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Sun L, Fan Z, Gao J, Zhao T, Si J, Zhang H, Li Y, Sun J, Wang X, Liu Z, Yi M, Hua Y, Xing Y, Liu Z, Li J. Association between patent foramen ovale morphology and clinical outcomes following transcatheter closure. Int J Cardiol 2024; 412:132307. [PMID: 38945369 DOI: 10.1016/j.ijcard.2024.132307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Revised: 05/27/2024] [Accepted: 06/26/2024] [Indexed: 07/02/2024]
Abstract
BACKGROUND Anatomic variations of the patent foramen ovale (PFO) are commonly observed, yet limited research has investigated their impact on clinical outcomes following transcatheter closure. We aimed to explore the association between PFO morphology and clinical outcomes. METHODS Consecutive patients with cryptogenic stroke who underwent PFO closure were prospectively enrolled at a single center from September 2019 to April 2023. Patients were categorized into simple and complex groups based on PFO morphology. Composite events were compared between the two groups during a median follow-up of 24 months, including all-cause mortality, recurrent stroke, residual moderate or severe shunt, and symptomatic atrial fibrillation. RESULTS A total of 247 patients were enrolled, with a mean age of 41.9 ± 13.0 years and 45.3% males. Ninety-one (36.8%) patients had complex PFO. These individuals were older (45.4 ± 12.5 years vs. 39.9 ± 12.9 years; P = 0.001), more males (56.0% vs. 39.1%; P = 0.010), had longer procedure times (54 ± 32 min vs 46 ± 29 min; P = 0.044), and had a higher rate of using delivery sheath-assisted crossing of the PFO (22.0% vs 12.8%; P = 0.040) than those with simple PFO. The estimated event rates were 27.9% and 11.3% (P = 0.006) in the complex and simple PFO groups, respectively (12.9 events and 5.2 events per 100 person-years; P = 0.001). After adjusting for age, sex, hypertension, diabetes, smoking, device type, and left atrial diameters, complex PFO remained independently associated with composite events (HR 2.10, 95%CI 1.06-4.17, P = 0.034). CONCLUSIONS Patients with complex PFO may suffer from a higher risk of adverse events following transcatheter PFO closure.
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Affiliation(s)
- Lijie Sun
- Department of Geriatrics, Xuanwu Hospital Capital Medical University, National Clinical Research Center for Geriatric Diseases, Beijing, China
| | - Zhenxing Fan
- Department of Cardiology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Jing Gao
- Department of Cardiology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Ting Zhao
- Department of Geriatrics, Xuanwu Hospital Capital Medical University, National Clinical Research Center for Geriatric Diseases, Beijing, China
| | - Jin Si
- Department of Geriatrics, Xuanwu Hospital Capital Medical University, National Clinical Research Center for Geriatric Diseases, Beijing, China
| | - Haoyu Zhang
- Department of Geriatrics, Xuanwu Hospital Capital Medical University, National Clinical Research Center for Geriatric Diseases, Beijing, China
| | - Yan Li
- Department of Geriatrics, Xuanwu Hospital Capital Medical University, National Clinical Research Center for Geriatric Diseases, Beijing, China
| | - Jinghao Sun
- Department of Geriatrics, Xuanwu Hospital Capital Medical University, National Clinical Research Center for Geriatric Diseases, Beijing, China
| | - Xinyi Wang
- Department of Geriatrics, Xuanwu Hospital Capital Medical University, National Clinical Research Center for Geriatric Diseases, Beijing, China
| | - Zhaoli Liu
- Department of Geriatrics, Xuanwu Hospital Capital Medical University, National Clinical Research Center for Geriatric Diseases, Beijing, China
| | - Ming Yi
- Department of Geriatrics, Xuanwu Hospital Capital Medical University, National Clinical Research Center for Geriatric Diseases, Beijing, China
| | - Yang Hua
- Department of Vascular Ultrasound, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Yingqi Xing
- Department of Vascular Ultrasound, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Zhi Liu
- Department of Emergency, Xuanwu Hospital Capital Medical University, Beijing, China.
| | - Jing Li
- Department of Geriatrics, Xuanwu Hospital Capital Medical University, National Clinical Research Center for Geriatric Diseases, Beijing, China.
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Aoun J, Hatab T, Volpi J, Lin CH. Patent Foramen Ovale and Atrial Septal Defect. Cardiol Clin 2024; 42:417-431. [PMID: 38910025 DOI: 10.1016/j.ccl.2024.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/25/2024]
Abstract
Patent foramen ovale (PFO) and atrial septal defects (ASDs) are two types of interatrial communications with unique clinical presentations and management strategies. The PFO is a normal part of fetal development that typically closes shortly after birth but may persist in as many as 25% to 30% of adults. The communication between atria may result in paradoxic embolism and embolic stroke. On the other hand, ASDs (anatomically defined as secundum, primum, sinus venosus, and coronary sinus in order of prevalence) typically result in right heart volume overload and are often associated with other congenital defects. The diagnostic methods, treatment options including surgical and percutaneous approaches, and potential complications are described. Both conditions underline the significance of precise diagnosis and appropriate management to mitigate risks and ensure optimal patient outcomes.
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Affiliation(s)
- Joe Aoun
- Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA.
| | - Taha Hatab
- Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA
| | - John Volpi
- Neurology Department, Houston Methodist Hospital, Houston, TX, USA
| | - Chun Huie Lin
- Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA
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Shehata A, Nasser A, Mohsen A, Anwar Samaan A, Mostafa A, Hassan M. Prevalence and characteristics of patent foramen ovale in a sample of Egyptian population: a computed tomography study. Egypt Heart J 2024; 76:73. [PMID: 38856789 PMCID: PMC11164847 DOI: 10.1186/s43044-024-00504-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 05/31/2024] [Indexed: 06/11/2024] Open
Abstract
BACKGROUND The reported prevalence of patent foramen ovale (PFO) in the general population is variable. It ranges between 8.6 and 42% according to the population studied and the imaging technique used. We aim to prospectively assess the prevalence and characteristics of PFO and interatrial septum (IAS) abnormalities as well as the related clinical manifestations in a sample of Egyptian population. RESULTS This study comprised 1000 patients who were referred for CT coronary angiography (CTCA). Mean age was 52.5 ± 10.9 years. The prevalence of PFO among the studied population was 16.3%; closed PFO (grade I) 44.2%, open PFO (grade II) 50.9%, and open PFO with jet (grade III) 4.9%. Anatomical high-risk PFO features-defined as the presence of at least 2 or more of the following (diameter ≥ 2 mm, length ≥ 10 mm, septal aneurysm "ASA", or redundant septum)-were found in 51.5% of PFOs' population. Other IAS abnormalities as redundant septum (8.6%), ASA (5.3%), Bachmann's bundle (4.5%), microaneurysm (2.6%), and atrial septal defect (ASD) (0.4%) were detected. There was a lower rate of coexistence of ASA with PFO (p = 0.031). Syncope was significantly higher in patients with PFO compared to those without PFO (6.7% vs. 1.6%, p = 0.001). Stroke, transient ischaemic attacks (TIA), and dizziness were similar in both groups. TIA, dizziness, and syncope were significantly higher in patients with IAS abnormalities including PFO compared to those without IAS abnormalities. Syncope was also significantly higher in PFO with high-risk anatomical features compared to those with non-high-risk PFO population (p = 0.02). CONCLUSION The prevalence of PFO in our study was approximately 16.3%, almost half of them showed anatomical high-risk features for stroke. Dizziness, syncope and TIA were significantly higher in patients with IAS abnormalities including PFO.
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Affiliation(s)
- Ahmed Shehata
- Cardiology Department, Cairo University, Giza, Egypt
| | | | - Ahmed Mohsen
- Cardiology Department, Cairo University, Giza, Egypt
| | - Amir Anwar Samaan
- Cardiology Department, Cairo University, Giza, Egypt
- Cardiology Department, AlNas Hospital, Qalyubia, Egypt
| | - Amir Mostafa
- Cardiology Department, Cairo University, Giza, Egypt
- Cardiology Department, AlNas Hospital, Qalyubia, Egypt
| | - Mohamed Hassan
- Cardiology Department, Cairo University, Giza, Egypt.
- Cardiology Department, AlNas Hospital, Qalyubia, Egypt.
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von Falkenhausen AS, Keidel LM, Wischmann J, Höglinger G, Massberg S, Kääb S, Kellert L, Sinner MF. Atrial fibrillation after patent foramen ovale closure in patients with embolic stroke of undetermined source. Europace 2024; 26:euae141. [PMID: 38842105 PMCID: PMC11154131 DOI: 10.1093/europace/euae141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 05/21/2024] [Indexed: 06/07/2024] Open
Affiliation(s)
- Aenne S von Falkenhausen
- Department of Medicine I, University Hospital, LMU Munich, Ziemssenstrasse 15, 80336 Munich, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Munich, Munich Heart Alliance (MHA), Pettenkoferstrasse 8a and 9, 80336 Munich, Germany
| | - Linus M Keidel
- Department of Neurology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377 Munich, Germany
| | - Johannes Wischmann
- Department of Neurology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377 Munich, Germany
| | - Günter Höglinger
- Department of Neurology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377 Munich, Germany
| | - Steffen Massberg
- Department of Medicine I, University Hospital, LMU Munich, Ziemssenstrasse 15, 80336 Munich, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Munich, Munich Heart Alliance (MHA), Pettenkoferstrasse 8a and 9, 80336 Munich, Germany
| | - Stefan Kääb
- Department of Medicine I, University Hospital, LMU Munich, Ziemssenstrasse 15, 80336 Munich, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Munich, Munich Heart Alliance (MHA), Pettenkoferstrasse 8a and 9, 80336 Munich, Germany
| | - Lars Kellert
- Department of Neurology, University Hospital, LMU Munich, Marchioninistrasse 15, 81377 Munich, Germany
| | - Moritz F Sinner
- Department of Medicine I, University Hospital, LMU Munich, Ziemssenstrasse 15, 80336 Munich, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Munich, Munich Heart Alliance (MHA), Pettenkoferstrasse 8a and 9, 80336 Munich, Germany
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Ter Schiphorst A, Lippi A, Corti L, Mourand I, Prin P, Agullo A, Cagnazzo F, Macia JC, Arquizan C. In young patients with stroke of undetermined etiology, large vessel occlusions are less frequent in the group with high-risk patent foramen ovale. Rev Neurol (Paris) 2024; 180:539-547. [PMID: 38102053 DOI: 10.1016/j.neurol.2023.11.002] [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: 04/17/2023] [Revised: 10/25/2023] [Accepted: 11/15/2023] [Indexed: 12/17/2023]
Abstract
INTRODUCTION Patent foramen ovale (PFO) is present in a significant proportion of young patients with stroke of undetermined etiology, but is not always causal. Therefore, classifications (RoPE, PASCAL) have been developed to determine the probability that PFO is the stroke cause. However, the presence of an initial arterial occlusion as a prediction factor was not studied when these classifications were built. Our aim was to evaluate the presence of arterial occlusion in young patients with stroke of undetermined etiology with/without high-risk PFO. METHODS From a prospectively-built monocentric database, we identified patients aged≥18 to<60-years with strokes of undetermined etiology and complete etiological work-up, including transesophageal echocardiography. We divided patients in two groups: (i) with high-risk PFO [i.e. PFO with large interatrial shunt (>30 microbubbles) or associated with atrial septal aneurysm] and (ii) with low-risk/without PFO. We recorded the presence of arterial occlusion and large vessel occlusion (LVO) in the acute phase. RESULTS We included 96 patients; 55 (57%) had high-risk PFO. Their median age was 48 (40-52) years, and 28 (29%) were women. The percentages of patients with arterial occlusion and with LVO were lower in the high-risk PFO group than in the low-risk/without PFO group: 11 (20%) versus 19 (46%) (P=0.008), and 5 (9%) versus 15 (37%) (P=0.002), respectively. There was no difference in the median RoPE score between groups (P=0.30). CONCLUSION The presence of LVO could represent a "red flag" of PFO causality in stroke of undetermined etiology, and could be implemented in future PFO-related stroke classifications.
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Affiliation(s)
- A Ter Schiphorst
- Department of Neurology, CHU Gui-de-Chauliac, Montpellier, France.
| | - A Lippi
- Department of Neurology, CHU Gui-de-Chauliac, Montpellier, France
| | - L Corti
- Department of Neurology, CHU Gui-de-Chauliac, Montpellier, France
| | - I Mourand
- Department of Neurology, CHU Gui-de-Chauliac, Montpellier, France
| | - P Prin
- Department of Neurology, CHU Gui-de-Chauliac, Montpellier, France
| | - A Agullo
- Department of Cardiology, CHU Arnaud-de-Villeneuve, Montpellier, France
| | - F Cagnazzo
- Department of Neuroradiology, CHU Gui-de-Chauliac, Montpellier, France
| | - J-C Macia
- Department of Cardiology, CHU Arnaud-de-Villeneuve, Montpellier, France
| | - C Arquizan
- Department of Neurology, CHU Gui-de-Chauliac, Montpellier, France
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Waqas S, Dawes S, Brar J, Abid W, Kanitkar A. Atrial Septal Aneurysm Leading to Ischemic Stroke: A Case Report and Literature Review. Cureus 2024; 16:e60955. [PMID: 38915999 PMCID: PMC11194138 DOI: 10.7759/cureus.60955] [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: 05/21/2024] [Indexed: 06/26/2024] Open
Abstract
Stroke is the most common cause of death and disability in the world, and ischemic etiology plays a major role. Atrial septal aneurysm (ASA) is a localized saccular deformity of the atrial septum, associated with ischemic stroke independently or in association with other atrial septal defects (ASD). There is a higher incidence of stroke in the population with ASD. In these patients, the presence of ASA is an important predictor of recurrent stroke. This is a case of ischemic stroke in a 44-year-old who presented with sudden-onset right-sided body weakness, expressive aphasia, and non-specific confusion for one hour, with an initial National Institutes of Health Stroke Scale (NIHSS) score of 7. CT angiogram revealed occlusion of the M3 branch of the left middle cerebral artery in the left lateral frontal lobe. Code stroke was called, and the patient was given tenecteplase (TNK), after which her right-side weakness and aphasia resolved. Trans-thoracic echo with bubble study showed ASA with positive bubble study. Lone ASA or ASA with concomitant ASD poses a higher risk of recurrent stroke in younger patients, especially those without significant risk factors for strokes. Patients with ASA and concomitant ASD are at high risk for recurrent ischemic stroke and should be kept under surveillance with continued medical therapy. We present a case of ischemic stroke caused by ASA and a review of the current literature and case reports documenting cases with similar presentations.
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Affiliation(s)
- Shamaiza Waqas
- Internal Medicine, Ascension Macomb-Oakland Hospital, Warren, USA
| | - Sean Dawes
- Critical Care Medicine, Ascension Macomb-Oakland Hospital, Warren, USA
| | - Jorawar Brar
- Cardiology, Ascension Macomb-Oakland Hospital, Warren, USA
| | - Waqas Abid
- Radiology, Ascension St. John Hospital, Detroit, USA
| | - Amaraja Kanitkar
- Intensive Care Unit and Pulmonology, Ascension Macomb-Oakland Hospital, Warren, USA
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Fuertes-Kenneally L, Angulo-Lara B, Forteza Gil A, Escudier Villa JM. Giant Aneurysm of the Interatrial Septum: A Multidisciplinary Approach. JACC Case Rep 2024; 29:102206. [PMID: 38379649 PMCID: PMC10874989 DOI: 10.1016/j.jaccas.2023.102206] [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: 11/17/2023] [Accepted: 12/08/2023] [Indexed: 02/22/2024]
Abstract
A 46-year-old woman presented for a routine echocardiogram, which revealed a giant atrial septal aneurysm (ASA) with an atrial septal defect (ASD). We surgically excised the ASA and closed the ASD with a pericardial patch. ASA, although rare, poses embolic risks, thus necessitating closure when associated with shunts. Optimal stroke prevention remains uncertain.
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Affiliation(s)
- Laura Fuertes-Kenneally
- Department of Cardiology, Dr Balmis General University Hospital of Alicante, Alicante, Spain
- Alicante Institute of Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Basilio Angulo-Lara
- Department of Cardiology, Puerta de Hierro Majadahonda University Hospital, Madrid, Spain
| | - Alberto Forteza Gil
- Department of Cardiovascular Surgery, Puerta de Hierro Majadahonda University Hospital, Madrid, Spain
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Dusonchet A, Varenne O, Puscas T, Saadi M, Hagege A, Calvet D, Mas J, Turc G. Does Atrial Septal Anatomy Still Matter in the Etiological Evaluation of Ischemic Stroke Beyond the Age of 60? J Am Heart Assoc 2024; 13:e031684. [PMID: 38353217 PMCID: PMC11010114 DOI: 10.1161/jaha.123.031684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 11/14/2023] [Indexed: 02/21/2024]
Abstract
BACKGROUND Patent foramen ovale (PFO) is causally associated with stroke in some patients younger than 60 years, especially when it is large or associated with an atrial septal aneurysm (ASA). After 60 years of age, this association is less well understood. We assessed the relationships between detailed atrial septal anatomy and the cryptogenic nature of stroke in this population. METHODS AND RESULTS We reviewed all patients aged 60 to 80 years admitted to our stroke center for ischemic stroke who underwent contrast echocardiography between 2016 and 2021. The atherosclerosis, small-vessel disease, cardiac pathology, other causes, and dissection (ASCOD) classification was used to reevaluate the etiological workup. Associations between cryptogenic stroke and (1) PFO presence or (2) categories of PFO anatomy (nonlarge PFO without ASA, nonlarge PFO with ASA, large PFO without ASA, and large PFO with ASA) were assessed using logistic regression. Among 533 patients (median National Institutes of Health Stroke Scale score=1), PFO was present in 152 (prevalence, 28.5% [95% CI, 24.9-32.5]). Compared with noncryptogenic stroke, cryptogenic stroke (n=218) was associated with PFO presence (44.5% versus 17.5%; P<0.0001). Among patients with a PFO, septal anatomy categories were associated with cryptogenic stroke (P=0.02), with a strong association for patients with both large PFO and ASA (38.1% versus 14.5%, P=0.002). CONCLUSIONS PFO presence remains strongly associated with cryptogenic stroke between 60 and 80 years of age. Large PFO, ASA, and their association were strongly associated with cryptogenic stroke in this age group. Our results support performing contrast echocardiography even after 60 years of age, although the optimal secondary prevention therapy in this population remains to be determined in randomized trials.
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Affiliation(s)
- Antoine Dusonchet
- Department of Neurology, GHU Paris Psychiatrie et NeurosciencesHôpital Sainte‐Anne, Université Paris Cité, INSERM U1266, and FHU NeurovascParisFrance
| | - Olivier Varenne
- Department of CardiologyHôpital Cochin, AP‐HP, Université Paris CitéParisFrance
| | - Tania Puscas
- Department of CardiologyHôpital Européen Georges Pompidou, AP‐HP, Université Paris CitéParisFrance
| | - Malika Saadi
- Department of CardiologyHôpital Cochin, AP‐HP, Université Paris CitéParisFrance
| | - Albert Hagege
- Department of CardiologyHôpital Européen Georges Pompidou, AP‐HP, Université Paris CitéParisFrance
| | - David Calvet
- Department of Neurology, GHU Paris Psychiatrie et NeurosciencesHôpital Sainte‐Anne, Université Paris Cité, INSERM U1266, and FHU NeurovascParisFrance
| | - Jean‐Louis Mas
- Department of Neurology, GHU Paris Psychiatrie et NeurosciencesHôpital Sainte‐Anne, Université Paris Cité, INSERM U1266, and FHU NeurovascParisFrance
| | - Guillaume Turc
- Department of Neurology, GHU Paris Psychiatrie et NeurosciencesHôpital Sainte‐Anne, Université Paris Cité, INSERM U1266, and FHU NeurovascParisFrance
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Sera S, Okazaki Y, Kashiwa K, Ichiba T. A Case Report of Under-Recognized Conditions in Pulmonary Embolism: Patent Foramen Ovale and Right Ventricular Thrombus. Cureus 2024; 16:e52535. [PMID: 38371032 PMCID: PMC10870038 DOI: 10.7759/cureus.52535] [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: 01/18/2024] [Indexed: 02/20/2024] Open
Abstract
Pulmonary embolism (PE) is a potentially life-threatening condition that presents with a spectrum of clinical symptoms ranging from asymptomatic to hemodynamic instability. The early diagnosis in the emergency department is often challenging. Although the association between patent foramen ovale (PFO) and thromboembolic events in patients with PE is well-documented, the significance of the presence of PFO in patients with PE may be underrecognized. In addition, the occurrence of right ventricular thrombus (RVT) in PE is a rare but significant complication with implications for disease management. We report a case of acute-on-chronic PE with concurrent bilateral renal infarction due to a paradoxical embolus, alongside RVT. A 35-year-old male presented at our emergency department with complaints of sudden onset abdominal pain. Bilateral renal infarction was identified on a contrast-enhanced computed tomography (CT). Point-of-care ultrasound showed suggestive findings of PE and RVT. Subsequently, a pulmonary CT angiography confirmed bilateral PE, a PFO, and RVT. The patient was effectively managed with thrombolytic therapy, with extracorporeal membrane oxygenation on standby. This case highlights the need to recognize the diverse clinical manifestations of PE and the importance of considering coexisting PFO and RVT in affected patients. The diagnosis of PE can be complex when symptoms overlap with arterial thrombosis, such as renal infarction secondary to a PFO. In addition, RVT, although uncommon, is a serious complication in patients with PE that may require careful evaluation for thrombolytic or anticoagulant therapy. It is critical to consider the possibility of a PFO in all cases of PE, even in the absence of arterial embolism, and to promptly evaluate for RVT prior to initiating treatment.
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Affiliation(s)
- Satoshi Sera
- Department of Emergency Medicine, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, JPN
| | - Yuji Okazaki
- Department of Emergency Medicine, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, JPN
| | - Kenichiro Kashiwa
- Department of Emergency Medicine, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, JPN
| | - Toshihisa Ichiba
- Department of Emergency Medicine, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, JPN
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Ravellette KS, Gornbein J, Tobis JM. Incidence of Atrial Fibrillation or Arrhythmias After Patent Foramen Ovale Closure. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2024; 3:101173. [PMID: 39131991 PMCID: PMC11307806 DOI: 10.1016/j.jscai.2023.101173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 08/13/2023] [Accepted: 09/05/2023] [Indexed: 08/13/2024]
Abstract
Background Patients with a patent foramen ovale (PFO) who undergo percutaneous PFO closure are at a greater risk of developing atrial fibrillation (AF) compared with patients whose PFOs are managed medically. Postclosure AF appears to be well tolerated if treated but may increase the risk for stroke. Postclosure AF is reported to occur in 3.7% to 7.4% of patients; however, incidence across devices remains uncertain. This study aims to evaluate the frequency of postclosure AF, atrial flutter, and arrhythmias in 6 PFO closure devices. Methods Four hundred forty-five patients underwent percutaneous PFO closure with appropriate follow-up between 2001 and 2021. The procedure was performed using Abbott Amplatzer PFO, Amplatzer ASD, Amplatzer Cribriform, NMT CardioSEAL, Gore Helex, or Gore Cardioform devices. Incidence of AF, atrial flutter, and arrhythmias were assessed by electrocardiogram within 6 months from closure. Multivariate logistic regression evaluated potential predictors of postclosure AF or atrial flutter. Results Postclosure AF or atrial flutter occurred in 30 patients (6.7%) within 6 months, and its incidence was significantly different across devices. Gore Cardioform had the greatest frequency of postclosure AF or atrial flutter events (16.8%) compared with other devices. The Gore Cardioform device, larger device sizes, and male sex were associated with greater risk of postclosure AF or atrial flutter. Conclusions Postclosure AF or atrial flutter was more likely to occur in the Gore Cardioform device, in males, and in patients who underwent PFO closure with larger devices. Although it is more effective for complete closure, the Gore Cardioform device was shown to be an independent predictor of postclosure AF or atrial flutter.
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Affiliation(s)
| | - Jeff Gornbein
- Statistics Core, Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, California
| | - Jonathan M. Tobis
- Department of Medicine, Division of Cardiology, UCLA, Los Angeles, California
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11
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Evola S, Camarda EA, Triolo OF, Adorno D, D’Agostino A, Novo G, Onorato EM. Clinical Outcomes and Quality of Life after Patent Foramen Ovale (PFO) Closure in Patients with Stroke/Transient Ischemic Attack of Undetermined Cause and Other PFO-Associated Clinical Conditions: A Single-Center Experience. J Clin Med 2023; 12:5788. [PMID: 37762729 PMCID: PMC10531865 DOI: 10.3390/jcm12185788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 08/24/2023] [Accepted: 09/04/2023] [Indexed: 09/29/2023] Open
Abstract
INTRODUCTION The aim of this study was to assess clinical outcomes and quality of life after PFO closure in patients with previous stroke/TIA of undetermined cause and in patients with other complex PFO-associated clinical conditions. METHODS Between July 2009 and December 2019 at our University Cardiology Department, 118 consecutive patients underwent a thorough diagnostic work-up including standardized history taking, clinical evaluation, full neurological examination, screening for thrombophilia, brain magnetic resonance imaging (MRI), ultrasound-Doppler sonography of supra-aortic vessels and 24 h ECG Holter monitoring. Anatomo-morphological evaluation using 2D transthoracic/transesophageal echocardiography (TTE/TEE) color Doppler and functional assessment using contrast TTE (cTTE) in the apical four-chamber view and contrast transcranial Doppler (cTCD) using power M-mode modality were performed to verify the presence, location and amount of right-to-left shunting via PFO or other extracardiac source. Completed questionnaires based on the Quality-of-Life Short Form-36 (QoL SF-36) and Migraine Disability Assessment (MIDAS) were obtained from the patients before PFO closure and after 12 months. Contrast TTE/TEE and cTCD were performed at dismission, 1, 6 and 12 months and yearly thereafter. Brain MRI was performed at 1-year follow-up in 54 patients. RESULTS Transcatheter PFO closure was performed in 106 selected symptomatic patients (mean age 41.7 ± 10.7 years, range 16-63, 65% women) with the following conditions: ischemic stroke (n = 23), transient ischemic attack (n = 22), peripheral and coronary embolism (n = 2), MRI lesions without cerebrovascular clinical events (n = 53), platypnea-orthodeoxia (n = 1), decompression sickness (n = 1) and refractory migraine without ischemic cerebral lesions (n = 4). The implanted devices were Occlutech Figulla Flex I/II PFO (n = 99), Occlutech UNI (n = 3), Amplatzer PFO (n = 3) and CeraFlex PFO occluders (n = 1). Procedures were performed under local anesthesia and rotational intracardiac monitoring (Ultra ICE) alone. The devices were correctly implanted in all patients. The mean fluoroscopy time was 15 ± 5 min (range = 10-45 min) and the mean procedural time was 55 ± 20 min (range = 35-90 min). The total occlusion rate at follow-up (mean 50 months, range 3-100) was 98.1%. No recurrent neurological events were observed in the long-term follow-up. CONCLUSIONS The data collected in this study demonstrate that percutaneous PFO closure is a safe and effective procedure, showing long-term prevention of recurrent cerebrovascular events, significant reduction in migraine symptoms and substantial improvement in quality of life.
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Affiliation(s)
- Salvatore Evola
- Catheterization Laboratory, Department of Medicine and Cardiology, Azienda Ospedaliera Universitaria Policlinico “P. Giaccone”, Via del Vespro 129, 90127 Palermo, Italy; (S.E.); (E.A.C.); (O.F.T.); (D.A.); (A.D.)
| | - Emmanuele Antonio Camarda
- Catheterization Laboratory, Department of Medicine and Cardiology, Azienda Ospedaliera Universitaria Policlinico “P. Giaccone”, Via del Vespro 129, 90127 Palermo, Italy; (S.E.); (E.A.C.); (O.F.T.); (D.A.); (A.D.)
| | - Oreste Fabio Triolo
- Catheterization Laboratory, Department of Medicine and Cardiology, Azienda Ospedaliera Universitaria Policlinico “P. Giaccone”, Via del Vespro 129, 90127 Palermo, Italy; (S.E.); (E.A.C.); (O.F.T.); (D.A.); (A.D.)
| | - Daniele Adorno
- Catheterization Laboratory, Department of Medicine and Cardiology, Azienda Ospedaliera Universitaria Policlinico “P. Giaccone”, Via del Vespro 129, 90127 Palermo, Italy; (S.E.); (E.A.C.); (O.F.T.); (D.A.); (A.D.)
| | - Alessandro D’Agostino
- Catheterization Laboratory, Department of Medicine and Cardiology, Azienda Ospedaliera Universitaria Policlinico “P. Giaccone”, Via del Vespro 129, 90127 Palermo, Italy; (S.E.); (E.A.C.); (O.F.T.); (D.A.); (A.D.)
| | - Giuseppina Novo
- Department Promise, Università di Palermo, UOC Cardiologia, Azienda Ospedaliera Universitaria Policlinico “P. Giaccone”, Via del Vespro 129, 90127 Palermo, Italy;
| | - Eustaquio Maria Onorato
- University Cardiology Department, Galeazzi-Sant’Ambrogio Hospital, Scientific Institute for Research, Hospitalization and Healthcare (I.R.C.C.S.), Via Cristina Belgioioso 173, 20157 Milan, Italy
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12
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Song JK. Pearls and Pitfalls in the Transesophageal Echocardiographic Diagnosis of Patent Foramen Ovale. J Am Soc Echocardiogr 2023; 36:895-905.e3. [PMID: 37196905 DOI: 10.1016/j.echo.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 05/01/2023] [Accepted: 05/02/2023] [Indexed: 05/19/2023]
Abstract
Large randomized controlled trials have shown the benefits of percutaneous closure of patent foramen ovale (PFO) in patients with cryptogenic stroke and PFO. Recent studies have highlighted the clinical significance and prognostic implication of various anatomical features of PFO and the adjacent atrial septum, such as atrial septal aneurysm (ASA), PFO size, large shunt, and hypermobility. Transthoracic echocardiography with contrast study is used for the indirect diagnosis of PFO, as it reveals the passage of the contrast into the left atrium. In contrast, transesophageal echocardiography (TEE) offers a direct demonstration of PFO by measuring its size using the maximum separation distance between the septum primum and septum secundum. Furthermore, TEE enables the acquisition of detailed anatomical features of the adjacent atrial septum including ASA, hypermobility, and PFO tunnel length, which carry significant prognostic implications. Transesophageal echocardiography also facilitates the diagnosis of pulmonary arteriovenous malformation, a relatively rare cause of paradoxical embolism. This review provides evidence for supporting TEE as a useful screening test for patients with cryptogenic stroke to identify suitable candidates for percutaneous device closure of PFO. Additionally, cardiac imaging specialists with proficiency in comprehensive TEE examination should be part of the heart-brain team for proper evaluation of and decision-making in patients with cryptogenic stroke.
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Affiliation(s)
- Jae-Kwan Song
- Professor of Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.
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13
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Lanzone AM, Albiero R, Boldi E, Safari D, Serafin P, Lussardi G, Rigamonti ER, Anselmi A. Clinical and echocardiographic outcomes after percutaneous closure of patent foramen ovale: a single center experience. Minerva Cardiol Angiol 2023; 71:157-164. [PMID: 33703865 DOI: 10.23736/s2724-5683.21.05609-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Patent foramen ovale (PFO) has a high estimated prevalence (25% of the general population) and has been implicated in the pathogenesis of cryptogenic stroke and transient ischemic attack (TIA), as well as in the pathogenesis of migraine headache. This study evaluated the effectiveness of percutaneous transcatheter PFO closure with Amplatzer™ (Abbott Laboratories, Abbott Park, IL, USA) devices, from a large single-center experience. METHODS From January 1998 to December 2014, 577 patients (243 males and 334 females, mean age 50 years, range 11-82 years) with documented PFO and history of at least one episode of cryptogenic stroke/TIA (N.=356) or occasional finding of previous ischemic lesions on MRI (N.=221) underwent percutaneous transcatheter closure of PFO using an Amplatzer™ Occluder (Abbott Laboratories). All the procedures were performed under general anesthesia or mild sedation and were assisted by transesophageal or intracardiac echocardiography. RESULTS Procedural success was 100%. After a median follow-up period of 2.7 years with echocardiographic evaluations, the rate of recurrent adverse cerebral events was 0.4%. Two patients (0.4%) required a secondary procedure for significant residual shunt. Of 36 patients with minor residual shunt, 30 (83%) showed spontaneous shunt regression at follow-up. There was a consistent decrease after procedure in headache migraine, platypnea-orthodeoxia, fainting episodes, syncope, and coenesthesia phenomena. CONCLUSIONS Transcatheter PFO closure is an effective and safe therapy for the prevention of thromboembolic events in the patients with cryptogenic stroke/TIA or an occasional finding of a positive cerebral MRI. Late follow-up shows device stability and clinical improvement in the majority of patients.
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Affiliation(s)
- Alberto M Lanzone
- Department of Cardiology, Cath Lab Service, Cardio-Neurological Center, San Rocco Clinical Institute, Ome, Brescia, Italy
| | - Remo Albiero
- Department of Cardiology, Cath Lab Service, Cardio-Neurological Center, San Rocco Clinical Institute, Ome, Brescia, Italy
| | - Emiliano Boldi
- Department of Cardiology, Cath Lab Service, Cardio-Neurological Center, San Rocco Clinical Institute, Ome, Brescia, Italy
| | - Davood Safari
- Department of Cardiology, Cath Lab Service, Cardio-Neurological Center, San Rocco Clinical Institute, Ome, Brescia, Italy
| | - Paolo Serafin
- Department of Cardiology, Cath Lab Service, Cardio-Neurological Center, San Rocco Clinical Institute, Ome, Brescia, Italy
| | - Gianluca Lussardi
- Department of Cardiology, Cath Lab Service, Cardio-Neurological Center, San Rocco Clinical Institute, Ome, Brescia, Italy
| | - Elia R Rigamonti
- Department of Internal Medicine, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Amedeo Anselmi
- Division of Thoracic and Cardiovascular Surgery, Pontchaillou University Hospital, Rennes, France -
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14
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Yang D, Elkind MSV. Current perspectives on the clinical management of cryptogenic stroke. Expert Rev Neurother 2023; 23:213-226. [PMID: 36934333 PMCID: PMC10166643 DOI: 10.1080/14737175.2023.2192403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 03/14/2023] [Indexed: 03/20/2023]
Abstract
INTRODUCTION Cryptogenic stroke is a heterogeneous entity defined as an ischemic stroke for which no probable cause is identified despite thorough diagnostic evaluation. Since about a quarter of all ischemic strokes are classified as cryptogenic, it is a commonly encountered problem for providers as secondary stroke prevention is guided by stroke etiology. AREAS COVERED In this review, the authors provide an overview of stroke subtype classification schemes and diagnostic evaluation in cryptogenic stroke. They then detail putative cryptogenic stroke mechanisms, their therapeutic implications, and ongoing research. This review synthesizes the available evidence on PubMed up to December 2022. EXPERT OPINION Cryptogenic stroke is an evolving concept that changes with ongoing research. Investigations are focused on improving our diagnostic capabilities and solidifying useful constructs within cryptogenic stroke that could become therapeutically targetable subgroups within an otherwise nonspecific entity. Advances in technology may help move specific proposed cryptogenic stroke mechanisms from undetermined to known source of ischemic stroke.
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Affiliation(s)
- Dixon Yang
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Mitchell S. V. Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
- American Heart Association
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15
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Laghlam D, Coroyer L, Martial PJ, Estagnasie P, Squara P, Nguyen LS. Risk factors and complications associated with intra-operative or post-operative identification of a PFO in cardiac surgery patients: A cohort study. Front Neurol 2023; 13:1057479. [PMID: 36703625 PMCID: PMC9871930 DOI: 10.3389/fneur.2022.1057479] [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: 09/29/2022] [Accepted: 12/13/2022] [Indexed: 01/12/2023] Open
Abstract
Introduction It is unknown whether patent foramen ovale (PFO) reopening in the peri-operative setting of cardiac surgery affects the risk for stroke and post-operative outcomes. Methods We performed a single-center, retrospective study based on a prospectively collected database in a tertiary cardiac surgery center. Using logistic regression, we assessed risk factors of PFO finding around surgery and subsequent clinical complications. Results Between January 2007 and July 2019, 11034 patients who underwent cardiac surgery in our center were included. A total of 233 patients (2.1%) presented a finding of PFO including 138 per-operative disclosures and 95 post-operative finding for hypoxemia. In the whole cohort, the mean age was 68.4 ± 11.5 years including 73.9% of men. Post-operative PFO finding was associated with more ischemic strokes compared with per-operative finding and control group [7(7.4%) vs. 3(2.2%) vs. 236(2.2), respectively; p = 0.003]. Moreover, patients with post-operative PFO reopening experienced a higher rate of pneumonia, reintubation, and longer length of stay in the ICU. Post-operative reopening of PFO, but not per-operative finding, was independently associated with ischemic strokes {adjusted odds-ratio = 3.5, 95% confidence interval (CI) [1.6-7.8]; p = 0.002}. Other variables associated with stroke incidence included age, mitral valve surgery, and ascending aorta surgery. Per- or post-operative PFO closure was associated with reduced adverse respiratory outcomes and a trend of the lower cerebral ischemic event. Conclusion Patent foramen ovale finding incidence in peri-operative cardiac surgery care was rare (2%) but post-operative finding of PFO was associated with a increased risk of ischemic strokes, worsened respiratory outcomes, and prolonged hospitalization.
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16
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Rodrigues R, Leitão K, Sousa C, Carvalho P, Marques D, Alves F. Interatrial septal aneurysm associated with patent foramen ovale in a dog - case report. ARQ BRAS MED VET ZOO 2023. [DOI: 10.1590/1678-4162-12793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023] Open
Abstract
ABSTRACT Atrial septal aneurysm (ASA) is a rare congenital deformity of variable clinical relevance, often reported in association with patent foramen ovale (PFO). Transthoracic Doppler echocardiography (TTE) is the first choice for diagnosis, but complementary techniques, such as microbubble contrast, should be used. Despite its importance, in Veterinary Medicine, there is little information related to the subject, and the present study is the second report of this condition in dogs. The objective was to report a case of ASA type IV LR associated with PFO in a Shar Pei bitch, diagnosed by a combined approach of transthoracic echocardiography backed by agitated saline solution (microbubbles). During clinical care, the owners reported episodes of seizures as their main complaint. Echocardiographic examination revealed a type 4 LR atrial septal aneurysm and left ventricular systolic dysfunction. The use of microbubble contrast showed right-to-left shunt, confirming PFO. The recommended treatment was medication. It was concluded that the rarity of ASA in dogs may be due to incomplete diagnoses and the transthoracic echocardiographic examination allows its analysis and classification. Furthermore, ASA can be found in animals with or without evidence of heart disease and it should be investigated in patients with neurological alterations.
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17
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Mas JL, Saver JL, Kasner SE, Nelson J, Carroll JD, Chatellier G, Derumeaux G, Furlan AJ, Herrmann HC, Jüni P, Kim JS, Koethe B, Lee PH, Lefebvre B, Mattle HP, Meier B, Reisman M, Smalling RW, Sondergaard L, Song JK, Thaler DE, Kent DM. Association of Atrial Septal Aneurysm and Shunt Size With Stroke Recurrence and Benefit From Patent Foramen Ovale Closure. JAMA Neurol 2022; 79:1175-1179. [PMID: 36215079 PMCID: PMC9552048 DOI: 10.1001/jamaneurol.2022.3248] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 06/22/2022] [Indexed: 11/14/2022]
Abstract
Importance The Patent Foramen Ovale (PFO)-Associated Stroke Causal Likelihood classification system combines information regarding noncardiac patient features (vascular risk factors, infarct topography) and PFO features (shunt size and presence of atrial septal aneurysm [ASA]) to classify patients into 3 validated categories of responsiveness to treatment with PFO closure. However, the distinctive associations of shunt size and ASA, alone and in combination, have not been completely delineated. Objective To evaluate the association of PFO closure with stroke recurrence according to shunt size and/or the presence of an ASA. Design, Setting, and Participants Pooled individual patient data from 6 randomized clinical trials conducted from February 2000 to October 2017 that compared PFO closure with medical therapy. Patients in North America, Europe, Australia, Brazil, and South Korea with PFO-associated stroke were included. Analysis was completed in January 2022. Exposures Transcatheter PFO closure plus antithrombotic therapy vs antithrombotic therapy alone, stratified into 4 groups based on the combination of 2 features: small vs large PFO shunt size and the presence or absence of an ASA. Main Outcomes and Measures Recurrent ischemic stroke. Results A total of 121 recurrent ischemic strokes occurred in the pooled 3740 patients (mean [SD] age, 45 [10] years; 1682 [45%] female) during a median (IQR) follow-up of 57 (23.7-63.8) months. Treatment with PFO closure was associated with reduced risk for recurrent ischemic stroke (adjusted hazard ratio [aHR], 0.41 [95% CI, 0.28-0.60]; P < .001). The reduction in hazard for recurrent stroke was greater for patients with both a large shunt and an ASA (aHR, 0.15 [95% CI, 0.06-0.35]) than for large shunt without ASA (aHR, 0.27 [95% CI, 0.14-0.56]), small shunt with ASA (aHR, 0.36 [95% CI, 0.17-0.78]), and small shunt without ASA (aHR, 0.68 [95% CI, 0.41-1.13]) (interaction P = .02). At 2 years, the absolute risk reduction of recurrent stroke was greater (5.5% [95% CI, 2.7-8.3]) in patients with large shunt and ASA than for patients in the other 3 categories (1.0% for all). Conclusions and Relevance Patients with both a large shunt and an ASA showed a substantially greater beneficial association with PFO closure than patients with large shunt alone, patients with small shunt and ASA, and patients with neither large shunt nor ASA. These findings, combined with other patient features, may inform shared patient-clinician decision-making.
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Affiliation(s)
- Jean-Louis Mas
- GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne, Service de Neurologie, Institut de Psychiatrie et Neurosciences de Paris, Université de Paris-Cité, Paris, France
| | - Jeffrey L. Saver
- Comprehensive Stroke Center and Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles
| | - Scott E. Kasner
- Comprehensive Stroke Center, Department of Neurology, University of Pennsylvania Medical Center, Philadelphia
| | - Jason Nelson
- Predictive Analytics and Comparative Effectiveness Center, Tufts Medical Center/Tufts University School of Medicine, Boston, Massachusetts
| | - John D. Carroll
- Division of Cardiology, Department of Medicine, University of Colorado Denver, Aurora
| | - Gilles Chatellier
- Centre d’Investigations Cliniques, Unité de Recherche Clinique, Hôpital Européen Georges–Pompidou, Assistance Publique–Hôpitaux de Paris, Paris, France
| | - Geneviève Derumeaux
- Département de Physiologie, Hôpital Henri Mondor, Assistance Publique–Hôpitaux de Paris, INSERM U955, Université Paris-Est Créteil (UPEC), Créteil, France
| | - Anthony J. Furlan
- Department of Neurology, Case Western Reserve University, Cleveland, Ohio
| | - Howard C. Herrmann
- Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Peter Jüni
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Jong S. Kim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Benjamin Koethe
- Predictive Analytics and Comparative Effectiveness Center, Tufts Medical Center/Tufts University School of Medicine, Boston, Massachusetts
| | - Pil Hyung Lee
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Benedicte Lefebvre
- Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | | | | | - Mark Reisman
- Weill Cornell Medical Center, New York, New York
| | - Richard W. Smalling
- Division of Cardiology, Department of Medicine, UTHealth/McGovern Medical School and The Memorial Hermann Heart and Vascular Institute, Houston, Texas
| | - Lars Sondergaard
- Department of Cardiology, University of Copenhagen Hospital Rigshospitalet, Denmark, Copenhagen
| | - Jae-Kwan Song
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - David E. Thaler
- Department of Neurology, Tufts Medical Center/Tufts University School of Medicine, Boston, Massachusetts
| | - David M. Kent
- Predictive Analytics and Comparative Effectiveness Center, Tufts Medical Center/Tufts University School of Medicine, Boston, Massachusetts
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Chino S, Mochizuki Y, Mizuma K, Ichikawa S, Miyazaki H, Hachiya R, Toyosaki E, Ota M, Fukuoka H, Yamochi T, Ono K, Shinke T. Transcranial Doppler for stratification of high-risk morphology of patent foramen ovale in patients with cryptogenic stroke. Heart Vessels 2022; 37:2119-2127. [PMID: 35701559 DOI: 10.1007/s00380-022-02117-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 06/03/2022] [Indexed: 12/28/2022]
Abstract
Microbubble testing using transcranial Doppler (TCD) is an important screening tool for diagnosing paradoxical cerebral embolism with high-risk PFO. However, little is known about the association between the microbubble test by TCD and the features of high-risk PFO evaluated by transesophageal echocardiography (TEE). We studied 101 consecutive patients at Showa University, from April 2019 to October 2020, who underwent both TCD and TEE with a sufficient Valsalva maneuver and who were strongly suspected by neurologists as cryptogenic stroke. According to the appearance of microbubbles as high-intensity transient signals (HITS), the TCD grade was stratified into three categories based on the criteria (A: none, no HITS, B: small; 1-10 HITS, and C: large; > 10 HITS, or an uncountable number of HITS). Among patients with RLS through the PFO in TEE, high-risk morphological features of PFO for cerebral embolism were evaluated as follows: (1) tunnel height, (2) tunnel length, (3) total excursion distance of the atrial septum into the right and left atrium, (4) existence of Eustachian valve or Chiari network, (5) angle of PFO from the inferior vena cava, and (6) large shunt (20 or more microbubbles). Of 101 patients (TCD grade; Group A = 49, Group B = 26, Group C = 26), RLS through PFO was detected in 37 patients (grade A = 8, grade B = 6, grade C = 23) by TEE. Among PFO-positive patients, tunnel height, length, total excursion distance into the right and left atria, angle of PFO from the inferior vena cava, and frequency of large shunt in TEE were significantly larger in grade C than in grade A and B (p < 0.05). Additionally, grade C patients had significantly more forms of high-risk PFOs than those in grades A and B when the six features of high-risk PFO were compared. A multivariate logistic regression demonstrated that the tunnel length of PFO and the presence of large shunt in TEE were independently associated with large HITS in TCD (odds ratio: 1.18 and 49.5, 95% confidence interval 1.043-1.337 and 10.05-244.3, p = 0.0086 and p < 0.0001, respectively). In conclusion, the existence of a large HITS detected by TCD may have a screening advantage in predicting the high-risk morphologies of PFO that can cause paradoxical cerebral embolism.
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Affiliation(s)
- Saori Chino
- Division of Cardiovascular Medicine, Department of Internal Medicine, Showa University, Tokyo, Japan
| | - Yasuhide Mochizuki
- Division of Cardiovascular Medicine, Department of Internal Medicine, Showa University, Tokyo, Japan.
| | - Keita Mizuma
- Division of Neurology, Department of Internal Medicine, Showa University, Tokyo, Japan
| | - Saaya Ichikawa
- Division of Cardiovascular Medicine, Department of Internal Medicine, Showa University, Tokyo, Japan
| | - Haruka Miyazaki
- Division of Cardiovascular Medicine, Department of Internal Medicine, Showa University, Tokyo, Japan
| | - Rumi Hachiya
- Division of Cardiovascular Medicine, Department of Internal Medicine, Showa University, Tokyo, Japan
| | - Eiji Toyosaki
- Division of Cardiovascular Medicine, Department of Internal Medicine, Showa University, Tokyo, Japan
| | - Masashi Ota
- Division of Cardiovascular Medicine, Department of Internal Medicine, Showa University, Tokyo, Japan
| | - Hiroto Fukuoka
- Division of Cardiovascular Medicine, Department of Internal Medicine, Showa University, Tokyo, Japan
| | | | - Kenjiro Ono
- Division of Neurology, Department of Internal Medicine, Showa University, Tokyo, Japan
| | - Toshiro Shinke
- Division of Cardiovascular Medicine, Department of Internal Medicine, Showa University, Tokyo, Japan
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Kompella D, Saleem M, Suter B, Harris DM. Multimodal Imaging Characterization of a Congenital Multilobular Interventricular Membranous Septal Aneurysm in a Patient Presenting with Embolic Stroke. CASE (PHILADELPHIA, PA.) 2022; 6:103-106. [PMID: 35602987 PMCID: PMC9120856 DOI: 10.1016/j.case.2022.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
• TTE is often performed to search for cardiac sources of emboli. • TTE must be comprehensive and assess the atria, valves, and ventricles. • TTE can be utilized to identify IVMSA as a rare cause of recurrent strokes. • Comprehensive imaging studies should be utilized to confirm the diagnosis of IVMSA. • Multidisciplinary care is necessary in the management of these patients.
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Affiliation(s)
- Divya Kompella
- Correspondence: Divya Kompella, MD, 231 Albert Sabin Way, Cincinnati, Ohio 45267-0557
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Gollion C, Lerebours F, Barbieux-Guillot M, Fabry V, Larrue V. Cryptogenic Ischemic Stroke in Migraine: Role of Patent Foramen Ovale. FRONTIERS IN PAIN RESEARCH 2022; 3:823595. [PMID: 35295806 PMCID: PMC8915651 DOI: 10.3389/fpain.2022.823595] [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: 11/27/2021] [Accepted: 01/21/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction Migraine with aura (MWA) has been associated with cryptogenic ischemic stroke (CIS) after adjustment for the presence of a patent foramen ovale (PFO) assessed by a transcranial Doppler. This study aimed at evaluating the association of MWA with causal PFO assessed by Transesophageal echocardiography (TEE) in CIS. Methods Patients aged 18–54 years consecutively treated for first acute ischemic stroke in a university hospital stroke unit, between January 2017 and December 2019, were included in this cross-sectional study. Associations between migraine subtypes and PFO were tested for all PFO, possibly causal PFO (PFO with large shunt and/or atrial septal aneurysm [ASA]), and the probably causal PFO subset (large shunt and/or ASA, plus risk of paradoxical embolism [RoPE] score ≥ 7). We adjusted the association between migraine subtypes and possibly causal PFO, which included the probably causal subset for age, sex, large artery atherosclerosis, and small vessel disease. Results A total of two hundred and two patients with CIS were included, of whom 42/202 (20%) had MWA, 32/202 (15%) had migraine without aura, and 128/202 (63%) had no migraine. MWA was associated with possibly causal PFO (OR = 4.0, 95%CI [1.78–9.3], P < 0.001) and with probably causal PFO (OR = 5.4, 95%CI [2.37–13], P < 0.001). In a multinomial logistic regression analysis, MWA remained associated with possibly causal PFO (OR = 3.24, 95% CI [1.45–7.2], P = 0.004). Conclusion In a young adult population with CIS, MWA was strongly associated with possibly causal PFO, i.e., with a large shunt or combined with an interatrial septal aneurysm.
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Affiliation(s)
- Cédric Gollion
- Department of Neurology, University Hospital of Toulouse, Toulouse, France
- ToNIC, Toulouse NeuroImaging Center, University of Toulouse, Inserm, Université Paul Sabatier (UPS), Toulouse, France
- *Correspondence: Cédric Gollion
| | - Fleur Lerebours
- Department of Neurology, University Hospital of Toulouse, Toulouse, France
| | | | - Vincent Fabry
- Department of Neurology, University Hospital of Toulouse, Toulouse, France
| | - Vincent Larrue
- Department of Neurology, University Hospital of Toulouse, Toulouse, France
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21
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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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22
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Secondary Prevention of Cardioembolic Stroke. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00064-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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23
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Scavasine VC, Chamma JF, Bazan R, Braga GP, Lange MC, Zétola VDHF. Comparison of right-to-left shunt characteristics in cryptogenic embolic ischemic stroke and non-cardioembolic ischemic stroke. ARQUIVOS DE NEURO-PSIQUIATRIA 2021; 79:859-863. [PMID: 34706014 DOI: 10.1590/0004-282x-anp-2020-0430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 12/07/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND Patent foramen ovale (PFO) has been considered a potential mechanism of embolic stroke of undetermined origin. OBJECTIVE The aim of the present study was to identify the features of the right-to-left shunt (RLS) in patients with undetermined embolic ischemic stroke and compare them with those of patients with non-cardioembolic ischemic stroke. METHODS A retrospective study was conducted with 168 patients with stroke and RLS separated into the following two groups: the undetermined embolic stroke group (UES group) and non-cardioembolic stroke group (NCES group). All patients were assessed by transcranial Doppler to evaluate the presence and quantification of microembolic signals (MES) at rest and under Valsalva maneuver. RESULTS Of all patients evaluated in the current study, 96 were included in the UES group and 72 in the NCES group. In the UES group, 65 patients had RLS with ≥10 MES (67.7%), which was higher than that observed in the NCES group (51.4%, p=0.038). According to the moment of the cardiac cycle, 75 patients (78.1%) in the UES group had a positive test at rest compared to 42 (58.3%) in the NCES group (p=0.007). CONCLUSIONS The current study demonstrated that almost 70% of patients with undetermined embolic stroke and PFO presented a large RLS and more than 75% had RLS at rest. These findings suggest that the size of the shunt should be taken into account when evaluating whether PFO could be a possible mechanism underlying cryptogenic stroke.
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Affiliation(s)
| | - Jamileh Ferreira Chamma
- Universidade Federal do Paraná, Hospital de Clínicas, Departamento de Neurologia, Curitiba PR, Brazil
| | - Rodrigo Bazan
- Universidade Estadual Paulista "Júlio de Mesquita Filho", Departamento de Neurologia, Botucatu SP, Brazil
| | - Gabriel Pereira Braga
- Universidade Federal de Mato Grosso do Sul, Departamento de Neurologia, Campo Grande MS, Brazil
| | - Marcos Christiano Lange
- Universidade Federal do Paraná, Hospital de Clínicas, Departamento de Neurologia, Curitiba PR, Brazil
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He L, Cheng G, Du Y, Zhang Y. Importance of Persistent Right-to-Left Shunt After Patent Foramen Ovale Closure in Cryptogenic Stroke Patients. Tex Heart Inst J 2021; 47:244-249. [PMID: 33472221 DOI: 10.14503/thij-17-6582] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Percutaneous closure of patent foramen ovale (PFO) is widely performed to prevent recurrent stroke or transient ischemic attack in patients with cryptogenic stroke. However, the influence of different degrees of right-to-left shunting (RLS) has rarely been reported. We retrospectively evaluated the cases of 268 patients with cryptogenic stroke who underwent PFO closure at our hospital from April 2012 through April 2015. In accordance with RLS severity, we divided the patients into 2 groups: persistent RLS during normal breathing and the Valsalva maneuver (n=112) and RLS only during the Valsalva maneuver (n=156). Baseline characteristics, morphologic features, and procedural and follow-up data were reviewed. The primary endpoint was stroke or transient ischemic attack. More patients in the persistent group had multiple or bilateral ischemic lesions, as well as a larger median PFO diameter (2.5 mm [range, 1.8-3.9 mm]) than did patients in the Valsalva maneuver group (1.3 mm [range, 0.9-1.9 mm]) (P <0.001). Atrial septal aneurysm was more frequent in the persistent group: 25 patients (22.3%) compared with 18 (11.5%) (P=0.018). Three patients in the persistent group had residual shunting. The annual risk of recurrent ischemic stroke was similar between groups: 0.298% (persistent) and 0.214% (Valsalva maneuver). Our findings suggest that patients with persistent RLS have more numerous severe ischemic lesions, larger PFOs, and a higher incidence of atrial septal aneurysm than do those without. Although our persistent group had a greater risk of residual shunting after PFO closure, recurrence of ischemic events did not differ significantly from that in the Valsalva maneuver group.
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Affiliation(s)
- Lu He
- Department of Structural Heart Disease, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710068, People's Republic of China
| | - Gesheng Cheng
- Department of Structural Heart Disease, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710068, People's Republic of China
| | - Yajuan Du
- Department of Structural Heart Disease, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710068, People's Republic of China
| | - Yushun Zhang
- Department of Structural Heart Disease, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710068, People's Republic of China
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Sun H, Zhou C, Xu L, Xu T. A meta-analysis of the association of atrial septal abnormalities and atrial vulnerability. Medicine (Baltimore) 2021; 100:e27165. [PMID: 34477173 PMCID: PMC8416013 DOI: 10.1097/md.0000000000027165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 08/19/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND The mechanism of cryptogenic stroke (CS) in patients with atrial septal abnormalities remains unclear, and the increased incidence of atrial vulnerability may be one of the reasons. We performed this meta-analysis to clarify the association between atrial septal abnormalities and atrial vulnerability, and to provide evidence-based basis for the prevention and mechanism of CS. METHODS We systematically searched for studies on the association between atrial septal abnormalities and atrial vulnerability, and pooled available data on types of atrial septal abnormalities, types of atrial vulnerability, and methods of atrial vulnerability detection. The primary endpoints were the occurrence of atrial arrhythmias or P wave abnormalities. Random-effects models were used to calculate odds ratios (OR) and 95% confidence intervals (CI). RESULTS Twelve case-control studies were eligible. Compared with the control group, patients with atrial septal abnormalities had a higher risk of atrial vulnerability (OR: 1.93; 95% CI: 1.13-3.30, P = .02). Data based on stroke patients showed that the group with atrial septal abnormalities had a higher risk of atrial vulnerability than the control group (OR: 2.00; 95% CI: 1.13-3.53, P = .02). However, there was no significant difference in the incidence of atrial vulnerability between the 2 groups of nonstroke patients. Subgroup analysis showed that although atrial septal abnormality increased the risk of atrial vulnerability in the subgroup of atrial septal aneurysm (OR: 1.68; 95% CI: 0.47-5.95, P = .42), the subgroup of atrial fibrillation (AF)/atrial fluster (OR: 1.81; 95% CI: 0.94-3.46, P = .07) and the subgroup of subcutaneous recording system (OR: 1.33; 95% CI: 0.68-2.61, P = .41), the difference was not statistically significant. CONCLUSIONS Atrial septal abnormalities can increase the risk of atrial vulnerability, and atrial arrhythmia caused by atrial septal abnormalities may be one of the mechanisms of CS.
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26
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Rhoades R, Tzeng D, Ruggiero N. Secondary stroke prevention in patients with patent foramen ovale. Curr Opin Hematol 2021; 28:292-300. [PMID: 34261880 DOI: 10.1097/moh.0000000000000672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Although a patent foramen ovale (PFO) is an established risk factor for cryptogenic ischemic stroke, strategies for secondary prevention remain controversial. Increasing evidence over the past decade from well designed clinical trials supports transcatheter PFO closure for selected patients whose stroke was likely attributable to the PFO. However, patient selection using imaging findings, clinical scoring systems, and in some cases, thrombophilia testing, is crucial for determining patients most likely to benefit from closure, anticoagulation, or antiplatelet therapy. RECENT FINDINGS Recent studies have found that patients with a high Risk of Paradoxical Embolism (RoPE) score and those with a thrombophilia benefit more from closure than medical therapy (including antiplatelet or anticoagulant therapy) alone. Meta-analyses have demonstrated an increased short-term risk of atrial fibrillation in closure patients, and that residual shunt after closure predicts stroke recurrence. Last, recent data have been inconclusive as to whether patients receiving medical therapy only benefit more from anticoagulation or antiplatelet therapy, so this remains an area of controversy. SUMMARY Transcatheter PFO closure is an evidence-based, guideline-supported therapy for secondary stroke prevention in patients with a PFO and cryptogenic stroke. However, proper patient selection is critical to achieve benefit, and recent studies have helped clarify those patients most likely to benefit from closure.
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Affiliation(s)
| | | | - Nicholas Ruggiero
- Division of Cardiology, Department of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Schnabel RB, Camen S, Knebel F, Hagendorff A, Bavendiek U, Böhm M, Doehner W, Endres M, Gröschel K, Goette A, Huttner HB, Jensen C, Kirchhof P, Korosoglou G, Laufs U, Liman J, Morbach C, Nabavi DG, Neumann-Haefelin T, Pfeilschifter W, Poli S, Rizos T, Rolf A, Röther J, Schäbitz WR, Steiner T, Thomalla G, Wachter R, Haeusler KG. Expert opinion paper on cardiac imaging after ischemic stroke. Clin Res Cardiol 2021; 110:938-958. [PMID: 34143285 PMCID: PMC8238761 DOI: 10.1007/s00392-021-01834-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 03/01/2021] [Indexed: 12/19/2022]
Abstract
This expert opinion paper on cardiac imaging after acute ischemic stroke or transient ischemic attack (TIA) includes a statement of the "Heart and Brain" consortium of the German Cardiac Society and the German Stroke Society. The Stroke Unit-Commission of the German Stroke Society and the German Atrial Fibrillation NETwork (AFNET) endorsed this paper. Cardiac imaging is a key component of etiological work-up after stroke. Enhanced echocardiographic tools, constantly improving cardiac computer tomography (CT) as well as cardiac magnetic resonance imaging (MRI) offer comprehensive non- or less-invasive cardiac evaluation at the expense of increased costs and/or radiation exposure. Certain imaging findings usually lead to a change in medical secondary stroke prevention or may influence medical treatment. However, there is no proof from a randomized controlled trial (RCT) that the choice of the imaging method influences the prognosis of stroke patients. Summarizing present knowledge, the German Heart and Brain consortium proposes an interdisciplinary, staged standard diagnostic scheme for the detection of risk factors of cardio-embolic stroke. This expert opinion paper aims to give practical advice to physicians who are involved in stroke care. In line with the nature of an expert opinion paper, labeling of classes of recommendations is not provided, since many statements are based on expert opinion, reported case series, and clinical experience.
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Affiliation(s)
- Renate B Schnabel
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
- Atrial Fibrillation NETwork (AFNET) e.V., Münster, Germany
| | - Stephan Camen
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Fabian Knebel
- Department of Cardiology and Angiology, University of Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Andreas Hagendorff
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig , Leipzig, Germany
| | - Udo Bavendiek
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Michael Böhm
- Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, University Hospital of Saarland, Saarland University, Homburg (Saar) , Germany
| | - Wolfram Doehner
- Berlin Institute of Health, Center for Regenerative Therapies, and Department of Cardiology (Virchow Klinikum), Charité-Universitätsmedizin Berlin, Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Matthias Endres
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité Universitätsmedizin Berlin, Berlin, Germany
- Klinik Und Hochschulambulanz Für Neurologie Mit Abteilung Für Experimentelle Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE), Partner Site Berlin, Berlin, Germany
- ExcellenceCluster NeuroCure, Berlin, Germany
| | - Klaus Gröschel
- Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Andreas Goette
- Atrial Fibrillation NETwork (AFNET) e.V., Münster, Germany
- Department of Cardiology & Intensive Care Medicine, St. Vincenz Hospital Paderborn, Paderborn, Germany
| | - Hagen B Huttner
- Department of Neurology, University Hospital Gießen, Gießen, Germany
| | - Christoph Jensen
- B. Braun Ambulantes Herzzentrum Kassel MVZ GmbH, Kassel, Germany
- Ruhr University Bochum, Bochum, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
- Atrial Fibrillation NETwork (AFNET) e.V., Münster, Germany
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, Medical School, University of Birmingham, Edgbaston, Birmingham, UK
| | - Grigorios Korosoglou
- Department of Cardiology and Vascular Medicine, GRN Hospital Weinheim, Weinheim, Germany
| | - Ulrich Laufs
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig , Leipzig, Germany
| | - Jan Liman
- Department of Neurology, University Medical Center Goettingen, Goettingen, Germany
| | - Caroline Morbach
- Comprehensive Heart Failure Center and Department for Medicine I, University Hospital Würzburg, Würzburg, Germany
| | | | - Tobias Neumann-Haefelin
- Department of Neurology, Klinikum Fulda, Universitätsmedizin Marburg - Campus Fulda, Fulda, Germany
| | - Waltraud Pfeilschifter
- Department of Neurology, Goethe-University Hospital Frankfurt, Frankfurt, Germany
- Department of Neurology and Clinical Neurophysiology, Klinikum Lüneburg, Lüneburg, Germany
| | - Sven Poli
- Department of Neurology & Stroke, Eberhard-Karls University Tübingen, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University Tübingen, Tübingen, Germany
| | - Timolaos Rizos
- Department of Neurology, Heidelberg University, Heidelberg, Germany
| | - Andreas Rolf
- Department of Cardiology, Kerckhoff-Heart-Center, Bad Nauheim, Germany and Campus Kerckhoff Justus-Liebig-University, Gießen, Germany
| | - Joachim Röther
- Department of Neurology, Asklepios Klinik Hamburg Altona, Hamburg, Germany
| | - Wolf Rüdiger Schäbitz
- Department of Neurology, Evangelisches Klinikum Bethel, Universitätsklinikum OWL der Universität Bielefeld, Campus Bielefeld-Bethel, Bielefeld, Germany
| | - Thorsten Steiner
- Department of Neurology, Heidelberg University, Heidelberg, Germany
- Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rolf Wachter
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig , Leipzig, Germany
- University Medical Center Goettingen, Göttingen, Germany
| | - Karl Georg Haeusler
- Atrial Fibrillation NETwork (AFNET) e.V., Münster, Germany.
- Department of Neurology, University Hospital Würzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Germany.
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Kumagai M, Nishizawa J, Takehara M, Shinoda E, Minatoya K. Surgical management of a giant atrial septal aneurysm. Clin Case Rep 2021; 9:e04125. [PMID: 34026164 PMCID: PMC8123557 DOI: 10.1002/ccr3.4125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 03/04/2021] [Accepted: 03/16/2021] [Indexed: 12/05/2022] Open
Abstract
We experienced a very rare case of surgical management of a giant atrial septal aneurysm. It is an interesting case and is supported by preoperative, intraoperative, and pathology images.
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Affiliation(s)
- Motoyuki Kumagai
- Department of Cardiovascular SurgeryGraduate School of Medicine Kyoto UniversityKyotoJapan
- Department of Cardiovascular SurgeryHamamatsu Rosai HospitalHamamatsuJapan
| | | | - Makoto Takehara
- Department of Cardiovascular SurgeryHamamatsu Rosai HospitalHamamatsuJapan
| | - Eiji Shinoda
- Department of CardiologyHamamatsu Rosai HospitalHamamatsuJapan
| | - Kenji Minatoya
- Department of Cardiovascular SurgeryGraduate School of Medicine Kyoto UniversityKyotoJapan
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29
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Kuriki A, Ueno Y, Kamiya Y, Shimizu T, Doijiri R, Tateishi Y, Kikuno M, Shimada Y, Takekawa H, Yamaguchi E, Koga M, Ihara M, Ono K, Tsujino A, Hirata K, Toyoda K, Hasegawa Y, Hattori N, Urabe T. Atrial Septal Aneurysm may Cause In-Hospital Recurrence of Cryptogenic Stroke. J Atheroscler Thromb 2021; 28:514-523. [PMID: 32684557 PMCID: PMC8193779 DOI: 10.5551/jat.56440] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 05/28/2020] [Indexed: 01/01/2023] Open
Abstract
AIMS Awareness of potentially embologenic diseases is critical to determining the prognosis of cryptogenic stroke. The clinical significance of atrial septal aneurysm (ASA) in cryptogenic stroke has not been fully studied. Therefore, we explored clinical characteristics and in-hospital recurrence in patients with ASA in cryptogenic stroke. METHODS A multicenter observational registry of cryptogenic stroke patients was conducted. We obtained baseline characteristics, radiological and laboratory findings, and echocardiographic findings, especially of embolic sources on transesophageal echocardiography. The CHALLENGE ESUS/CS (Mechanisms of Embolic Stroke Clarified by Transesophageal Echocardiography for embolic stroke of undetermined source/cryptogenic stroke) registry was recorded at http://www.umin.ac.jp/ctr/ (UMIN000032957). Patients' clinical characteristics were compared according to the presence of ASA, and factors associated with in-hospital stroke recurrence were assessed. RESULTS The study included 671 patients (age, 68.7±12.7 years; 450 males; median National Institutes of Health Stroke Scale score, 2). ASA was detected in 92 patients (14%), displaying higher age (72.4±11.0 vs. 68.1 ±12.9 years, p=0.004), reduced frequency of diabetes mellitus (16% vs. 27%, p=0.030), higher frequency of right-to-left shunt (66% vs. 45%, p<0.001), and in-hospital stroke recurrence (8% vs. 3%, p=0.034). ASA was relatively associated with in-hospital recurrence (odds ratio 2.497, 95% confidence interval 0.959-6.500, p= 0.061). CONCLUSIONS The CHALLENGE ESUS/CS registry indicated that ASA was not rare in cryptogenic stroke, and ASA's clinical characteristics included higher age, reduced frequency of diabetes mellitus, and increased frequency of concomitant right-to-left shunt. ASA may be related to in-hospital stroke recurrence in cryptogenic stroke.
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Affiliation(s)
- Ayako Kuriki
- Department of Neurology, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Yuji Ueno
- Department of Neurology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Yuki Kamiya
- Department of Neurology, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Takahiro Shimizu
- Department of Neurology, St.Marianna University School of Medicine, Kanagawa, Japan
| | - Ryosuke Doijiri
- Department of Neurology, Iwate Prefectural Central Hospital, Iwate, Japan
| | - Yohei Tateishi
- Department of Neurology and Strokology, Nagasaki University Hospital, Nagasaki, Japan
| | - Muneaki Kikuno
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yoshiaki Shimada
- Department of Neurology, Juntendo University Urayasu Hospital, Chiba, Japan
| | | | - Eriko Yamaguchi
- Department of Neurology, Iwate Prefectural Central Hospital, Iwate, Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Masafumi Ihara
- Department of Neurology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kenjiro Ono
- Division of Neurology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Akira Tsujino
- Department of Neurology and Strokology, Nagasaki University Hospital, Nagasaki, Japan
| | - Koichi Hirata
- Department of Neurology, Dokkyo Medical University, Tochigi, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yasuhiro Hasegawa
- Department of Neurology, St.Marianna University School of Medicine, Kanagawa, Japan
| | - Nobutaka Hattori
- Department of Neurology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Takao Urabe
- Department of Neurology, Juntendo University Urayasu Hospital, Chiba, Japan
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Chen JZJ, Thijs VN. Presence of Atrial Fibrillation in Stroke Patients With Patent Foramen Ovale: Systematic Review and Meta-Analysis. Front Neurol 2021; 12:613758. [PMID: 33935933 PMCID: PMC8081982 DOI: 10.3389/fneur.2021.613758] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 03/11/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose: Patent foramen ovale (PFO) is associated with ischemic stroke, especially in patients with embolic stroke of undetermined source. This study aims to evaluate the presence of atrial fibrillation (AF) in ischemic stroke patients with PFO. Methods: We systematically searched EMBASE and MEDLINE databases on May 21, 2020 for studies that analyzed the presence of AF in patients with PFO. The primary outcome was the presence of AF in patients with PFO compared with those without. Outcomes were pooled using a random-effects model using the method of DerSimonian and Laird. We recorded demographic characteristics and the methods used for AF detection in the studies included (unspecified, history/medical records review, ECG, Holter monitor, or loop recorder). Results: A total of 14 studies and 13,245 patients fulfilled the entry criteria. The average age was 61.2 years and 41.3% of the participants were female. There was a lower risk of AF in patients with PFO compared with those without (RR 0.52, 95% confidence interval, 0.41-0.63, p < 0.001). There was no evidence of heterogeneity. The lower risk of AF was found in cross-sectional and longitudinal studies and in studies stratified by average age (<60 or ≥60) and in cryptogenic stroke. Meta-regression by PFO detection technique suggested that studies using transoesophageal echocardiogram for PFO detection reported higher risk of AF (1.39, 95% confidence interval 1.14-1.70, p = 0.004). Conclusion: The presence of a PFO in patients with ischemic stroke/TIA may be associated with a lower risk of AF. Few studies have estimated the risk of future AF in patients with PFO.
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Affiliation(s)
| | - Vincent N Thijs
- Department of Neurology, Austin Health, Heidelberg, VIC, Australia.,Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, VIC, Australia
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Poli S, Siebert E, Mbroh J, Poli K, Krumbholz M, Mengel A, Greulich S, Härtig F, Müller KAL, Bocksch W, Gawaz M, Ziemann U, Zuern CS. Closure or medical therapy of patent foramen ovale in cryptogenic stroke: prospective case series. Neurol Res Pract 2021; 3:16. [PMID: 33789756 PMCID: PMC8015114 DOI: 10.1186/s42466-021-00114-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 03/01/2021] [Indexed: 11/17/2022] Open
Abstract
Background Results of randomized controlled trials (RCT) do not provide definite guidance for secondary prevention after ischemic stroke (IS)/transient ischemic attack (TIA) attributed to patent foramen ovale (PFO). No recommendations can be made for patients > 60 years. We aimed to compare interventional and medical PFO-management in cryptogenic IS/TIA patients, including patients > 60 years. Methods Prospective case series including consecutive cryptogenic IS/TIA patients with PFO at Tuebingen university stroke unit, Germany. ‘PFO-closure’ was recommended in patients ≤70 years when featuring high-risk PFO (i.e., with atrial septal aneurysm, spontaneous, or high-grade right-to-left shunt during Valsalva). Primary (recurrent IS/intracranial hemorrhage) and secondary endpoints (e.g., disability) were assessed during ≥1-year follow-up; planned subgroup analyses of patients ≤60/> 60 years. Results Among 236 patients with median age of 58 (range 18–88) years, 38.6% were females and median presenting National Institutes of Health Stroke Scale score was 1 (IQR 0–4). Mean follow-up was 2.8 ± 1.3 years. No intracranial hemorrhage was observed. Recurrent IS rate after ‘PFO-closure’ was 2.9% (95%CI 0–6.8%) and 7% (4–16.4) in high-risk PFO patients ≤60 (n = 103) and > 60 years (n = 43), respectively, versus 4% (0–11.5) during ‘medical therapy alone’ MTA (n = 28). 42 low-risk PFO patients treated with MTA experienced no recurrent IS/TIA. Conclusions In our real-world study, IS recurrence rate in ‘PFO-closure’ high-risk PFO patients ≤60 years was comparable to that observed in recent RCT. High-risk PFO patients > 60 years who underwent PFO-closure had similar IS recurrence rates than those who received MTA. MTA seems the appropriate treatment for low-risk PFO. Trial registration ClinicalTrials.gov, registration number: NCT04352790, registered on: April 20, 2020 – retrospectively registered. Supplementary Information The online version contains supplementary material available at 10.1186/s42466-021-00114-3.
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Affiliation(s)
- Sven Poli
- Department of Neurology & Stroke, Eberhard-Karls University, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany. .,Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tuebingen, Germany.
| | - Elisabeth Siebert
- Department of Cardiology, Eberhard-Karls University, Tuebingen, Germany
| | - Joshua Mbroh
- Department of Neurology & Stroke, Eberhard-Karls University, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tuebingen, Germany
| | - Khouloud Poli
- Department of Neurology & Stroke, Eberhard-Karls University, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tuebingen, Germany
| | - Markus Krumbholz
- Department of Neurology & Stroke, Eberhard-Karls University, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tuebingen, Germany
| | - Annerose Mengel
- Department of Neurology & Stroke, Eberhard-Karls University, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tuebingen, Germany
| | - Simon Greulich
- Department of Cardiology, Eberhard-Karls University, Tuebingen, Germany
| | - Florian Härtig
- Department of Neurology & Stroke, Eberhard-Karls University, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tuebingen, Germany
| | - Karin A L Müller
- Department of Cardiology, Eberhard-Karls University, Tuebingen, Germany
| | - Wolfgang Bocksch
- Department of Cardiology, Eberhard-Karls University, Tuebingen, Germany
| | - Meinrad Gawaz
- Department of Cardiology, Eberhard-Karls University, Tuebingen, Germany
| | - Ulf Ziemann
- Department of Neurology & Stroke, Eberhard-Karls University, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tuebingen, Germany
| | - Christine S Zuern
- Department of Neurology & Stroke, Eberhard-Karls University, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany.,Department of Cardiology, Eberhard-Karls University, Tuebingen, Germany.,Cardiology Division, Department of Medicine, University Hospital, and Cardiovascular Research Institute, Basel, Switzerland
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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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Gollion C, Gazagnes J, Fabry V, Barbieux-Guillot M, Lerebours F, Larrue V. Atrial fibrillation and migraine with aura in young adults with ischemic stroke. Cephalalgia 2020; 41:375-382. [PMID: 33200948 DOI: 10.1177/0333102420970880] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Migraine is associated with an increased risk of ischemic stroke. The associations are stronger in migraine with aura than in migraine without aura, in women than in men, and in younger subjects. However, the mechanisms by which migraine might increase the risk of ischemic stroke are debated. METHODS We analysed the associations between migraine without aura and migraine with aura and the causes of ischemic stroke in patients aged 18-54 years treated consecutively in a university hospital stroke center. RESULTS A total of 339 patients (mean/SD age 43.8/8.8 years, 62.83% male) were included. Migraine with aura was diagnosed in 58 patients, and migraine without aura in 54 patients. Patients with migraine with aura were younger and had fewer traditional cardiovascular risk factors than patients with no migraine. Migraine with aura was strongly associated with atrial fibrillation (odds ratio, 5.08; 95% confidence interval, 1.24-21.92; p = 0.011) and negatively associated with atherosclerosis (odds ratio, 0.29; 95% confidence interval, 0.05-0.97; p = 0.033) and small vessel disease (odds ratio, 0.13; 95% confidence interval, 0.00-0.87; p = 0.022). No other cause of stroke was significantly associated with migraine. The most common cause of stroke was atherosclerosis in no-migraine patients, dissection in migraine without aura patients and patent foramen ovale in migraine with aura patients. Atrial fibrillation was, together with dissection, the second leading cause of stroke in migraine with aura patients, accounting for 10.34% of cases in this subgroup. CONCLUSION We showed that atrial fibrillation was a common cause of ischemic stroke in young adults with migraine with aura.
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Affiliation(s)
- Cédric Gollion
- Department of Neurology, University of Toulouse, Toulouse, France.,ToNIC, Toulouse NeuroImaging Center, University of Toulouse, INSERM, France
| | - Julie Gazagnes
- Department of Neurology, University of Toulouse, Toulouse, France
| | - Vincent Fabry
- Department of Neurology, University of Toulouse, Toulouse, France
| | | | - Fleur Lerebours
- Department of Neurology, University of Toulouse, Toulouse, France
| | - Vincent Larrue
- Department of Neurology, University of Toulouse, Toulouse, France
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Sievert K, Yu J, Bertog S, Hornung M, von Bardeleben RS, Gafoor S, Reinartz M, Matic P, Hofmann I, Grunwald I, Schnelle N, Sievert H. Post-Market Clinical Follow-Up With the Patent Foramen Ovale Closure Device IrisFIT (Lifetech) in Patients With Stroke, Transient Ischemic Attack, or Other Thromboembolic Events. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 30:72-75. [PMID: 33097460 DOI: 10.1016/j.carrev.2020.09.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/14/2020] [Accepted: 09/21/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND A patent foramen ovale (PFO) has been associated with embolic strokes and transient ischemic attacks (TIAs). Catheter closure of PFO is effective in preventing recurrent events. Residual shunts and procedure or device related complications can occur, including atrial fibrillation and thrombus formation. This study examines the initial experience with a new PFO closure device, the IrisFIT PFO-Occluder (Lifetech Scientific, Shenzhen, China). METHODS 95 patients with indications for PFO closure underwent percutaneous closure with the IrisFIT PFO-Occluder. The primary endpoint was the rate of accurate device placement with no/small residual shunt at 3 or 6 months follow-up. All patients underwent transoesophageal echocardiography (TEE) after 1 to 6 months. In case of a residual shunt, an additional TEE was performed after 12 months. Clinical follow-up was performed up to a mean of 33.1 ± 3.6 months. RESULTS The device was successfully implanted in 95 (100%) patients with no relevant procedural complications. At final TEE follow-up (7.6 ± 3.9 months) the effective closure rate was 96.8% with 1 moderate and 2 large residual shunts. There were 8 cases of new onset atrial fibrillation and 2 TIAs. There were no cases of device embolization or erosion. CONCLUSION The IrisFIT occluder is a new PFO closure device with several advantages compared to other devices. In this small study cohort, technical success rate, closure rate and adverse event rate were comparable to other devices. The rate of new onset atrial fibrillation was higher in comparison to other studies and warrants further investigation.
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Affiliation(s)
| | - Jiangtao Yu
- Helmut-G.-Walther-Klinikum, Lichtenfels, Germany
| | | | | | - Ralph Stephan von Bardeleben
- Medizinische Klinik - Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsmedizin Mainz, Mainz, Germany
| | | | | | | | | | - Iris Grunwald
- CardioVascular Center Frankfurt, Frankfurt, Germany; Anglia Ruskin University, Chelmsford, United Kingdom
| | - Nalan Schnelle
- CardioVascular Center Frankfurt, Frankfurt, Germany; Medizinische Klinik - Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsmedizin Mainz, Mainz, Germany
| | - Horst Sievert
- CardioVascular Center Frankfurt, Frankfurt, Germany; Anglia Ruskin University, Chelmsford, United Kingdom.
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Fukutomi M, Wilkins B, Søndergaard L. The role of device closure of patent foramen ovale in patients with cryptogenic stroke. J Intern Med 2020; 288:400-409. [PMID: 32812297 DOI: 10.1111/joim.13143] [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: 02/10/2020] [Revised: 06/16/2020] [Accepted: 06/16/2020] [Indexed: 01/16/2023]
Abstract
One of the most frequent causes of cardiac embolism in cryptogenic stroke is a paradoxical embolus, which originate from systemic venous source though an unidentified patent foramen ovale (PFO). PFO is a common finding in the general population with a prevalence of 25% to 30%. Transcatheter PFO device closure is known to be feasible and safety treatment for such patients. In recent years, several randomized controlled trials (RCTs) have been conducted to address the superiority of PFO closure over medical therapy alone in the prevention of stroke recurrence in patients with PFO. In contrast to findings from early 3 RCTs, recent 4 RCTs could successfully show the benefits of PFO device closure compared with medical therapy, with less peri- and postprocedural complication. Based on these data, PFO device closure is recommended to carefully select cryptogenic stroke patients aged from 18 to 65 years, with a high probability of a causal role of the PFO in stroke events. However, it is still uncertain whether PFO closure is superior to oral anticoagulants therapy in these patients. Therefore, further prospective randomized trials are needed to address the efficacy of PFO device closure to oral anticoagulants therapy.
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Affiliation(s)
- M Fukutomi
- From the Heart Center, Rigshospitalet, Copenhagen, Denmark
| | - B Wilkins
- From the Heart Center, Rigshospitalet, Copenhagen, Denmark
| | - L Søndergaard
- From the Heart Center, Rigshospitalet, Copenhagen, Denmark
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36
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Routine surveillance of pelvic and lower extremity deep vein thrombosis in stroke patients with patent foramen ovale. J Thromb Thrombolysis 2020; 51:1150-1156. [PMID: 32888135 DOI: 10.1007/s11239-020-02262-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Patent foramen ovale (PFO) is a potential conduit for paradoxical embolization to the systemic atrial circulation of a thrombus originating in the venous system. In a selected group of subjects, the prevalence of deep vein thrombosis (DVT) was assessed. Subjects were identified if they underwent magnetic resonance venography (MRV) pelvis and lower extremity doppler (LE-VDU) for assessment of DVT with PFO. The primary outcome measure was to report the number of patients with paradoxical embolization as their suspected etiology of stroke due to the presence of DVT, which then will be considered as determined stroke. Others with determined stroke diagnosis were reported using Treatment of Acute Stroke Trial (TOAST) criteria. At discharge, those without etiology of their stroke were grouped under embolic stroke of undetermined source (ESUS). We further analyzed the prevalence of DVT by age group, ≤ 60 years vs > 60 years to describe if the prevalence is higher with younger age and to evaluate if higher Risk of Paradoxical Embolism (ROPE) score will have higher number of DVTs compared to lower ROPE scores. Of the 293, 19 (7%) were strokes due to paradoxical embolism. At discharge, determined stroke were 54% vs ESUS were 46%. The overall prevalence of DVT was 19 (7%); MRV-pelvis 13 (4%), and LE-VDU was 9 (3%). No significant difference was noted using both modalities. However, in multivariable regression analysis, a trend suggested an association between pelvic thrombi and high ROPE score as the etiology of stroke; OR 3.56 (0.98, 12.93); p = 0.054. Detection of DVT was not associated with PFO, high ROPE scores or young age. Our data indicate an over-reliance of testing for DVT, particularly MRV pelvis with contrast, in patients with PFO. Clinical studies are needed to identify other factors predictive of DVT in patients with ischemic stroke and PFO.
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Blissett S, Lin S, Mahadevan V, Ordovas K. Adult Presentation of Congenital Heart Disease. Semin Roentgenol 2020; 55:251-263. [PMID: 32859342 DOI: 10.1053/j.ro.2020.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Sarah Blissett
- Department of Cardiology, University of California, San Francisco, San Francisco, CA
| | - Shezhang Lin
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA
| | - Vaikom Mahadevan
- Department of Cardiology, University of California, San Francisco, San Francisco, CA
| | - Karen Ordovas
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA.
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Recurrent cerebrovascular events in patients after percutaneous closure of patent foramen ovale. J Stroke Cerebrovasc Dis 2020; 29:104860. [PMID: 32430239 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104860] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 03/20/2020] [Accepted: 03/31/2020] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Recent published trials have shown the efficacy of transcatheter closure of patent foramen ovale (PFO) for preventing recurrent cryptogenic cerebrovascular events. However, the risk of recurrent cerebrovascular events (rCVEs) is up to 5.7%, and the etiology is unclear. OBJECTIVE This study aimed to investigate the risk factors for rCVEs after closure of PFO during long-term follow-up. METHODS In our center, 282 consecutive patients underwent PFO closure because of a cryptogenic cerebrovascular event between 2006 and 2014. Their Risk of Paradoxical Embolism (RoPE) score was calculated retrospectively. We followed up with the patients by telephone, using hospital records to identify those who suffered from rCVEs. Patients with rCVEs were matched with two control patients of the same sex and RoPE score without rCVEs who underwent PFO closure at approximately the same time. The patients with rCVEs and controls participated in a clinical examination, including contrast transthoracic echocardiography (TTE) and Holter electrocardiography, to investigate the possible cause of rCVEs compared with controls. RESULTS Fourteen (5%) out of the 282 consecutive patients who underwent PFO closure suffered from rCVEs during a mean follow-up of 8.4 years (1.7 rCVEs per 100 patient-years). The median RoPE score of the patients was 7. Recurrent CVE occurred in 3.2 patients per 100 patient-years in patients with residual shunting compared with 0.8 patients per 100 patient-years in those without residual shunt. These patients were on antiplatelet treatment or without any effective anticoagulant treatment at the time rCVE occurred. The risk ratio of rCVEs in patients with residual shunting was 2.9-times higher than in patients without residual shunting (95% CI: 1.4-6.1) at follow-up visit. Four patients who had the BioSTAR device implanted suffered from an rCVE despite lack of residual shunting. CONCLUSIONS This study indicates that residual shunting and choice of the device may be the major reasons for rCVEs.
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Ioannidis SG, Mitsias PD. Patent Foramen Ovale in Cryptogenic Ischemic Stroke: Direct Cause, Risk Factor, or Incidental Finding? Front Neurol 2020; 11:567. [PMID: 32670184 PMCID: PMC7330017 DOI: 10.3389/fneur.2020.00567] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 05/19/2020] [Indexed: 01/27/2023] Open
Abstract
Patent foramen ovale (PFO) has been associated with cryptogenic stroke. There is conflicting data and it remains uncertain whether PFO is the direct cause, a risk factor or an incidental finding. Potential stroke mechanisms include paradoxical embolism from a venous clot which traverses the PFO, in situ clot formation within the PFO, and atrial arrhythmias due to electrical signaling disruption. Main risk factors linked with PFO-attributable strokes are young age, PFO size, right-to-left shunt degree, PFO morphology, presence of atrial septal aneurysm, intrinsic coagulation-anticoagulation systems imbalance, and co-existence of other atrial abnormalities, such as right atrial septal pouch, Eustachian valve and Chiari's network. These may act independently or synergistically, multiplying the risk of embolic events. The RoPE score, a scale that includes factors such as young age, cortical infarct location and absence of traditional stroke risk factors, is associated with the probability of a PFO being pathogenic and stroke recurrence risk after the index stroke. Multiple investigators have attempted to correlate other PFO features with the risk of PFO-related stroke, but further investigation is needed before any robust conclusions are reached. PFO presence in young patients with cryptogenic stroke should be considered as etiologically suspect. Caution should be exercised in interpreting the relevance of other PFO features.
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Affiliation(s)
| | - Panayiotis D Mitsias
- Department of Neurology, University Hospital of Heraklion, Heraklion, Greece.,School of Medicine, University of Crete, Heraklion, Greece.,Department of Neurology and Comprehensive Stroke Center, Henry Ford Hospital, Detroit, MI, United States.,School of Medicine, Wayne State University, Detroit, MI, United States
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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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Liu Y, Wu Y, Xiong L. Surgical vs. drug therapy in patients with patent foramen ovale and cryptogenic stroke. Herz 2020; 46:250-254. [PMID: 32394019 DOI: 10.1007/s00059-020-04921-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 04/06/2020] [Accepted: 04/10/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVE This study aimed to investigate the effectiveness of risk scoring for predicting stroke recurrence after percutaneous patent foramen ovale (PFO) closure or medication therapy in patients with PFO and a history of cryptogenic stroke. METHODS This study included 559 patients with PFO and cryptogenic stroke who were treated in our hospital from January 2013 to January 2018 and were followed up for 15-72 months. After calculating the risk scores for stroke recurrence, we randomly divided the patients into two groups (ratio, 1:1): Patients in one group underwent PFO closure and those in the other received drug therapy. RESULTS Patients in the PFO closure group had a lower risk of recurrent stroke than those in the drug therapy group (1.1% vs. 4.2%). Moreover, serious bleeding was less frequent in the PFO closure group than in the drug therapy group (0% vs. 3.2%), although the incidence of atrial fibrillation or flutter did not significantly differ between the groups (p = 0.67). Interestingly, a subgroup analysis revealed no inter-treatment group difference in the rate of cryptogenic stroke recurrence among patients with risk scores of 0-1. By contrast, PFO closure yielded superior outcomes among patients with risk scores of ≥2. CONCLUSION Compared with drug therapy, PFO closure reduced the risk of recurrent stroke among patients with a risk score of ≥2 and reduced the incidence of serious bleeding without increasing the risk of new-onset atrial fibrillation or atrial flutter.
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Affiliation(s)
- Yunbing Liu
- Cardiac Electrophysiological Center, Mianyang Central Hospital, 621000, Mianyang, Sichuan, China.
| | - Yi Wu
- Cardiac Electrophysiological Center, Mianyang Central Hospital, 621000, Mianyang, Sichuan, China
| | - Lu Xiong
- Cardiac Electrophysiological Center, Mianyang Central Hospital, 621000, Mianyang, Sichuan, China
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42
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Turc G, Lee JY, Brochet E, Kim JS, Song JK, Mas JL. Atrial Septal Aneurysm, Shunt Size, and Recurrent Stroke Risk in Patients With Patent Foramen Ovale. J Am Coll Cardiol 2020; 75:2312-2320. [DOI: 10.1016/j.jacc.2020.02.068] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 02/18/2020] [Accepted: 02/28/2020] [Indexed: 01/10/2023]
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Koutroulou I, Tsivgoulis G, Tsalikakis D, Karacostas D, Grigoriadis N, Karapanayiotides T. Epidemiology of Patent Foramen Ovale in General Population and in Stroke Patients: A Narrative Review. Front Neurol 2020; 11:281. [PMID: 32411074 PMCID: PMC7198765 DOI: 10.3389/fneur.2020.00281] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 03/25/2020] [Indexed: 01/11/2023] Open
Abstract
Introduction: Percutaneous closure of patent foramen ovale (PFO) in selected patients with cryptogenic cerebrovascular ischemic events (CEs) decreases the risk of recurrent stroke; however, optimal patient selection criteria are still under investigation. Candidates for PFO closure are usually selected from the pool of CE patients with a high risk of Paradoxical Embolism (RoPE) score. The RoPE score calculates the probability that PFO is causally related to stroke, based on PFO prevalence in patients with CE compared with that in healthy subjects. The latter has been set at 25% based on the average of autopsy and transesophageal echocardiography (TEE) studies. Methods: We conducted a comprehensive review of studies investigating PFO prevalence in general population and in patients with CE and non-CE using autopsy, TEE, transcranial Doppler (TCD) or transthoracic echocardiography (TTE). Studies were excluded if they (1) reported data from referred subjects with underlying cerebrovascular disease or (2) did not specify etiologically the events. Results: In healthy/control subjects, PFO prevalence was 24.2% (1,872/7,747) in autopsy studies, 23.7% (325/1,369) in TEE, 31.3% (111/355) in TCD, and 14.7% (186/1,267) in TTE studies. All diagnostic modalities included PFO prevalence was higher in CE compared with healthy/control population [odds ratio (OR) = 3.1, 95% confidence interval (CI) = 2.5–3.8] and compared with non-CE (OR = 2.3, 95% CI = 2.0–2.6). In patients with CE, PFO prevalence in the young compared to the old was higher when the diagnostic modality was TEE (48.9 vs. 27.3%, p < 0.0001, OR = 2.6 with 95% CI = 2.0–3.3) or TCD (58.1 vs. 41%, OR = 1.9, 95% CI = 1.6–2.5), but not TTE (53.3 vs. 37.5%, p = 0.16). Regarding non-CE, PFO prevalence in the young compared to the old was higher when the diagnostic modality was TEE (20 vs. 12.9%, OR = 1.7, 95% CI = 1.0–2.8) but not TTE (10.4 vs. 7.8%, p = 0.75) or TCD (22.8 vs. 20.1%, p = 0.56). Conclusions: Given the limitations of autopsy and TEE studies, there is good reason not to take a fixed 25% PFO prevalence for granted. The estimation of degree of causality may be underestimated or overestimated in populations with PFO prevalence significantly lower or higher than the established. Given the high sensitivity, non-invasive nature, low cost, and repeatability of TCD, future large-scale TCD-based studies should investigate potential heterogeneity in PFO prevalence in different healthy racial/ethnic populations.
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Affiliation(s)
- Ioanna Koutroulou
- Second Department of Neurology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Dimitris Karacostas
- Second Department of Neurology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Nikolaos Grigoriadis
- Second Department of Neurology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Theodoros Karapanayiotides
- Second Department of Neurology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Takafuji H, Ogura R, Izumi T, Hosokawa S. Paradoxical Embolism of Stroke-Related Patent Foramen Ovale in a Nonagenarian Woman. J Cardiovasc Echogr 2020; 29:172-174. [PMID: 32089998 PMCID: PMC7011487 DOI: 10.4103/jcecho.jcecho_35_19] [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] [Indexed: 11/23/2022] Open
Abstract
There are few clinical reports of elderly patients with paradoxical embolism in the current literature. Herein, we describe the case of a nonagenarian patient with paradoxical embolism of stroke-related patent foramen ovale (PFO). A 95-year-old woman was admitted to our hospital because of dysarthria. Her medical history included cerebral infarction, hypertension, and dyslipidemia. Magnetic resonance imaging performed in the emergency room revealed cerebral infarction of the left temporal lobe. After hospitalization in the neurosurgery department, we performed further clinical investigations to diagnose the type of stroke. There was no significant stenosis with plaque of the carotid and cerebral arteries, and there were no sources of cardiac embolism or an episode of atrial arrhythmia. Transesophageal echocardiography (TEE) showed PFO with separation and the Eustachian valve. In addition, spontaneous bidirectional shunt flow through the PFO was detected by TEE with the patient at rest. Ultrasonography of the leg vein revealed a thrombus in the deep vein. Therefore, she was diagnosed as having paradoxical embolism of stroke-related PFO and prescribed a direct oral anticoagulant (DOAC). This very rare case in which stroke-related PFO was diagnosed in a nonagenarian patient demonstrates that PFO is the cause of paradoxical embolism of stroke regardless of age.
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Affiliation(s)
- Hiroya Takafuji
- Department of Cardiology, Tokushima Red Cross Hospital, Tokushima, Japan
| | - Riyo Ogura
- Department of Cardiology, Tokushima Red Cross Hospital, Tokushima, Japan
| | - Tomoko Izumi
- Department of Cardiology, Tokushima Red Cross Hospital, Tokushima, Japan
| | - Shinobu Hosokawa
- Department of Cardiology, Tokushima Red Cross Hospital, Tokushima, Japan
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Khan R. Examining the evidence for PFO closure and novel oral anticoagulants for treatment of cryptogenic stroke. Expert Rev Cardiovasc Ther 2020; 18:139-148. [PMID: 32085690 DOI: 10.1080/14779072.2020.1733977] [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: 10/24/2022]
Abstract
Introduction: There has been considerable study assessing the treatment of cryptogenic stroke (CS) recently. This review examines the role of patent foramen ovale (PFO) closure in CS, while also discussing the evidence for alternative medical therapies in disease treatment.Areas covered: PFO closure for treatment of CS has been assessed in 6 randomized controlled trials (RCTs). This review summarizes the background, results and limitations of these trials. Methodological and treatment-related differences in RCTs provide potential explanations for the discordance in outcomes observed between older (CLOSURE, PC, RESPECT-Early) and newer PFO closure trials (RESPECT-Late, CLOSE, REDUCE, DEFENSE-PFO). With regards to medical therapy for CS, two RCTs (NAVIGATE ESUS and RE-SPECT ESUS) did not show any benefit in recurrent stroke prevention with the use of novel oral anticoagulants (NOAC) compared with aspirin. Marked differences in baseline characteristics and rates of recurrent stroke between PFO closure and NOAC trials underlie the heterogeneous nature of CS.Expert commentary: In young patients with CS, PFO closure reduces the risk of recurrent stroke, with newer RCTs emphasizing the importance of identifying those with 'high-risk' PFO and the need for continued antiplatelet therapy. Additionally, treatment for CS should not be uniform but directed at disease-specific pathologies.
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Affiliation(s)
- Razi Khan
- Department of Cardiology, Royal Columbian Hospital, New Westminster, Canada
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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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Echocardiographic Findings in Patients with Atrial Septal Aneurysm: A Prospective Case-Control Study. Cardiol Res Pract 2019; 2019:3215765. [PMID: 31061729 PMCID: PMC6466951 DOI: 10.1155/2019/3215765] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Revised: 02/12/2019] [Accepted: 02/28/2019] [Indexed: 11/23/2022] Open
Abstract
Background Atrial septal aneurysm (ASA) is a congenital deformity of the interatrial septum with a prevalence of 1-2% in the adult population. Although ASA has been supposed to be an incidental finding in echocardiographic examination, its structural and clinical associations have gained an increasing interest. Aim To investigate and compare the clinical features and echocardiographic parameters between ASA patients and age- and gender-matched control group patients. Methods 410 patients with ASA were enrolled in the study, prospectively. After the exclusion of 33 patients, the remaining 377 patients comprised the study group. The control group consisted of 377 age- and gender-matched patients without ASA. Results Aortic valve regurgitation and mitral valve regurgitation were more often observed in patients with ASA, and percentages of patients with ascending aortic aneurysm (AAA), patent foramen ovale (PFO), and atrial septal defect (ASD) were higher in ASA patients compared to control group patients. Aortic root diameter was larger in ASA patients compared to control group patients (29.2 ± 3.9, 28.6 ± 3.1, p=0.05, respectively). Ascending aorta diameter was higher in ASA patients compared to patients without ASA (44 ± 0.3, 41.5 ± 0.2, p=0.02). Logistic regression analysis revealed that mitral valve regurgitation (OR: 2.05, 95% CI : 1.44–2.92, p < 0.001) and PFO (OR: 11.62, 95% CI : 2.64–51.02, p=0.001) were positively and independently associated with the presence of ASA. AAA tended to be statistically and independently associated with ASA (OR: 2.69, 95% CI : 0.97–7.47, p=0.05). Conclusions We have demonstrated a higher incidence of mitral/aortic valvular regurgitations, AAA, PFO, and ASD in ASA patients compared to age- and gender-matched control group patients. In addition, we have shown that ASA is significantly and positively associated with mild mitral regurgitation and PFO.
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Mas JL. Closure of patent foramen ovale and “cryptogenic” stroke: What's new, what's next? Arch Cardiovasc Dis 2019; 112:145-149. [DOI: 10.1016/j.acvd.2019.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 01/14/2019] [Indexed: 01/14/2023]
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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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Moon J, Kim M, Oh PC, Shin DH, Park HMI, Jo YY, Lee JS, Kang WC. Residual Shunt after Patent Foramen Ovale Device Closure in Patients With Cryptogenic Stroke: Serial Bubble Contrast Transesophageal Echocardiography Data. J Stroke Cerebrovasc Dis 2019; 28:347-353. [DOI: 10.1016/j.jstrokecerebrovasdis.2018.10.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 09/18/2018] [Accepted: 10/05/2018] [Indexed: 12/19/2022] Open
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