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Patent Foramen Ovale and Cryptogenic Stroke: Integrated Management. J Clin Med 2023; 12:jcm12051952. [PMID: 36902748 PMCID: PMC10004032 DOI: 10.3390/jcm12051952] [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: 12/31/2022] [Revised: 02/13/2023] [Accepted: 02/27/2023] [Indexed: 03/06/2023] Open
Abstract
Patent foramen ovale (PFO) is a common cardiac abnormality with a prevalence of 25% in the general population. PFO has been associated with the paradoxical embolism causing cryptogenic stroke and systemic embolization. Results from clinical trials, meta-analyses, and position papers support percutaneous PFO device closure (PPFOC), especially if interatrial septal aneurysms coexist and in the presence of large shunts in young patients. Remarkably, accurately evaluating patients to refer to the closure strategy is extremely important. However, the selection of patients for PFO closure is still not so clear. The aim of this review is to update and clarify which patients should be considered for closure treatment.
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Comparison of Intracardiac Echocardiography and Transesophageal Echocardiography for Image Guidance in Percutaneous Patent Foramen Ovale Closure. MEDICINA-LITHUANIA 2020; 56:medicina56080401. [PMID: 32784843 PMCID: PMC7466370 DOI: 10.3390/medicina56080401] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 07/28/2020] [Accepted: 08/05/2020] [Indexed: 11/17/2022]
Abstract
Background and Objectives: Transesophageal echocardiography (TEE) guidance is the current gold standard for catheter-based procedures in the treatment of structural heart diseases. Intracardiac echocardiography (ICE), which can be performed under local anesthesia, has been recently introduced and is becoming more widely used. We aimed to compare the efficacy and safety of ICE and TEE in patent foramen ovale (PFO) device closure. Materials and Methods: All 74 patients with a history of cryptogenic stroke undergoing PFO closure for secondary prophylaxis were selected from our registry. Intraprocedural TEE was performed by echocardiographer-cardiologists with the patient under general anesthesia. Conversely, ICE was performed with the patient under local anesthesia. Baseline characteristics, procedural details, and immediate outcomes were compared between the TEE and ICE groups (n = 49 and n = 25, respectively). Results: Although patients in the ICE group were older (47 ± 10 vs. 57 ± 7 years, p < 0.001), sex and comorbidity variables were similar between the two groups. The degree of inducible right-to-left shunt via the PFO, assessed using preprocedural TEE, was also comparable. Notably, fluoroscopy time (22 ± 18 vs. 16 ± 7 min, p = 0.030), radiation dose (498 ± 880 vs. 196 ± 111 mGy, p = 0.022), and total procedural time in the catheter laboratory (99 ± 30 vs. 67 ± 12 min, p < 0.001) were significantly lower in the ICE group than those in the TEE group. The entire hospital stay was similar between groups (3.8 ± 2.2 vs. 3.4 ± 1.3 days, p = 0.433). No procedural complications, such as device embolization, pericardial hemorrhage, major bleeding, mortality, or access-related vascular injury were reported in either group. Conclusions: ICE-guided PFO device closure is quicker and less hazardous in terms of radiation exposure than the TEE-guided procedure, with similar procedural outcomes and duration of hospital stay.
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Appropriate selection of echocardiographic guidance for transcatheter atrial septal defect closure. Int J Cardiovasc Imaging 2020; 36:855-863. [DOI: 10.1007/s10554-020-01778-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 01/24/2020] [Indexed: 01/26/2023]
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Kumar P, Rusheen J, Tobis JM. A comparison of methods to determine patent foramen ovale size. Catheter Cardiovasc Interv 2019; 96:E621-E629. [DOI: 10.1002/ccd.28665] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 12/07/2019] [Indexed: 11/10/2022]
Affiliation(s)
- Preetham Kumar
- Division of Cardiology, Department of Medicine University of California Los Angeles California
| | - Joshua Rusheen
- Division of Cardiology, Department of Medicine University of California Los Angeles California
| | - Jonathan M. Tobis
- Division of Cardiology, Department of Medicine University of California Los Angeles California
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VanLoozen D, Amin Z, Javaheri S, Agarwal S. Percutaneous Closure of a Complex Intradevice Residual Patent Foramen Ovale Under Transesophageal Echocardiographic Guidance. A A Pract 2019; 12:340-343. [PMID: 31048601 DOI: 10.1213/xaa.0000000000000971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Dennis VanLoozen
- From the Division of Pediatric Cardiology, Children's Hospital of Georgia, Augusta University, Augusta, Georgia
| | - Zahid Amin
- From the Division of Pediatric Cardiology, Children's Hospital of Georgia, Augusta University, Augusta, Georgia
| | | | - Shvetank Agarwal
- Anesthesiology and Perioperative Medicine, Augusta University, Augusta, Georgia
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Kjeld T, Jørgensen TS, Fornitz G, Roland J, Arendrup HC. Patent foramen ovale and atrial fibrillation as causes of cryptogenic stroke: is treatment with surgery superior to device closure and anticoagulation? A review of the literature. Acta Radiol Open 2018; 7:2058460118793922. [PMID: 30159163 PMCID: PMC6109859 DOI: 10.1177/2058460118793922] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 07/03/2018] [Indexed: 11/30/2022] Open
Abstract
Closure of persistent foramen ovale (PFO) to avoid cryptogenic strokes is performed globally with enthusiasm but lacks prove of efficacy. We present a 79-year-old man who had had a PFO device introduced nine years previously because of cryptogenic strokes presenting as syncopes. The patient was referred from his general practitioner with two new syncopes. Transthoracic echocardiography revealed no cardiac causes of embolism. Transesophageal echocardiography (TEE) revealed a misplaced device like an umbrella in a storm, but no septum defects. Holter revealed seconds-long episodes of atrial fibrillation (AF). The patient was successfully treated with anticoagulation. A literature review showed that: (i) the efficacy of PFO closure devices has not been proven in any trial, but was demonstrated in a meta-analysis comparing three different devices; (ii) PFO devices are rarely controlled by TEE during or after insertion; (iii) residual shunts are detected in up to 45% of cases; (iv) there is an increased rate of post-arrhythmic complications; (v) the risk of AF in congenital heart disease increases with increasing age, with a 13% risk of transient ischemic attacks and stroke; and (vi) surgical treatment of PFO was found to have a 4.1% risk of complications including stroke. The question to be asked is whether device closure of PFO should be avoided, considering that PFO is a congenital heart defect with risks of AF and (cryptogenic) stroke? Heart surgery should be a treatment option for symptomatic PFO.
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Affiliation(s)
- Thomas Kjeld
- 1Department of Cardiothoracic Surgery, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Tem S Jørgensen
- 2Department of Cardiology, University of Copenhagen, Amager Hospital, Copenhagen, Denmark
| | - Gitte Fornitz
- Department of Cardiology, University of Zealand, Slagelse Hospital, Slagelse, Denmark
| | - Jan Roland
- Department of Cardiology, University of Zealand, Slagelse Hospital, Slagelse, Denmark
| | - Henrik C Arendrup
- 1Department of Cardiothoracic Surgery, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
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Scacciatella P, Meynet I, Giorgi M, Biava LM, Matranga I, Biasco L, Omedè P, Orzan F, Gaita F. Angiography vs transesophageal echocardiography-guided patent foramen ovale closure: A propensity score matched analysis of a two-center registry. Echocardiography 2018; 35:834-840. [PMID: 29457261 DOI: 10.1111/echo.13842] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES The purpose of this study is to compare the long-term outcomes of patent foramen ovale (PFO) closure using angiography or transesophageal echocardiography as procedural guidance. BACKGROUND The interventional treatment is emerging as a safe and efficient option for patients with high likelihood of PFO-related cryptogenic stroke and high risk of recurrence. The "gold-standard" guidance technique remains an issue. METHODS Two cohorts of patients undergoing PFO closure for cryptogenic stroke in two catheterization laboratories of the same institution, using similar inclusion criteria but different guidance, were compared with propensity score matching. RESULTS A total of 374 patients were enrolled, 161 in Angio-group and 213 in Echo-group. No difference was detected in the procedural complication rate. In Angio-group, radiological exposure (P = .001) and 6-month residual shunt (16.8% vs 8.0%, P = .015) were higher. After a mean follow-up of 41 ± 30 months, 28 patients (7.5%) presented any adverse event (death, recurrent cerebral ischemia, device-related complications, reintervention), with a higher rate in Angio-group (13.0% vs 3.3%, P = .001), mainly due to repeated percutaneous intervention (10.6% vs 1.4%, P = .001). The results were confirmed after propensity score matching (118 patients/group). The rate of recurrent cerebral ischemia was 1.9% and was not significantly different in the two groups. Intra-procedural guidance and atrial septum aneurysm were independent predictors of the composite primary endpoint (OR 1.2, P = .016). CONCLUSIONS The use of intra-procedural transesophageal echocardiography (TEE) guidance for PFO closure allows lower residual shunt rate, radiological exposure, and adverse events, mainly driven by a significant reduction in percutaneous reintervention.
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Affiliation(s)
- Paolo Scacciatella
- Cardiovascular and Thoracic Department, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Ilaria Meynet
- Cardiovascular and Thoracic Department, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Mauro Giorgi
- Cardiovascular and Thoracic Department, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Lorenza M Biava
- Cardiovascular and Thoracic Department, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Ivana Matranga
- Cardiovascular and Thoracic Department, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Luigi Biasco
- Cardiovascular and Thoracic Department, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Pierluigi Omedè
- Cardiovascular and Thoracic Department, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Fulvio Orzan
- Cardiovascular and Thoracic Department, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Fiorenzo Gaita
- Cardiovascular and Thoracic Department, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
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Davies A, Ekmejian A, Collins N, Bhagwandeen R. Multidisciplinary Assessment in Optimising Results of Percutaneous Patent Foramen Ovale Closure. Heart Lung Circ 2016; 26:246-250. [PMID: 27555053 DOI: 10.1016/j.hlc.2016.06.1211] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2016] [Revised: 06/14/2016] [Accepted: 06/16/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Percutaneous patent foramen ovale (PFO) closure is a therapeutic option to prevent recurrent cerebral ischaemia in patients with cryptogenic stroke and transient cerebral ischaemia (TIA). The apparent lack of benefit seen in previous randomised trials has, in part, reflected inclusion of patients with alternate mechanisms of stroke. The role of formal neurology involvement in accurately delineating the likely aetiology of stroke or TIA is crucial in appropriate identification of patients for device closure. Furthermore, as the benefits of device closure may accrue over time, long-term follow-up is essential to define the role of device closure in management of presumed cryptogenic stroke. METHODS We retrospectively reviewed our experience with percutaneous PFO device closure since 2005. All subjects who underwent PFO closure at John Hunter and Lake Macquarie Private Hospitals were included in the study. All patients referred for device closure following cryptogenic stroke or TIA had first undergone formal neurology review with appropriate imaging and exclusion of paroxysmal atrial arrhythmia. Patients with a history of transient ischaemic attack (TIA) are frequently referred to a specialised clinic, aimed to identify patients with conditions not referable to cerebral ischaemia, with investigations initiated by the specialist clinic to elucidate an underlying aetiology. Outcome data was derived from the Hunter New England Area Local Health District Cardiac and Stroke Outcomes Unit, in addition to review of the medical record. The Cardiac and Stroke Outcomes Unit prospectively identified all patients presenting with stroke, TIA and atrial fibrillation. RESULTS One hundred and twelve consecutive patients undergoing percutaneous patent foramen ovale closure between 2005 and 2015 were identified. The average age was 42.7 years and 57 (50.9%) patients were male. Cryptogenic stroke (68.8%) and transient cerebral ischaemia (23.2%) were the most common indications for PFO closure, with the Amplatzer device used in 83 cases (74.1%). Early residual shunting was visible in seven patients (6.3%), however on follow-up agitated saline study only two patients had residual shunt (1.8%). The annual risk of recurrent stroke or TIA was 0.21%. CONCLUSIONS Percutaneous patent foramen ovale closure can be performed safely and effectively in patients with paradoxical embolism. In selected patients, following appropriate multidisciplinary specialist pre-procedural assessment, excellent long-term results with low incidence of recurrent events may be achieved.
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Affiliation(s)
- Allan Davies
- Department of Cardiovascular Medicine, John Hunter Hospital, Newcastle, NSW, Australia.
| | - Avedis Ekmejian
- Department of Medicine, John Hunter Hospital, Newcastle, NSW, Australia
| | - Nicholas Collins
- Department of Cardiovascular Medicine, John Hunter Hospital, Newcastle, NSW, Australia
| | - Rohan Bhagwandeen
- Department of Cardiovascular Medicine, John Hunter Hospital, Newcastle, NSW, Australia
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Silvestry FE, Cohen MS, Armsby LB, Burkule NJ, Fleishman CE, Hijazi ZM, Lang RM, Rome JJ, Wang Y. Guidelines for the Echocardiographic Assessment of Atrial Septal Defect and Patent Foramen Ovale: From the American Society of Echocardiography and Society for Cardiac Angiography and Interventions. J Am Soc Echocardiogr 2016; 28:910-58. [PMID: 26239900 DOI: 10.1016/j.echo.2015.05.015] [Citation(s) in RCA: 298] [Impact Index Per Article: 37.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Frank E Silvestry
- Hospital of the University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Meryl S Cohen
- Children's Hospital of Philadelphia, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Laurie B Armsby
- Doernbecher Children's Hospital, Oregon Health and Sciences University, Portland, Oregon
| | | | - Craig E Fleishman
- Arnold Palmer Hospital for Children, University of Central Florida College of Medicine, Orlando, Florida
| | | | - Roberto M Lang
- University of Chicago Hospital, University of Chicago School of Medicine, Chicago, Illinois
| | - Jonathan J Rome
- Children's Hospital of Philadelphia, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Yan Wang
- Children's Hospital of Philadelphia, Perelman School of Medicine, Philadelphia, Pennsylvania
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Marchese N, Pacilli MA, Inchingolo V, Fanelli R, Loperfido F, Vigna C. Residual shunt after percutaneous closure of patent foramen ovale with AMPLATZER occluder devices - influence of anatomic features: a transcranial Doppler and intracardiac echocardiography study. EUROINTERVENTION 2014; 9:382-8. [PMID: 23872652 DOI: 10.4244/eijv9i3a61] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS To evaluate the relationship between the anatomic features of the fossa ovalis (FO) and residual right-to-left shunt (RLS) after percutaneous patent foramen ovale (PFO) closure with AMPLATZER PFO occluder devices. METHODS AND RESULTS FO anatomic features were assessed by intracardiac echocardiography in 127 patients with large RLS at contrast-enhanced transcranial colour Doppler (TCCD) undergoing percutaneous PFO closure with an AMPLATZER device. Residual RLS was evaluated by TCCD three and 12 months after the procedure. PFO closure was successful in all but two patients. At TCCD, a significant residual RLS (grade ≥2) was observed in 27 (21.6%) and 17 (13.6%) patients at three and 12 months, respectively. Larger baseline RLS, presence of atrial septal aneurysm, greater longitudinal and transverse FO dimensions, and use of larger devices were associated with significant residual RLS. At multivariate analysis, the presence of atrial septal aneurysm (OR 7.6; 95% CI: 1.38-42.35; p=0.02) and longitudinal FO dimension >20.8 mm (OR 8.5; 95% CI: 1.55-46.95; p=0.014) were identified as independent predictors of significant residual RLS at 12 months. CONCLUSIONS Our study suggests that a large FO and the presence of atrial septal aneurysm are independent predictors of persistent residual RLS after PFO closure with AMPLATZER devices.
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Affiliation(s)
- Nicola Marchese
- Department of Cardiology, Casa Sollievo della Sofferenza Hospital IRCCS, San Giovanni Rotondo, Italy.
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Melgarejo I, Palau RG. Cartas al editor. REVISTA COLOMBIANA DE CARDIOLOGÍA 2013. [DOI: 10.1016/s0120-5633(13)70066-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Echocardiography in the era of multimodality cardiovascular imaging. BIOMED RESEARCH INTERNATIONAL 2013; 2013:310483. [PMID: 23878804 PMCID: PMC3708397 DOI: 10.1155/2013/310483] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Accepted: 06/11/2013] [Indexed: 12/17/2022]
Abstract
Echocardiography remains the most frequently performed cardiac imaging investigation and is an invaluable tool for detailed and accurate evaluation of cardiac structure and function. Echocardiography, nuclear cardiology, cardiac magnetic resonance imaging, and cardiovascular-computed tomography comprise the subspeciality of cardiovascular imaging, and these techniques are often used together for a multimodality, comprehensive assessment of a number of cardiac diseases. This paper provides the general cardiologist and physician with an overview of state-of-the-art modern echocardiography, summarising established indications as well as highlighting advances in stress echocardiography, three-dimensional echocardiography, deformation imaging, and contrast echocardiography. Strengths and limitations of echocardiography are discussed as well as the growing role of real-time three-dimensional echocardiography in the guidance of structural heart interventions in the cardiac catheter laboratory.
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Rostamian A, Rathod A, Makkar RR, Siegel RJ. Three-Dimensional Echocardiographic Assessment of Patent Foramen Ovale in Platypnea-Orthodeoxia. Echocardiography 2013; 30:E239-42. [DOI: 10.1111/echo.12265] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
- Armand Rostamian
- Heart Institute; Cedars-Sinai Medical Center; Los Angeles; California
| | - Ankit Rathod
- Heart Institute; Cedars-Sinai Medical Center; Los Angeles; California
| | | | - Robert J. Siegel
- Heart Institute; Cedars-Sinai Medical Center; Los Angeles; California
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