieved after 1 week although the initial thrombus size was quite large. Nevertheless, this approach may not be applicable to every patient. In addition to TTE, multimodality imaging using transesophageal echocardiography and cardiac magnetic resonance is helpful to identify the mechanism of stroke, which in our case is a thrombus-straddled PFO, and to make early treatment decisions. Serial TTEs help assess the response to anticoagulation. An individualized approach should be made with a multidisciplinary Heart Team. Conclusion Echocardiography plays an important role in the diagnosis and treatment evaluation for patients with a thrombus straddling a PFO. An individualized approach to manage the patient should be made with a multidisciplinary Heart Team.
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Affiliation(s)
| | | | - Hoai Thi Thu Nguyen
- Vietnam Heart Institute, Bach Mai Hospital
- Department of Internal Medicine, VNU—University of Medicine and Pharmacy
| | | | | | - Hung Manh Pham
- Vietnam Heart Institute, Bach Mai Hospital
- Department of Internal Medicine, Hanoi Medical University, Hanoi, Vietnam
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Farjat‐Pasos JI, Guedeney P, Houde C, Alperi A, Robichaud M, Côté M, Montalescot G, Rodés‐Cabau J. Sex Differences in Patients With Cryptogenic Cerebrovascular Events Undergoing Transcatheter Closure of Patent Foramen Ovale. J Am Heart Assoc 2023; 12:e030359. [PMID: 37776218 PMCID: PMC10727268 DOI: 10.1161/jaha.123.030359] [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: 05/16/2023] [Accepted: 07/18/2023] [Indexed: 10/02/2023]
Abstract
Background Scarce data exist on sex differences in patients with cryptogenic cerebrovascular events undergoing patent foramen ovale (PFO) closure. This study aimed to determine the sex differences in clinical profile, procedural characteristics, and long-term outcomes of patients with cryptogenic cerebrovascular events undergoing PFO closure. Methods and Results A retrospective cohort was used, including 1076 consecutive patients undergoing PFO closure because of a cryptogenic cerebrovascular event. Patients were divided into 2 groups: 469 (43.6%) women and 607 (56.4%) men. The median follow-up was 3 years (interquartile range, 2-8 years). Women were younger (46±13 versus 50±12 years; P<0.01) and had a higher risk of paradoxical embolism score (6.9±1.7 versus 6.6±1.6; P<0.01). Procedural characteristics and postprocedural antithrombotic therapy were similar. At follow-up, there were no differences in atrial fibrillation (women versus men: 0.47 versus 0.97 per 100 patient-years; incidence rate ratio [IRR], 0.55 [95% CI, 0.27-1.11]; P=0.095; adjusted P=0.901), stroke (0.17 versus 0.07 per 100 patient-years; IRR, 2.58 [95% CI, 0.47-14.1]; P=0.274; adjusted P=0.201), or transient ischemic attack (0.43 versus 0.18 per 100 patient-years; IRR, 2.58 [95% CI, 0.88-7.54]; P=0.084; adjusted P=0.121); nevertheless, women exhibited a higher incidence of combined ischemic cerebrovascular events (0.61 versus 0.26 per 100 patient-years; IRR, 2.58 [95% CI, 1.04-6.39]; P=0.041; adjusted P=0.028) and bleeding events (1.04 versus 0.45 per 100 patient-years; IRR, 2.82 [95% CI, 1.41-5.65]; P=0.003; adjusted P=0.004). Conclusions Compared with men, women with cryptogenic cerebrovascular events undergoing PFO closure were younger and had a higher risk of paradoxical embolism score. After a median follow-up of 3 years, there were no differences in stroke events, but women exhibited a higher rate of combined (stroke and transient ischemic attack) cerebrovascular events and bleeding complications. Additional studies are warranted to clarify sex-related outcomes after PFO closure further.
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Affiliation(s)
| | - Paul Guedeney
- Sorbonne Université, ACTION Study Group, INSERM UMRS_1166 Institut de Cardiologie (AP‐HP)ParisFrance
| | - Christine Houde
- Centre Hospitalier Universitaire de QuebecLaval UniversityQuebec CityQuebecCanada
| | - Alberto Alperi
- Quebec Heart and Lung Institute, Laval UniversityQuebec CityQuebecCanada
| | - Mathieu Robichaud
- Quebec Heart and Lung Institute, Laval UniversityQuebec CityQuebecCanada
| | - Mélanie Côté
- Quebec Heart and Lung Institute, Laval UniversityQuebec CityQuebecCanada
| | - Gilles Montalescot
- Sorbonne Université, ACTION Study Group, INSERM UMRS_1166 Institut de Cardiologie (AP‐HP)ParisFrance
| | - Josep Rodés‐Cabau
- Quebec Heart and Lung Institute, Laval UniversityQuebec CityQuebecCanada
- Centre Hospitalier Universitaire de QuebecLaval UniversityQuebec CityQuebecCanada
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Skibsted CV, Korsholm K, Pedersen L, Bonnesen K, Nielsen-Kudsk JE, Schmidt M. Long-term risk of atrial fibrillation or flutter after transcatheter patent foramen ovale closure: a nationwide Danish study. Eur Heart J 2023; 44:3469-3477. [PMID: 37279491 DOI: 10.1093/eurheartj/ehad305] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 04/20/2023] [Accepted: 05/08/2023] [Indexed: 06/08/2023] Open
Abstract
AIMS Transcatheter closure of patent foramen ovale (PFO) is the recommended stroke prevention treatment in patients ≤60 years with cryptogenic ischemic stroke and PFO. Atrial fibrillation or flutter (AF) is a known potential procedure-related complication, but long-term risk of developing AF remains unknown. This paper studied the long-term risk of developing AF following PFO closure. METHODS AND RESULTS A Danish nationwide cohort study was conducted. During 2008-2020, this study identified a PFO closure cohort, a PFO diagnosis cohort without PFO closure, and a general population comparison cohort matched 10:1 to the PFO closure cohort on age and sex. The outcome was first-time AF diagnosis. Risk of AF and multivariable-adjusted hazard ratio (HR) of the association between PFO closure or PFO diagnosis and AF were calculated. A total of 817 patients with PFO closure, 1224 with PFO diagnosis, and 8170 matched individuals were identified. The 5 year risk of AF was 7.8% [95% confidence interval (CI): 5.5-10] in the PFO closure cohort, 3.1% (95% CI: 2.0-4.2) in the PFO diagnosis cohort, and 1.2% (95% CI: 0.8-1.6) in the matched cohort. The HR of AF comparing PFO closure with PFO diagnosis was 2.3 (95% CI: 1.3-4.0) within the first 3 months and 0.7 (95% CI: 0.3-1.7) thereafter. The HR of AF comparing PFO closure with the matched cohort was 51 (95% CI: 21-125) within the first 3 months and 2.5 (95% CI: 1.2-5.0) thereafter. CONCLUSION Patent foramen ovale closure was not associated with any substantial increased long-term risk of developing AF beyond the well-known procedure-related short-term risk.
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Affiliation(s)
- Christian Valdemar Skibsted
- Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Allé 43-45, 8200 Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus University Hospital A1001, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Kasper Korsholm
- Department of Clinical Medicine, Aarhus University, Aarhus University Hospital A1001, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Lars Pedersen
- Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Allé 43-45, 8200 Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus University Hospital A1001, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Kasper Bonnesen
- Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Allé 43-45, 8200 Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus University Hospital A1001, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Jens Erik Nielsen-Kudsk
- Department of Clinical Medicine, Aarhus University, Aarhus University Hospital A1001, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Morten Schmidt
- Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Allé 43-45, 8200 Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus University Hospital A1001, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
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Tumminello G, Barbieri L, Avallone C, Bellissimo N, Mircoli L, Colombo F, Vicenzi M, Ruscica M, Carugo S. The "Woggle" Technique for Venous Access Site Management: An Old Technique for a New Need. J Clin Med 2023; 12:6087. [PMID: 37763027 PMCID: PMC10532262 DOI: 10.3390/jcm12186087] [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: 08/16/2023] [Revised: 09/12/2023] [Accepted: 09/18/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Several closure devices are routinely used for percutaneous arterial access, while a relatively low number is available for the management of large bore venous accesses. The Woggle technique is a modification of the purse-string suture which was introduced several years ago in patients undergoing hemodialysis. METHODS A population of 45 patients who underwent transvenous femoral structural heart interventions was retrospectively evaluated. The Woggle technique consists of a purge string suture with a collar to maintain the tension as stable over time and a suture lock to tighten the suture. RESULTS Sheaths magnitude ranged from 8 French (F) to 14 F. A rapid post-procedural hemostasis was achieved in the whole population, and in 95% of cases, definite hemostasis was obtained after the first single release; the mean time of release was 302 ± 83 min. Although no relevant bleedings were reported, a significant reduction in hemoglobin levels was found in the whole population. This decrement was statistically significant only in the group with sheaths higher than 12 F. A single mild local hematoma was recorded in the group in which smaller sheaths were used. Seventy-two percent of patients were pre-treated with a dual antiplatelet therapy. CONCLUSIONS The Woggle technique has shown to be a simple, effective, and safe approach for the management of large bore venous in percutaneous structural heart interventions.
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Affiliation(s)
- Gabriele Tumminello
- Department of Cardio-Thoracic-Vascular Diseases, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20154 Milan, Italy; (L.B.); (L.M.); (F.C.); (M.V.); (M.R.); (S.C.)
| | - Lucia Barbieri
- Department of Cardio-Thoracic-Vascular Diseases, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20154 Milan, Italy; (L.B.); (L.M.); (F.C.); (M.V.); (M.R.); (S.C.)
| | - Carlo Avallone
- Dyspnea Lab, Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy; (C.A.); (N.B.)
| | - Nello Bellissimo
- Dyspnea Lab, Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy; (C.A.); (N.B.)
| | - Luca Mircoli
- Department of Cardio-Thoracic-Vascular Diseases, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20154 Milan, Italy; (L.B.); (L.M.); (F.C.); (M.V.); (M.R.); (S.C.)
| | - Federico Colombo
- Department of Cardio-Thoracic-Vascular Diseases, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20154 Milan, Italy; (L.B.); (L.M.); (F.C.); (M.V.); (M.R.); (S.C.)
| | - Marco Vicenzi
- Department of Cardio-Thoracic-Vascular Diseases, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20154 Milan, Italy; (L.B.); (L.M.); (F.C.); (M.V.); (M.R.); (S.C.)
- Dyspnea Lab, Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy; (C.A.); (N.B.)
| | - Massimiliano Ruscica
- Department of Cardio-Thoracic-Vascular Diseases, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20154 Milan, Italy; (L.B.); (L.M.); (F.C.); (M.V.); (M.R.); (S.C.)
- Department of Pharmacological and Biomolecular Sciences “Rodolfo Paoletti”, Università degli Studi di Milano, 20133 Milan, Italy
| | - Stefano Carugo
- Department of Cardio-Thoracic-Vascular Diseases, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20154 Milan, Italy; (L.B.); (L.M.); (F.C.); (M.V.); (M.R.); (S.C.)
- Dyspnea Lab, Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy; (C.A.); (N.B.)
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Verolino G, Calderone D, Gavazzoni M, Sala D, Sganzerla P. Clinical Performance of the Gore Septal Occluder in Patent Foramen Ovale Closure in Different Septal Anatomies: 1-Year Results from a Single-Center Experience. J Clin Med 2023; 12:5936. [PMID: 37762877 PMCID: PMC10531839 DOI: 10.3390/jcm12185936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 08/21/2023] [Accepted: 09/06/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND PFO (Patent foramen ovale) is a common defect that affects about 25% of the population. Although its presence is asymptomatic in the majority of the cases, the remaining part becomes overt with different symptoms, including cryptogenic stroke. PFO closure is currently a widely available procedure in complex anatomy, with Amplatzer PFO Occluder (APO) being the most commonly used tool. However, the performance of another device, the GORE Septal Occluder (GSO), has not been completely explored with regard to different septal anatomies. METHODS From March 2012 to June 2020, 118 consecutive patients with an indication of PFO closure were treated using the GSO system, included in a prospective analysis, and followed. After 12 months, every patient underwent transcranial Doppler ultrasound to evaluate the effectiveness of treatment. RESULTS Of 111 patients evaluated, 107 showed effective PFO closure (96.4%), and 4 showed a residual shunt (3.6%). To better evaluate the device performance, the overall population was sorted into two clusters based on the echocardiographic characteristics. The main difference between groups was for PFO width (4.85 ± 1.8 vs. 2.9 ± 1 mm, p < 0.001) and PFO tunnel length (12.6 ± 3.8 vs. 7.2 ± 2, p < 0.001), allowing complex and simple anatomies to be identified, respectively. Regardless of the aforementioned cluster, the GSO performance required to reach an effective closure was independent of anatomy type and the chosen device size. CONCLUSION The GSO device showed a high closure rate at 1-year follow-up in patients, with at least one anatomical factor of complexity of PFO irrespective of the level of complexity itself.
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Affiliation(s)
- Giuseppe Verolino
- Invasive Cardiology, Department of Cardiology, San Luca Hospital, IRCCS Istituto Auxologico Italiano, 20149 Milan, Italy; (G.V.); (P.S.)
| | - Dario Calderone
- Invasive Cardiology, Department of Cardiology, San Luca Hospital, IRCCS Istituto Auxologico Italiano, 20149 Milan, Italy; (G.V.); (P.S.)
| | - Mara Gavazzoni
- Cardiology Unit, San Luca Hospital, IRCCS Istituto Auxologico Italiano, 20149 Milan, Italy
| | - Davide Sala
- Invasive Cardiology, Department of Cardiology, San Luca Hospital, IRCCS Istituto Auxologico Italiano, 20149 Milan, Italy; (G.V.); (P.S.)
| | - Paolo Sganzerla
- Invasive Cardiology, Department of Cardiology, San Luca Hospital, IRCCS Istituto Auxologico Italiano, 20149 Milan, Italy; (G.V.); (P.S.)
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