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Wong M, Parsi K, Myers K, De Maeseneer M, Caprini J, Cavezzi A, Connor DE, Davies AH, Gianesini S, Gillet JL, Grondin L, Guex JJ, Hamel-Desnos C, Morrison N, Mosti G, Orrego A, Partsch H, Rabe E, Raymond-Martimbeau P, Schadeck M, Simkin R, Tessari L, Thibault PK, Ulloa JH, Whiteley M, Yamaki T, Zimmet S, Kang M, Vuong S, Yang A, Zhang L. Sclerotherapy of lower limb veins: Indications, contraindications and treatment strategies to prevent complications - A consensus document of the International Union of Phlebology-2023. Phlebology 2023; 38:205-258. [PMID: 36916540 DOI: 10.1177/02683555231151350] [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: 03/16/2023]
Abstract
BACKGROUND Sclerotherapy is a non-invasive procedure commonly used to treat superficial venous disease, vascular malformations and other ectatic vascular lesions. While extremely rare, sclerotherapy may be complicated by serious adverse events. OBJECTIVES To categorise contraindications to sclerotherapy based on the available scientific evidence. METHODS An international, multi-disciplinary panel of phlebologists reviewed the available scientific evidence and developed consensus where evidence was lacking or limited. RESULTS Absolute Contraindications to sclerotherapy where the risk of harm would outweigh any benefits include known hypersensitivity to sclerosing agents; acute venous thromboembolism (VTE); severe neurological or cardiac adverse events complicating a previous sclerotherapy treatment; severe acute systemic illness or infection; and critical limb ischaemia. Relative Contraindications to sclerotherapy where the potential benefits of the proposed treatment would outweigh the risk of harm or the risks may be mitigated by other measures include pregnancy, postpartum and breastfeeding; hypercoagulable states with risk of VTE; risk of neurological adverse events; risk of cardiac adverse events and poorly controlled chronic systemic illness. Conditions and circumstances where Warnings and Precautions should be considered before proceeding with sclerotherapy include risk of cutaneous necrosis or cosmetic complications such as pigmentation and telangiectatic matting; intake of medications such as the oral contraceptive and other exogenous oestrogens, disulfiram and minocycline; and psychosocial factors and psychiatric comorbidities that may increase the risk of adverse events or compromise optimal treatment outcomes. CONCLUSIONS Sclerotherapy can achieve safe clinical outcomes provided that (1) patient-related risk factors and in particular all material risks are (1a) adequately identified and the risk benefit ratio is clearly and openly discussed with treatment candidates within a reasonable timeframe prior to the actual procedure; (1b) when an individual is not a suitable candidate for the proposed intervention, conservative treatment options including the option of 'no intervention as a treatment option' are discussed; (1c) complex cases are referred for treatment in controlled and standardised settings and by practitioners with more expertise in the field; (1d) only suitable individuals with no absolute contraindications or those with relative contraindications where the benefits outweigh the risks are offered intervention; (1e) if proceeding with intervention, appropriate prophylactic measures and other risk-mitigating strategies are adopted and appropriate follow-up is organised; and (2) procedure-related risk factors are minimised by ensuring the treating physicians (2a) have adequate training in general phlebology with additional training in duplex ultrasound, procedural phlebology and in particular sclerotherapy; (2b) maintain their knowledge and competency over time and (2c) review and optimise their treatment strategies and techniques on a regular basis to keep up with the ongoing progress in medical technology and contemporary scientific evidence.
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Affiliation(s)
- Mandy Wong
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Kurosh Parsi
- Department of Dermatology, St Vincent's Hospital, Sydney, Darlinghurst, NSW, Australia.,Faculty of Medicine, 7800University of New South Wales, Sydney, NSW, Australia.,Dermatology, Phlebology and Fluid Mechanics Research Laboratory, St Vincent's Centre for Applied Medical Research, Sydney, NSW, Australia.,Australasian College of Phlebology, Chatswood, NSW, Australia
| | - Kenneth Myers
- Australasian College of Phlebology, Chatswood, NSW, Australia
| | | | - Joseph Caprini
- University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | | | - David E Connor
- Department of Dermatology, St Vincent's Hospital, Sydney, Darlinghurst, NSW, Australia.,Faculty of Medicine, 7800University of New South Wales, Sydney, NSW, Australia.,Dermatology, Phlebology and Fluid Mechanics Research Laboratory, St Vincent's Centre for Applied Medical Research, Sydney, NSW, Australia
| | - Alun H Davies
- 4615Department of Surgery & Cancer, Imperial College London, UK
| | - Sergio Gianesini
- Department of Translational Medicine, University of Ferrara, Italy
| | | | | | | | - Claudine Hamel-Desnos
- Department of Vascular Medicine, Saint Martin Private Hospital Ramsay GdS, Caen,France and Paris Saint Joseph Hospital Group, France
| | | | | | | | | | - Eberhard Rabe
- Emeritus, Department of Dermatology, University of Bonn, Germany
| | | | | | - Roberto Simkin
- Faculty of Medicine, 28196University of Buenos Aires, Argentina
| | | | - Paul K Thibault
- Australasian College of Phlebology, Chatswood, NSW, Australia.,Central Vein and Cosmetic Medical Centre, Newcastle, Australia
| | - Jorge H Ulloa
- Hospital Universitario Fundación Santa Fé - Universidad de los Andes, Bogotá, Colombia
| | | | - Takashi Yamaki
- Department of Plastic and Reconstructive Surgery, Tokyo Women's Medical University Adachi Medical Center, Japan
| | | | - Mina Kang
- Department of Dermatology, St Vincent's Hospital, Sydney, Darlinghurst, NSW, Australia.,Faculty of Medicine, 7800University of New South Wales, Sydney, NSW, Australia.,Dermatology, Phlebology and Fluid Mechanics Research Laboratory, St Vincent's Centre for Applied Medical Research, Sydney, NSW, Australia
| | - Selene Vuong
- Dermatology, Phlebology and Fluid Mechanics Research Laboratory, St Vincent's Centre for Applied Medical Research, Sydney, NSW, Australia
| | - Anes Yang
- Department of Dermatology, St Vincent's Hospital, Sydney, Darlinghurst, NSW, Australia.,Dermatology, Phlebology and Fluid Mechanics Research Laboratory, St Vincent's Centre for Applied Medical Research, Sydney, NSW, Australia
| | - Lois Zhang
- Department of Dermatology, St Vincent's Hospital, Sydney, Darlinghurst, NSW, Australia.,Faculty of Medicine, 7800University of New South Wales, Sydney, NSW, Australia.,Dermatology, Phlebology and Fluid Mechanics Research Laboratory, St Vincent's Centre for Applied Medical Research, Sydney, NSW, Australia
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2
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Gonnah AR, Bharadwaj MS, Nassar H, Abdelaziz HK, Roberts DH. Patent foramen ovale: diagnostic evaluation and the role of device closure. Clin Med (Lond) 2022; 22:441-448. [PMID: 38589065 PMCID: PMC9595009 DOI: 10.7861/clinmed.2022-0040] [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: 12/15/2022]
Abstract
Although seemingly benign, the presence of a patent foramen ovale (PFO) may play an important role in the pathophysiology of disease, specifically a paradoxical embolism leading to cryptogenic stroke. The European Society of Cardiology recently published guidelines detailing how PFOs are associated with paradoxical embolism and how they are diagnosed and managed. This review guides physicians in the diagnostic and referral process to a multidisciplinary team involved in PFO closure. It reviews the clinical trials comparing device closure with medical therapy and highlights the current NHS England commissioning process on PFO management. Finally, we give an overview of other conditions where PFO device closure may need to be considered.
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Affiliation(s)
- Ahmed R Gonnah
- University of Liverpool School of Medicine, Liverpool, UK; joint first authors
| | - Mahima S Bharadwaj
- University of Liverpool School of Medicine, Liverpool, UK; joint first authors.
| | - Hassan Nassar
- University of Liverpool School of Medicine, Liverpool, UK
| | | | - David Hesketh Roberts
- Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK and honorary senior clinical lecturer, University of Liverpool, Liverpool, UK
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3
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Kolte D, Palacios IF. Patent foramen ovale closure for secondary prevention of cryptogenic stroke. Expert Rev Cardiovasc Ther 2021; 19:211-220. [PMID: 33605829 DOI: 10.1080/14779072.2021.1878026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: A patent foramen ovale (PFO) is highly prevalent among the adult population. It allows shunting of blood through the inter-atrial septum and has been associated with cryptogenic stroke, transient ischemic attack, platypnea-orthodeoxia syndrome, decompression sickness (e.g. deep-water divers), and migraines.Areas Covered: In this manuscript, we will review the anatomy of PFO with particular emphasis on the factors associated with increased risk of paradoxical embolization, as well as the different modalities for the diagnosis of PFO. We will discuss medical, surgical, and transcatheter therapy for secondary prevention in patients with PFO and cryptogenic stroke, and summarize the data from observational studies, randomized controlled trials (RCTs), and meta-analysis of RCTs that have established the beneficial effect of transcatheter PFO closure in this patient population. Finally, we will provide a brief overview of the role of transcatheter PFO closure in patients with migraine.Expert Opinion: Transcatheter closure is the preferred treatment option in young (<60 years) patients with PFO and cryptogenic stroke. A multi-disciplinary approach with input from clinical cardiologist, neurologist, hematologist, cardiac surgeon, and interventional cardiologist provides the best therapeutic plan for each patient taking into account the available data, but also medical, social, and occupational considerations.
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Affiliation(s)
- Dhaval Kolte
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Igor F Palacios
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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4
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Bruce L, Gunston G, Myburgh A, Keet K, Augoustides JG, Pulton DA, Thalappillil R, Rong LQ, Garner C, Fernando RJ. The Anatomy of the Eustachian Valve-Navigating the Implications for Right-Sided Surgical and Transcatheter Cardiac Interventions. J Cardiothorac Vasc Anesth 2020; 35:1215-1224. [PMID: 33455884 DOI: 10.1053/j.jvca.2020.12.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 12/09/2020] [Indexed: 02/06/2023]
Affiliation(s)
- Louren Bruce
- Division of Clinical Anatomy and Biological Anthropology, Department of Human Biology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Geney Gunston
- Division of Clinical Anatomy and Biological Anthropology, Department of Human Biology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Adriaan Myburgh
- Department of Anesthesia and Perioperative Medicine, Groote Schuur Hospital, Cape Town, South Africa
| | - Kerri Keet
- Division of Clinical Anatomy, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - John G Augoustides
- Cardiovascular and Thoracic Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| | - Danielle A Pulton
- Cardiovascular and Thoracic Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | - Lisa Q Rong
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY
| | - Chandrika Garner
- Cardiothoracic Section, Department of Anesthesiology, School of Medicine, Wake Forest University, Winston Salem, NC
| | - Rohesh J Fernando
- Cardiothoracic Section, Department of Anesthesiology, School of Medicine, Wake Forest University, Winston Salem, NC
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5
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Abusnina W, Megri M, Edris B, El-Hamdani M. Arterial embolism in a patient with pulmonary embolism and patent foramen ovale. Proc (Bayl Univ Med Cent) 2019; 32:256-258. [PMID: 31191146 DOI: 10.1080/08998280.2019.1576460] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 01/24/2019] [Accepted: 01/28/2019] [Indexed: 10/27/2022] Open
Abstract
Paradoxical embolization is an uncommon but devastating complication of pulmonary embolism and continues to be frequently missed. Although the prevalence of patent foramen ovale is 25% to 30%, the risk of paradoxical embolism is <2% of all arterial ischemia. Paradoxical embolism is infrequent but can involve almost any artery of the body. Here, we present a case of a 65-year-old woman with paradoxical systemic arterial embolism secondary to deep venous thrombosis and pulmonary embolism in the presence of patent foramen ovale. High suspicion for paradoxical embolism is needed in the event of unexplained arterial occlusion. Awareness of this complication with prompt recognition and treatment could serve to preclude significant disability and death.
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Affiliation(s)
- Waiel Abusnina
- Department of Internal Medicine, Joan C. Edwards School of Medicine, Marshall UniversityHuntingtonWest Virginia
| | - Mohammed Megri
- Division of Pulmonary/Critical Care and Sleep Medicine, University of Kentucky Medical CenterLexingtonKentucky
| | - Basel Edris
- Department of Cardiovascular Disease, Joan C. Edwards School of Medicine, Marshall UniversityHuntingtonWest Virginia
| | - Mehiar El-Hamdani
- Department of Cardiovascular Disease, Joan C. Edwards School of Medicine, Marshall UniversityHuntingtonWest Virginia
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6
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Agdamag AC, Gomez JM, Collado FM, Kavinsky C. Patent foramen ovale and ascending aortic aneurysm causing the platypnea-orthodeoxia syndrome. Proc (Bayl Univ Med Cent) 2019; 32:242-244. [PMID: 31191140 DOI: 10.1080/08998280.2018.1559387] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Revised: 12/09/2018] [Accepted: 12/10/2018] [Indexed: 10/27/2022] Open
Abstract
Patent foramen ovale (PFO) is present in about 25% of the population. Platypnea-orthodeoxia syndrome (POS), which is dyspnea and hypoxemia in the upright position that is relieved when supine, is a rare manifestation of PFO. We describe a case of a 74-year-old woman who presented with new-onset hypoxia. A PFO and a dilated aorta causing POS were found on workup. Symptoms were resolved after undergoing percutaneous PFO closure. This case highlights the mechanism by which an ascending aortic aneurysm can alter hemodynamics through an existing PFO, leading to symptoms of a previously clinically insignificant PFO, and emphasizes how early recognition of POS allows for appropriate intervention.
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Affiliation(s)
| | | | - Fareed Moses Collado
- Division of Cardiology, Department of Internal Medicine, Rush University Medical CenterChicagoIllinois
| | - Clifford Kavinsky
- Division of Cardiology, Department of Internal Medicine, Rush University Medical CenterChicagoIllinois
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7
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Xia T, Zarbin MA, Bhagat N. Retinal Artery Occlusion in Young Patients: A 6-Year Review. ACTA ACUST UNITED AC 2019. [DOI: 10.1177/2474126419828239] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: This article describes the characteristics, management, and etiology of retinal artery occlusions (RAOs) in young patients. Methods: A retrospective chart review of patients <50 years of age with ophthalmic and RAOs was conducted. Data were collected on demographics, clinical presentation, laboratory and imaging evaluation, management, and outcome. Results: Seventeen eyes of 15 patients younger than 50 (mean age, 34±8 years; 71% male, 29% female) with RAOs were identified. AOs included: 8 (47%) central RAOs (CRAOs), 5 (29%) branch RAOs (BRAOs), 3 (18%) ophthalmic AOs (OAOs), and 1 (6%) combined CRAO and vein occlusion (CRAO/CRVO). Logarithm of the minimum angle of resolution visual acuity (VA) at presentation was 2.6±4 (Snellen range 20/15 to no light perception). Systemic diseases in patients with BRAO included Susac disease (n = 1), sickle cell disease (n = 2), patent foramen ovale (PFO) (n = 1), and HIV (n = 1). CRAO was diagnosed in 4 patients after invasive surgery (3 after neurosurgery and 1 after cardiac surgery). Other patients had hypertension (n = 3), hypercoagulability due to uterine cancer (n = 1), and PFO (n = 1). OAOs were noted in 1 patient with Saturday night retinopathy and in 1 with ruptured internal carotid aneurysm at the level of the ophthalmic artery. Two eyes with CRAO were treated with tissue plasminogen activator (1 intraophthalmic artery through catheterization and 1 intravenously) without any change in final VA. In these patients, VA remained poor (VA hand motions – counting fingers) at 6 months or greater follow-up visits. Conclusion: RAO in young patients is uncommon. In this series, one-fourth of occlusions were seen during the perioperative period. A significant number of patients had concurrent uncontrolled hypertension. Other associated systemic findings included PFO, hypercoagulability, sickle cell disease, Susac disease, and HIV.
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Affiliation(s)
- Tian Xia
- Institute of Ophthalmology and Visual Science, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Marco A. Zarbin
- Institute of Ophthalmology and Visual Science, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Neelakshi Bhagat
- Institute of Ophthalmology and Visual Science, Rutgers New Jersey Medical School, Newark, NJ, USA
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8
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Interatrial septum: A pictorial review of congenital and acquired pathologies and their management. Clin Imaging 2019; 55:53-64. [PMID: 30754012 DOI: 10.1016/j.clinimag.2019.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 01/28/2019] [Accepted: 02/05/2019] [Indexed: 11/21/2022]
Abstract
There are many different congenital abnormalities and acquired pathologies involving the interatrial septum. Differentiation of these pathologies significantly affects patient management. We have reviewed the various interatrial septal pathologies and discussed their congenital associates, clinical significance, and management. After reading this article, the reader should be able to better characterize the interatrial septal pathologies using the optimal imaging tools, and have a better understanding of their clinical significance and management.
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9
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Vaidya K, Khandkar C, Celermajer D. Current management aspects in adult congenital heart disease: non-surgical closure of patent foramen ovale. Cardiovasc Diagn Ther 2019; 8:739-753. [PMID: 30740321 DOI: 10.21037/cdt.2018.09.09] [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] [Indexed: 01/10/2023]
Abstract
A patent foramen ovale (PFO) is a remnant interatrial communication, best diagnosed with transoesophageal echocardiography (TOE) and bubble study. Although quite common and often asymptomatic, PFO is associated with cryptogenic stroke and migraine. Approximately one-half of patients with a cryptogenic stroke have a PFO, and the dilemma regarding whether or not to proceed with percutaneous device closure, to reduce the risk of future recurrent events due to paradoxical embolism, has been subject to debate for nearly two decades. Despite promising observational data, initial randomised clinical trials failed to demonstrate superiority of closure over medical therapy. However, long-term follow-up data from one of these early trials, combined with two new randomised trials, have provided more evidence for the benefits of closure in selected patients. This new evidence suggests that younger patients with high-risk features such as an atrial septal aneurysm (ASA) or large interatrial shunt are more likely to benefit from PFO closure, after fastidious exclusion of an alternative cause for the index stroke. However, issues which require further clarification include whether anticoagulant therapy is preferable to antiplatelet therapy for medical management, and which particular type of closure device is optimal. Finally, despite promising retrospective observational data suggesting improvement in migraine attacks after PFO closure, high quality evidence is lacking in this regard.
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Affiliation(s)
- Kaivan Vaidya
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia.,Central Clinical School, Faculty of Medicine, University of Sydney, Sydney, Australia
| | - Chinmay Khandkar
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia.,Central Clinical School, Faculty of Medicine, University of Sydney, Sydney, Australia
| | - David Celermajer
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia.,Central Clinical School, Faculty of Medicine, University of Sydney, Sydney, Australia
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10
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Patent foramen ovale closure versus medical therapy for cryptogenic stroke: An updated meta-analysis. J Neurol Sci 2018; 390:139-149. [DOI: 10.1016/j.jns.2018.04.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 04/02/2018] [Accepted: 04/18/2018] [Indexed: 11/19/2022]
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Reinthaler M, Ozga AK, Sinning D, Curio J, Al-Hindwan HS, Bäckemo Johansson J, Jung F, Lendlein A, Rauch G, Landmesser U. Revival of transcatheter PFO closure: A meta-analysis of randomized controlled trials - impact of shunt size and age. Am Heart J 2018; 201:95-102. [PMID: 29910060 DOI: 10.1016/j.ahj.2018.03.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 03/28/2018] [Indexed: 11/15/2022]
Abstract
BACKGROUND Transcatheter foramen ovale closure (TPC) has emerged as a potential treatment option for patients with cryptogenic strokes and persistent foramen ovale (PFO). However, previous randomized controlled trials could hardly demonstrate any benefit compared to medical treatment (Med-Tx). Recently new data have become available which may change current practice of transcatheter PFO closure. METHODS A systematic review and meta-analysis comparing TPC and Med-Tx based on all available multicentric randomized controlled trials was performed. The primary outcome of interest was the recurrence of stroke in both groups. RESULTS Five studies met the inclusion criteria with 1829 patients in the TPC and 1622 in the Med-Tx group. The median follow-up was 4 years. In the intention-to-treat analysis we found a statistically significant relative risk reduction in recurrence of strokes in the TPC group compared to the Med-Tx group (pooled hazard ratio (HR): 0.32; 95% CI: 0.13-0.8; P = .018). Excluding one study due to potential publication bias resulted in a pooled HR of 0.48 (95% CI: 0.25-0.91, P = .024). Patients younger than 45 years of age (pooled HR: 0.35; 95% CI: 0.16-0.75; P = .007) and those with moderate to severe shunt (pooled HR: 0.28; 95% CI: 0.14-0.55; P < .001) were more likely to benefit from closure. CONCLUSION According to our meta-analysis TPC plus antiplatelets was superior in terms of stroke prevention when compared to Med-Tx. Furthermore, patients with moderate to severe shunts and those younger than 45 years of age were found to benefit most from TPC.
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Affiliation(s)
- Markus Reinthaler
- Department of Cardiology, Campus Benjamin Franklin, Charité Berlin, Berlin, Germany; Institute for Biomaterial Science, Helmholtz-Institute Geesthacht, Campus Teltow, Teltow, Germany.
| | - Ann-Kathrin Ozga
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf
| | - David Sinning
- Department of Cardiology, Campus Benjamin Franklin, Charité Berlin, Berlin, Germany
| | - Jonathan Curio
- Department of Cardiology, Campus Benjamin Franklin, Charité Berlin, Berlin, Germany
| | - Haitham S Al-Hindwan
- Department of Cardiology, Campus Benjamin Franklin, Charité Berlin, Berlin, Germany
| | - Johan Bäckemo Johansson
- Institute for Biomaterial Science, Helmholtz-Institute Geesthacht, Campus Teltow, Teltow, Germany
| | - Friedrich Jung
- Institute for Biomaterial Science, Helmholtz-Institute Geesthacht, Campus Teltow, Teltow, Germany
| | - Andreas Lendlein
- Institute for Biomaterial Science, Helmholtz-Institute Geesthacht, Campus Teltow, Teltow, Germany
| | - Geraldine Rauch
- Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Institute of Biometry and Clinical Epidemiology, Berlin, Germany
| | - Ulf Landmesser
- Department of Cardiology, Campus Benjamin Franklin, Charité Berlin, Berlin, Germany
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12
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Falcetta G, Scioti G, Barzaghi C, Bortolotti U. Pulmonary and paradoxical coronary embolism with a patent foramen ovale. Asian Cardiovasc Thorac Ann 2018; 26:413-415. [PMID: 29734837 DOI: 10.1177/0218492318777394] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Paradoxical embolism through a patent foramen ovale is a very unusual event considering that this cardiac anomaly may be present in as much as 26% of the general population. We describe the case of a 68-year-old man with a pulmonary and paradoxical coronary embolism in the presence of a patent foramen ovale. The finding of a worm-shaped thrombus though the atrial septum together with the risk of further embolization through the atrial septum prompted surgical treatment.
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Affiliation(s)
- Giosuè Falcetta
- Section of Cardiac Surgery, Cardiac Thoracic and Vascular Department, University Hospital, Pisa, Italy
| | - Giovanni Scioti
- Section of Cardiac Surgery, Cardiac Thoracic and Vascular Department, University Hospital, Pisa, Italy
| | - Carlo Barzaghi
- Section of Cardiac Surgery, Cardiac Thoracic and Vascular Department, University Hospital, Pisa, Italy
| | - Uberto Bortolotti
- Section of Cardiac Surgery, Cardiac Thoracic and Vascular Department, University Hospital, Pisa, Italy
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13
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Lattanzi S, Brigo F, Cagnetti C, Di Napoli M, Silvestrini M. Patent Foramen Ovale and Cryptogenic Stroke or Transient Ischemic Attack: To Close or Not to Close? A Systematic Review and Meta-Analysis. Cerebrovasc Dis 2018; 45:193-203. [PMID: 29649819 DOI: 10.1159/000488401] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 03/13/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The optimal strategy of secondary stroke prevention in patients with patent foramen ovale (PFO) is controversial. This study was performed to evaluate the efficacy and safety of the device closure (DC) versus the medical therapy (MT) in patients with cryptogenic stroke or transient ischemic attack (TIA) and PFO. SUMMARY Randomized controlled trials with active and control groups receiving the DC plus MT and MT alone in patients with history of cryptogenic stroke/TIA and diagnosis of PFO were systematically searched. The main efficacy outcome was stroke recurrence. Subgroup-analyses were performed according to age, shunt size, and presence of atrial septal aneurysm (ASA). Safety endpoints included any serious adverse event (SAE), atrial fibrillation (AF), and major bleeding complications. Risk ratios (RRs) and hazard ratios (HRs) with 95% CIs were estimated. Five trials were included, involving 3,440 participants (DC = 1,829, MT = 1,611). There was a protective effect of closure in the risk of recurrent stroke (RR 0.43 [0.21-0.90]; p = 0.024; HR = 0.39 [0.19-0.83]; p = 0.014). The benefit of PFO closure was significant in patients with PFO associated with substantial right-to-left shunt or ASA. There were no differences in the risks of SAEs and major bleedings between the groups. The rate of new-onset AF was higher in the DC than in the MT arm (RR 4.46 [2.35-8.41]; p < 0.001). Successful device implantation and effective PFO closure were achieved in 96 and 91% of the patients respectively. Key Messages: In selected adult patients with PFO and history of cryptogenic stroke, the DC plus MT is more effective to prevent stroke recurrence and is associated with an increased risk of new-onset AF compared to the MT alone.
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Affiliation(s)
- Simona Lattanzi
- Department of Experimental and Clinical Medicine, Neurological Clinic, Marche Polytechnic University, Ancona, Italy
| | - Francesco Brigo
- Department of Neuroscience, Biomedicine and Movement Science, University of Verona, Verona, Italy.,Division of Neurology, "Franz Tappeiner" Hospital, Merano, Italy
| | - Claudia Cagnetti
- Department of Experimental and Clinical Medicine, Neurological Clinic, Marche Polytechnic University, Ancona, Italy
| | - Mario Di Napoli
- Neurological Service, San Camillo de' Lellis General Hospital, Rieti, Italy.,Neurological Section, Neuro-Epidemiology Unit, SMDN, Centre for Cardiovascular Medicine and Cerebrovascular Disease Prevention, L'Aquila, Italy
| | - Mauro Silvestrini
- Department of Experimental and Clinical Medicine, Neurological Clinic, Marche Polytechnic University, Ancona, Italy
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Parikh A, Vacek TP. PFO closure in high-risk patient with paradoxical arterial embolism, deep vein thrombosis, pulmonary embolism and factor V Leiden genetic mutation. Oxf Med Case Reports 2018; 2018:omx105. [PMID: 29576872 PMCID: PMC5853008 DOI: 10.1093/omcr/omx105] [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: 09/20/2017] [Revised: 11/25/2017] [Accepted: 12/13/2017] [Indexed: 11/12/2022] Open
Abstract
Occurrence of paradoxical arterial embolism may cause the first symptoms in patients with a coexisting hypercoagulable state and patent foramen ovale (PFO). This can result in significant morbidity and mortality depending on the location of the embolism. The risks and benefits of closure of small PFOs have not been well elucidated in prior studies. We describe a patient with a history of Factor V Leiden heterozygosity who presented with left arm pain secondary to arterial embolism. The patient was a 51-year-old male who initially presented to the emergency department after awaking from sleep with progressive, severe, burning left arm pain. He had also noted intermittent shortness of breath over the 2 weeks prior to admission. Temperature was 97.4 F, pulse 86, respiratory rate 20 and blood pressure 121/87. Oxygen saturation was 94% on supplemental oxygen. He had a cool left upper extremity and the patient described subjective paresthesias in this extremity. Left radial pulse was difficult to palpate. Physical exam was otherwise unremarkable. Troponin I was mildly elevated at 0.217 ng/l. White blood cell count was 11.8 and INR 1.1. EKG showed sinus tachycardia with non-specific T abnormalities in the anterior leads. His past medical history was notable for only hypertension and hyperlipidemia. Current recommendation is for antiplatelet or anticoagulation for those with hypercoaguable states who suffer a stroke; there is currently no absolute indication for closure device. We describe the case of a 51-year-old male who had presented with left arm pain and shortness of breath. The computed tomography (CT) angiography of chest showed pulmonary emboli with heavy clot burden bilaterally. Heparin was started, but patient was found to have occlusion along large arteries of the left arm. Emergent left axillary, brachial, radial and ulnar embolectomy for acute critical arm ischemia were performed. The transthoracic echocardiogram done the next day with bubble study was positive for patent foramen ovale. Hypercoaguability showed factor V Leiden heterozygosity. Decision was made for the patient to initiate long-term anticoagulation with rivaroxaban and closure was performed. Patient was advised that closure is off label but opted to proceed with closure in light of hypercoaguable state.
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Affiliation(s)
- A Parikh
- Wright State University, Cardiology, Dayton, OH, USA
| | - T P Vacek
- Wright State University, Cardiology, Dayton, OH, USA
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Coughlan JJ, Daly A, Arnous S, Kiernan TJ. Patent foramen ovale and cryptogenic stroke: contemporary evidence and treatment. Expert Rev Cardiovasc Ther 2017; 16:27-37. [PMID: 29256291 DOI: 10.1080/14779072.2018.1419064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Patent foramen ovale (PFO) is a common anatomical variant in the adult circulation. It is a channel allowing communication between the left and right atria and is a remnant of the foetal circulation. In approximately 25% of the population, this channel persists into adulthood. PFO has been proposed as a potential pathophysiological mechanism for cryptogenic stroke. Areas covered: This review will examine the contemporary evidence for both the association between cryptogenic stroke and PFO and the management of this condition. The authors hope to provide a comprehensive overview of the current evidence and best practice in relation to PFO closure. In addition, the authors will propose some potential avenues for future research in this controversial area and try to predict how PFOs in cryptogenic stroke will be managed in the near future. Expert commentary: In carefully selected patients with cryptogenic stroke, PFO closure represents an evidence based treatment option for the prevention of further ischemic neurological events. A multidisciplinary approach is necessary to ensure appropriate patient selection for the procedure. This should include a vascular neurologist/stroke physician and an interventional cardiologist with an interest in PFO closure.
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Affiliation(s)
- J J Coughlan
- a Department of Cardiology , University Hospital Limerick , Limerick , Ireland
| | - Aidan Daly
- a Department of Cardiology , University Hospital Limerick , Limerick , Ireland
| | - Samer Arnous
- a Department of Cardiology , University Hospital Limerick , Limerick , Ireland
| | - Tom J Kiernan
- b Department of Cardiology, Graduate Entry Medical School , University of Limerick , Limerick , Ireland.,c Graduate Entry Medical School , University of Limerick , Limerick , Ireland
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Harrer JU, Wessels T, Franke A, Lucas S, Berlit P, Klötzsch C. Stroke Recurrence and its Prevention in Patients with Patent Foramen Ovale. Can J Neurol Sci 2014; 33:39-47. [PMID: 16583720 DOI: 10.1017/s0317167100004674] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND It is unclear whether medical or invasive (surgical or catheter interventional) treatment is preferable to prevent recurrence of cerebral ischemia in patients with patent foramen ovale (PFO) as the suspected cause of stroke and what the role of concomitant risk factors is in stroke recurrence. METHODS Over a period of ten years, 124 patients (mean age 51 +/- 15 years) with cryptogenic cerebral ischemia and PFO were included into the study and prospectively followed over a mean of 52 +/- 32 months. Of these, 83 were treated medically, 34 underwent transcatheter closure, and seven had surgical closure of the foramen. Of the medically treated patients, 11 stopped medication during follow-up. Recurrent ischemic events and risk factors for recurrence were analyzed. RESULTS Annual stroke recurrence rates were generally low and comparable in catheter and medically treated patients, and in patients who had stopped medication (2.9%/2.1%2.2%/year). Patients suffering from recurrence after transcatheter closure (n = 2) both had residual shunts. No stroke recurrence was observed in the few surgically treated patients. An atrial septal aneurysm was not a predictor of recurrent or multiple strokes (p > 0.05, OR = 0.31, and OR = 0.74). Large shunts and a history of previous ischemic events were considerably more frequent in patients with recurrent strokes (p < 0.05, OR = 5.0, and OR = 4.4). Pulmonary embolism and case fatality rates were significantly higher in patients with stroke recurrence (p < 0.001, and p < 0.01). CONCLUSIONS The absolute risk of recurrent cerebrovascular events in patients with PFO receiving medical or catheter interventional therapy is low. The small group of untreated patients had a comparably low rate of stroke recurrences. Previous ischemic events and shunt size were risk factors in this observational study. Given conflicting findings across multiple studies, enrollment into a randomized controlled trial would be the optimal choice.
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Affiliation(s)
- J U Harrer
- Department of Neurology, Aachen University Hospital, Aachen, Germany
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Patent Foramen Ovale Closure vs Medical Therapy for Stroke Prevention: Meta-analysis of Randomized Trials and Review of Heterogeneity in Meta-analyses. Can J Cardiol 2014; 30:1216-24. [DOI: 10.1016/j.cjca.2014.05.004] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Revised: 04/26/2014] [Accepted: 05/05/2014] [Indexed: 11/20/2022] Open
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Vitarelli A, Mangieri E, Capotosto L, Tanzilli G, D'Angeli I, Toni D, Azzano A, Ricci S, Placanica A, Rinaldi E, Mukred K, Placanica G, Ashurov R. Echocardiographic findings in simple and complex patent foramen ovale before and after transcatheter closure. Eur Heart J Cardiovasc Imaging 2014; 15:1377-85. [PMID: 25139906 DOI: 10.1093/ehjci/jeu143] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS Percutaneous closure of patent foramen ovale (PFO) in cryptogenic cerebrovascular events is an alternative to medical therapy. The interpretation of residual shunts after implantation of different devices for PFO with different morphologies is controversial. METHODS AND RESULTS Transcatheter PFO closure was performed in 123 patients with a history of ≥1 paradoxical embolism using three different devices: Amplatzer (n = 46), Figulla Occlutech (n = 41), and Atriasept Cardia (n = 36). Fifty-six patients presented with simple PFO and 67 patients had complex morphologies. All patients were studied with contrast enhanced transesophageal echocardiography (TEE) before interventional procedure and thereafter at 1 and 6 months and every 6-12 months in case of incomplete closure. Definite closure was confirmed in at least two consecutive TEE studies. Various PFO morphologies were identified by TEE before device implantation. The device size to PFO diameter ratio was significantly increased in patients with complex PFO compared with those patients with a simple PFO morphology (P < 0.05). The difference between the closure rate of S-PFO and C-PFO concerning each device type was significant (Amplatzer P = 0.0027, Figulla P = 0.0043, and Atriasept P < 0.01). The mean follow-up period was 3.4 years (median 2.7 years) with a cerebrovascular re-event rate of 2.4% per year. In three patients, thrombi were detected in the 6-month TEE controls and resolved after medical therapy. In three other patients, the implantation of an adjunctive device was necessary for residual shunt. CONCLUSION In our series of patients, the closure rate was dependent on PFO morphology more than occluder size and type. An adjunctive device was implanted in selected cases.
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Affiliation(s)
| | | | | | | | | | - Danilo Toni
- Sapienza University, Via Lima 35, Rome 00198, Italy
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Chiu AH, Haluszkiewicz E, McAuliffe W. Micro-bubble transcranial Doppler ultrasound for exclusion of right-to-left circulatory shunts: why should we provide the service? J Med Imaging Radiat Oncol 2014; 58:464-8. [PMID: 24589171 DOI: 10.1111/1754-9485.12162] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Accepted: 12/28/2013] [Indexed: 11/29/2022]
Abstract
Micro-bubble transcranial Doppler ultrasound is a study used for the identification and quantification of a right-to-left circulatory shunt which can be implicated in stroke. It is an underused technique in many centres. Micro-bubble transcranial Doppler ultrasound is non-invasive, innocuous, quick and requires no fasting or sedation. Published literature also suggests almost perfect concordance with transoesophageal echocardiography and potentially greater sensitivity. We believe there is a great potential for neuroradiologists to provide this service as part of the diagnostic workup in patients with cryptogenic stroke.
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Affiliation(s)
- Albert H Chiu
- Neurological Intervention and Imaging Service of WA (NIISwa), Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
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20
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Abstract
Transcatheter closure of atrial septal defects has evolved significantly over the last 20 years. Transcatheter closure has replaced surgical closure for the treatment of most secundum atrial septal defectsat the current time. A major reason for this is the lower morbidity of transcatheter closure procedures. Several closure devices have come into clinical use. The Amplatzer septal occluder (AGA Medical Co.) currently has the largest reported experience and subsequently the best-established safety and efficacy features. Clinically challenging situations, such as larger atrial septal defects, atrial septal defects with deficient rims and multiple atrial septal defects, are increasingly being addressed using the transcatheter approach, with improved results. The incidence of most complications has significantly reduced over time, and serious side effects are relatively uncommon. In this review, the literature is summarized regarding the current role of transcatheter closure, the evolution of the different available devices for clinical use and the complications that occur with their use. A comparison is also made with surgical closure techniques.
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Affiliation(s)
- Anuja Gupta
- KEM Hospital, 48/49 Hatkesh Society, Road number 7, Juhu Scheme, Mumbai400 049, India.
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21
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Residual Shunt after Patent Foramen Ovale Closure: Preliminary Results from Italian Patent Foramen Ovale Survey. J Stroke Cerebrovasc Dis 2013; 22:e219-26. [DOI: 10.1016/j.jstrokecerebrovasdis.2012.12.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2012] [Accepted: 12/08/2012] [Indexed: 11/20/2022] Open
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Rengifo-Moreno P, Palacios IF, Junpaparp P, Witzke CF, Morris DL, Romero-Corral A. Patent foramen ovale transcatheter closure vs. medical therapy on recurrent vascular events: a systematic review and meta-analysis of randomized controlled trials. Eur Heart J 2013; 34:3342-52. [PMID: 23847132 DOI: 10.1093/eurheartj/eht285] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND In patients with cryptogenic stroke, transcatheter (TC) closure of a patent foramen ovale (PFO) has not been shown to better prevent recurrent vascular events than medical therapy. However, randomized controlled trials (RCT) to date have included few vascular events, and lack of power has been raised as an important concern. OBJECTIVE To conduct a systematic review and meta-analysis of existing RCT published studies assessing the recurrence of vascular events after TC PFO closure when compared to medical therapy. METHODS Using the search terms "patent foramen ovale", "PFO", "stroke", "percutaneous closure" and "transcatheter closure", Medline, Pubmed, Embase, and Cochrane databases were reviewed from inception through April 2013, with no language restrictions. Only studies in adult humans were considered. Additional references were obtained from the bibliographies of studies reviewed. The following criteria were used for study selection: 1) randomized controlled trial, 2) subjects were adult patients with cryptogenic stroke who were randomized to TC PFO closure or medical treatment (antiplatelet therapy and/or anticoagulation), and 3) reported outcomes included cardiac death, all death, stroke, transient ischemic attack, and peripheral embolism. Methodological and descriptive data, adverse events (including raw data and risk estimates), as well as procedural success and complications were abstracted in duplicate from each study independently, and agreement was tested. We followed rigorously the recommended guidelines for reporting and conducting and assessing quality of meta-analysis of RCT. The primary endpoints pre-specified in advance were recurrent vascular events, and composite endpoint of death, and recurrent vascular events. RESULTS Three studies were identified as meeting selection criteria. These included a total of 2,303 patients, with 1,150 patients randomized to TC PFO closure and 1,153 patients randomized to medical therapy. Mean follow-up was 3.5 years. Baseline characteristics (age, sex, and cardiovascular risk factors) were similar across studies. Intention-to-treat analyses showed a statistically significant risk reduction in stroke and/or transient ischemic attack in the TC PFO closure group when compared to medical treatment, pooled HR = 0.59, 95%CI (0.36-0.97), P = 0.04. The combined outcome of death, and vascular events, showed a borderline statistically significant benefit for TC PFO closure when compared to medical treatment, pooled HR = 0.67, 95%CI (0.44-1.00), P = 0.05 Subjects with a substantial PFO shunt seem to benefit the most with TC PFO closure, pooled HR = 0.35, 95%CI (0.12-1.03), P = 0.06, however, it did not reach statistical significance. CONCLUSION These results suggest that in patients with cryptogenic stroke, TC PFO closure may be beneficial in reducing the risk of recurrent vascular events when compared to medical treatment. The benefit of TC PFO closure may be greater in patients with a substantial shunt.
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Affiliation(s)
- Pablo Rengifo-Moreno
- The Institute for Heart and Vascular Health and Cardiovascular Diseases, Einstein Medical Center, Philadelphia, PA, USA
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23
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Loar RW, Johnson JN, Cabalka AK, Cetta F, Hagler DJ, Eidem BW, Taggart NW. Effect of percutaneous atrial septal defect and patent foramen ovale device closure on degree of aortic regurgitation. Catheter Cardiovasc Interv 2013; 81:1234-7. [DOI: 10.1002/ccd.24779] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2012] [Revised: 11/16/2012] [Accepted: 12/06/2012] [Indexed: 11/12/2022]
Affiliation(s)
- Robert W. Loar
- Department of Pediatrics; Mayo Clinic; Rochester; Minnesota
| | - Jonathan N. Johnson
- Department of Pediatrics/Division of Pediatric Cardiology; Mayo Clinic; Rochester; Minnesota
| | - Allison K. Cabalka
- Department of Pediatrics/Division of Pediatric Cardiology; Mayo Clinic; Rochester; Minnesota
| | | | | | | | - Nathaniel W. Taggart
- Department of Pediatrics/Division of Pediatric Cardiology; Mayo Clinic; Rochester; Minnesota
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Misra S, Dash PK, Koshy T, Varma PK, Pal S, Dineshkumar US, Banayan J, Capdeville M. CASE 5—2012: Incidentally Detected Patent Foramen Ovale in A Patient Undergoing Aortic Valve Replacement: To Close or Not to Close? J Cardiothorac Vasc Anesth 2012; 26:721-8. [DOI: 10.1053/j.jvca.2012.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2011] [Indexed: 11/11/2022]
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Boussuges A, Pontier JM, Schmid B, Dussault C. Paradoxical gas embolism after SCUBA diving: hemodynamic changes studied by echocardiography. Scand J Med Sci Sports 2012; 24:111-6. [PMID: 22612401 DOI: 10.1111/j.1600-0838.2012.01474.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2012] [Indexed: 11/29/2022]
Abstract
Hemodynamic changes induced by self-contained underwater breathing apparatus diving were investigated using Doppler echocardiography. We detected circulating bubbles in both right and left cavities of the heart and in the cerebral circulation in two divers with a large patent foramen ovale. A reduction in the left ventricular preload was suggested by echocardiographic measurements. The decreased cardiac preload was paralleled to a lower stroke volume and cardiac output. These findings were also observed in divers with no evidence of circulating bubbles. In these subjects, pulmonary vascular resistances remained unchanged while an increase was observed in the two divers with arterial bubbles. This increase could promote right-to-left shunting.
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Affiliation(s)
- A Boussuges
- Institut de Recherche Biomédicale des Armées (IRBA), Brétigny sur Orge, France
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26
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Faggiano P, Frattini S, Piovesana P, Lorusso R, Chiari E, Scolari F, Padovani A, Cas LD. Low cerebrovascular event rate in subjects with patent foramen ovale and different clinical presentations. Int J Cardiol 2012; 156:47-52. [DOI: 10.1016/j.ijcard.2010.10.032] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2010] [Revised: 08/22/2010] [Accepted: 10/23/2010] [Indexed: 11/25/2022]
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Kitsios GD, Lasker A, Singh J, Thaler DE. Recurrent stroke on imaging and presumed paradoxical embolism: a cross-sectional analysis. Neurology 2012; 78:993-7. [PMID: 22422892 DOI: 10.1212/wnl.0b013e31824d58bc] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE To identify whether factors supporting a diagnosis of paradoxical embolism (i.e., venous thrombosis or Valsalva maneuver) are associated with radiologic markers of recurrent strokes in patients with patent foramen ovale (PFO) and cryptogenic stroke (CS). Such clinical indicators of paradoxical embolism are commonly viewed as risk factors for CS recurrence, but precise risk estimates are lacking. METHODS Data from the prospective Tufts PFO Registry collected at the time of the index CS were analyzed. We defined the following radiologic markers of stroke recurrence: 1) strokes of different radiologic ages and 2) silent strokes (detected on MRI but without symptoms preceding the index event). We examined the association between the radiologic endpoints and the clinical indicators of paradoxical embolism with multivariate logistic regression models, adjusting for age and gender. RESULTS Data were available for 224 subjects. Strokes of different radiologic ages were not associated with the thrombosis-predisposing conditions (1.2 [95% confidence interval 0.5-2.7]), the Valsalva maneuver (1.3 [0.6-3.1]), or the presence of either of these factors. No statistically significant association was found in subgroups stratified by anatomic location of the index stroke or for the outcome of silent strokes. CONCLUSIONS Our negative findings do not lend support to using the presence of clinical indicators of paradoxical embolism as an indication for percutaneous PFO closure. Factors that support a paradoxical embolism mechanism may be different from those that predict paradoxical embolism recurrence. Further investigations with clinical follow-up and larger sample sizes are needed to reach more precise estimates for the associations examined.
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Affiliation(s)
- Georgios D Kitsios
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA.
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28
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Kitsios GD, Dahabreh IJ, Abu Dabrh AM, Thaler DE, Kent DM. Patent foramen ovale closure and medical treatments for secondary stroke prevention: a systematic review of observational and randomized evidence. Stroke 2011; 43:422-31. [PMID: 22180252 DOI: 10.1161/strokeaha.111.631648] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND PURPOSE Patients discovered to have a patent foramen ovale in the setting of a cryptogenic stroke may be treated with percutaneous closure, antiplatelet therapy, or anticoagulants. A recent randomized trial (CLOSURE I) did not detect any benefit of closure over medical treatment alone; the optimal medical therapy is also unknown. We synthesized the available evidence on secondary stroke prevention in patients with patent foramen ovale and cryptogenic stroke. METHODS A MEDLINE search was performed for finding longitudinal studies investigating medical treatment or closure, meta-analysis of incidence rates (IR), and IR ratios of recurrent cerebrovascular events. RESULTS Fifty-two single-arm studies and 7 comparative nonrandomized studies and the CLOSURE I trial were reviewed. The summary IR of recurrent stroke was 0.36 events (95% confidence interval [CI], 0.24-0.56) per 100 person-years with closure versus 2.53 events (95% CI, 1.91-3.35) per 100 person-years with medical therapy. In comparative observational studies, closure was superior to medical therapy (IR ratio=0.19; 95% CI, 0.07-0.54). The IR for the closure arm of the CLOSURE I trial was higher than the summary estimate from observational studies; there was no significant benefit of closure over medical treatment (P=0.002 comparing efficacy estimates between observational studies and the trial). Observational and randomized data (9 studies) comparing medical therapies were consistent and suggested that anticoagulants are superior to antiplatelets for preventing stroke recurrence (IR ratio=0.42; 95% CI, 0.18-0.98). CONCLUSIONS Although further randomized trial data are needed to precisely determine the effects of closure on stroke recurrence, the results of CLOSURE I challenge the credibility of a substantial body of observational evidence strongly favoring mechanical closure over medical therapy.
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Affiliation(s)
- Georgios D Kitsios
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA 02111, USA
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29
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Affiliation(s)
- Zahid Amin
- Professor and Director, Cardiac Catheterization and Hybrid Suites, RUSH Center for Congenital and Structural Heart Disease, RUSH Univeristy Medical Center, Chicago, Illinois, USA
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Orzan F, Liboni W, Bonzano A, Molinari F, Ribezzo M, Rebaudengo N, Grippi G, Negri E. Follow-up of residual shunt after patent foramen ovale closure. Acta Neurol Scand 2010; 122:257-61. [PMID: 19951266 DOI: 10.1111/j.1600-0404.2009.01302.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Transesophageal echocardiography (TEE) is usually recommended in the evaluation of the patent foramen ovale (PFO). Our goal is to confirm the efficacy of contrast-enhanced transcranial Doppler (ce-TCD) in detecting residual significant right-to-left shunts (RLS) after PFO percutaneous closure. MATERIALS AND METHODS Sixty-eight patients with a previous transient ischemic attack, stroke and a large PFO were investigated for residual RLS after percutaneous closure. RESULTS Assuming TEE as the gold standard, the sensitivity and negative predictive value of ce-TCD was 100%, whereas the specificity was 75.8% and the positive predictive value was 28%. CONCLUSIONS ce-TCD appears to be the preferable technique to identify subjects with significant residual shunts after percutaneous closure of a PFO. In follow-up, if ce-TCD is negative, no further examination may be necessary; whereas if ce-TCD shows a residual shunt, it is advisable to perform a TEE investigation.
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Affiliation(s)
- F Orzan
- Department of Internal Medicine - Cardiology, University of Torino, Torino, Italy
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31
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Miyazawa A, Vardiman P, Magee LM, Washington E. Cryptogenic stroke associated with patent foramen ovale in a collegiate volleyball athlete: a case report. Sports Health 2010; 2:395-7. [PMID: 23015966 PMCID: PMC3445063 DOI: 10.1177/1941738110374598] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Cryptogenic stroke is a form of cerebral vascular accident that has an unknown origin and is rarely associated with patent foramen ovale (PFO) and migraine headaches. This is an uncommon occurrence in young, healthy, active adults, and it is increasingly rare for the episode to occur during an athletic competition. Stroke is easily recognizable with its distinct signs and symptoms, but it is also easily confused with many of its differential diagnoses, such as seizures or head trauma, if the episode occurs during an athletic competition. This case report describes the stroke episode, incidence of migraine headaches, diagnostic testing, and surgical management of a college female volleyball athlete who suffered a cryptogenic stroke associated with PFO during an athletic competition. Diagnostic testing included magnetic resonance imaging with contrast, electroencephalograph, lower extremity Doppler testing, and a transesophageal echocardiograph with agitated saline study. Surgical correction of the PFO included a cardiac catheterization percutaneous procedure based on fluoroscopic and echocardiograph imaging. After release from physicians, the athlete returned to full participation in the sport of volleyball, where she competed for the next 2 years without complications. The patient has reported no symptoms from stroke or PFO closure procedure in 3 years, and migraine headaches have decreased in severity, frequency, and duration.
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Affiliation(s)
- Aimee Miyazawa
- University of Kansas Athletic Department, Lawrence, Kansas
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Agarwal SK, Binbrek AS, Thompson JA, Siddiqui SAP. Massive pulmonary embolism and acute limb ischaemia in a patient of hereditary spherocytosis and patent foramen ovale. Heart Lung Circ 2010; 19:742-4. [PMID: 20619736 DOI: 10.1016/j.hlc.2010.05.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2009] [Revised: 01/09/2010] [Accepted: 05/20/2010] [Indexed: 11/19/2022]
Abstract
Paradoxical embolism accounts for 2% of patients who present with acute arterial embolism of extremities. We report a case of a 41 year-old male with hereditary spherocytosis who presented to the emergency department with acute limb ischaemia and pulmonary embolism. On further evaluation, he was found to have patent foramen ovale (PFO) and deep vein thrombosis (DVT), leading to paradoxical embolism. The purpose of this report is to emphasise that in a patient presenting with acute limb ischaemia without an obvious systemic arterial embolic source, an evaluation for a right-to-left shunting lesion, especially PFO, should be performed.
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Affiliation(s)
- S K Agarwal
- Rashid Hospital, PO Box 4545, Dubai, United Arab Emirates.
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33
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Kimmelstiel C. Closing one hole leads to another: delayed aortic perforation following closure of a patent foramen ovale. Catheter Cardiovasc Interv 2010; 76:135-6. [PMID: 20578219 DOI: 10.1002/ccd.22677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Percutaneous closure of patent foramen ovale and atrial septal defect in adults: the impact of clinical variables and hospital procedure volume on in-hospital adverse events. Am Heart J 2009; 157:867-74. [PMID: 19376313 DOI: 10.1016/j.ahj.2009.02.019] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2008] [Accepted: 02/26/2009] [Indexed: 12/23/2022]
Abstract
BACKGROUND Percutaneous closure of patent foramen ovale/atrial septal defect (PFO/ASD) is an increasingly common procedure perceived as having minimal risk. There are no population-based estimates of in-hospital adverse event rates of percutaneous PFO/ASD closure. METHODS We used nationally representative data from the 2001-2005 Nationwide Inpatient Sample to identify patients >or-=20 years old admitted to an acute care hospital with an International Classification of Diseases, Ninth Revision code designating percutaneous PFO/ASD closure on the first or second hospital day. Variables analyzed included age, sex, number of comorbidities, year, same-day use of intracardiac or other echocardiography, same-day left heart catheterization, hospital size and teaching status, PFO/ASD procedural volume, and coronary intervention volume. Outcomes of interest included length of stay, charges, and adverse events. RESULTS The study included 2,555 (weighted to United States population: 12,544 +/- 1,987) PFO/ASD closure procedures. Mean age was 52.0 +/- 0.4 years, and 57.3% +/- 1.0% were women. Annual hospital volume averaged 40.8 +/- 7.7 procedures (range, 1-114). Overall, 8.2 +/- 0.8% of admissions involved an adverse event. Older patients and those with comorbidities were more likely to sustain adverse events. Use of intracardiac echocardiography was associated with fewer adverse events. The risk of adverse events was inversely proportional to annual hospital volume (odds ratio [OR] 0.91, 95% confidence interval [CI] 0.86-0.96, per 10 procedures), even after limiting the analysis to hospitals performing >or=10 procedures annually (OR 0.91, 95% CI 0.85-0.98). Adverse events were more frequent at hospitals in the lowest volume quintile as compared with the highest volume quintile (13.3% vs 5.4%, OR 2.42, 95% CI 1.55-3.78). CONCLUSIONS The risk of adverse events of percutaneous PFO/ASD closure is inversely correlated with hospital volume. This relationship applies even to hospitals meeting the current guidelines, performing >or=10 procedures annually.
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von Bardeleben RS, Richter C, Otto J, Himmrich L, Schnabel R, Kampmann C, Rupprecht HJ, Marx J, Hommel G, Münzel T, Horstick G. Long term follow up after percutaneous closure of PFO in 357 patients with paradoxical embolism: Difference in occlusion systems and influence of atrial septum aneurysm. Int J Cardiol 2009; 134:33-41. [DOI: 10.1016/j.ijcard.2008.02.031] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2007] [Revised: 02/06/2008] [Accepted: 02/27/2008] [Indexed: 10/21/2022]
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Amin Z, Hijazi ZM, Bass JL, Cheatham JP, Hellenbrand W, Kleinman CS. PFO closure complications from the AGA registry. Catheter Cardiovasc Interv 2008; 72:74-9. [PMID: 18546236 DOI: 10.1002/ccd.21582] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVES To evaluate all complications that occurred during or after cardiac catheterizations for Amplatzer PFO device closure of patent foramen ovale (PFO), determine the cause of the complications and recommend techniques to minimize complications in the future. BACKGROUND Rare complications were reported to the manufacturer of the Amplatzer PFO occluder since the introduction of the device. METHODS A panel of independent physicians reviewed all complications reported to the manufacturer to determine whether the complication was related to the device or related to the cardiac catheterization procedure. Demographic data, echocardiograms, operative reports, and time to occurrence of complications were reviewed. RESULTS A total of 11 events were reported. Only two patients had device related complications (erosion), an incidence of 0.018%. Two patients were found to have additional atrial septal defect after PFO closure. Two patients were thought to have an inflammatory reaction without any serious sequelae. Five complications were related to the cardiac catheterization procedure (atrial appendage perforation). CONCLUSIONS Device related complications after Amplatzer PFO occluder placement are extremely rare. Cardiac catheterization related complications appear to be the most common cause of the hemodynamic compromise. Careful manipulation of catheters and wires, recognition of the location of the catheter by fluoroscopy and echocardiography will decrease the risk of such complications.
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Affiliation(s)
- Zahid Amin
- RUSH University Medical Center, Chicago, Illinois 60612, USA.
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Cruz-González I, Solis J, Inglessis-Azuaje I, Palacios IF. Foramen oval permeable: situación actual. Rev Esp Cardiol 2008. [DOI: 10.1157/13123995] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Mansencal N, Mitry E, Pillière R, Lepère C, Gérardin B, Petit J, Gandjbakhch I, Rougier P, Dubourg O. Prevalence of patent foramen ovale and usefulness of percutaneous closure device in carcinoid heart disease. Am J Cardiol 2008; 101:1035-8. [PMID: 18359327 DOI: 10.1016/j.amjcard.2007.11.056] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2007] [Revised: 11/14/2007] [Accepted: 11/14/2007] [Indexed: 10/22/2022]
Abstract
The aim of this study was to assess (1) the incidence of patent foramen ovale (PFO) in carcinoid syndrome (CS) and (2) the feasibility of percutaneous closure procedure in selected patients with CS. One hundred eight patients were prospectively studied: 54 with CS and an age- and gender-matched control group. All patients underwent conventional and contrast echocardiography. Patients with clinical signs of dyspnea (New York Heart Association class > or =III), cyanosis, carcinoid heart disease (CHD), and severe PFO were referred for the percutaneous closure of PFO. The prevalence of PFO was 41% in patients with CS and 22% in the control group (p = 0.03) and was significantly higher in patients with CHD (59%, p = 0.009). Four patients (14% of those with CHD) were referred for the percutaneous closure of PFO, and 3 patients ultimately underwent PFO closure (using Amplatzer septal occluders). At 6-month follow-up, New York Heart Association class was improved in all patients, as well as arterial blood gas results (p = 0.04) and 6-minute walking distance (p = 0.03), but all patients presented residual right-to-left shunts. In conclusion, this prospective study demonstrates that in patients with CHD, the prevalence of PFO is high and that percutaneous closure of PFO is feasible, with a reduction in symptoms but with residual shunting.
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Motreff P, Dauphin C, Souteyrand G. Cardiac perforation and tamponade 3 months after transcatheter PFO closure by STARFlex device: A case report. Catheter Cardiovasc Interv 2008; 71:412-6. [DOI: 10.1002/ccd.21339] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Feldman T. PFO closure devices: The disconnect between technology, technique, and indications for use. Catheter Cardiovasc Interv 2008; 71:403-4. [PMID: 18288746 DOI: 10.1002/ccd.21501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Dixon T, Panda M, Desbiens N. The simultaneous occurrence of deep vein thrombosis and pulmonary and arterial embolization. J Gen Intern Med 2007; 22:1040-1. [PMID: 17450391 PMCID: PMC2219736 DOI: 10.1007/s11606-007-0169-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2006] [Revised: 09/27/2006] [Accepted: 02/06/2007] [Indexed: 11/26/2022]
Abstract
INTRODUCTION A 45-year-old female presented with 8 hours of right lower extremity pain and dyspnea. She was tachycardic and her right lower extremity was dusky, cold, and pulseless. DISCUSSION Computerized tomography of the venous and arterial systems revealed massive pulmonary embolism and right lower extremity arterial and left lower extremity venous thromboses. Management included intra-arterial thrombolytics, right lower extremity arterial embolectomy, and anticoagulation. Echocardiogram revealed a patent foramen ovale (PFO) with a right-to-left shunt. CONCLUSION We hypothesize that our patient developed deep venous thrombosis that led to major pulmonary embolization and increased right-sided pressures. In the setting of a patent foramen ovale, a later venous embolus transversed the PFO and lodged in the femoral artery. Our case illustrates the importance of a high index of suspicion for a paradoxical embolus in patients with arterial thrombosis.
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Affiliation(s)
- Teabra Dixon
- Department of Medicine, University of Tennessee College of Medicine-Chattanooga Unit, 975 East Third St., Box 94, Chattanooga, TN 37403, USA.
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Abstract
We describe a case in which the patient developed profound, intermittent hypoxemia after implantation of a permanent pacemaker and subsequently after revision of its leads. Cardiac catheterization demonstrated right-to-left shunting at the level of the atria in the presence of a patent foramen ovale that required closure, resulting in the resolution of symptoms. Our report highlights the fact that the presence of a patent foramen ovale with intermittent right-to-left shunting should be considered in a differential diagnosis of hypoxemia after implantation of heart rhythm devices.
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Affiliation(s)
- Bharat K Kantharia
- Division of Cardiac Electrophysiology, Ohio State University Medical Center, Columbus, Ohio 43210, USA.
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Ballerini L, Cifarelli A, Ammirati A, Gimigliano F. Patent foramen ovale and cryptogenic stroke. A critical review. J Cardiovasc Med (Hagerstown) 2007; 8:34-8. [PMID: 17255814 DOI: 10.2459/01.jcm.0000247433.82322.df] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The underlying causes of ischemic stroke in young patients are often difficult to find, despite systematic investigations concerning heart, coagulation system or any other type of vascular disease, thus the definition of 'cryptogenic'. In patients with cryptogenic stroke, the prevalence of a patent foramen ovale is about 45%, versus 25% of the general healthy population, leading to many speculations about a potential role of intracardiac right-to-left shunts in determining ischemic cerebral disease. Since a possible mechanism has been thought to be paradoxical embolism, percutaneous closure of the foramen ovale is currently discussed, at least until the appearance of data from the ongoing randomized trials. However, recurrent paradoxical embolism in patients with an aneurysmal atrial septum and a patent foramen ovale is currently the only unequivocal indication for percutaneous closure. Professional divers may benefit from the procedure as well, whereas migraine is still not considered an indication. In the pediatric population, closure of the patent foramen ovale seems to be safe and effective to prevent recurrent stroke. As the complication rate for device implantation decreases, the threshold for percutaneous closure is likely to decline.
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MESH Headings
- Adolescent
- Adult
- Anticoagulants/therapeutic use
- Cardiac Catheterization
- Child
- Embolism, Paradoxical/etiology
- Embolism, Paradoxical/prevention & control
- Heart Septal Defects, Atrial/complications
- Heart Septal Defects, Atrial/diagnostic imaging
- Heart Septal Defects, Atrial/drug therapy
- Heart Septal Defects, Atrial/therapy
- Humans
- Ischemic Attack, Transient/etiology
- Ischemic Attack, Transient/prevention & control
- Middle Aged
- Migraine with Aura/etiology
- Platelet Aggregation Inhibitors/therapeutic use
- Risk Factors
- Secondary Prevention
- Stroke/etiology
- Stroke/prevention & control
- Treatment Outcome
- Ultrasonography, Doppler, Transcranial
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Affiliation(s)
- Luigi Ballerini
- Department of Pediatric Cardiology, Bambino Gesù Hospital, Rome, Italy.
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Abstract
Recent epidemiological data suggest a bidirectional link between patent foramen ovale (PFO) and migraine with aura (MA) with a relative risk of 2 for PFO in subjects with MA and for MA in subjects with PFO. There is no evidence for a link between PFO and migraine without aura. This link is not systematic and applies only to subsets of PFO, mostly large ones, and to subsets of patients with MA. Although comorbidity cannot be ruled out, it may be that this link is partly causal and that some large PFOs may favor MA attacks in genetically predisposed subjects, by allowing vasoactive substances, platelet emboli or paradoxical emboli to bypass the lung filter and trigger the cortical spreading depression of the aura. The first double blind randomised trial of PFO closure in refractory MA, "MIST", has failed to show a benefit on the primary efficacy end point: cessation of attacks during the analysis period included between 3 and 6 months after the procedure. There is thus at present no scientific reason to look for PFO or to close PFO in migraine patients.
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Affiliation(s)
- M G Bousser
- Service de Neurologie, Hôpital Lariboisière, Paris.
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Saura D, García-Alberola A, Florenciano R, de la Morena G, Sánchez-Muñoz JJ, Soria F, Martínez-Sánchez J, Valdés-Chávarri M. Alternative explanations to the differences of femoral and brachial saline contrast injections for echocardiographic detection of patent foramen ovale. Med Hypotheses 2006; 68:1378-81. [PMID: 17166671 DOI: 10.1016/j.mehy.2006.10.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2006] [Accepted: 10/12/2006] [Indexed: 10/23/2022]
Abstract
Patent foramen ovale (PFO) of the interatrial septum is a cardiac foetal remnant, which frequent persistence in adulthood has important implications in a variety of clinical conditions. Echographic diagnosis of PFO is based on detection of interatrial shunt by means of contrast microbubbles identification after venous injection of a first-generation echographic contrast agent. Current recommendations propose venous femoral injection of contrast for enhanced echographic detection of PFO instead of venous brachial administration, as femoral injection has been shown to have higher sensitivity for PFO detection. Inferior vena cava inflow directed toward interatrial septum has been considered the explanation for increased sensitivity of femoral delivery of contrast. In the present paper, it is hypothesised that the main determinants of these differences between injection sites are technical factors related to right atrial contrast opacification and proper transient right atrial pressure rise, rather than intraatrial flow streaming. Effects of inferior vena cava inflow stream, although significant during foetal life, would be negligible after birth. Rationale and evidence, basis for further research, and practical implications leading to a simpler and safer routine technique for echographic detection of PFO are presented and discussed.
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Affiliation(s)
- Daniel Saura
- Servicio de Cardiología, Hospital Universitario Virgen de la Arrixaca, Carretera Murcia-Cartagena, S/N. 30120 Murcia, Spain.
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Abstract
The role of heart catheterization continues to evolve as the sophistication of cardiac MRI and CT improves and the breadth of interventional catheter techniques widens. This analysis is approached from four perspectives: (1) planning of the procedure, including information required, potential pitfalls, and equipment; (2) performance of the procedure, including sample run, coronary arteriography, chamber angiography, and angiography of selected lesions; (3) current role of heart catheterization, considering the impact of echo, MRI, and CT on indications for catheterization procedures and current interventional procedures; and (4) new and emerging interventions and speculation as to the future role of diagnostic heart catheterization in patients who have adult congenital heart disease.
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Hanslik A, Pospisil U, Salzer-Muhar U, Greber-Platzer S, Male C. Predictors of spontaneous closure of isolated secundum atrial septal defect in children: a longitudinal study. Pediatrics 2006; 118:1560-5. [PMID: 17015547 DOI: 10.1542/peds.2005-3037] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES The goals were to assess the frequency of spontaneous closure of isolated secundum atrial septal defect in children and to identify predictors of spontaneous atrial septal defect closure. METHODS A retrospective cohort study was performed in a tertiary care pediatric cardiology center. Consecutive patients (n = 200) diagnosed as having isolated atrial septal defects (no multiple or fenestrated atrial septal defects, no additional congenital heart disease, and no syndromes) were monitored for > 6 months with serial 2-dimensional echocardiography, according to a standardized protocol. RESULTS The median age at diagnosis was 5 months (minimum: 0 months; maximum: 13.9 years). The atrial septal defect diameter at diagnosis was 4 to 5 mm in 40% of cases, 6 to 7 mm in 28% of cases, 8 to 10 mm in 21% of cases, and > 10 mm in 11% of cases. The median age at the final follow-up evaluation was 4.5 years (range: 6.8 months to 16.2 years). Thirty-four percent of atrial septal defects showed spontaneous closure, and 28% decreased to a diameter of < or = 3 mm. Logistic regression analysis revealed atrial septal defect diameter and age at diagnosis as independent predictors of spontaneous closure or regression to < or = 3-mm defect size. Of atrial septal defects with a diameter of 4 to 5 mm at diagnosis, 56% showed spontaneous closure, 30% regressed to a diameter of < or = 3 mm, and none required surgical closure. Of atrial septal defects with a diameter of > 10 mm at diagnosis, none closed spontaneously, whereas 77% required surgical or device closure. Gender and observation time were not associated with spontaneous atrial septal defect closure or regression to < or = 3 mm. CONCLUSIONS In the present study population of children with atrial septal defects, 62% showed spontaneous closure (34%) or regression to < or = 3 mm (28%). Initial atrial septal defect diameter was the main predictor of spontaneous closure.
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Affiliation(s)
- Andreas Hanslik
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
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Manolis AS, Andrikopoulos G, Tsagou V, Pyrros J, Kranidis A. Transcatheter closure of patent foramen ovale during a radiofrequency ablation procedure. Clin Cardiol 2006; 29:369-71. [PMID: 16933579 PMCID: PMC6654535 DOI: 10.1002/clc.4960290810] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
A 43-year-old woman was undergoing radiofrequency catheter ablation of a symptomatic supraventricular tachycardia when a patent foramen ovale (PFO) was detected with passage of the diagnostic electrocatheter into the left atrium. Prior echocardiographic studies had been unrevealing. Upon questioning during the procedure, the patient now admitted to frequent and disabling daily migraine attacks, while her family described two recent brief episodes of disorientation and dysarthria, consistent with transient ischemic attacks. The patient was informed of the option of future closure of the PFO, but she insisted on having this done concurrently with her ablation procedure. After successful ablation of the slow pathway considered responsible for the supraventricular tachycardia, an Amplatzer closure device was utilized and the PFO was successfully closed during the same procedure. A postprocedural transesophageal echocardiogram showed complete sealing of the PFO, while over the ensuing 10 months the patient reported virtual elimination of her daily attacks of migrainous headaches, limited to a single episode the day after the procedure and none thereafter.
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Affiliation(s)
- Antonis S Manolis
- First Department of Cardiology, Evagelismos General Hospital of Athens, Athens, Greece.
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Abstract
Patent foramen ovale is incriminated in patients with cryptogenic stroke; however, concrete evidence that closure of patent foramen ovale using various devices is superior to continued medical therapy is not yet available. Controlled randomized trials are well underway to address this issue.
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Affiliation(s)
- Yun-Ching Fu
- Department of Pediatrics, Taichung Veterans General Hospital, National Yang-Ming University, Taichung, Taiwan.
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