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Nakiri M, Ueda K, Hoshino R, Ito N, Kurose H, Nohara S, Muraki K, Hattori C, Ogo E, Igawa T. Prostate brachytherapy seed migration to the right renal artery due to right-to-left shunting across a patent foramen ovale. IJU Case Rep 2024; 7:221-224. [PMID: 38686070 PMCID: PMC11056261 DOI: 10.1002/iju5.12707] [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: 10/24/2023] [Accepted: 02/09/2024] [Indexed: 05/02/2024] Open
Abstract
Introduction The seeds used in brachytherapy for prostate cancer may migrate through the surrounding venous plexus to other sites in the body, most commonly to the pulmonary vasculature. Case presentation A 78-year-old Japanese man received iodine-125 low-dose-rate prostate brachytherapy. Computed tomography revealed that one seed had migrated to the right kidney. No seed was observed in the ureter upon ureteroscopy. Transesophageal echocardiography confirmed a right-to-left shunt due to a patent foramen ovale, suggesting that the seed had migrated into the right renal artery. Three years after treatment, no recurrence of prostate cancer and no adverse events due to seed migration or due to the patent foramen ovale occurred. Conclusion Arteriovenous malformations and a right-to-left shunt should be suspected if a brachytherapy seed has migrated to an artery of the systemic circulatory system.
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Affiliation(s)
- Makoto Nakiri
- Department of UrologyKurume University School of MedicineKurumeJapan
| | - Kosuke Ueda
- Department of UrologyKurume University School of MedicineKurumeJapan
| | - Ryuji Hoshino
- Department of UrologyKurume University School of MedicineKurumeJapan
| | - Naoki Ito
- Department of UrologyKurume University School of MedicineKurumeJapan
| | - Hirofumi Kurose
- Department of UrologyKurume University School of MedicineKurumeJapan
| | - Shoichiro Nohara
- Division of Cardiovascular Medicine, Department of Internal MedicineKurume University School of MedicineKurumeJapan
| | - Koichiro Muraki
- Department of RadiologyKurume University School of MedicineKurumeJapan
| | - Chikayuki Hattori
- Department of RadiologyKurume University School of MedicineKurumeJapan
| | - Etsuyo Ogo
- Department of RadiologyKurume University School of MedicineKurumeJapan
| | - Tsukasa Igawa
- Department of UrologyKurume University School of MedicineKurumeJapan
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Zou R, Wang S, Liu P, Chen D, Yan J, Cai H, Wang Y, Wang C. The association between patent foramen ovale and unexplained syncope in pediatric patients. Ital J Pediatr 2024; 50:2. [PMID: 38185629 PMCID: PMC10773133 DOI: 10.1186/s13052-023-01572-y] [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: 08/09/2023] [Accepted: 12/26/2023] [Indexed: 01/09/2024] Open
Abstract
BACKGROUND Patent foramen ovale (PFO) is associated with transient ischemia attack (TIA) or stroke, paradoxical embolism, and migraines. PFO closure decreases the recurrent incidence of cerebral ischemic events and reduces the incidence of syncope in adults. However, whether PFO is associated with syncope in pediatric patients has not been investigated. METHODS 1001 pediatric patients (aged 4 to 17 years, mean age 10.31 ± 2.61 years, 519 males) who complained of unexplained syncope, palpitation, headache, dizziness and chest pain and were hospitalized in the Syncope Ward, The Second Xiangya Hospital, Central South University between January 2013 and April 2022 were recruited. Children with definite etiology of syncope, neurological, cardiogenic, psychological and other system diseases were excluded. PFO was measured by transthoracic echocardiography and right-heart contrast echocardiography was performed to identify the presence of right-to-left shunting. The demographic data and medical records were retrospectively reviewed and analyzed. RESULTS 276 cases were included in the simple syncope group, 379 cases in the headache/dizziness group, 265 cases in the chest pain group, and 81 cases in the palpitation group. The incidence of PFO between the four groups was insignificant (4.71%, 4.74%, 4.15%, 6.17%, respectively, P = 0.903). Multivariate Logistic regression demonstrated that PFO is not associated with the increased risk of syncope (P = 0.081). CONCLUSION PFO may not increase the risk of syncope in pediatric patients. Further study may include a large and multicenter sample to investigate the association between PFO and unexplained syncope.
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Affiliation(s)
- Runmei Zou
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, No.139 Renmin Middle Road, Changsha, Hunan, 410011, China
| | - Shuo Wang
- Department of Pediatrics, Xiangya Hospital, Central South University, Changsha, Hunan, 410008, China
| | - Ping Liu
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, No.139 Renmin Middle Road, Changsha, Hunan, 410011, China
| | - Donghai Chen
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, No.139 Renmin Middle Road, Changsha, Hunan, 410011, China
| | - Jun Yan
- Department of Pediatrics, The First Affiliated Hospital, Hunan University of Medicine, Huaihua, Hunan, 418000, China
| | - Hong Cai
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, No.139 Renmin Middle Road, Changsha, Hunan, 410011, China
| | - Yuwen Wang
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, No.139 Renmin Middle Road, Changsha, Hunan, 410011, China
| | - Cheng Wang
- Department of Pediatric Cardiovasology, Children's Medical Center, The Second Xiangya Hospital, Central South University, No.139 Renmin Middle Road, Changsha, Hunan, 410011, China.
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Stoller N, Wertli MM, Haynes AG, Chiolero A, Rodondi N, Panczak R, Aujesky D. Large regional variation in cardiac closure procedures to prevent ischemic stroke in Switzerland a population-based small area analysis. PLoS One 2024; 19:e0291299. [PMID: 38166018 PMCID: PMC10760725 DOI: 10.1371/journal.pone.0291299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 08/23/2023] [Indexed: 01/04/2024] Open
Abstract
BACKGROUND Percutaneous closure of a patent foramen ovale (PFO) or the left atrial appendage (LAA) are controversial procedures to prevent stroke but often used in clinical practice. We assessed the regional variation of these interventions and explored potential determinants of such a variation. METHODS We conducted a population-based analysis using patient discharge data from all Swiss hospitals from 2013-2018. We derived hospital service areas (HSAs) using patient flows for PFO and LAA closure. We calculated age-standardized mean procedure rates and variation indices (extremal quotient [EQ] and systematic component of variation [SCV]). SCV values >5.4 indicate a high and >10 a very high variation. Because the evidence on the efficacy of PFO closure may differ in patients aged <60 years and ≥60 years, age-stratified analyses were performed. We assessed the influence of potential determinants of variation using multilevel regression models with incremental adjustment for demographics, cultural/socioeconomic, health, and supply factors. RESULTS Overall, 2574 PFO and 2081 LAA closures from 10 HSAs were analyzed. The fully adjusted PFO and LAA closure rates varied from 3 to 8 and from 1 to 9 procedures per 100,000 persons per year across HSAs, respectively. The regional variation was high with respect to overall PFO closures (EQ 3.0, SCV 8.3) and very high in patients aged ≥60 years (EQ 4.0, SCV 12.3). The variation in LAA closures was very high (EQ 16.2, SCV 32.1). In multivariate analysis, women had a 28% lower PFO and a 59% lower LAA closure rate than men. French/Italian language areas had a 63% lower LAA closure rate than Swiss German speaking regions and areas with a higher proportion of privately insured patients had a 86% higher LAA closure rate. After full adjustment, 44.2% of the variance in PFO closure and 30.3% in LAA closure remained unexplained. CONCLUSIONS We found a high to very high regional variation in PFO closure and LAA closure rates within Switzerland. Several factors, including sex, language area, and insurance status, were associated with procedure rates. Overall, 30-45% of the regional procedure variation remained unexplained and most probably represents differing physician practices.
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Affiliation(s)
- Nina Stoller
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Emergency Department, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Maria M. Wertli
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Internal Medicine, Kantonsspital Baden, Baden, Switzerland
| | | | - Arnaud Chiolero
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- School of Population and Global Health, McGill University, Montreal, Canada
- Population Health Laboratory (#PopHealthLab), University of Fribourg, Fribourg, Switzerland
| | - Nicolas Rodondi
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Radoslaw Panczak
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Scalera S, Pizzuto A, Marchese P, Santoro G. Percutaneous closure of 'complex' multi-fenestrated atrial septal aneurysm in visceral situs inversus using a multi-device approach: a case report. Eur Heart J Case Rep 2023; 7:ytad467. [PMID: 37942352 PMCID: PMC10629585 DOI: 10.1093/ehjcr/ytad467] [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: 03/13/2023] [Revised: 09/05/2023] [Accepted: 09/18/2023] [Indexed: 11/10/2023]
Abstract
Background Percutaneous closure is nowadays still deemed challenging in patent forame ovale (PFO) associated to multi-fenestrated atrial septal aneurysm (ASA). This anatomic arrangement is still considered a significant risk factor for recurrence of paradoxical embolism. Theoretically, transcatheter approach could be theoretically even more complex in the case of dextrocardia and visceral situs inversus. Case summary A 59-year-old man with history of migraine with aura and multiple cryptogenic strokes was referred for percutaneous closure of a PFO with associated ASA. He had been previously submitted to repeat attempt of percutaneous closure with not self-centering and self-centering devices that failed due to unfavorable anatomic characteristics (dextrocardia with situs viscerum inversus, huge ASA, multiple fenestrations, large PFO). Based on this "complex" anatomy, a sequential 2-step interventional approach aiming to reduce size and mobility of the atrial septal aneurysm with a suture-based approach (Noblestich™ EL, HeartStitch, Fountain Valley, CA, USA) and to close any eventual accessory fenestrations with a not self-centering occluding device was planned. At the end of the procedure, the ASA completely disappeared and no residual shunt was imaged at TEE bubble test. Discussion We describe a very rare case of symptomatic ASA-PFO in dextrocardia with situs viscerum inversus as well as an innovative approach to treat such complex anatomic setting by using the suture-based closure of a PFO to reduce size and mobility of an ASA in order to deploy dedicated not-self-centering occluding devices.
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Affiliation(s)
- Silvia Scalera
- Pediatric Cardiology and GUCH Unit, Heart Hospital ‘G. Pasquinucci’, National Research Council-Tuscany Foundation ‘G. Monasterio’, Via Aurelia Sud, Massa 54100, Italy
| | - Alessandra Pizzuto
- Pediatric Cardiology and GUCH Unit, Heart Hospital ‘G. Pasquinucci’, National Research Council-Tuscany Foundation ‘G. Monasterio’, Via Aurelia Sud, Massa 54100, Italy
| | - Pietro Marchese
- Pediatric Cardiology and GUCH Unit, Heart Hospital ‘G. Pasquinucci’, National Research Council-Tuscany Foundation ‘G. Monasterio’, Via Aurelia Sud, Massa 54100, Italy
| | - Giuseppe Santoro
- Pediatric Cardiology and GUCH Unit, Heart Hospital ‘G. Pasquinucci’, National Research Council-Tuscany Foundation ‘G. Monasterio’, Via Aurelia Sud, Massa 54100, Italy
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5
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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: 12] [Impact Index Per Article: 12.0] [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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6
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Khalid N, Abdullah M, Ozgur SS, Elkattawy S, Shamoon F. Managing Patent Foramen Ovale (PFO) in Adults With Cryptogenic Stroke and Lymphoma: A Multidisciplinary Perspective. Cureus 2023; 15:e40316. [PMID: 37448395 PMCID: PMC10337876 DOI: 10.7759/cureus.40316] [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] [Accepted: 06/12/2023] [Indexed: 07/15/2023] Open
Abstract
Cryptogenic strokes are strokes with no clear underlying cause. Patent foramen ovale (PFO) is believed to be one of the causes of cryptogenic strokes. To manage such cases, closing the PFO is usually considered an option. We report a case of a middle-aged male with lymphoma who presented with an altered mental status due to a stroke, which, on investigation, was found to be due to an underlying PFO. This report explores the factors that must be considered when making the decision to close the PFO and emphasizes the vital role of a multi-disciplinary team in determining the best course of action for patients with cryptogenic strokes.
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Affiliation(s)
- Noman Khalid
- Internal Medicine, St. Joseph's Regional Medical Center, Paterson, USA
| | - Muhammad Abdullah
- Public Health & Community Medicine, Shaikh Khalifa Bin Zayed Al-Nahyan Medical and Dental College, Shaikh Zayed Federal Postgraduate Medical Institute, Shaikh Zayed Medical Complex, Lahore, PAK
| | - Sacide S Ozgur
- Internal Medicine, St. Joseph's Regional Medical Center, Paterson, USA
| | | | - Fayez Shamoon
- Cardiology, St. Joseph's Regional Medical Center, Paterson, USA
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7
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Liu TT, Jiao RH, Chen T, Jiang ZA, Bai WL. A Systematic Review and Meta-Analysis of the Association between Residual Shunts after Patent Foramen Ovale Closure and Long-Term Cerebrovascular Events. Cerebrovasc Dis 2023; 52:387-392. [PMID: 36882039 DOI: 10.1159/000527457] [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: 05/07/2022] [Accepted: 09/28/2022] [Indexed: 03/09/2023] Open
Abstract
BACKGROUND The association between a patent foramen ovale (PFO) and cryptogenic stroke (CS) is well established, and the benefits of PFO closure are clearly recognized. This study aimed to investigate the presence of a residual shunt in patients who have experienced cryptogenic cerebrovascular events following a PFO closure. METHODS Two researchers systematically searched the PubMed and Embase online database for pertinent clinical studies published between January 2000 and July 2021 concerning the recurrence of cerebrovascular events after PFO closures. RESULTS Upon screening an initial list of 2,342 articles, six studies were identified, involving 2,083 patients. Overall, the analysis indicated a marked difference in the recurrence of cerebrovascular events in 8.89% of residual shunt (RS) cases compared to only 2.90% of non-RS cases. The summary odds ratio was 3.484 (95% confidence interval, 2.169-5.596), which suggested that RS may be a risk factor for recurrent cerebrovascular events in patients that experienced PFO-related cerebrovascular events within 6 months after PFO closure surgery. CONCLUSIONS The presence of RS significantly increases the risk of recurrent cerebrovascular events in patients with clinical PFO closure.
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Affiliation(s)
- Ting-Ting Liu
- Department of Heart Center, Hebei General Hospital, Shijiazhuang, China
| | - Rong-Hong Jiao
- Department of Ultrasound, Hebei General Hospital, Shijiazhuang, China
| | - Tao Chen
- Department of Cardiology, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Zhi-An Jiang
- Department of Cardiology, The Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Wen-Lou Bai
- Department of Heart Center, Hebei General Hospital, Shijiazhuang, China
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8
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Mead GE, Sposato LA, Sampaio Silva G, Yperzeele L, Wu S, Kutlubaev M, Cheyne J, Wahab K, Urrutia VC, Sharma VK, Sylaja PN, Hill K, Steiner T, Liebeskind DS, Rabinstein AA. A systematic review and synthesis of global stroke guidelines on behalf of the World Stroke Organization. Int J Stroke 2023; 18:499-531. [PMID: 36725717 DOI: 10.1177/17474930231156753] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND There are multiple stroke guidelines globally. To synthesize these and summarize what existing stroke guidelines recommend about the management of people with stroke, the World Stroke Organization (WSO) Guideline committee, under the auspices of the WSO, reviewed available guidelines. AIMS To systematically review the literature to identify stroke guidelines (excluding primary stroke prevention and subarachnoid hemorrhage) since 1 January 2011, evaluate quality (The international Appraisal of Guidelines, Research and Evaluation (AGREE II)), tabulate strong recommendations, and judge applicability according to stroke care available (minimal, essential, advanced). SUMMARY OF REVIEW Searches identified 15,400 titles; 911 texts were retrieved, 200 publications scrutinized by the three subgroups (acute, secondary prevention, rehabilitation), and recommendations extracted from most recent version of relevant guidelines. For acute treatment, there were more guidelines about ischemic stroke than intracerebral hemorrhage; recommendations addressed pre-hospital, emergency, and acute hospital care. Strong recommendations were made for reperfusion therapies for acute ischemic stroke. For secondary prevention, strong recommendations included establishing etiological diagnosis; management of hypertension, weight, diabetes, lipids, and lifestyle modification; and for ischemic stroke, management of atrial fibrillation, valvular heart disease, left ventricular and atrial thrombi, patent foramen ovale, atherosclerotic extracranial large vessel disease, intracranial atherosclerotic disease, and antithrombotics in non-cardioembolic stroke. For rehabilitation, there were strong recommendations for organized stroke unit care, multidisciplinary rehabilitation, task-specific training, fitness training, and specific interventions for post-stroke impairments. Most recommendations were from high-income countries, and most did not consider comorbidity, resource implications, and implementation. Patient and public involvement was limited. CONCLUSION The review identified a number of areas of stroke care where there was strong consensus. However, there was extensive repetition and redundancy in guideline recommendations. Future guideline groups should consider closer collaboration to improve efficiency, include more people with lived experience in the development process, consider comorbidity, and advise on implementation.
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Affiliation(s)
- Gillian E Mead
- Usher Institute, University of Edinburgh and Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh, UK
| | - Luciano A Sposato
- Department of Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, ON, Canada.,Heart & Brain Lab, Western University, London, ON, Canada.,Robarts Research Institute, London, ON, Canada.,Lawson Health Research Institute, London, ON, Canada
| | - Gisele Sampaio Silva
- Department of Neurology and Neurosurgery, Federal University of São Paulo (UNIFESP), São Paulo, Brazil.,Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Laetitia Yperzeele
- Antwerp NeuroVascular Center and Stroke Unit, Antwerp University Hospital, Antwerp, Belgium.,Research Group on Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Simiao Wu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Mansur Kutlubaev
- Department of Neurology, Bashkir State Medical University, Ufa, Russia
| | - Joshua Cheyne
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Kolawole Wahab
- Department of Medicine, University of Ilorin, Ilorin, Nigeria
| | - Victor C Urrutia
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Vijay K Sharma
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Division of Neurology, University Medicine Cluster, National University Health System, Singapore
| | - P N Sylaja
- Neurology and Comprehensive Stroke Care Program, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | - Kelvin Hill
- Stroke Treatment, Stroke Foundation, Melbourne, VIC, Australia
| | - Thorsten Steiner
- Departments of Neurology, Klinikum Frankfurt Höchst and Heidelberg University Hospital, Frankfurt, Germany
| | - David S Liebeskind
- UCLA Department of Neurology, Neurovascular Imaging Research Core, UCLA Comprehensive Stroke Center, Los Angeles, CA, USA
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9
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Wang X, Liu X, Zheng L, Liu Y, Guan Z, Dai J, Chen X. Correlation between percutaneous patent foramen ovale closure and recurrence of unexplained syncope. Front Neurol 2023; 14:1104621. [PMID: 36816564 PMCID: PMC9928853 DOI: 10.3389/fneur.2023.1104621] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 01/03/2023] [Indexed: 02/04/2023] Open
Abstract
Background The relationship between patent foramen ovale (PFO) and unexplained syncope remains to be illustrated. Therefore, this study aimed to explore the outcomes and prognostic factors for syncope recurrence after PFO closure. Methods Patients with both large right-to-left shunting (RLS) PFO and unexplained syncope who visited the cardiovascular department of Xiangya Hospital Central South University from 1 January 2017 to 31 December 2021 were consecutively enrolled in our study. The recurrence rate of syncope was compared between the non-closure group (n = 20) and the closure group (n = 91). Results A total of 111 patients were finally included. After 31.11 ± 14.30 months of follow-up, only 11% of patients in the closure group had recurrent syncope, which was much lower than that of the non-closure group (11.0 vs. 35%, P = 0.018). We further investigated the possible prognostic factors for syncope recurrence in the closure group and found syncope occurring more than five times preoperatively, hypertension, and residual RLS at 12-month follow-up were significantly correlated with a higher number of recurrences. Conclusions PFO closure reduced the recurrence rate of unexplained syncope. The efficacy of prevention was prognosticated by factors including the presence or absence of syncope induction, the frequency of syncope episodes, and the presence or absence of hypertension. Syncope recurrence was also related to residual shunts post closure.
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Affiliation(s)
- Xianwen Wang
- Department of Cardiology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Xiangwei Liu
- Department of Cardiology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Lulu Zheng
- Department of Cardiology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yubo Liu
- Department of Cardiology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Zhengyan Guan
- Department of Cardiology, The Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen, Guangdong, China
| | - Jingyi Dai
- Department of Cardiology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Xiaobin Chen
- Department of Cardiology, Xiangya Hospital, Central South University, Changsha, Hunan, China,*Correspondence: Xiaobin Chen ✉
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10
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Testa L, Popolo Rubbio A, Squillace M, Albano F, Cesario V, Casenghi M, Tarantini G, Pagnotta P, Ielasi A, Popusoi G, Paloscia L, Durante A, Maffeo D, Meucci F, Valentini G, Ussia GP, Cioffi P, Cortese B, Sangiorgi G, Contegiacomo G, Bedogni F. Patent foramen ovale occlusion with the Cocoon PFO Occluder. The PROS-IT collaborative project. Front Cardiovasc Med 2023; 9:1064026. [PMID: 36712245 PMCID: PMC9875285 DOI: 10.3389/fcvm.2022.1064026] [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: 10/07/2022] [Accepted: 12/20/2022] [Indexed: 01/12/2023] Open
Abstract
Background The Cocoon patent foramen ovale (PFO) Occluder is a new generation nitinol alloy double-disk device coated with nanoplatinum, likely useful in patients with nickel hypersensitivity. Early results and mid-term outcomes of this device in percutaneous PFO closure are missing. Aims To assess the preliminary efficacy and safety profile of PFO closure with Cocoon device in an Italian multi-center registry. Methods This is a prospective registry of 189 consecutive adult patients treated with the Cocoon PFO Occluder at 15 Italian centers from May 2017 till May 2020. Patients were followed up for 2 years. Results Closure of the PFO with Cocoon Occluder was carried out successfully in all patients, with complete closure without residual shunt in 94.7% of the patients and minimal shunt in 5.3%. Except from a case of paroxysmal supraventricular tachycardia and a major vascular bleeding, no procedural and in-hospital device-related complications occurred. No patient developed cardiac erosions, allergic reactions to nickel, or any other major complications during the follow-up. During the follow-up period, 2 cases of new-onset atrial fibrillation occurred within thirty-day. Conclusions Percutaneous closure of PFO with Cocoon Occluder provided satisfactory procedural and mid-term clinical follow-up results in a real-world registry.
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Affiliation(s)
- Luca Testa
- Department of Cardiology, IRCCS Policlinico San Donato, Milan, Italy,*Correspondence: Luca Testa ✉
| | | | - Mattia Squillace
- Department of Cardiology, IRCCS Policlinico San Donato, Milan, Italy
| | - Flavio Albano
- Department of Cardiology, IRCCS Policlinico San Donato, Milan, Italy
| | - Vincenzo Cesario
- Department of Cardiology, IRCCS Policlinico San Donato, Milan, Italy
| | - Matteo Casenghi
- Department of Cardiology, IRCCS Policlinico San Donato, Milan, Italy
| | - Giuseppe Tarantini
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Paolo Pagnotta
- Cardio Center, Humanitas Research Hospital, Milan, Italy
| | - Alfonso Ielasi
- Clinical and Interventional Cardiology Unit, Istituto Clinico Sant'Ambrogio, Milan, Italy
| | - Grigore Popusoi
- Interventional Cardiology Service, Montevergine Clinic, Mercogliano, Italy
| | | | | | | | - Francesco Meucci
- Structural Interventional Cardiology, Careggi University Hospital, Florence, Italy
| | - Giuliano Valentini
- Cardiology Intensive Care Unit and Cath Lab, Ospedale Civile SS. Filippo e Nicola, L'Aquila, Italy
| | - Gian Paolo Ussia
- Unit of Cardiovascular Science, Department of Medicine, Campus Bio-Medico University, Rome, Italy
| | - Paolo Cioffi
- Department of Cardiology, Cardiac Cath Lab, Città di Alessandria Institute, Alessandria, Italy
| | | | - Giuseppe Sangiorgi
- Department of Biomedicine and Prevention, Tor Vergata University of Rome, Rome, Italy
| | - Gaetano Contegiacomo
- Department of Interventional Cardiology, Anthea Hospital, GVM Care and Research, Bari, Italy
| | - Francesco Bedogni
- Department of Cardiology, IRCCS Policlinico San Donato, Milan, Italy
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11
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Karagianni A, Mandalenakis Z, Papadopoulos S, Dellborg M, Eriksson P. Long-term outcome after closure of an atrial shunt in patients aged 60 years or older with ischemic stroke: A nationwide, registry-based, case-control study. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2023. [DOI: 10.1016/j.ijcchd.2022.100438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
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12
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Song L, Shi P, Zheng X, Hongxin L, Li Z, Lv M, Wang H. Echocardiographic characteristics of transcatheter closure of patent foramen ovale with mallow biodegradable occluder: A single-center, phase III clinical study. Front Cardiovasc Med 2022; 9:945275. [PMID: 36035958 PMCID: PMC9411996 DOI: 10.3389/fcvm.2022.945275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 07/18/2022] [Indexed: 12/03/2022] Open
Abstract
Background Transcatheter occlusion of patent foramen ovale (PFO) has become a recognized treatment option for high-risk PFO-related diseases. However, traditional metal occluders have some disadvantages, such as permanent retention in the body, abrasion of tissues, and obstruction of access to the left side of the heart for interventional procedures. With biodegradable occluders that release non-toxic degradation products and are absorbable by the body, the risk of long-term complications could be greatly reduced. The experimental results of using a PFO-degradable occluder in beagle dogs in early stages, independently developed by Shanghai Mallow Medical Instrument Co., Ltd., showed that the occluding umbrella disc network was degraded 6 months after occlusion. The occluder also showed good memory, biocompatibility, and mechanical properties. Methods As one of the multi-center research units, this prospective Phase III clinical trial study included 16 patients with PFO-related complications who were treated with a degradable occluder. The follow-up period lasted for 12 months to analyze the echocardiographic characteristics and procedural feasibility. Results The immediate success rate of the procedure was 100% with no serious complications. Postoperative color Doppler transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) at 12 months showed that one patient with atrial septal aneurysm (ASA) had a residual shunt at the edge of the occluder, and contrast transcranial Doppler (cTCD) showed that all patients were grade I or 0 right-to-left shunts (RLS), indicating that the occlusion success rate was 100%. The occluder gradually degraded after the procedure, particularly when the umbrella disc structure became vague, and the size of the occluder decreased significantly 6 months after occlusion. Conclusions PFO closure with a Mallow degradable occluder has a high plugging success rate, is safe and effective, and has no serious complications. However, for PFO closure with special anatomical features, further research with a larger sample size is required. TTE can dynamically, conveniently, and accurately observe the entire degradation process of the occluder. Clinical Trial Registration ChiCTR1900024036.
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Affiliation(s)
- Lin Song
- Department of Medical Ultrasound, Shandong Medicine and Health Key Laboratory of Abdominal Medical Imaging, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Peixuan Shi
- Department of Medical Ultrasound, Shandong Provincial Qianfoshan Hospital, Shandong First Medical University, Jinan, China
| | - Xiaozhou Zheng
- Department of Cardiovascular Surgery, Shandong Engineering Research Center for Health Transplant and Material, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Li Hongxin
- Department of Cardiovascular Surgery, Shandong Engineering Research Center for Health Transplant and Material, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Ziang Li
- Department of Cardiovascular Surgery, Shandong Engineering Research Center for Health Transplant and Material, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Meng Lv
- Department of Anesthesiology, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Haiyan Wang
- Department of Medical Ultrasound, Shandong Medicine and Health Key Laboratory of Abdominal Medical Imaging, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Jinan, China
- *Correspondence: Haiyan Wang
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13
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Khan F, Fiorilli P, Messé SR, Kasner SE, Derbas LA, Kavinsky CJ, Favilla CG. Clinicians' Approach to Patent Foramen Ovale Closure after Stroke: Comparing Cardiologists and Neurologists. J Am Heart Assoc 2022; 11:e025598. [PMID: 35861812 PMCID: PMC9707820 DOI: 10.1161/jaha.122.025598] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background
Evidence from randomized trials and updated professional society guidelines supports patent foramen ovale (PFO) closure after cryptogenic stroke in select patients. It is unclear how this has been integrated into real‐world practice, so we aimed to compare practice patterns between cardiologists and neurologists.
Methods and Results
In March of 2021, a survey of cardiologists and neurologists who work or previously trained at the University of Pennsylvania Health System assessed practice preferences with respect to PFO closure after stroke. Clinical vignettes isolated specific variables of interest and used a 5‐point Likert scale to assess the level of support for PFO closure. Stroke neurologists and interventional cardiologists were compared by Wilcoxon‐Mann–Whitney tests. Secondarily, Kruskal–Wallis tests compared stroke neurologists, general neurologists, interventional cardiologists, and general cardiologists. We received 106 responses from 182 survey recipients (31/31 stroke neurologists, 38/46 interventional cardiologists, 20/30 general neurologists, and 17/77 general cardiologists). A similar proportion of stroke neurologists and interventional cardiologists favored PFO closure in a young patient with cryptogenic stroke, 88% and 87%, respectively (
P
=0.54). Interventionalists were more likely than stroke neurologists to support closure in the context of an alternative high‐risk stroke mechanism, 14% and 0%, respectively (
P
=0.003). Stroke neurologists were more likely to oppose closure on the basis of older age (
P
=0.01).
Conclusions
There are key differences between how neurologists and cardiologists approach PFO closure after stroke, particularly when interpreting the stroke etiology and when considering closure beyond the scope of prior trials; this underscores the importance of collaboration between cardiologists and neurologists.
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Affiliation(s)
- Farhan Khan
- Department of Neurology University of Pennsylvania Philadelphia PA
| | - Paul Fiorilli
- Department of Cardiology University of Pennsylvania Philadelphia PA
| | - Steven R. Messé
- Department of Neurology University of Pennsylvania Philadelphia PA
| | - Scott E. Kasner
- Department of Neurology University of Pennsylvania Philadelphia PA
| | - Laith A. Derbas
- Division of Cardiovascular Medicine Rush University Medical Center Chicago IL
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14
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To the Editor,. Clin Neurol Neurosurg 2022; 221:107308. [DOI: 10.1016/j.clineuro.2022.107308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 05/22/2022] [Accepted: 05/25/2022] [Indexed: 11/03/2022]
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15
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Mac Grory B, Ohman EM, Feng W, Xian Y, Yaghi S, Kamel H, Reznik ME. Advances in the management of cardioembolic stroke associated with patent foramen ovale. BMJ 2022; 376:e063161. [PMID: 35140114 DOI: 10.1136/bmj-2020-063161] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Patent foramen ovale (PFO) describes a valve in the interatrial septum that permits shunting of blood or thrombotic material between the atria. PFOs are present in approximately 25% of the healthy population and are not associated with any pathology in the vast majority of cases. However, comparisons between patients with stroke and healthy controls suggest that PFOs may be causative of stroke in certain patients whose stroke is otherwise cryptogenic. Options for the diagnosis of PFO include transthoracic echocardiography, transesophageal echocardiography, and transcranial Doppler ultrasonography. PFOs associated with an interatrial septal aneurysm seem to be more strongly linked to risk of recurrent stroke. Therapeutic options for secondary stroke prevention in the setting of a PFO include antiplatelet therapy, anticoagulation, and percutaneous device closure. Recent randomized clinical trials suggest that percutaneous closure reduces the subsequent risk of stroke in appropriately selected patients, with a large relative benefit but small absolute benefit. Referral for percutaneous PFO closure should therefore be considered in certain patients after a multidisciplinary, patient centered discussion. Areas for future study include structural biomarkers to aid in determining the role of PFO closure in older people with possible PFO associated stroke, the role of direct oral anticoagulants, and very long term outcomes after device closure.
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Affiliation(s)
- Brian Mac Grory
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - E Magnus Ohman
- Duke Clinical Research Institute, Durham, NC, USA
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Wuwei Feng
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
| | - Ying Xian
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Shadi Yaghi
- Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Hooman Kamel
- Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Michael E Reznik
- Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI, USA
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16
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Cho H, Kim T, Song IU, Chung SW. The Prevalence of Microembolic Signals in Transcranial Doppler Sonography With Bubble Test in Acute Ischemic Stroke. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2022; 41:439-446. [PMID: 33885173 DOI: 10.1002/jum.15724] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 03/29/2021] [Accepted: 04/08/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVES Transcranial Doppler ultrasound (TCD) is noninvasive and highly sensitive and specific for the diagnosis of patent foramen ovale (PFO). We evaluated the diagnostic implications of the TCD with a saline agitation test as a routine work-up for ischemic stroke patients. METHODS A TCD bubble study was performed in all consecutive ischemic stroke patients as a routine work-up. We evaluated the prevalence of microembolic signals (MES) for each stroke etiology and the optimal number of MES for predicting the PFO-attributable stroke. RESULTS Subjects (N = 499) with acute ischemic stroke were enrolled. A significant fraction of patients had MES during both normal respiration (5.7-44.4%) and the Valsalva maneuver (19.5-55.6%) across all stroke etiology categories. The optimal MES threshold for the diagnosis of PFO-attributable stroke confirmed by transesophageal echocardiography was 46 MES during the Valsalva maneuver (96% sensitivity and 95% specificity). Applying ≥46 MES during the Valsalva maneuver as a threshold effectively increased the ability to differentially diagnose PFO-attributable stroke from other etiologies. The number of MES during the Valsalva maneuver was negatively correlated with increasing age (r = -.108; P = .016). CONCLUSIONS A significant fraction of patients had right to left shunt across all Trial of ORG 10172 in Acute Stroke Treatment etiologies. A threshold number of MES facilitated the differential diagnosis of PFO-attributable stroke from other etiologies, and the optimal threshold was 46 MES during the Valsalva maneuver.
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Affiliation(s)
- Hyunji Cho
- Department of Neurology, College of Medicine, Incheon St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Taewon Kim
- Department of Neurology, College of Medicine, Incheon St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - In-Uk Song
- Department of Neurology, College of Medicine, Incheon St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Sung-Woo Chung
- Department of Neurology, College of Medicine, Incheon St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
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17
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Greer DM, Aparicio HJ, Siddiqi OK, Furie KL. Cardiac Diseases. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00032-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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18
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Kleindorfer DO, Towfighi A, Chaturvedi S, Cockroft KM, Gutierrez J, Lombardi-Hill D, Kamel H, Kernan WN, Kittner SJ, Leira EC, Lennon O, Meschia JF, Nguyen TN, Pollak PM, Santangeli P, Sharrief AZ, Smith SC, Turan TN, Williams LS. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. Stroke 2021; 52:e364-e467. [PMID: 34024117 DOI: 10.1161/str.0000000000000375] [Citation(s) in RCA: 1134] [Impact Index Per Article: 378.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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19
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Chong JH, Baumbach A, Khanji MY. A Middle-aged Woman With Recurrent Chest Pain With Troponin Elevation and Unobstructed Coronary Arteries. JAMA Cardiol 2021; 6:600-601. [PMID: 33688912 DOI: 10.1001/jamacardio.2021.0116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Jun Hua Chong
- Cardiologist at the National Heart Centre Singapore, Singapore.,Duke-National University of Singapore Medical School, Singapore
| | - Andreas Baumbach
- Queen Mary University of London, London, England.,Barts Heart Centre, London, England.,Yale School of Medicine, New Haven, Connecticut.,European Association of Percutaneous Cardiovascular Interventions, Sophia Antipolis, France
| | - Mohammed Y Khanji
- Queen Mary University of London, London, England.,Barts Heart Centre, London, England.,Newham University Hospital, Barts Health National Health Services Trust, London, England
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20
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Elzanaty AM, Patel N, Sabbagh E, Eltahawy EA. Patent foramen ovale closure in the management of cryptogenic stroke: a review of current literature and guideline statements. Curr Med Res Opin 2021; 37:377-384. [PMID: 33460329 DOI: 10.1080/03007995.2021.1876648] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The management recommendations for patent foramen ovale (PFO) closure in cryptogenic stroke are rapidly evolving. The data has expanded recently with four major trials demonstrating superiority of percutaneous device closure over medical management in preventing cryptogenic stroke recurrence. This paper aims to review the current literature for referring physicians who may encounter patients with patent foramen ovale before referring these patients to stroke specialists and/or interventional cardiologists. METHOD For this Narrative review, we conducted a broad literature search with expert selection of relevant data. Our search included a review of the currently available trials, guideline statements, position papers, cost-effectiveness of device closure data, as well as the impact of device closure on quality of life. RESULTS Most European societies are now in favor of evaluating all patients aged 60 years or younger with recent cryptogenic stroke in the setting of a PFO after careful consideration of the patient's echocardiographic and clinical risk factors. On the other hand, American societies, except for the American Academy of Neurology, have not yet passed official updated recommendations. CONCLUSION PFO closure can be considered for the prevention of recurrent cryptogenic stroke in patients aged ≤60 years after a thorough evaluation and discussion about benefits and potential risks (including but not limited to atrial fibrillation) of the procedure. Accumulating evidence supports prognostic, quality of life, and economic benefit from percutaneous PFO closure with newer generation closure devices in the right subset of patients. HIGHLIGHTS Data from 4 major trials (RESPECT, CLOSE, DEFENSE-PFO, REDUCE) demonstrates the superiority of PFO closure over medical management alone in preventing cryptogenic stroke recurrence. Trials investigated mostly patients ≤60 years old, and therefore results may not be generalizable to the entire population. Further randomized trials evaluating the safety and efficacy of PFO closure in patients older than 60 years are warranted.Atrial fibrillation is one of the most common "occult" causes of cryptogenic stroke and should be excluded by ambulatory electrocardiographic monitoring. It is important to also rule out other causes of stroke, including hypercoagulable states, atherosclerotic lesions, other cardioembolic sources, and arterial dissection.Complications of PFO procedure include new-onset AF, development of scar tissue, risk of aortic root dilation and subsequent erosions, and potential thrombi formation on the device.PFO closure with medical therapy is more cost-effective than medical therapy alone.Patients who underwent PFO closure had lower rates of depression, anxiety, and stress compared to those who did undergo closure.Development of the RoPE score has helped clinicians identify patients with cryptogenic stroke and PFO who might be a candidate for PFO closure. A score of 7, 8, and 9-10 corresponds to a causal risk of 72%, 84%, and 88%, respectively, and defines a subset of patients who may benefit from PFO closure.Current guidelines recommend determining the need for PFO closure on a case-by-case basis, depending on risk factors, in patients age 60 or less with recent cryptogenic stroke in the setting of PFO.
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Affiliation(s)
- Ahmed M Elzanaty
- Department of Internal Medicine, University of Toledo, Toledo, OH, USA
| | - Neha Patel
- Department of Internal Medicine, University of Toledo, Toledo, OH, USA
| | - Ebrahim Sabbagh
- Department of Cardiology, University of Toledo, Toledo, OH, USA
| | - Ehab A Eltahawy
- Department of Cardiology, University of Toledo, Toledo, OH, USA
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21
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Hochholzer W, Nührenberg T, Flierl U, Olivier CB, Landmesser U, Möllmann H, Dörr M, Mehilli J, Schäfer A, Dürschmied D, Sibbing D, El-Armouche A, Zeymer U, Neumann FJ, Ahrens I, Geisler T. Antithrombotische Therapie nach strukturellen kardialen Interventionen. DER KARDIOLOGE 2021. [DOI: 10.1007/s12181-020-00441-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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22
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Diener HC, Chutinet A, Easton JD, Granger CB, Kleine E, Marquardt L, Meyerhoff J, Zini A, Sacco RL. Dabigatran or Aspirin After Embolic Stroke of Undetermined Source in Patients With Patent Foramen Ovale: Results From RE-SPECT ESUS. Stroke 2021; 52:1065-1068. [PMID: 33504190 DOI: 10.1161/strokeaha.120.031237] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND PURPOSE Patent foramen ovale (PFO) may increase the risk of embolic stroke of undetermined source (ESUS). Guidelines suggest anticoagulation may be more effective than antiplatelets in preventing stroke in patients with ESUS and PFO when interventional closure is not performed. METHODS Patients with ESUS randomized to dabigatran (150/110 mg BID) or aspirin (100 mg QD) from the RE-SPECT ESUS study (Randomized, Double-Blind, Evaluation in Secondary Stroke Prevention Comparing the Efficacy and Safety of the Oral Thrombin Inhibitor Dabigatran Etexilate Versus Acetylsalicylic Acid in Patients With Embolic Stroke of Undetermined Source) were included. The rate of recurrent stroke (primary end point) and ischemic stroke was reported for patients with and without baseline PFO. A meta-analysis comparing the effects of anticoagulant and antiplatelet therapy on ischemic stroke in patients with PFO was updated to include RE-SPECT ESUS. RESULTS PFO was present in 680 of 5388 (12.6%) patients with documented PFO status. The risk of recurrent stroke with dabigatran versus aspirin was similar in patients with and without PFO (P for interaction, 0.8290). In patients with PFO, the meta-analysis found no statistically significant difference between anticoagulant and antiplatelet therapy (odds ratio, 0.70 [95% CI, 0.43-1.14]) for ischemic stroke. CONCLUSIONS There is insufficient evidence to recommend anticoagulation over antiplatelet therapy for patients with ESUS and a PFO. More data are needed to guide antithrombotic therapy in this population. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02239120.
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Affiliation(s)
- Hans-Christoph Diener
- Institute for Medical Informatics, Biometry and Epidemiology, University Duisburg-Essen, Germany (H-C.D.)
| | - Aurauma Chutinet
- Department of Medicine, Faculty of Medicine, Chulalongkorn Stroke Center, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Thai Red Cross Society, Bangkok, Thailand (A.C.)
| | - J Donald Easton
- Department of Neurology, University of California, San Francisco (J.D.E.)
| | | | - Eva Kleine
- Biostatistics and Data Sciences, Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany (E.K.)
| | - Lars Marquardt
- University Department of Neurology, Asklepios Hospital Hamburg Wandsbek, Germany (L.M.).,Faculty of Medicine, Semmelweis University Campus Hamburg, Germany (L.M.)
| | - Juliane Meyerhoff
- Cardiology Medicine, Boehringer Ingelheim International GmbH, Germany (J.M.)
| | - Andrea Zini
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Italy (A.Z.)
| | - Ralph L Sacco
- Department of Neurology, Miller School of Medicine, University of Miami, FL (R.L.S.)
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23
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Thet MS, Sepehripour A, Atieh AEFA, Di Salvo C. Migration of PFO closure device and entrapment within tricuspid valve leading to tricuspid regurgitation: surgical correction of an extremely rare complication after transcutaneous PFO closure. BMJ Case Rep 2021; 14:14/1/e239398. [PMID: 33500310 PMCID: PMC7843329 DOI: 10.1136/bcr-2020-239398] [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: 01/28/2023] Open
Abstract
A 41-year-old woman was referred to tertiary cardiothoracic surgery centre following embolisation of the Amplatzer patent foramen ovale (PFO) closure device to septal leaflet of tricuspid valve with reopening of PFO. Two years earlier, she presented with thalamic stroke, and she was found to have a PFO following investigations. The following year she underwent transcatheter closure. Six months after the percutaneous closure, she presented again with significant periods of shortness of breath. Imaging studies revealed the migration and embolisation of PFO closure device to the septal leaflet of tricuspid valve with reopening of the foramen and significant tricuspid valve regurgitation. She underwent open heart surgery using cardiopulmonary bypass for retrieval of the device, closure of the foramen and repair of the tricuspid valve. The patient recovered well without any significant issues following surgery.
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Affiliation(s)
- Myat Soe Thet
- Cardiothoracic Surgery, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Amir Sepehripour
- Cardiothoracic Surgery, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | | | - Carmelo Di Salvo
- Cardiothoracic Surgery, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
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Abstract
PURPOSE OF REVIEW Recent data have changed the landscape of patent foramen ovale (PFO) closure for secondary stroke prevention. This review synthesizes the data and provides a framework for optimal management of stroke patients with PFO. RECENT FINDINGS The cumulative evidence indicates that PFO closure reduces the risk of recurrent stroke in carefully selected young cryptogenic stroke patients, with an annualized risk reduction of ∼0.6%. The benefit of PFO closure is particularly evident in patients with embolic appearing strokes, large right-to-left shunt, or an associated atrial septal aneurysm. There may be little or no benefit in patients with small deep infarcts, a small PFO, or an indication for long-term anticoagulation. Closure is accompanied by a small risk of major procedural complication and atrial fibrillation. SUMMARY The annual risk of stroke from PFO is low relative to other stroke mechanisms, but the life-time cumulative risk in young patients who have experienced a prior stroke may be substantial, in which case the absolute benefit of closure is likely impactful. PFO is highly prevalent in the general population, present in about one in four adults, and should not be considered to be the cause of the stroke until a thorough workup has excluded alternative mechanisms.
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New-onset atrial fibrillation following percutaneous closure of patent foramen ovale: a systematic review and meta-analysis. J Interv Card Electrophysiol 2021; 60:165-174. [PMID: 33420712 DOI: 10.1007/s10840-020-00925-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 12/27/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE A patent foramen ovale (PFO), present in up to 25% of adults, is an embryologic remnant which allows for right to left shunting and has been implicated in cryptogenic stroke (Neill and Lin, Methodist Debakey Cardiovasc J. 13(3):152-159, 2017; Bass 2015). The current standard of care for selected patients with PFO and cryptogenic stroke is transcatheter closure, but the risk of post-closure, new-onset atrial fibrillation (AF) is unknown (Vaidya et al., Cardiovasc Diagn Ther. 8(6):739-753, 2018; Kjeld et al., Acta Radiol Open. 7(9):2058460118793922, 2018; Staubach et al., Catheter Cardiovasc Interv. 74(6):889-95, 2009). This systematic review and meta-analysis synthesized evidence on AF development post transcatheter PFO closure and predictors of AF development, and assessed existing knowledge gaps. METHODS Randomized controlled trials and observational studies were selected according to the inclusion criteria of adults that underwent a transcatheter PFO closure without a history of AF. Studies were retrieved from electronic databases from inception until February 2019. A Freeman-Tukey arcsine transformation was performed for meta-analysis of AF incidence rate. RESULTS From 765 studies, 45 were included in quantitative data synthesis. Study sample sizes ranged between 20 and 1887 individuals, and average patient age between 37 to 67 years across studies. The overall incidence rate was 0.013 person-years, and 0.014 person-years for the within 6 months follow-up subgroup. There was no consistency in reported predictors of AF development. CONCLUSIONS The incidence of AF post-PFO closure was low across studies, with a high level of between-study heterogeneity. Until a concerted effort is made to improve accurate AF diagnosis, it will be difficult to gauge the association between transcatheter PFO closure and incidence of AF.
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Drakopoulou M, Soulaidopoulos S, Stathogiannis K, Oikonomou G, Papanikolaou A, Toutouzas K, Tousoulis D. Antiplatelet and Antithrombotic Therapy After Patent Foramen Oval and Atrial Septal Defect Closure. Curr Pharm Des 2021; 26:2769-2779. [PMID: 32338207 DOI: 10.2174/1385272824999200427083838] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 05/18/2020] [Indexed: 12/18/2022]
Abstract
Pathologies of the atrial septum include different interatrial communications varying from patent foramen ovale (PFO) to actual defects. Atrial septal defects (ASDs) may be localized within the fossa ovalis such as the secundum type ASD or outside the region of fossa ovalis, such as the ostium primum defect and sinus venosus defect. Over the last decades, the percutaneous closure of interatrial shunts has become a feasible and safe method. During these procedures, the delicate balance between thrombotic risk, device sealing process and bleeding risk is crucial. In this review, we sought to describe current available data on the antiplatelet and antithrombotic management of patients after percutaneous ASD or PFO closure.
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Affiliation(s)
- Maria Drakopoulou
- First Department of Cardiology, Hippokration Hospital, Medical School of Athens University, Athens, Greece
| | - Stergios Soulaidopoulos
- First Department of Cardiology, Hippokration Hospital, Medical School of Athens University, Athens, Greece
| | - Konstantinos Stathogiannis
- First Department of Cardiology, Hippokration Hospital, Medical School of Athens University, Athens, Greece
| | - Georgios Oikonomou
- First Department of Cardiology, Hippokration Hospital, Medical School of Athens University, Athens, Greece
| | - Aggelos Papanikolaou
- First Department of Cardiology, Hippokration Hospital, Medical School of Athens University, Athens, Greece
| | - Konstantinos Toutouzas
- First Department of Cardiology, Hippokration Hospital, Medical School of Athens University, Athens, Greece
| | - Dimitrios Tousoulis
- First Department of Cardiology, Hippokration Hospital, Medical School of Athens University, Athens, Greece
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Transcatheter closure of patent foramen ovale: Current evidence and future perspectives. J Cardiol 2020; 77:3-9. [PMID: 33144025 DOI: 10.1016/j.jjcc.2020.09.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 09/03/2020] [Indexed: 11/21/2022]
Abstract
Recent prospective controlled studies have demonstrated that transcatheter closure of a patent foramen ovale (PFO) reduces recurrent stroke risk in select patients, especially in patients younger than 60 years with PFO and embolic-appearing infarct and where no other mechanism of stroke was identified. Detection of PFO depends on the intensity of the Valsalva maneuver, and not all PFOs can be diagnosed using transesophageal echocardiography. Transthoracic contrast echocardiography using abdominal compression during the Valsalva maneuver is an easy method that can increase the detection sensitivity of PFO shunt. PFO with two or more of the following factors is most likely considered a "high-risk PFO" and as such, has a significantly higher probability of cryptogenic stroke: (1) a long-tunnel PFO (≥10 mm in length), (2) atrial septal aneurysm and/or hypermobile interatrial septum, (3) prominent Eustachian valve or Chiari's network, (4) large right-to-left shunt at rest and during the Valsalva maneuver, and (5) low-angle PFO. In order to establish the benefit of catheter-based PFO closure as a safe and effective treatment in clinical practice, the degree of accuracy of PFO diagnosis and its long-term safety need to be confirmed.
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A framework for practical issues was developed to inform shared decision-making tools and clinical guidelines. J Clin Epidemiol 2020; 129:104-113. [PMID: 33049326 DOI: 10.1016/j.jclinepi.2020.10.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 08/24/2020] [Accepted: 10/06/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVES The objective of the study was to develop and test feasibility of a framework of patient-important practical issues. STUDY DESIGN AND SETTING Guidelines and shared decision-making tools help facilitate discussions about patient-important outcomes of care alternatives, but typically ignore practical issues patients consider when implementing care into their daily routines. Using grounded theory, practical issues in the HealthTalk.org registry and in Option Grids were identified and categorized into a framework. We integrated the framework into the MAGIC authoring and publication platform and digitally structured authoring and publication platform and appraised its use in The BMJ Rapid Recommendations. RESULTS The framework included the following 15 categories: medication routine, tests and visits, procedure and device, recovery and adaptation, coordination of care, adverse effects, interactions and antidote, physical well-being, emotional well-being, pregnancy and nursing, costs and access, food and drinks, exercise and activities, social life and relationships, work and education, travel and driving. Implementation in 15 BMJ Rapid Recommendations added 283 issues to 35 recommendations. The most frequently used category was procedure and device, and the least frequent was social life and relationship. CONCLUSION Adding practical issues systematically to evidence summaries is feasible and can inform guidelines and tools for shared decision-making. How this inclusion can improve patient-centered care remains to be determined.
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Closure of the patent foramen ovale in patients with embolic stroke of undetermined source: A clinical expert opinion and consensus statement for the Asian-Pacific region. Int J Stroke 2020; 15:937-944. [DOI: 10.1177/1747493020941658] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Recently published long-term data from randomized controlled trials have provided evidence for the prevention of recurrent embolic stroke of undetermined source by percutaneous closure of the patent foramen ovale. However, most data were obtained from Caucasian populations and evidence on patent foramen ovale closure in Asian-Pacific patients is limited. The relative paucity in clinical data from this population, as well as the fact that Asian-Pacific patients may have higher bleeding risks than Caucasians, complicates clinical decision-making. This document, resulting from a consensus meeting of Asian-Pacific clinical experts, states the consensus among these experts about how to treat Asian-Pacific patients who had an embolic stroke of undetermined source and have a patent foramen ovale, based on currently available evidence and expert opinions. In addition, uncertainties and the need for clinical data regarding patent foramen ovale closure for prevention of recurrent embolic stroke of undetermined source in general, and specifically for Asian-Pacific patients, are identified.
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Chockalingam A, Nezami N, Murali N, Mojibian H, Pollak JS, Weiss CR. Catheter-directed therapies for pulmonary embolism: considerations for patients with patent foramen ovale. J Thromb Thrombolysis 2020; 51:516-521. [PMID: 32557222 DOI: 10.1007/s11239-020-02189-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Pulmonary embolism can be fatal, especially in high-risk patients who have contraindications to systemic thrombolysis or surgical embolectomy. For this population, interventionalists can provide catheter-directed therapies, including catheter-directed thrombolysis and thrombectomy, using a wide array of devices. Endovascular treatment of pulmonary embolism shows great promise through fractionated thrombolytic drug delivery, fragmentation, and aspiration mechanisms with thrombectomy devices. Although successful outcomes have been reported after using these treatments, evidence is especially limited in patients with both a patent foramen ovale (PFO) and acute pulmonary embolism. In patients with PFO, it is important to consider whether catheter-directed therapy is appropriate or whether surgical embolectomy should instead be performed. An increased risk of paradoxical embolus in these patients supports the use of diagnostic echocardiography with possible surgical closure of PFO after one episode of pulmonary embolism. Percutaneous PFO closure, which can be performed at the time of catheter-based therapy, theoretically reduces risk of future paradoxical embolization, although more data are needed before making a recommendation for this specific group of patients.
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Affiliation(s)
- Arun Chockalingam
- Division of Vascular and Interventional Radiology, The Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Zayed Tower 7203, Baltimore, MD, 21287, USA.,Albany Medical Center, Albany Medical College, Albany, NY, USA
| | - Nariman Nezami
- Division of Vascular and Interventional Radiology, The Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Zayed Tower 7203, Baltimore, MD, 21287, USA.,Section of Interventional Radiology, Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, USA
| | | | - Hamid Mojibian
- Section of Interventional Radiology, Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, USA
| | - Jeffrey S Pollak
- Section of Interventional Radiology, Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, USA
| | - Clifford R Weiss
- Division of Vascular and Interventional Radiology, The Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Zayed Tower 7203, Baltimore, MD, 21287, USA.
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Safouris A, Kargiotis O, Psychogios K, Kalyvas P, Ikonomidis I, Drakopoulou M, Toutouzas K, Tsivgoulis G. A Narrative and Critical Review of Randomized-Controlled Clinical Trials on Patent Foramen Ovale Closure for Reducing the Risk of Stroke Recurrence. Front Neurol 2020; 11:434. [PMID: 32655469 PMCID: PMC7326015 DOI: 10.3389/fneur.2020.00434] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 04/23/2020] [Indexed: 01/03/2023] Open
Abstract
Patent foramen ovale (PFO) is a common cardiac anatomic variant that has been increasingly found in young (<60 years) cryptogenic stroke patients. Despite initial neutral randomized-controlled clinical trials (RCTs), there have been four recent RCTs providing consistent data in favor of the efficacy and safety of PFO closure compared to medical therapy for secondary stroke prevention. However, taking into consideration the high prevalence of PFO, the low risk of stroke recurrence under medical treatment and the uncommon yet severe adverse events of the intervention, patient selection is crucial for attaining meaningful clinical benefits. Thorough workup to exclude alternative causes of stroke and identification of high-risk PFOs through clinical, neuroimaging and echocardiographic criteria are essential. Cost effectiveness of the procedure cannot be proven for the time being, since there are no robust data on clinical outcome after PFO-associated stroke but only limited anecdotal data suggesting low risk for long-term disability.
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Affiliation(s)
| | | | - Klearchos Psychogios
- Stroke Unit, Metropolitan Hospital, Pireus, Greece.,Second Department of Neurology, School of Medicine, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Ignatios Ikonomidis
- Department of Echocardiography and Laboratory of Preventive Cardiology, Second Cardiology Department, Attikon Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria Drakopoulou
- First Department of Cardiology, Athens School of Medicine, Hippokration Hospital, Athens, Greece
| | - Konstantinos Toutouzas
- First Department of Cardiology, Medical School of Athens University, Hippokration Hospital, Athens, Greece
| | - Georgios Tsivgoulis
- Second Department of Neurology, School of Medicine, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece.,Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, United States
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Fralick M, Goldberg N, Rohailla S, Guo Y, Burke MJ, Lapointe-Shaw L, Kwan JL, Weinerman AS, Rawal S, Tang T, Razak F, Verma AA. Value of routine echocardiography in the management of stroke. CMAJ 2020; 191:E853-E859. [PMID: 31387955 DOI: 10.1503/cmaj.190111] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Transthoracic echocardiography is routinely performed in patients with stroke or transient ischemic attack (TIA) to help plan secondary stroke management, but recent data evaluating its usefulness in this context are lacking. We sought to evaluate the value of echocardiography for identifying clinically actionable findings for secondary stroke prevention. METHODS We conducted a multicentre cohort study of patients admitted to hospital with stroke or TIA between 2010 and 2015 at 2 academic hospitals in Toronto, Ontario, Canada. Clinically actionable echocardiographic findings for secondary stroke prevention included cardiac thrombus, patent foramen ovale, atrial myxoma or valvular vegetation. We identified patient characteristics associated with clinically actionable findings using logistic regression. RESULTS Of the 1862 patients with stroke or TIA we identified, 1272 (68%) had at least 1 echocardiogram. Nearly all echocardiograms were transthoracic; 1097 (86%) were normal, 1 (0.08%) had an atrial myxoma, 2 (0.2%) had a valvular vegetation, 11 (0.9%) had a cardiac thrombus and 66 (5.2%) had a PFO. Patent foramen ovale was less likely among patients older than 60 years (adjusted odds ratio [OR] 0.34, 95% confidence interval [CI] 0.20-0.57), with prior stroke or TIA (adjusted OR 0.31, 95% CI 0.09-0.76) or with dyslipidemia (adjusted OR 0.39, 95% CI 0.15-0.84). Among the 130 patients with cryptogenic stroke who had an echocardiogram (n = 110), a PFO was detected in 19 (17%) on transthoracic echocardiogram. INTERPRETATION Most patients with stroke or TIA had a normal echocardiogram, with few having clinically actionable findings for secondary stroke prevention. Clinically actionable findings, specifically PFO, were more common in patients with cryptogenic stroke.
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Affiliation(s)
- Mike Fralick
- Division of General Internal Medicine (Fralick, Goldberg, Rohailla, Razak, Verma) and Li Ka Shing Centre for Healthcare Analytics Research and Training (Guo), St. Michael's Hospital, Toronto, Ont.; Department of Neurology (Burke), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.; Division of General Internal Medicine (Lapointe-Shaw, Rawal), University Health Network; Department of Medicine (Lapointe-Shaw, Rawal), University of Toronto; Division of General Internal Medicine (Kwan), Mount Sinai Hospital; Division of General Internal Medicine (Weinerman), Sunnybrook Health Sciences Centre, Toronto, Ont.; Program of Medicine and Institute for Better Health (Tang), Trillium Health Partners, Mississauga, Ont.
| | - Nicola Goldberg
- Division of General Internal Medicine (Fralick, Goldberg, Rohailla, Razak, Verma) and Li Ka Shing Centre for Healthcare Analytics Research and Training (Guo), St. Michael's Hospital, Toronto, Ont.; Department of Neurology (Burke), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.; Division of General Internal Medicine (Lapointe-Shaw, Rawal), University Health Network; Department of Medicine (Lapointe-Shaw, Rawal), University of Toronto; Division of General Internal Medicine (Kwan), Mount Sinai Hospital; Division of General Internal Medicine (Weinerman), Sunnybrook Health Sciences Centre, Toronto, Ont.; Program of Medicine and Institute for Better Health (Tang), Trillium Health Partners, Mississauga, Ont
| | - Sagar Rohailla
- Division of General Internal Medicine (Fralick, Goldberg, Rohailla, Razak, Verma) and Li Ka Shing Centre for Healthcare Analytics Research and Training (Guo), St. Michael's Hospital, Toronto, Ont.; Department of Neurology (Burke), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.; Division of General Internal Medicine (Lapointe-Shaw, Rawal), University Health Network; Department of Medicine (Lapointe-Shaw, Rawal), University of Toronto; Division of General Internal Medicine (Kwan), Mount Sinai Hospital; Division of General Internal Medicine (Weinerman), Sunnybrook Health Sciences Centre, Toronto, Ont.; Program of Medicine and Institute for Better Health (Tang), Trillium Health Partners, Mississauga, Ont
| | - Yishan Guo
- Division of General Internal Medicine (Fralick, Goldberg, Rohailla, Razak, Verma) and Li Ka Shing Centre for Healthcare Analytics Research and Training (Guo), St. Michael's Hospital, Toronto, Ont.; Department of Neurology (Burke), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.; Division of General Internal Medicine (Lapointe-Shaw, Rawal), University Health Network; Department of Medicine (Lapointe-Shaw, Rawal), University of Toronto; Division of General Internal Medicine (Kwan), Mount Sinai Hospital; Division of General Internal Medicine (Weinerman), Sunnybrook Health Sciences Centre, Toronto, Ont.; Program of Medicine and Institute for Better Health (Tang), Trillium Health Partners, Mississauga, Ont
| | - Matthew J Burke
- Division of General Internal Medicine (Fralick, Goldberg, Rohailla, Razak, Verma) and Li Ka Shing Centre for Healthcare Analytics Research and Training (Guo), St. Michael's Hospital, Toronto, Ont.; Department of Neurology (Burke), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.; Division of General Internal Medicine (Lapointe-Shaw, Rawal), University Health Network; Department of Medicine (Lapointe-Shaw, Rawal), University of Toronto; Division of General Internal Medicine (Kwan), Mount Sinai Hospital; Division of General Internal Medicine (Weinerman), Sunnybrook Health Sciences Centre, Toronto, Ont.; Program of Medicine and Institute for Better Health (Tang), Trillium Health Partners, Mississauga, Ont
| | - Lauren Lapointe-Shaw
- Division of General Internal Medicine (Fralick, Goldberg, Rohailla, Razak, Verma) and Li Ka Shing Centre for Healthcare Analytics Research and Training (Guo), St. Michael's Hospital, Toronto, Ont.; Department of Neurology (Burke), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.; Division of General Internal Medicine (Lapointe-Shaw, Rawal), University Health Network; Department of Medicine (Lapointe-Shaw, Rawal), University of Toronto; Division of General Internal Medicine (Kwan), Mount Sinai Hospital; Division of General Internal Medicine (Weinerman), Sunnybrook Health Sciences Centre, Toronto, Ont.; Program of Medicine and Institute for Better Health (Tang), Trillium Health Partners, Mississauga, Ont
| | - Janice L Kwan
- Division of General Internal Medicine (Fralick, Goldberg, Rohailla, Razak, Verma) and Li Ka Shing Centre for Healthcare Analytics Research and Training (Guo), St. Michael's Hospital, Toronto, Ont.; Department of Neurology (Burke), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.; Division of General Internal Medicine (Lapointe-Shaw, Rawal), University Health Network; Department of Medicine (Lapointe-Shaw, Rawal), University of Toronto; Division of General Internal Medicine (Kwan), Mount Sinai Hospital; Division of General Internal Medicine (Weinerman), Sunnybrook Health Sciences Centre, Toronto, Ont.; Program of Medicine and Institute for Better Health (Tang), Trillium Health Partners, Mississauga, Ont
| | - Adina S Weinerman
- Division of General Internal Medicine (Fralick, Goldberg, Rohailla, Razak, Verma) and Li Ka Shing Centre for Healthcare Analytics Research and Training (Guo), St. Michael's Hospital, Toronto, Ont.; Department of Neurology (Burke), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.; Division of General Internal Medicine (Lapointe-Shaw, Rawal), University Health Network; Department of Medicine (Lapointe-Shaw, Rawal), University of Toronto; Division of General Internal Medicine (Kwan), Mount Sinai Hospital; Division of General Internal Medicine (Weinerman), Sunnybrook Health Sciences Centre, Toronto, Ont.; Program of Medicine and Institute for Better Health (Tang), Trillium Health Partners, Mississauga, Ont
| | - Shail Rawal
- Division of General Internal Medicine (Fralick, Goldberg, Rohailla, Razak, Verma) and Li Ka Shing Centre for Healthcare Analytics Research and Training (Guo), St. Michael's Hospital, Toronto, Ont.; Department of Neurology (Burke), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.; Division of General Internal Medicine (Lapointe-Shaw, Rawal), University Health Network; Department of Medicine (Lapointe-Shaw, Rawal), University of Toronto; Division of General Internal Medicine (Kwan), Mount Sinai Hospital; Division of General Internal Medicine (Weinerman), Sunnybrook Health Sciences Centre, Toronto, Ont.; Program of Medicine and Institute for Better Health (Tang), Trillium Health Partners, Mississauga, Ont
| | - Terence Tang
- Division of General Internal Medicine (Fralick, Goldberg, Rohailla, Razak, Verma) and Li Ka Shing Centre for Healthcare Analytics Research and Training (Guo), St. Michael's Hospital, Toronto, Ont.; Department of Neurology (Burke), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.; Division of General Internal Medicine (Lapointe-Shaw, Rawal), University Health Network; Department of Medicine (Lapointe-Shaw, Rawal), University of Toronto; Division of General Internal Medicine (Kwan), Mount Sinai Hospital; Division of General Internal Medicine (Weinerman), Sunnybrook Health Sciences Centre, Toronto, Ont.; Program of Medicine and Institute for Better Health (Tang), Trillium Health Partners, Mississauga, Ont
| | - Fahad Razak
- Division of General Internal Medicine (Fralick, Goldberg, Rohailla, Razak, Verma) and Li Ka Shing Centre for Healthcare Analytics Research and Training (Guo), St. Michael's Hospital, Toronto, Ont.; Department of Neurology (Burke), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.; Division of General Internal Medicine (Lapointe-Shaw, Rawal), University Health Network; Department of Medicine (Lapointe-Shaw, Rawal), University of Toronto; Division of General Internal Medicine (Kwan), Mount Sinai Hospital; Division of General Internal Medicine (Weinerman), Sunnybrook Health Sciences Centre, Toronto, Ont.; Program of Medicine and Institute for Better Health (Tang), Trillium Health Partners, Mississauga, Ont
| | - Amol A Verma
- Division of General Internal Medicine (Fralick, Goldberg, Rohailla, Razak, Verma) and Li Ka Shing Centre for Healthcare Analytics Research and Training (Guo), St. Michael's Hospital, Toronto, Ont.; Department of Neurology (Burke), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.; Division of General Internal Medicine (Lapointe-Shaw, Rawal), University Health Network; Department of Medicine (Lapointe-Shaw, Rawal), University of Toronto; Division of General Internal Medicine (Kwan), Mount Sinai Hospital; Division of General Internal Medicine (Weinerman), Sunnybrook Health Sciences Centre, Toronto, Ont.; Program of Medicine and Institute for Better Health (Tang), Trillium Health Partners, Mississauga, Ont
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Alakbarzade V, Keteepe-Arachi T, Karsan N, Ray R, Pereira AC. Patent foramen ovale. Pract Neurol 2020; 20:225-233. [DOI: 10.1136/practneurol-2019-002450] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2020] [Indexed: 11/03/2022]
Abstract
Patent foramen ovale (PFO) is the most common anatomical cause of an interatrial shunt. It is usually asymptomatic but may cause paradoxical embolism, manifesting as stroke, myocardial infarction or visceral/peripheral ischaemia. PFO is a risk factor for stroke and may be associated with migraine with aura. New evidence suggests PFO closure reduces the risk of recurrent ischaemic stroke in a highly selected population of stroke survivors: those aged 60 years or younger with a cryptogenic stroke syndrome, a large right-to-left shunt, an atrial septal aneurysm and no evidence of atrial fibrillation. They benefit from percutaneous PFO closure in addition to antiplatelet therapy, rather than antiplatelet therapy alone. Current evidence does not support PFO closure in the treatment of migraine.
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Wintzer-Wehekind J, Alperi A, Houde C, Côté JM, del Val D, Côté M, Rodés-Cabau J. Cierre percutáneo del foramen oval permeable en pacientes mayores de 60 años con ictus criptogénico. Rev Esp Cardiol 2020. [DOI: 10.1016/j.recesp.2019.07.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Feil K, Heinrich J, von Falkenhausen AS, Becker R, Küpper C, Müller K, Thunstedt DC, Sinner MF, Kääb S, Kellert L. Recurrent Stroke in a Young Patient with Embolic Stroke of Undetermined Source and Patent Foramen Ovale: Quo Vadis? Case Rep Neurol 2020; 12:45-49. [PMID: 32110227 PMCID: PMC7036551 DOI: 10.1159/000505180] [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: 11/12/2019] [Accepted: 11/26/2019] [Indexed: 11/25/2022] Open
Abstract
So far, there has been no generally accepted diagnostic and therapeutic algorithm for patients with embolic stroke of undetermined source (ESUS). As recent clinical trials on secondary stroke prevention in ESUS did not support the use of oral anticoagulation and the concept of ESUS comprises heterogeneous subgroups of patients, including a wide age range, concomitant patent foramen ovale (PFO), variable cardiovascular risk factors as well as a variable probability for atrial fibrillation (AF), an individualized clinical approach is needed. In this context, we here present a case of recurrent stroke in a young patient with ESUS and PFO. During treatment according to our Catch-up-ESUS registry study, prolonged cardiac monitoring diagnosed AF, and PFO closure was omitted.
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Affiliation(s)
- Katharina Feil
- Department of Neurology, Ludwig Maximilian University, Munich, Germany.,German Center for Vertigo and Balance Disorders, Ludwig Maximilian University, Munich, Germany
| | - Johanna Heinrich
- Department of Neurology, Ludwig Maximilian University, Munich, Germany
| | - Aenne S von Falkenhausen
- Department of Medicine 1, Ludwig Maximilian University, Munich, Germany.,German Centre for Cardiovascular Research (DZHK), partner site: Munich Heart Alliance, Munich, Germany
| | - Regina Becker
- Department of Neurology, Ludwig Maximilian University, Munich, Germany.,German Center for Vertigo and Balance Disorders, Ludwig Maximilian University, Munich, Germany
| | - Clemens Küpper
- Department of Neurology, Ludwig Maximilian University, Munich, Germany
| | - Katharina Müller
- Department of Neurology, Ludwig Maximilian University, Munich, Germany
| | | | - Moritz F Sinner
- Department of Medicine 1, Ludwig Maximilian University, Munich, Germany.,German Centre for Cardiovascular Research (DZHK), partner site: Munich Heart Alliance, Munich, Germany
| | - Stefan Kääb
- Department of Medicine 1, Ludwig Maximilian University, Munich, Germany.,German Centre for Cardiovascular Research (DZHK), partner site: Munich Heart Alliance, Munich, Germany
| | - Lars Kellert
- Department of Neurology, Ludwig Maximilian University, Munich, Germany
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Xu L, Pan X, Zhou C, Li J, Wang F. Long-term efficacy after closure of patent foramen ovale for ischemic neurological events in young adults: A systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e18675. [PMID: 31914059 PMCID: PMC6959863 DOI: 10.1097/md.0000000000018675] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The efficacy of patent foramen ovale (PFO) closure remains controversial, and it is unclear which patient groups are best benefited. We performed this meta-analysis to clarify the efficacy of PFO closure of younger patients for prevention of recurrent ischemic neurological events. METHODS We systematically searched for studies of PFO closure for younger patients under the age of 55, and pooled available data on PFO closure of younger vs older patients and on PFO closure of younger patients vs medical therapy. The primary endpoints were the composite outcome of recurrent ischemic neurological events [stroke and/or transient ischemic attack (TIA)]. The secondary endpoints included recurrent stroke, TIA, atrial fibrillation (AF) and bleeding events. We calculated the odds ratios (OR) and 95% confidence interval (CI) using fixed-effect and random-effect models. RESULTS Three randomized controlled trials (RCT) and 13 observational studies were eligible. Compared with older patients undergoing PFO closure, younger patients undergoing closure had a lower risk of composite outcome (OR: 0.40, 95% CI: 0.28 to .56; P < .001) and AF (OR: 0.25, 95% CI: 0.10-0.61; P = .003). Compared with medical therapy, PFO closure of younger patients reduced the risk of composite outcome (OR: 0.50, 95% CI: 0.33-0.75; P<.001); there was no statistical difference in total complications of AF and bleeding events (OR: 2.15, 95% CI: 0.15-30.37; P = .57). Separate analysis of stroke and TIA showed that PFO closure in younger patients was more effective in preventing stroke (OR: 0.45, 95% CI: 0.28-0.72; P < .001) and TIA (OR: 0.35, 95% CI: 0.21-0.58); P < .001) compared with older patients. Compared with medical therapy, PFO closure of younger patients reduced the risk of stroke (OR: 0.26, 95% CI: 0.13-0.51; P < .001); but there was no difference in the risk of TIA (OR: 1.07, 95% CI: 0.16-7.01; P = .94). CONCLUSIONS Compared with PFO closure of older patients and medical therapy, PFO closure of younger patients can benefit more for the prevention of recurrent ischemic neurological events. Our results indicate that PFO closure is the best treatment strategy for younger patients under the age of 55.
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Affiliation(s)
- Liang Xu
- Department of Ultrasound, The First College of Clinical Medical Sciences, China Three Gorges University
| | - Xuemei Pan
- Department of Ultrasound, The Third People's Hospital of Yichang City, Yichang, Hubei Province, China
| | - Chang Zhou
- Department of Ultrasound, The First College of Clinical Medical Sciences, China Three Gorges University
| | - Jie Li
- Department of Ultrasound, The First College of Clinical Medical Sciences, China Three Gorges University
| | - Fangyuan Wang
- Department of Ultrasound, The First College of Clinical Medical Sciences, China Three Gorges University
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Nagarajarao HS, Ojha CP, Kedar A, Mukherjee D. Patent Foramen Ovale, the Role of Antiplatelet Therapy Alone or Anticoagulant Therapy Alone Versus Device Closure for Cryptogenic Stroke: A Review of the Literature and Current Recommendations. Cardiovasc Hematol Agents Med Chem 2020; 18:135-150. [PMID: 32013839 DOI: 10.2174/1871525718666200203111641] [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: 09/20/2019] [Revised: 11/22/2019] [Accepted: 01/16/2020] [Indexed: 06/10/2023]
Abstract
Cryptogenic stroke and its relation to the Patent Foramen Ovale (PFO) is a long-debated topic. Recent clinical trials have unequivocally established the relationship between cryptogenic strokes and paradoxical embolism across the PFO. This slit-like communication exists in everyone before birth, but most often closes shortly after birth. PFO may persist as a narrow channel of communication between the right and left atria in approximately 25-27% of adults. In this review, we examine the clinical relevance of the PFO with analysis of the latest trials evaluating catheter-based closure of PFO's for cryptogenic stroke. We also review the current evidence examining the use of antiplatelet medications versus anticoagulants for stroke prevention in those patients with PFO who do not qualify for closure per current guidelines.
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Affiliation(s)
- Harsha S Nagarajarao
- Department of Medicine, Texas Tech University of Health Sciences, El Paso, TX, United States
| | - Chandra P Ojha
- Department of Medicine, Texas Tech University of Health Sciences, El Paso, TX, United States
| | - Archana Kedar
- Department of Medicine, Clinical Instructor, University of Louisville, Kentucky, Louisville, Kentucky, United States
| | - Debabrata Mukherjee
- Department of Medicine, Texas Tech University of Health Sciences, El Paso, TX, United States
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Feil K, Heinrich J, Küpper C, Müller K, Laub C, von Falkenhausen AS, Becker R, Wollenweber FA, Kääb S, Sinner MF, Kellert L. Catch-up-ESUS - follow-up in embolic stroke of undetermined source (ESUS) in a prospective, open-label, observational study: study protocol and initial baseline data. BMJ Open 2019; 9:e031716. [PMID: 31822542 PMCID: PMC6924738 DOI: 10.1136/bmjopen-2019-031716] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
INTRODUCTION So far there is no uniform, commonly accepted diagnostic and therapeutic algorithm for patients with embolic stroke of undetermined source (ESUS). Recent clinical trials on secondary stroke prevention in ESUS did not support the use of oral anticoagulation. As ESUS comprises heterogeneous subgroups including a wide age-range, concomitant patent foramen ovale (PFO), and variable probability for atrial fibrillation (AF), an individualised approach is urgently needed. This prospective registry study aims to provide initial data towards an individual, structured diagnostic and therapeutic approach in ESUS patients. METHODS AND ANALYSIS The open-label, investigator-initiated, prospective, single-centre, observational registry study (Catch-up-ESUS) started in 01/2018. Consecutive ESUS patients ≥18 years who give informed consent are included and will be followed up for 3 years. Stratified by age <60 or ≥60 years, the patients are processed following a standardised diagnostic and treatment algorithm with an interdisciplinary design involving neurologists and cardiologists. Depending on the strata, patients receive a transesophageal echocardiogram; all patients receive an implantable cardiac monitor. Patients <60 years with PFO and without evidence of concomitant AF are planned for PFO closure within 6 months after stroke. The current diagnostic and therapeutic workup of ESUS patients requires improvement by both standardisation and a more individualised approach. Catch-up-ESUS will provide important data with respect to AF detection and PFO closure and will estimate stratified stroke recurrence rates after ESUS. ETHICS AND DISSEMINATION The study has been approved by the responsible ethics committee at the Ludwig Maximilian University, Munich, Germany (project number 17-685). Catch-Up-ESUS is conducted in accordance with the Declaration of Helsinki. All patients will have to give written informed consent or, if unable to give consent themselves, their legal guardian will have to provide written informed consent for their participation. The first observation period of the registry study is 1 year, followed by the first publication of the results including follow-up of the patients. Further publications will be considered according the predefined individual follow-up dates of the stroke patients up to 36 months. TRIAL REGISTRATION NUMBER Clinicaltrialsregister.gov registry (NCT03820375).
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Affiliation(s)
- Katharina Feil
- Department of Neurology, Ludwig-Maximilians-Universitaet (LMU) Muenchen, Muenchen, Bayern, Germany
- German Center for Vertigo and Balance Disorders, Ludwig-Maximilians-Universitaet (LMU) Muenchen, Muenchen, Bayern, Germany
| | - Johanna Heinrich
- Department of Neurology, Ludwig-Maximilians-Universitaet (LMU) Muenchen, Muenchen, Bayern, Germany
| | - Clemens Küpper
- Department of Neurology, Ludwig-Maximilians-Universitaet (LMU) Muenchen, Muenchen, Bayern, Germany
| | - Katharina Müller
- Department of Neurology, Ludwig-Maximilians-Universitaet (LMU) Muenchen, Muenchen, Bayern, Germany
| | - Christoph Laub
- Department of Neurology, Ludwig-Maximilians-Universitaet (LMU) Muenchen, Muenchen, Bayern, Germany
| | - Aenne S von Falkenhausen
- Department of Medicine 1, Ludwig-Maximilians-Universitaet (LMU) Muenchen, Muenchen, Bayern, Germany
- German Centre for Cardiovascular Research (DZHK), partner site: Munich Heart Alliance, Muenchen, Bayern, Germany
| | - Regina Becker
- Department of Neurology, Ludwig-Maximilians-Universitaet (LMU) Muenchen, Muenchen, Bayern, Germany
| | - Frank A Wollenweber
- Department of Neurology, Ludwig-Maximilians-Universitaet (LMU) Muenchen, Muenchen, Bayern, Germany
- Institute for Stroke and Dementia Research (ISD), Ludwig-Maximilians-Universität (LMU) Muenchen, Muenchen, Bayern, Germany
| | - Stefan Kääb
- Department of Medicine 1, Ludwig-Maximilians-Universitaet (LMU) Muenchen, Muenchen, Bayern, Germany
- German Centre for Cardiovascular Research (DZHK), partner site: Munich Heart Alliance, Muenchen, Bayern, Germany
| | - Moritz F Sinner
- Department of Medicine 1, Ludwig-Maximilians-Universitaet (LMU) Muenchen, Muenchen, Bayern, Germany
- German Centre for Cardiovascular Research (DZHK), partner site: Munich Heart Alliance, Muenchen, Bayern, Germany
| | - Lars Kellert
- Department of Neurology, Ludwig-Maximilians-Universitaet (LMU) Muenchen, Muenchen, Bayern, Germany
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Mongeon FP, Macle L, Beauchesne LM, Bouma BJ, Schwerzmann M, Mulder BJ, Khairy P. Non-Vitamin K Antagonist Oral Anticoagulants in Adult Congenital Heart Disease. Can J Cardiol 2019; 35:1686-1697. [DOI: 10.1016/j.cjca.2019.06.022] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 06/18/2019] [Accepted: 06/18/2019] [Indexed: 12/14/2022] Open
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Abstract
PURPOSE OF REVIEW To highlight recent advancements in the management of acute ischemic stroke patients with patent foramen ovale (PFO). RECENT FINDINGS One significant recent development was publication of long-term follow-up data from the RESPECT trial demonstrating evidence in favor of PFO closure over medical management. This data subsequently led to FDA approval for AMPLATZER™ septal occluder in the treatment of patients aged 18 to 60 years with both PFO and no other determined etiology for ischemic stroke, otherwise referred to as embolic stroke of undetermined source. Several subsequent closure trial results have recently been published, which also demonstrated benefit of PFO closure over medical management for ischemic stroke risk reduction in select patients. Based on the results of the more recently published REDUCE trial, the FDA granted approval for the GORE™ septal occluder. There is current, well-established evidence that PFO closure for secondary stroke prevention is effective in select cases.
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41
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Wintzer-Wehekind J, Alperi A, Houde C, Côté JM, Del Val D, Côté M, Rodés-Cabau J. Transcatheter closure of patent foramen ovale in patients older than 60 years of age with cryptogenic embolism. ACTA ACUST UNITED AC 2019; 73:219-224. [PMID: 31585849 DOI: 10.1016/j.rec.2019.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Accepted: 07/05/2019] [Indexed: 11/26/2022]
Abstract
INTRODUCTION AND OBJECTIVES Randomized trials have shown the efficacy of transcatheter closure of patent foramen ovale (PFO) in patients aged ≤ 60 years with cryptogenic embolism. We aimed to assess the long-term safety and efficacy of PFO closure in patients aged> 60 years. METHODS Of 475 consecutive patients with cryptogenic embolism who underwent PFO closure, 90 older patients aged> 60 years (mean, 66±5 years) were compared with 385 younger patients aged ≤ 60 years (mean, 44±10 years). RESULTS Older patients had a higher prevalence of cardiovascular risk factors (CVRF) (hypertension, dyslipidemia, diabetes; P <.01 for all vs younger patients). There were no differences in periprocedural complications between the 2 groups. During a median follow-up of 8 (4-12) years, there were a total of 17 deaths, all from noncardiovascular causes (7.8% and 2.6% in the older and younger patient groups, respectively; HR, 4.12; 95%CI, 1.56-10.89). Four patients had a recurrent stroke (2.2% and 0.5% in the older and younger patient groups, respectively; HR, 5.08; 95%CI, 0.71-36.2), and 12 patients had a transient ischemic attack (TIA) (3.3% and 2.3% in the older and younger patient groups, respectively; HR, 1.71; 95%CI, 0.46-6.39). There was a trend toward a higher rate of the composite of stroke/TIA in older patients (5.5% vs 2.6%; HR, 2.62; 95%CI, 0.89-7.75; P=.081), which did not persist after adjustment for CVRF (HR, 1.97; 95%CI, 0.59-6.56; P=.269). CONCLUSIONS In older patients with cryptogenic embolism, PFO closure was safe and associated with a low rate of ischemic events at long-term. However, older patients exhibited a tendency toward a higher incidence of recurrent stroke/TIA compared with younger patients, likely related to a higher burden of CVRF.
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Affiliation(s)
| | - Alberto Alperi
- Quebec Heart and Lung Institute, Laval University, Quebec, Canada
| | | | - Jean-Marc Côté
- Centre Hospitalier Universitaire de Quebec, Quebec, Canada
| | - David Del Val
- Quebec Heart and Lung Institute, Laval University, Quebec, Canada
| | - Mélanie Côté
- Quebec Heart and Lung Institute, Laval University, Quebec, Canada
| | - Josep Rodés-Cabau
- Quebec Heart and Lung Institute, Laval University, Quebec, Canada; Centre Hospitalier Universitaire de Quebec, Quebec, Canada.
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42
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Ha FJ, Adams H, Palmer S. Device closure for patent foramen ovale in patients with cryptogenic stroke: a paradigm in evidence. Med J Aust 2019; 211:343-344.e1. [DOI: 10.5694/mja2.50341] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
| | - Heath Adams
- St Vincent's Hospital Melbourne Melbourne VIC
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Affiliation(s)
- David L. Tirschwell
- From the Department of Neurology, Harborview Division, University of Washington, Seattle
| | - Breana L. Taylor
- From the Department of Neurology, Harborview Division, University of Washington, Seattle
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44
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Arfaras-Melainis A, Palaiodimos L, Mojadidi MK. Transcatheter Closure of Patent Foramen Ovale: Randomized Trial Update. Interv Cardiol Clin 2019; 8:341-356. [PMID: 31445719 DOI: 10.1016/j.iccl.2019.05.002] [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: 01/10/2023]
Abstract
A patent foramen ovale (PFO) is found in about one-quarter of all adults, but the prevalence increases to approximately half of those with a history of a so-called cryptogenic stroke. The true efficacy of PFO closure for prevention of recurrent paradoxical embolism has been debated for years, as the early 3 randomized trials did not show a statistically significant benefit of PFO closure over standard-of-care medical therapy. However, 3 recent randomized trials along with the long-term follow-up data from the largest early trial demonstrated superiority of device closure for secondary stroke prevention.
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Affiliation(s)
- Angelos Arfaras-Melainis
- Second Cardiology Department, National and Kapodistrian University of Athens, Attikon University Hospital, 1 Rimini Street, Haidari, Athens 12462, Greece
| | - Leonidas Palaiodimos
- Department of Medicine, Division of Hospital Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467, USA.
| | - Mohammad K Mojadidi
- Division of Cardiology, Department of Medicine, Virginia Commonwealth University, 1101 East Marshall Street, Richmond, VA 23298, USA
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45
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Darmoch F, Al-Khadra Y, Bacha HM, Soud M, Alraies MC. Closing the gap on patent foramen ovale and cryptogenic stroke. Expert Rev Cardiovasc Ther 2019; 17:389-394. [PMID: 31184225 DOI: 10.1080/14779072.2019.1627875] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Introduction: The treatment options for prevention of recurrent of cryptogenic stroke in patients with patent foramen ovale (PFO) have been intensely debated in the recent decades. The suggested options were percutaneous closure of PFO versus medical therapy. However, up to these date there is a controversy regarding the indication of percutaneous closure. Multiple meta-analysis and recent randomized control trials showed the benefit of PFO closure when compared with medical therapy alone. Areas covered: The article reviews the prevalence, physiology, diagnosis and treatment options of PFO after cryptogenic stroke. Furthermore, it will discuss the results of randomized control trials that compared the PFO closure to medical therapy. Expert opinion: The association between PFO and unexplained cryptogenic stroke has been well established in the multiple studies. The diagnosis and management of PFO might be challenging in some cases. Although multiple studies showed that PFO closure is associated with lower rates of recurrent stroke in patients presenting with cryptogenic stroke, the indication and patient selection for this intervention are not well established yet in the guidelines.
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Affiliation(s)
- Fahed Darmoch
- a Beth Israel Deaconess Medical Center/Harvard School of Medicine , Boston , MA , USA
| | | | | | - Mohammad Soud
- c MedStar Washington Hospital Center , Washington, D.C. , USA
| | - M Chadi Alraies
- d Wayne State University, Detroit Medical Center , Detroit Heart Hospital , Detroit , MI , USA
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46
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Wintzer-Wehekind J, Alperi A, Houde C, Côté JM, Guimaraes LDFC, Côté M, Rodés-Cabau J. Impact of Discontinuation of Antithrombotic Therapy Following Closure of Patent Foramen Ovale in Patients With Cryptogenic Embolism. Am J Cardiol 2019; 123:1538-1545. [PMID: 30792001 DOI: 10.1016/j.amjcard.2019.01.043] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Revised: 01/19/2019] [Accepted: 01/22/2019] [Indexed: 01/10/2023]
Abstract
No data exist on the optimal duration of antithrombotic therapy (AT) following patent foramen ovale (PFO) closure. We sought to assess the safety of AT discontinuation following PFO closure in patients with a cryptogenic ischemic event. A total of 453 consecutive patients (mean age: 48 ± 13years, men: 51%) who underwent PFO closure due to a cryptogenic ischemic event were included. All patients were on AT following PFO closure (antiplatelet therapy: 92.7%, anticoagulation: 7.3%). Ischemic and bleeding events, and AT were assessed at a median follow-up of 8 (IQR: 4 to 11) years, and follow-up was complete in 96% of patients. Stroke and transient ischemic attack occurred in 4 (0.9%) and 12 (2.6%) patients, respectively, and 27 (6.0%) patients had bleeding events (major in 6 [1.3%] patients, including 4 episodes of intracranial hemorrhage). All major bleeding events occurred under aspirin therapy. A total of 82 patients (18%) stopped the AT at a median of 7 (IQR: 5 to 34) months post-PFO closure (due to a bleeding event or gastrointestinal symptoms: 13 patients, no specific reason: 69 patients), and none of them had any ischemic event after a median time of 7 (IQR 3 to 10) years without any AT. A propensity score matched analysis including 46 patients who discontinued the AT within 1-year post-PFO closure and 120 patients with an ongoing AT showed the lack of differences in ischemic events between groups (0 vs 0.2 stroke/transient ischemic attack per 100 patient-years in the no-AT and AT groups, respectively). In conclusion, in young patients who underwent PFO closure, bleeding events occurred in ∼6% of patients after a median follow-up of 8years. AT was discontinued in about one fifth of patients (most of them within the year following PFO closure), and this was not associated with any increase in ischemic events at long-term follow-up. These results suggest that, in patients without other co-morbidities increasing the risk of stroke, temporary AT following PFO closure may be a reasonable strategy.
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Alkhouli M, Sievert H, Holmes DR. Patent foramen ovale closure for secondary stroke prevention. Eur Heart J 2019; 40:2339-2350. [PMID: 30957864 DOI: 10.1093/eurheartj/ehz157] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 10/30/2018] [Accepted: 03/05/2019] [Indexed: 01/10/2023] Open
Abstract
Abstract
Transcatheter closure of patent foramen ovale (PFO) in patients with cryptogenic stroke is gaining momentum after the recent publication of four randomized clinical trials suggesting its benefit. This article provides a contemporary overview of the anatomy and pathophysiology of PFO, the available diagnostic tools for the assessment and risk stratification of PFO, and the current and future landscape of PFO closure devices and their optimal utilization. It also summarizes the current data on PFO closure for stroke prevention, and discusses the remaining open issues in the field of PFO closure.
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Affiliation(s)
- Mohamad Alkhouli
- Division of Cardiology, School of Medicine, West Virginia University, 1 Medical Center Drive, Morgantown, WV, USA
| | - Horst Sievert
- Department of Medicine, CardioVascular Center Frankfurt, Seckbacher Landstraße 65, Frankfurt am Main, Germany
- Anglia Ruskin University, Cambridge Campus, East Rd, Cambridge, UK
- Yunnan Hospital Fuwai, Intersection of Shahe Beilu and Jinchuan Lu, Kunming, China
- University of California, 550 16th Street, San Francisco, CA, USA
| | - David R Holmes
- Department of Cardiology, Mayo Clinic School of Medicine, 200 1st St SW, Rochester, MN, USA
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48
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[Closure of the patent foramen ovale (PFO) in cryptogenic stroke]. Herz 2019; 44:304-309. [PMID: 30941472 DOI: 10.1007/s00059-019-4800-0] [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: 01/10/2023]
Abstract
Autopsy studies and echocardiographic investigations have shown that around 20-25% of the healthy population have a patent foramen ovale (PFO). In patients younger than 55 years the risk of a cryptogenic stroke is increased in the presence of a PFO. The first three randomized studies could not demonstrate superiority of an interventional closure of a PFO compared to antithrombotic treatment in patients with cryptogenic stroke. The results of three recently published studies and the extension of an earlier study showed a superiority of an interventional closure of a PFO compared to stroke prevention with antiplatelet therapy in patients aged 18-60 years after a cryptogenic stroke; however, PFO closure was not superior to oral anticoagulation but anticoagulation is associated with an increased risk of bleeding. The implantation of a PFO occluder can be associated with transient atrial fibrillation in some patients. The collaboration of neurologists and cardiologists is essential in order to select patients who are most likely to benefit from a PFO closure.
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49
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Agasthi P, Kolla KR, Yerasi C, Tullah S, Pulivarthi VS, Louka B, Arsanjani R, Yang EH, Mookadam F, Fortuin FD. Are we there yet with patent foramen ovale closure for secondary prevention in cryptogenic stroke? A systematic review and meta-analysis of randomized trials. SAGE Open Med 2019; 7:2050312119828261. [PMID: 30783525 PMCID: PMC6365999 DOI: 10.1177/2050312119828261] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 01/14/2019] [Indexed: 01/02/2023] Open
Abstract
Background: We performed a meta-analysis to evaluate the benefit of patent foramen ovale closure in stroke prevention. Methods: We searched Medline/PubMed, EMBASE, Web of Science and Cochrane central database for randomized control trials assessing the incidence of recurrent stroke after patent foramen ovale closure when compared to medical therapy. Pooled odds ratio and 95% confidence intervals were calculated using a random effects model. The heterogeneity among studies was tested using the χ2 test and inconsistency was quantified using the I2 statistic. Results: Our search strategy yielded 71 articles. We included five studies with a total of 3440 patients. Median age in the device group was 45 (43, 5.5) years and in the medical group was 45 (44.5, 46) years; 52% were male, 27.7% of patients had an atrial septal aneurysm, 25% had hypertension, and 20.5% had diabetes mellitus. The median follow-up time was 44 (34.5–50) months. The pooled odds ratio of recurrent stroke, transient ischemic attack and composite end point of stroke + transient ischemic attack + peripheral embolism in the patent foramen ovale closure versus medical therapy group were 0.4 (95% confidence interval 0.25–0.63, I2 = 57.5%), 0.93 (95% confidence interval 0.61–1.42, I2 = 0%), and 0.6 (95% confidence interval 0.44–0.82, I2 = 0%), respectively. The incidence of atrial fibrillation was found to be significantly higher in the patent foramen ovale closure group with odds ratio of 6 (95% confidence interval 3.13–11.4, I2 = 33.5%). On subgroup analysis, patent foramen ovale closure appeared to benefit males and patients with a large shunt. Number needed to treat to prevent one recurrent stroke with patent foramen ovale closure is 42. Number needed to harm to cause one atrial fibrillation with patent foramen ovale closure is 39. Conclusion: This meta-analysis of randomized trials concludes that percutaneous patent foramen ovale closure is effective in recurrent stroke prevention especially in males and in those with a large shunt.
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Affiliation(s)
- Pradyumna Agasthi
- Department of Cardiovascular Diseases, Mayo Clinic, Phoenix, AZ, USA
| | | | - Charan Yerasi
- Department of Cardiovascular Diseases, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Sibghat Tullah
- Department of Cardiovascular Diseases, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | | | - Boshra Louka
- Department of Cardiovascular Diseases, Mayo Clinic, Phoenix, AZ, USA
| | - Reza Arsanjani
- Department of Cardiovascular Diseases, Mayo Clinic, Phoenix, AZ, USA
| | - Eric H Yang
- Department of Cardiovascular Diseases, Mayo Clinic, Phoenix, AZ, USA
| | - Farouk Mookadam
- Department of Cardiovascular Diseases, Mayo Clinic, Phoenix, AZ, USA
| | - F David Fortuin
- Department of Cardiovascular Diseases, Mayo Clinic, Phoenix, AZ, USA
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50
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Köhrmann M, Schellinger PD, Tsivgoulis G, Steiner T. Patent Foramen Ovale: Story Closed? J Stroke 2019; 21:23-30. [PMID: 30732440 PMCID: PMC6372901 DOI: 10.5853/jos.2018.03097] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 12/11/2018] [Indexed: 12/24/2022] Open
Abstract
The optimal treatment strategy for secondary prevention in patients with cryptogenic stroke and patent foramen ovale (PFO) has been a matter of controversy for decades. After three randomized trials failed to show a benefit of closure with an excess of complications in the interventional arm, two large recent trials suggest a benefit with regard of preventing further ischemic strokes. With this discrepancy in results it is important to discuss recent trials in detail and evolve an informed clinical approach for daily practice.
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Affiliation(s)
- Martin Köhrmann
- Department of Neurology, Essen University Hospital, Essen, Germany
| | | | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece.,Department of Neurology, University of Tennessee Health Sciences Center, Memphis, TN, USA
| | - Thorsten Steiner
- Department of Neurology, Frankfurt Hoechst Hospital, Frankfurt, Germany.,Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
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