Percutaneous closure of patent foramen ovale in symptomatic patients

Impact of the antiplatelet strategy following patent foramen ovale percutaneous closure

AIMS

Temporary dual antiplatelet therapy (DAPT) is recommended following patent foramen ovale (PFO) percutaneous closure although its benefit, compared to single antiplatelet therapy (SAPT), has not been demonstrated in this setting. We aimed at assessing outcomes following PFO closure according to the antiplatelet strategy at discharge.

METHODS AND RESULTS

The ambispective AIR-FORCE cohort included consecutive patients from seven centres in France and Canada undergoing PFO closure and discharged without anticoagulation. Patients treated in French and Canadian centres were mostly discharged with DAPT and SAPT, respectively. The primary endpoint was the composite of death, stroke, transient ischaemic attack, peripheral embolism, myocardial infarction, or BARC type ≥2 bleeding with up to 5 years of follow-up. The impact of the antiplatelet strategy on outcomes was evaluated with a marginal Cox model (cluster analyses per country) with inverse probability weighting according to propensity score. A total of 1532 patients (42.2% female, median age: 49 [40-57] years) were included from 2001 to 2022, of whom 599 (39.1%) were discharged with SAPT and 933 (60.9%) with DAPT, for ≤3 months in 894/923 (96.9%) cases. After a median follow-up of 2.4 [1.1-4.4] years, a total of 58 events were observed. In the weighted analysis, the rate of the primary endpoint up to 5 years was 7.8% in the SAPT strategy and 7.3% in the DAPT strategy (weighted hazard ratio 1.04, 95% confidence interval 0.59-1.83).

CONCLUSION

The antiplatelet strategy following PFO closure did not seem to impact clinical outcomes, thus challenging the current recommendations of temporary DAPT.

Platypnoea-orthodeoxia syndrome in the elderly: A difficult-to-make diagnosis of intracardiac right-to-left shunt

Introduction

Platypnea-orthodeoxia syndrome is a combination of positional dyspnoea and hypoxemia; it is caused by several cardiac, pulmonary and hepatic diseases.

Case presentation

In this study, we describe a 77-year-old female affected by unexplained dizziness and hypoxia that exacerbated in upright position. After diagnosing platypnea-orthodeoxia syndrome and excluding all possible causes (liver cirrhosis, acute and chronic pulmonary diseases and arteriovenous malformations), the origin of the syndrome was individuated in the presence of a patent foramen ovale with right-to-left shunt. Endovascular patent foramen ovale closure permitted the resolution of symptoms and disappearance of platypnea-orthodeoxia syndrome.

Conclusion

Although patent foramen ovale may be present since birth without giving clinical signs, it may represent a common enough cause of platypnea-orthodeoxia syndrome and other vascular complications in the elderly.

Percutaneous closure of patent foramen ovale in patients with anatomical and clinical high-risk characteristics: long-term efficacy and safety

BACKGROUND

Transcatheter closure of patent foramen ovale (PFO) is a widespread procedure, but no randomized study on its outcome in high-risk patients is available. Our aims were to determine the efficacy and safety of this procedure in a cohort of high-risk patients through the observation of clinical adverse events and residual shunt, to evaluate the impact of transesophageal echocardiography (TEE) guidance during the procedure, and investigate the relationship between the anatomical and clinical characteristics and the outcome.

METHODS AND RESULTS

Ninety-five patients underwent PFO closure for cryptogenic cerebral ischemia; each of them presented one or more of the following risk factors: recurrent cerebral ischemia (9.5%), atrial septum aneurysm (ASA, 74.5%), prominent Eustachian valve (EV, 23.2%), severe basal shunt (9.5%), thrombophilic factors (20%), deep vein thrombosis (4.2%). The procedure was performed successfully in all patients. On median follow-up of 18 months, the neurologic recurrent events rate was 1.1% and the major adverse cardiac event (MACE) rate was 1.1%. At 6-month TEE follow-up, the residual shunt rate was 12.6% (3.1% moderate to severe). A significant correlation was found between residual shunt and prominent EV alone (P = 0.036) or in association with ASA (P = 0.021). All adverse events occurred in the first 8 months, and the event-free survival rate was 86.2%.

CONCLUSIONS

Our study suggests that transcatheter PFO closure is a safe procedure even in a selected population of high-risk patients, presenting satisfactory efficacy and safety. The presence of a prominent EV alone or with ASA correlates positively with the occurrence of residual shunt.

[Feasibility and results of transcatheter treatment of patent foramen ovale associated with atrial septal aneurysm. Experience of a general hospital in Mulhouse, France]

OBJECTIVE

To evaluate the results and the feasibility of the technique of percutaneous closing of patent foramen oval (PFO) with Atrial Septal Aneurysm (ASA) among young patients having presented a cryptogenic cerebral ischemia.

PATIENTS AND METHODS

Eighteen patients: 14 cryptogenic stroke and 4 TIA with a broad PFO (rank III) and an important ASA (excursion higher than 15 mm) at transesophageal echocardiography (TEE). The average age is 48.2 years: man 61%, women 39%. The patients have little cardiovascular risk factor (0.83/patient) and 38% presented recurrent thromboembolic events. Percutaneous closing is carried out under general anaesthesia with TEE and Amplatzer devices implantation. A control TEE is carried out 6 months after closing.

RESULTS

No complication occurred at the time of the procedures. After 72 hours, one patient presented a major complication: one arteriovenous fistula requiring a surgery. Five patients presented a minor complication: two non complicated femoral hematoma, two atrial arrhytmias and one asymptomatic secondary displacement of the device without need for surgery. Seven-teen patients had TEE at six months: the shunt disappeared for 95% from the patients, no thrombus was found. No recurrent thromboembolic event appeared for the 18 patients (median follow-up 19.2 months).

CONCLUSION

The installation of a technique of percutaneous closing of the PFO+ASA is safe and effective.

Correlation or causation: Untangling the relationship between patent foramen ovale and migraine

Observational evidence from the literature has shown an association between migraine headaches and patent foramen ovale (PFO). This observation has led to hypotheses that could explain the etiology of migraines in those with a PFO, including right-to-left shunting of venous agents such as serotonin that are normally broken down in the pulmonary circulation. Further evidence suggests that closure of a PFO may improve migraine symptoms and serve as an effective treatment modality for migraines. Several randomized controlled double-blinded studies are underway that will more definitively establish the role of specific devices in PFO closure in those suffering from migraines.

Transcatheter closure of patent foramen ovale in older adults

OBJECTIVES

Comparing results of patent foramen ovale (PFO) closure in older and younger patient cohorts.

BACKGROUND

The literature pertaining to stroke and PFO has focused on patients <55 years of age.

METHODS

Between March 2000 and December 2003, 456 consecutive stroke/transient ischemic attack (TIA) patients (14.2-91.1 years, mean 51.4 +/- 15.5) underwent successful closure of PFO with a CardioSEAL Septal Occluder by one operator at five hospitals. Of the 456 patients, 184 (40.4%) were >55 years of age at the time of the procedure (mean 66.9 +/- 8.3 years) and comprise the subject group (OLDER). The remaining 272 patients (mean 41.1 +/- 7.7) comprise the control group (YOUNGER). Data were collected prospectively in a registry type format.

RESULTS

Minor procedural complications were comparable: 7/184 (3.8%) OLDER vs. 12/272 (4.4%) YOUNGER (P = NS). In the follow-up period (1-45 months, mean = 17.8 +/- 11.1), there was no significant difference in the rate of recurrent stroke/TIA, headaches, or late unrelated death. Forty OLDER patients and 47 YOUNGER developed new onset atrial arrhythmia (P = NS). The incidence of new onset atrial fibrillation (AF), however, was significantly higher in OLDER (14/40 OLDER and only 2/47 YOUNGER, P < 0.025). All patients who were in normal sinus rhythm (NSR) before the procedure are in NSR at last follow-up.

CONCLUSIONS

Older patients should not be excluded from PFO closure. The procedure seems as safe and effective in preventing recurrent stroke in the older, as in the younger population. Older patients seem more prone to developing AF.

Transcatheter Closure of Patent Foramen Ovale in Patients with Platypnea-Orthodeoxia: Results of a Multicentric French Registry

BACKGROUND

Dyspnea and the decrease in arterial saturation in the upright position in elderly subjects is described as platypnea-orthodeoxia syndrome (POS). POS is secondary to the occurrence of an atrial right-to-left shunt through a patent foramen ovale (PFO).

METHODS

This French multicentric study reports on 78 patients (mean age 67 +/- 11.3 years) with POS who had transcatheter closure of the PFO; frequently associated diseases were pneumonectomy (n = 36) and an ascending aortic aneurysm (n = 11). In all patients, the diagnosis was confirmed by transthoracic or/and transesophageal echocardiography. Five different closure devices were used: Amplatz (n = 45), Cardioseal (n = 13), Sideris (n = 11), Das Angel Wings (n = 8) and Starflex (n = 1). Closure was successful in 76 patients (97%).

RESULTS

Oxygen saturation increased immediately after occlusion from 84.6 +/- 10.7% to 95.1 +/- 6.4% (p < 0.001) and dyspnea improved from grade 2.7 +/- 0.7 to grade 1 +/- 1 (p < 0.001). A small residual shunt was immediately observed in 5 patients (3 with the Cardioseal device, 1 with the Sideris and 1 with the Amplatz) leading to the implantation of a second device in one case (Cardioseal). Two early deaths occurred unrelated to the procedure (one due to sepsis probably related to pneumonectomy, another due to respiratory insufficiency). Other complications were: a small shunt between the aorta and the left atrium, two atrial fibrillations and a left-sided thrombus which disappeared with anticoagulant therapy. At a mean follow-up of 15 +/- 12 months, there were 7 late deaths related to the underlying disease.

CONCLUSION

Percutaneous occlusion of the foramen ovale is safe and gives excellent results thanks to continuing improvement in available devices. This technique enables some patients in an unstable condition to avoid a surgical closure.

Antithrombotic and Thrombolytic Therapy for Ischemic Stroke

This chapter about treatment and prevention of stroke is part of the 7th ACCP Conference on Antithrombotic and Thrombolytic Therapy: Evidence Based Guidelines. Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh risks, burden, and costs. Grade 2 suggests that individual patients' values may lead to different choices (for a full understanding of the grading see Guyatt et al). Among the key recommendations in this chapter are the following: For patients with acute ischemic stroke (AIS), we recommend administration of i.v. tissue plasminogen activator (tPA), if treatment is initiated within 3 h of clearly defined symptom onset (Grade 1A). For patients with extensive and clearly identifiable hypodensity on CT, we recommend against thrombolytic therapy (Grade 1B). For unselected patients with AIS of > 3 h but < 6 h, we suggest clinicians not use i.v. tPA (Grade 2A). For patients with AIS, we recommend against streptokinase (Grade 1A) and suggest clinicians not use full-dose anticoagulation with i.v. or subcutaneous heparins or heparinoids (Grade 2B). For patients with AIS who are not receiving thrombolysis, we recommend early aspirin therapy, 160 to 325 mg qd (Grade 1A). For AIS patients with restricted mobility, we recommend prophylactic low-dose subcutaneous heparin or low molecular weight heparins or heparinoids (Grade 1A); and for patients who have contraindications to anticoagulants, we recommend use of intermittent pneumatic compression devices or elastic stockings (Grade 1C). In patients with acute intracerebral hematoma, we recommend the initial use of intermittent pneumatic compression (Grade 1C+). In patients with noncardioembolic stroke or transient ischemic attack (TIA) [ie, atherothrombotic, lacunar or cryptogenic], we recommend treatment with an antiplatelet agent (Grade 1A) including aspirin, 50 to 325 mg qd; the combination of aspirin and extended-release dipyridamole, 25 mg/200 mg bid; or clopidogrel, 75 mg qd. In these patients, we suggest use of the combination of aspirin and extended-release dipyridamole, 25/200 mg bid, over aspirin (Grade 2A) and clopidogrel over aspirin (Grade 2B). For patients who are allergic to aspirin, we recommend clopidogrel (Grade 1C+). In patients with atrial fibrillation and a recent stroke or TIA, we recommend long-term oral anticoagulation (target international normalized ratio, 2.5; range, 2.0 to 3.0) [Grade 1A]. In patients with venous sinus thrombosis, we recommend unfractionated heparin (Grade 1B) or low molecular weight heparin (Grade 1B) over no anticoagulant therapy during the acute phase.

Patent foramen ovale, systemic embolization and closure

The recognition, evaluation and treatment of patent foramen ovale has attracted increasing interest as the importance and frequency of paradoxical embolism has become better understood. The interest in this field has been driven largely by the widespread application of echocardiography with identification of a patent foramen ovale and/or an atrial septal aneurysm. The evaluation of the role of a patent foramen ovale in patients with a neurologic event is complex because the patent foramen ovale or atrial septal aneurysm may either be an innocent bystander or could be the etiologic mechanisms involved in the paradoxical embolus. In patients younger than 55 years, a causal relationship between a patent foramen ovale/atrial septal aneurysm and a neurologic ischemic event is considerably stronger than in those patients older than 55 years. In patients with a presumed diagnosis of paradoxical embolus in the setting of a patent foramen ovale, percutaneous closure is now possible and 2 devices are relatively widely used. Both of these devices reliably close the defect with a very acceptable risk profile and have been found in the longer term to be associated with excellent outcome. The exact role, however, that these devices play vis a vis continued medical therapy for prevention of recurrent events is being tested in 2 randomized clinical trials. The field continues to change with new technology being developed and with new applications. A recently exciting finding has been the identification that closure of a patent foramen ovale may be associated with dramatic improvement in symptoms of patients with disabling migraine headaches. Other potential applications of these devices include those patients who are deep-sea divers, in whom the potential for "bends" exists, or high altitude airplane pilots.

Transcatheter patent foramen ovale closure for secondary prevention of paradoxical embolic events: Acute results from the FORECAST registry

Patients with patent foramen ovale (PFO) and paradoxical embolism are at increased risk for recurrent events. Percutaneous PFO closure is a new treatment modality aimed at secondary prevention. We report the multicenter experience of interventional closure of PFO using two different devices in 272 patients. The mean age was 51 +/- 14.2 years and 52.9% were males. The implantation procedure resulted in an initial complete shunt closure rate of 74.3% with a periprocedural complication rate of 6.6%. There were no deaths or pericardial tamponade. The mean procedure time was less than 44 min under either conscious sedation, local or general anesthesia. This is the largest report to date demonstrating the procedural safety, reliability, and feasibility of the transcatheter PFO closure technique with the STARFlex and CardioSEAL septal implants. Randomized clinical trials are currently in progress to identify patients most likely to benefit from this intervention.

Clinical outcomes of patent foramen ovale closure for paradoxical emboli without echocardiographic guidance

The objective of this study was to determine the feasibility of device closure of patent foramen ovale (PFO) for presumed paradoxical emboli without echocardiographic guidance or balloon sizing and the clinical outcome after device closure. Closure of the PFO has been proposed as an alternative to anticoagulation in patients with presumed paradoxical emboli. At present, most centers perform device closure with transesophageal echocardiographic guidance and balloon sizing of the defect. Between May 1998 and April 2002, 92 consecutive patients underwent device closure for a PFO using fluoroscopic monitoring only. Procedural success and major complications were recorded. Follow-up outcomes were recurrence rate and residual atrial shunting on transthoracic echocardiography. All patients (mean age, 45 +/- 13 years; 52% male) had successful device deployment using either the CardioSeal (n = 78) and Amplatzer (n = 14) PFO occluders with no major complications. Mean procedure time and fluoroscopy time was 27 +/- 13 and 6 +/- 4 min, respectively. One patient had a residual shunt on echocardiography at 1 year. Cumulative event-free survival for recurrence of paradoxical embolus at 1 year was 97.3% +/- 1.8%. This study provides a basis for device closure of PFO becoming a safe, day-case procedure, resulting in a low rate of residual shunting and recurrent thromboembolic events.

Transcatheter closure of patent foramen ovale associated with paradoxical embolism using the amplatzer PFO occluder: Initial and intermediate-term results of the U.S. multicenter clinical trial

Closure of patent foramen ovale (PFO) has been proposed as an alternative to anticoagulation in patients with presumed paradoxical emboli. We report the immediate and mid-term results of the phase 1 U.S. Multicenter Clinical Trial of patients who underwent transcatheter PFO closure for paradoxical embolism using the new Amplatzer PFO device. Fifty patients (28 male/22 female) underwent catheter closure of their PFOs at a mean age of 41 +/- 11 years. Thirty-six patients had ischemic stroke, 10 had transient ischemic attack, and 4 had peripheral embolism. Seventeen patients had atrial septal aneurysm. The implantation procedure was successful in 49/49 patients; one patient did not have a PFO. Complete closure was seen immediately after the procedure in 26/49 patients; 17 had minimal residual shunt, 4 had moderate and 2 had large residual shunts. The median fluoroscopy time was 10.5 min (2.8-43 min). There were no complications related to the device. One patient developed an arteriovenous fistula at the catheter site requiring surgical repair. At a mean follow-up interval of 16.5 +/- 7.2 months, there were no deaths or recurrent neurological or peripheral embolic events. Eight patients reported an episode of dizziness or palpitations (four of them within 18 days of the procedure). No episodes of atrial dysrhythmias were noted. Contrast bubble study at last follow-up documented complete closure in 45/48 patients; one patient had minimal, one had moderate residual shunt, and one had a large shunt. One patient was lost to follow-up. We conclude that catheter closure of PFO associated with stroke/transient ischemic attack or peripheral embolism using the new Amplatzer PFO device is a safe and effective method in preventing recurrence of such episodes. Randomized clinical trials comparing device closure versus continued medical therapy are underway.

Cardioembolic stroke: an update

Embolism of cardiac origin accounts for about one fifth of ischaemic strokes. Strokes due to cardioembolism are in general severe and prone to early recurrence. The risk of long term recurrence and mortality are high after a cardioembolic stroke. Cardioembolism can be reliably predicted on clinical grounds but is difficult to document. MRI, transcranial doppler, echocardiogram, Holter monitoring, and electrophysiological studies increase our ability to identify the source of cardioembolism. Non-valvular atrial fibrillation is the commonest cause of cardioembolic stroke. Despite its enormous preventive potential, continuous oral anticoagulation is prescribed for less than half of patients with atrial fibrillation who have risk factors for cardioembolism and no contraindications for anticoagulation. Alternatives to oral anticoagulation in this setting include safer and easier to use antithrombotic drugs and definitive treatment of atrial fibrillation. Available evidence does not support routine immediate anticoagulation of acute cardioembolic stroke.