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Shah AH, Horlick EM, Kass M, Carroll JD, Krasuski RA. The pathophysiology of patent foramen ovale and its related complications. Am Heart J 2024; 277:76-92. [PMID: 39134216 DOI: 10.1016/j.ahj.2024.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2024] [Accepted: 08/02/2024] [Indexed: 08/29/2024]
Abstract
The foramen ovale plays a vital role in sustaining life in-utero; however, a patent foramen ovale (PFO) after birth has been associated with pathologic sequelae in the systemic circulation including stroke/transient ischemic attack (TIA), migraine, high altitude pulmonary edema, decompression illness, platypnea-orthodeoxia syndrome (POS) and worsened severity of obstructive sleep apnea. Importantly, each of these conditions is most commonly observed among specific age groups: migraine in the 20 to 40s, stroke/TIA in the 30-50s and POS in patients >50 years of age. The common and central pathophysiologic mechanism in each of these conditions is PFO-mediated shunting of blood and its contents from the right to the left atrium. PFO-associated pathologies can therefore be divided into (1) paradoxical systemic embolization and (2) right to left shunting (RLS) of blood through the PFO. Missing in the extensive literature on these clinical syndromes are mechanistic explanations for the occurrence of RLS, including timing and the volume of blood shunted, the impact of age on RLS, and the specific anatomical pathway that blood takes from the venous system to the left atrium. Visualization of the flow pattern graphically illustrates the underlying RLS and provides a greater understanding of the critical flow dynamics that determine the frequency, volume, and pathway of flow. In the present review, we describe the important role of foramen ovale in in-utero physiology, flow visualization in patients with PFO, as well as contributing factors that work in concert with PFO to result in the diverse pathophysiological sequelae.
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Affiliation(s)
- Ashish H Shah
- Department of Internal Medicine, St Boniface Hospital, Section of Cardiology, University of Manitoba, Winnipeg, Manitoba, Canada.
| | - Eric M Horlick
- Division of Cardiology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.
| | - Malek Kass
- Department of Internal Medicine, St Boniface Hospital, Section of Cardiology, University of Manitoba, Winnipeg, Manitoba, Canada.
| | - John D Carroll
- Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora, CO.
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Galasso F, Wassenaar F, Barry T, Baqal OJ, Hagler DJ, Sweeney JP, Fortuin FD. A Retrospective Analysis of Self-Limiting Fever following Percutaneous Patent Foramen Ovale and Atrial Septal Defect Closure. Cardiol Res Pract 2024; 2024:5562208. [PMID: 39421324 PMCID: PMC11483646 DOI: 10.1155/2024/5562208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 08/23/2024] [Accepted: 09/16/2024] [Indexed: 10/19/2024] Open
Abstract
While percutaneous closure of patent foramen ovale (PFO) and atrial septal defect (ASD) are generally well-tolerated procedures, the development of postprocedure fever has been observed at a higher frequency than reported in the initial device trials. We performed a retrospective analysis of 62 patients who underwent PFO or ASD closure from January 1, 2020, to December 31, 2022, at Mayo Clinic, Arizona. Eight patients out of 62 (12.9%) developed fever following PFO or ASD closure. In each of the fever cases, the Gore Cardioform devices (W.L. Gore and Associates, Flagstaff, AZ) were used. No association was found between clinical characteristics or procedural details and the development of fever. The reactions occurred 24 to 48 hours following device implantation and resolved spontaneously. No evidence of infection was found upon diagnostic evaluation. There was a higher incidence of self-limited atrial fibrillation (AF) in the fever patients (37.5% vs. 18.5%) which was not statistically significant. All patients who developed fever had successful closure with no other subsequent clinical events. We have found a high incidence of fever following PFO or ASD closure using the Gore family of devices that has not been observed in prior years. A unifying etiology or risk factor, such as infection or medication, for the fever could not be identified. Long-term device success was achieved in all fever patients. This small retrospective study suggests that the observed fever is benign and self-limiting but further investigation is warranted to determine its true incidence, mechanism, and prognosis.
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Affiliation(s)
- Francesca Galasso
- Department of Cardiovascular Diseases, Mayo Clinic Arizona, 5777 E Mayo Boulevard, Phoenix 85054, AZ, USA
| | - Felicia Wassenaar
- Department of Cardiovascular Diseases, Mayo Clinic Arizona, 5777 E Mayo Boulevard, Phoenix 85054, AZ, USA
| | - Timothy Barry
- Department of Cardiovascular Diseases, Mayo Clinic Arizona, 5777 E Mayo Boulevard, Phoenix 85054, AZ, USA
| | - Omar J. Baqal
- Department of Internal Medicine, Mayo Clinic Arizona, 5777 E Mayo Boulevard, Phoenix 85054, AZ, USA
| | - Donald J. Hagler
- Department of Cardiovascular Diseases, Mayo Clinic Arizona, 5777 E Mayo Boulevard, Phoenix 85054, AZ, USA
| | - John P. Sweeney
- Department of Cardiovascular Diseases, Mayo Clinic Arizona, 5777 E Mayo Boulevard, Phoenix 85054, AZ, USA
| | - F. David Fortuin
- Department of Cardiovascular Diseases, Mayo Clinic Arizona, 5777 E Mayo Boulevard, Phoenix 85054, AZ, USA
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3
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Sørensen H, Grove EL, Hojbjerg JA, Andersen A, Nielsen-Kudsk JE, Simonsen CZ. Recurrent ischemic stroke/transient ischemic attack after patent foramen ovale closure: A cohort study. Int J Stroke 2024:17474930241281120. [PMID: 39177060 DOI: 10.1177/17474930241281120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2024]
Abstract
BACKGROUND Patent foramen ovale (PFO) has been associated with ischemic stroke and transient ischemic attack (TIA). Guidelines recommend PFO closure for stroke prevention in selected patients, but the risk of recurrent stroke remains high compared to the background population. We aimed to evaluate the causes of recurrent stroke/TIA and post-interventional complications in patients after PFO closure. METHODS Patients from the Central Denmark Region who underwent PFO closure at Aarhus University Hospital between November 5, 2018, and May 12, 2023, following an ischemic stroke, TIA, amaurosis fugax, or retinal emboli were included. Data on patient demographics, risk factors, procedural details, post-interventional complications, and recurrent stroke/TIA were collected from electronic medical records. RESULTS PFO closure was performed in 310 patients (median age: 49 years). During a median follow-up of 2.6 years (interquartile range: 1.5-3.6, 814 total patient-years), recurrent stroke/TIA was observed in 8 patients (2.6%), or 0.98 recurrent strokes per 100 patient-years. Recurrent stroke/TIA was more frequent in patients with hypertension (50.0% vs. 16.9%, p = 0.039). Recurrent stroke/TIA was related to thrombophilia or hematologic conditions entailing hypercoagulability in 62.5% of patients. New-onset atrial fibrillation was observed in 9.4% of patients within 45 days after the procedure. None of these patients subsequently developed an ischemic event. Other adverse outcomes were uncommon. CONCLUSION Rates of recurrent ischemic stroke/TIA after PFO closure were comparable to findings in previous trials. Pre-existing vascular risk factors (hypertension), and a hypercoagulable state were associated with recurrent ischemic stroke/TIA.
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Affiliation(s)
- Henrik Sørensen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Erik L Grove
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Johanne Andersen Hojbjerg
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
| | - Asger Andersen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jens Erik Nielsen-Kudsk
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Claus Z Simonsen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Dimitriadis K, Pyrpyris N, Aznaouridis K, Adamopoulou E, Soulaidopoulos S, Beneki E, Iliakis P, Fragkoulis C, Aggeli K, Tsioufis K. Transcatheter Structural Heart Disease Interventions and Concomitant Left Atrial Appendage Occlusion: A State of the Art Review. Can J Cardiol 2024:S0828-282X(24)00935-8. [PMID: 39236977 DOI: 10.1016/j.cjca.2024.08.282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Revised: 08/28/2024] [Accepted: 08/29/2024] [Indexed: 09/07/2024] Open
Abstract
Atrial fibrillation (AF) is the most common arrhythmia in patients with valvular heart disease, and it can be associated with adverse patient outcomes. However, the need for anticoagulation to counterbalance AF-associated stroke risk may further lead to suboptimal outcomes via increasing bleeding events, especially in high-risk individuals. Because the vast majority of thrombi occur in the left atrial appendage, left atrial appendage occlusion (LAAO) is an established procedure for preventing ischemic stroke in patients with AF, while limiting anticoagulation-related bleeding events. Thus, the concept of combining an index procedure for structural heart disease (SHD) with LAAO seems promising for preventing future stroke events. A combined procedure has been described in aortic stenosis (transcatheter aortic valve implantation + LAAO), mitral regurgitation (transcatheter edge-to-edge repair + LAAO), and atrial septal defects (patent foramen ovale/atrial septal defect + LAAO). Evidence shows that a combined procedure can be safely performed in a "1-stop shop" fashion, without increased rates of procedural adverse events, with the potential to limit bleeding risk and provide prophylaxis against stroke events. This review analyses indications and clinical evidence regarding the safety and efficacy of combined SHD+LAAO procedures, while also providing insights into gaps in knowledge and future directions for the evolution of this field.
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Affiliation(s)
- Kyriakos Dimitriadis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece.
| | - Nikolaos Pyrpyris
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Konstantinos Aznaouridis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Elena Adamopoulou
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Stergios Soulaidopoulos
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Eirini Beneki
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Panagiotis Iliakis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Christos Fragkoulis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Konstantina Aggeli
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Konstantinos Tsioufis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
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Farjat-Pasos JI, Guedeney P, Horlick E, Abtan J, Nombela-Franco L, Hibbert B, Sondergaard L, Freixa X, Masson JB, Cruz-González I, Estévez-Loureiro R, Faroux L, Shah AH, Abrahamyan L, Mesnier J, Jerónimo A, Abdel-Razek O, Jørgensen TH, Asmar MA, Sitbon S, Abalhassan M, Robichaud M, Houde C, Côté M, Chamorro A, Lanthier S, Verreault S, Montalescot G, Rodés-Cabau J. Determinants of adverse outcomes following patent foramen ovale closure in elderly patients. EUROINTERVENTION 2024; 20:1029-1038. [PMID: 39155753 PMCID: PMC11317834 DOI: 10.4244/eij-d-24-00156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 04/26/2024] [Indexed: 08/20/2024]
Abstract
BACKGROUND Limited data are available on transcatheter patent foramen ovale (PFO) closure outcomes in the elderly. AIMS Through this study, we aimed to determine the incidence and predictors of adverse events (recurrent cerebrovascular events [CVE] and atrial fibrillation [AF]) post-PFO closure in older patients with cryptogenic events. METHODS This multicentre international study included patients over 60 years undergoing PFO closure for cryptogenic thromboembolic events. A dedicated database compiled baseline, procedural, and follow-up data. Competing risk and adjusted outcome predictor analyses were conducted. RESULTS A total of 689 patients were included (median age 65 years, 41.2% female, mean Risk of Paradoxical Embolism [RoPE] score 4.5). The procedural success rate was 99.4%. After a median follow-up of 2 (interquartile range 1-5) years, 66 patients (9.6%) had died. CVE and stroke rates were 1.21 and 0.55 per 100 patient-years, respectively. Diabetes (hazard ratio [HR] 3.89, 95% confidence interval [CI]: 1.67-9.07; p=0.002) and atrial septal aneurysm (ASA; HR 5.25, 95% CI: 1.56-17.62; p=0.007) increased the CVE risk. New-onset AF occurred at a rate of 3.30 per 100 patient-years, with 51.3% within one month post-procedure. Older age (HR 1.05 per year, 95% CI: 1.00-1.09; p=0.023) and the absence of hypertension (HR 2.04, 95% CI: 1.19-3.57; p=0.010) were associated with an increased risk of AF. CONCLUSIONS Older patients undergoing PFO closure had a relatively low rate of CVE and new-onset AF after a median follow-up of 2 years. The presence of diabetes, ASA, and a more advanced age determined an increased risk of adverse clinical events. These factors may be considered in the clinical decision-making process regarding PFO closure in this challenging population.
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Affiliation(s)
- Julio I Farjat-Pasos
- Cardiology Department, Quebec Heart and Lung Institute, Québec, QC, Canada
- Pediatric Cardiology Department, Centre Hospitalier Universitaire de Québec, Québec, QC, Canada
| | - Paul Guedeney
- Sorbonne Université, ACTION Study Group, INSERM UMRS_1166, Institut de Cardiologie (AP-HP), Paris, France
| | - Eric Horlick
- Cardiology Department, Toronto General Hospital, Toronto, ON, Canada
| | - Jeremie Abtan
- Cardiology Department, Bichat-Claude-Bernard Hospital, Paris, France
| | - Luis Nombela-Franco
- Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Benjamin Hibbert
- Cardiology Department, Ottawa Heart Institute, Ottawa, ON, Canada
| | - Lars Sondergaard
- Cardiology Department, Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Xavier Freixa
- Cardiology Department, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Jean-Bernard Masson
- Cardiology Department, University of Montreal Health Centre, Montreal, QC, Canada
| | - Ignacio Cruz-González
- Cardiology Department, University Hospital of Salamanca, IBSAL, CIBER-CV, Salamanca, Spain
| | | | - Laurent Faroux
- Cardiology Department, Reims University Hospital, Reims, France
| | - Ashish H Shah
- Section of Cardiology, Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Lusine Abrahamyan
- Cardiology Department, Toronto General Hospital, Toronto, ON, Canada
| | - Jules Mesnier
- Cardiology Department, Bichat-Claude-Bernard Hospital, Paris, France
| | - Adrián Jerónimo
- Cardiovascular Institute, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Omar Abdel-Razek
- Cardiology Department, Ottawa Heart Institute, Ottawa, ON, Canada
| | - Troels Højsgaard Jørgensen
- Cardiology Department, Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Mike Al Asmar
- Cardiology Department, University of Montreal Health Centre, Montreal, QC, Canada
| | - Samuel Sitbon
- Cardiology Department, Bichat-Claude-Bernard Hospital, Paris, France
| | | | - Mathieu Robichaud
- Cardiology Department, Quebec Heart and Lung Institute, Québec, QC, Canada
| | - Christine Houde
- Pediatric Cardiology Department, Centre Hospitalier Universitaire de Québec, Québec, QC, Canada
| | - Mélanie Côté
- Cardiology Department, Quebec Heart and Lung Institute, Québec, QC, Canada
| | - Angel Chamorro
- Neuroscience Department, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Sylvain Lanthier
- Neurovascular Program and Research Center, Hôpital du Sacré-Coeur-de-Montréal, Montreal, QC, Canada
| | - Steve Verreault
- Neurovascular Department, Centre Hospitalier Universitaire de Québec, Québec, QC, Canada
| | - Gilles Montalescot
- Sorbonne Université, ACTION Study Group, INSERM UMRS_1166, Institut de Cardiologie (AP-HP), Paris, France
| | - Josep Rodés-Cabau
- Cardiology Department, Quebec Heart and Lung Institute, Québec, QC, Canada
- Pediatric Cardiology Department, Centre Hospitalier Universitaire de Québec, Québec, QC, Canada
- Cardiology Department, Hospital Clinic of Barcelona, Barcelona, Spain
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Cannata F, Stankowski K, Donia D, Figliozzi S, Fazzari F, Regazzoli D, Reimers B, Bragato RM, Pontone G, Trabattoni D, Colombo A, De Marco F, Mangieri A. Percutaneous suture-based patent foramen ovale closure: A state-of-the-art review. Trends Cardiovasc Med 2024; 34:404-413. [PMID: 37931791 DOI: 10.1016/j.tcm.2023.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 10/18/2023] [Accepted: 10/31/2023] [Indexed: 11/08/2023]
Abstract
Percutaneous closure of a patent foramen ovale (PFO), a common variation of interatrial septum anatomy, is a commonly performed procedure in the catheterization laboratory to reduce the risk of recurrent stroke in selected patients and to treat other PFO-related syndromes. In the last twenty years, disc-based devices have represented the armamentarium of the interventional cardiologist; recently, suture-based devices have become an attractive alternative, despite limited data regarding their long-term performance. The present review gives an overview of the current evidence regarding suture-based PFO closure, the device's characteristics, the echocardiographic evaluation of the PFO anatomy, and recommendations for patient selection. A detailed procedural guide is then provided, and potential complications and future developments in the field are discussed.
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Affiliation(s)
- Francesco Cannata
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, 20090 Pieve Emanuele, Milano, Italy; IRCCS Humanitas Research Hospital, Via Alessandro Manzoni, 56, 20089 Rozzano, Milano, Italy; Department of Perioperative Cardiology and Cardiovascular imaging, Centro Cardiologico Monzino IRCCS, Milan, Italy.
| | - Kamil Stankowski
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, 20090 Pieve Emanuele, Milano, Italy; IRCCS Humanitas Research Hospital, Via Alessandro Manzoni, 56, 20089 Rozzano, Milano, Italy
| | - Dario Donia
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, 20090 Pieve Emanuele, Milano, Italy; IRCCS Humanitas Research Hospital, Via Alessandro Manzoni, 56, 20089 Rozzano, Milano, Italy
| | - Stefano Figliozzi
- IRCCS Humanitas Research Hospital, Via Alessandro Manzoni, 56, 20089 Rozzano, Milano, Italy
| | - Fabio Fazzari
- Department of Perioperative Cardiology and Cardiovascular imaging, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | - Damiano Regazzoli
- IRCCS Humanitas Research Hospital, Via Alessandro Manzoni, 56, 20089 Rozzano, Milano, Italy
| | - Bernhard Reimers
- IRCCS Humanitas Research Hospital, Via Alessandro Manzoni, 56, 20089 Rozzano, Milano, Italy
| | - Renato Maria Bragato
- IRCCS Humanitas Research Hospital, Via Alessandro Manzoni, 56, 20089 Rozzano, Milano, Italy
| | - Gianluca Pontone
- Department of Perioperative Cardiology and Cardiovascular imaging, Centro Cardiologico Monzino IRCCS, Milan, Italy; Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Daniela Trabattoni
- Department of Interventional Cardiology, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | - Antonio Colombo
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini, 4, 20090 Pieve Emanuele, Milano, Italy; IRCCS Humanitas Research Hospital, Via Alessandro Manzoni, 56, 20089 Rozzano, Milano, Italy
| | - Federico De Marco
- Department of Interventional Cardiology, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | - Antonio Mangieri
- IRCCS Humanitas Research Hospital, Via Alessandro Manzoni, 56, 20089 Rozzano, Milano, Italy.
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Poulin MF, Kavinsky CJ. Low Burden of Atrial Fibrillation After PFO Closure: Is There a Need to Worry? JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2024; 3:102145. [PMID: 39132003 PMCID: PMC11307763 DOI: 10.1016/j.jscai.2024.102145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Accepted: 04/22/2024] [Indexed: 08/13/2024]
Affiliation(s)
- Marie-France Poulin
- Cardiovascular Institute, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Clifford J. Kavinsky
- Cardiovascular Institute, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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8
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Deng J, Wang E, Liu G, Qin C, Dong Q, Yang W, Wang Y, Abdul Qadir R, Jia F. Feasibility and safety of cryoballoon ablation for atrial fibrillation and closing patent foramen ovale without implantation:A pilot study. Heart Rhythm 2024:S1547-5271(24)02682-1. [PMID: 38871264 DOI: 10.1016/j.hrthm.2024.06.006] [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] [Received: 12/05/2023] [Revised: 05/25/2024] [Accepted: 06/06/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND Patent foramen ovale (PFO) affects 20%-34% of adults and is associated with strokes and other disorders. The conventional treatment of PFO-related strokes is a closure procedure. The metal device is associated with some adverse events. OBJECTIVE Our aim was to investigate the efficacy and safety of PFO closure using cryoablation without implantation in patients with atrial fibrillation (AF) who underwent pulmonary vein isolation (PVI). METHODS We divided the 22 patients with both PFO and AF who underwent PVI via cryoablation into 2 groups: standard PVI + atrial septal (AS) cryoablation group (group 1, n = 11) and standard PVI group (group 2, n = 11). The guidewire accesses the left atrium through the PFO without AS puncture during the procedure. Standard PVI via cryoablation was performed. The cryoballoon was retracted to the right atrium and inflated against the AS post-PVI. Patients in group 1 had cryoablation for 120-150 seconds, whereas patients in group 2 received sham ablation. The co-primary end points were the PFO closure rate and a composite of AF recurrence and stroke/transient ischemic attack (TIA) events. RESULTS There were no differences in procedure-related adverse events between the 2 groups. Neither group had an ischemic stroke report at 1-year follow-up. The PFO closure rate at 6 months in group 1 was significantly higher than that in group 2 (7 [63.6%] vs 1 [9.1%]; P = .002). AF recurrence post ablation was comparable in both groups at 3 months (3 [27.3%] vs 1 [9.1%]; P = .269), 6 months (0 vs 0), and 12 months (2 [18.2%%] vs 1 [9.1%]; P = .534) of follow-up. CONCLUSION Cryoablation is a safe and effective approach to close PFO in patients with AF undergoing PVI in a single procedure.
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Affiliation(s)
- Jiang Deng
- Department of Cardiovascular Medicine, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - EnRun Wang
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Gang Liu
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - ChunChang Qin
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qian Dong
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wei Yang
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - YanFei Wang
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Rana Abdul Qadir
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Fengpeng Jia
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
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9
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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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Apostolos A, Tsiachris D, Drakopoulou M, Trantalis G, Oikonomou G, Ktenopoulos N, Simopoulou C, Katsaros O, Tsalamandris S, Aggeli C, Tsivgoulis G, Tsioufis C, Toutouzas K. Atrial Fibrillation After Patent Foramen Ovale Closure: Incidence, Pathophysiology, and Management. J Am Heart Assoc 2024; 13:e034249. [PMID: 38639354 PMCID: PMC11179870 DOI: 10.1161/jaha.124.034249] [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: 01/01/2024] [Accepted: 02/06/2024] [Indexed: 04/20/2024]
Abstract
This comprehensive review explores the incidence, pathophysiology, and management of atrial fibrillation (AF) following percutaneous closure of patent foramen ovale (PFO). Although AF is considered a common adverse event post PFO closure, its incidence, estimated at <5%, varies based on monitoring methods. The review delves into the challenging task of precisely estimating AF incidence, given subclinical AF and diverse diagnostic approaches. Notably, a temporal pattern emerges, with peak incidence around the 14th day after closure and a subsequent decline after the 45th day, mimicking general population AF trends. The pathophysiological mechanisms behind post PFO closure AF remain elusive, with proposed factors including local irritation, device-related interference, tissue stretch, and nickel hypersensitivity. Management considerations encompass rhythm control, with flecainide showing promise, and anticoagulation tailored to individual risk profiles. The authors advocate for a personalized approach, weighing factors like age, comorbidities, and device characteristics. Notably, postclosure AF is generally considered benign, often resolving spontaneously within 45 days, minimizing thromboembolic risks. Further studies are required to refine understanding and provide evidence-based guidelines.
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Affiliation(s)
- Anastasios Apostolos
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
| | - Dimitrios Tsiachris
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
| | - Maria Drakopoulou
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
| | - Georgios Trantalis
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
| | - Georgios Oikonomou
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
| | - Nikolaos Ktenopoulos
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
| | - Chrysavgi Simopoulou
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
| | - Odysseas Katsaros
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
| | - Sotirios Tsalamandris
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
| | - Constantina Aggeli
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
| | - Georgios Tsivgoulis
- Second Department of Neurology, Medical SchoolNational and Kapodistrian University of Athens, Attikon University Hospital of AthensAthensGreece
| | - Costas Tsioufis
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
| | - Konstantinos Toutouzas
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
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Hauguel-Moreau M, Guedeney P, Dauphin C, Auffret V, Marijon E, Aldebert P, Clerc JM, Beygui F, Elbaz M, Khalil WA, Da Costa A, Macia JC, Elhadad S, Cayla G, Brugier D, Silvain J, Hammoudi N, Duthoit G, Vicaut E, Montalescot G. Flecainide to prevent atrial arrhythmia after patent foramen ovale closure, Rationale and design of the randomized AFLOAT study. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2024; 10:184-189. [PMID: 38216511 DOI: 10.1093/ehjcvp/pvad100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 10/25/2023] [Accepted: 01/09/2024] [Indexed: 01/14/2024]
Abstract
INTRODUCTION Atrial arrhythmia is the most common complication of patent foramen ovale (PFO) closure. The real incidence of post-PFO closure atrial arrhytmia and whether this complication can be prevented is unknown. METHODS/DESIGN The Assessment of Flecainide to Lower the PFO closure risk of Atrial fibrillation or Tachycardia (AFLOAT) trial is a prospective, national, multicentre, randomized, open-label, superiority trial with a blind evaluation of all the endpoints (PROBE design). A total of 186 patients are randomized in a 1:1:1 ratio immediately after PFO closure to receive Flecainide (150 mg per day in a single sustained-release (SR) dose) for 6 months (Group 1), Flecainide (150 mg per day in a single SR dose) for 3 months (Group 2), or no additional treatment (standard of care) for 6 months (Group 3). The primary endpoint is the percentage of patients with at least one episode of symptomatic or asymptomatic atrial arrhythmia episode (≥30 s) recorded within 3 months after PFO closure on long-term monitoring with an insertable cardiac monitor. Whether 3 months of treatment is sufficient compared to 6 months will be analysed as a secondary objective of the study. CONCLUSION AFLOAT is the first trial to test the hypothesis that a short treatment with oral Flecainide can prevent the new-onset of atrial arrhythmia after PFO closure. CLINICAL TRIAL REGISTRATION NCT05213104 (clinicaltrials.gov).
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Affiliation(s)
- Marie Hauguel-Moreau
- Université de Versailles-Saint Quentin, INSERM U1018, CESP, ACTION Study Group, Department of Cardiology, Ambroise Paré Hospital (AP-HP), 92100 Boulogne, France
| | - Paul Guedeney
- Sorbonne Université, ACTION Study Group, INSERM UMRS1166, ICAN-Institute of CardioMetabolism and Nutrition, Institut de Cardiologie, Hôpital Pitié-Salpêtrière (AP-HP), 75013 Paris, France
| | - Claire Dauphin
- Department of Cardiology and Cardiovascular Diseases, Clermont-Ferrand University Hospital, 63000 Clermont-Ferrand, France
| | - Vincent Auffret
- University Hospital Pontchaillou, Cardiology and Vascular Disease Department, CIC-IT 804, Rennes 1 University, Signal and Image Processing Laboratory (LTSI), INSERM U1099, 35000 Rennes, France
| | - Eloi Marijon
- Cardiology Department, European Georges Pompidou Hospital, 75015 Paris, France
| | | | - Jean-Michel Clerc
- Cardiology Department, Centre Hospitalier Universitaire de Tours, 37000 Tours, France
| | - Farzin Beygui
- CHU de la Côte de Nacre, Département de Cardiologie, 14000 Caen, France
| | - Meyer Elbaz
- Department of Cardiology, Institute CARDIOMET, CHU-Toulouse, 31000 Toulouse, France
| | - Wissam Abi Khalil
- Institut Mitovasc, University of Angers, UMR CNRS 6015-INSERMU1083, 49000 Angers, France
| | - Antoine Da Costa
- Service de cardiologie, Hôpital Nord, Université Jean-Monnet, CHU de Saint-Étienne, 42000 Saint-Étienne, France
| | - Jean-Christophe Macia
- Montpellier University Hospital, UFR de Médecine, Université Montpellier 1, Department of Cardiology, 371, avenue du Doyen-Gaston-Giraud, 34000 Montpellier 5, France
| | - Simon Elhadad
- Service de Cardiologie, Centre hospitalier de Marne-la-Vallée, 77600 Jossigny, France
| | - Guillaume Cayla
- Cardiology department, Nimes University Hospital, Montpellier University, ACTION group, 34000 Nimes, France
| | - Delphine Brugier
- Sorbonne Université, ACTION Study Group, INSERM UMRS1166, ICAN-Institute of CardioMetabolism and Nutrition, Institut de Cardiologie, Hôpital Pitié-Salpêtrière (AP-HP), 75013 Paris, France
| | - Johanne Silvain
- Sorbonne Université, ACTION Study Group, INSERM UMRS1166, ICAN-Institute of CardioMetabolism and Nutrition, Institut de Cardiologie, Hôpital Pitié-Salpêtrière (AP-HP), 75013 Paris, France
| | - Nadjib Hammoudi
- Sorbonne Université, ACTION Study Group, INSERM UMRS1166, ICAN-Institute of CardioMetabolism and Nutrition, Institut de Cardiologie, Hôpital Pitié-Salpêtrière (AP-HP), 75013 Paris, France
| | - Guillaume Duthoit
- Sorbonne Université, ACTION Study Group, INSERM UMRS1166, ICAN-Institute of CardioMetabolism and Nutrition, Institut de Cardiologie, Hôpital Pitié-Salpêtrière (AP-HP), 75013 Paris, France
| | - Eric Vicaut
- ACTION Study Group, Unité de Recherche Clinique, Hopital Lariboisière, (APHP), Université Paris-Diderot Paris 7, 75010 Paris, France
| | - Gilles Montalescot
- Sorbonne Université, ACTION Study Group, INSERM UMRS1166, ICAN-Institute of CardioMetabolism and Nutrition, Institut de Cardiologie, Hôpital Pitié-Salpêtrière (AP-HP), 75013 Paris, France
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12
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Baqal O, Habib EA, Hasabo EA, Galasso F, Barry T, Arsanjani R, Sweeney JP, Noseworthy P, David Fortuin F. Artificial intelligence-enabled electrocardiogram (AI-ECG) does not predict atrial fibrillation following patent foramen ovale closure. IJC HEART & VASCULATURE 2024; 51:101361. [PMID: 38379633 PMCID: PMC10877678 DOI: 10.1016/j.ijcha.2024.101361] [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: 01/07/2024] [Revised: 02/06/2024] [Accepted: 02/08/2024] [Indexed: 02/22/2024]
Abstract
Background Atrial fibrillation (AF) is a known complication following patent foramen ovale (PFO) closure. AI-enabled ECG (AI-ECG) acquired during normal sinus rhythm has been shown to identify individuals with AF by noting high-risk ECG features invisible to the human eye. We sought to characterize the value of AI-ECG in predicting AF development following PFO closure and investigate key clinical and procedural characteristics possibly associated with post-procedural AF. Methods We performed a retrospective analysis of patients who underwent PFO closure at our hospital from January 2011 to December 2022. We recorded the probability (%) of AF using the Mayo Clinic AI-ECG dashboard from pre- and post-procedure ECGs. The cut-off point of ≥ 11 %, which was found to optimally balance sensitivity and specificity in the original derivation paper (the Youden index) was used to label an AI-ECG "positive" for AF. Pre-procedural transesophageal echocardiography (TEE) and pre- and post-procedure transcranial doppler (TCD) data was also recorded. Results Out of 93 patients, 49 (53 %) were male, mean age was 55 ± 15 years with mean post-procedure follow up of 29 ± 3 months. Indication for PFO closure in 69 (74 %) patients was for secondary prevention of transient ischemic attack (TIA) and/or stroke. Twenty patients (22 %) developed paroxysmal AF post-procedure, with the majority within the first month post-procedure (15 patients, 75 %). Patients who developed AF were not significantly more likely to have a positive post-procedure AI-ECG than those who did not develop AF (30 % AF vs 27 % no AF, p = 0.8).Based on the PFO-Associated Stroke Causal Likelihood (PASCAL) classification, patients who had PFO closure for secondary prevention of TIA and/or stroke in the "possible" group were significantly more likely to develop AF than patients in "probable" and "unlikely" groups (p = 0.034). AF-developing patients were more likely to have post-procedure implantable loop recorder (ILR) (55 % vs 9.6 %, p < 0.001), and longer duration of ILR monitoring (121 vs 92.5 weeks, p = 0.035). There were no significant differences in TCD and TEE characteristics, device type, or device size between those who developed AF vs those who did not. Conclusions In this small, retrospective study, AI-ECG did not accurately distinguish patients who developed AF post-PFO closure from those who did not. Although AI-ECG has emerged as a valuable tool for risk prediction of AF, extrapolation of its performance to procedural settings such as PFO closure requires further investigation.
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Affiliation(s)
- Omar Baqal
- Department of Internal Medicine, Mayo Clinic, Phoenix, AZ, USA
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Eiad A. Habib
- Department of Internal Medicine, Mayo Clinic, Phoenix, AZ, USA
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Elfatih A. Hasabo
- CORRIB Research Centre for Advanced Imaging and Core Laboratory, Clinical Science Institute, University of Galway, Galway, Ireland
- Discipline of Cardiology, Saolta Healthcare Group, Health Service Executive, Galway University Hospital, Galway, Ireland
| | - Francesca Galasso
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Timothy Barry
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Reza Arsanjani
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - John P. Sweeney
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Peter Noseworthy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - F. David Fortuin
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ, USA
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Wei Y, Su Y, Cao S, He Z, Wang R, Qin X, Feng Y, Yang C, Jiang H. Experimental study of the bilateral asymmetric single-rivet occluder device for transcatheter patent foramen ovale closure with reserved interatrial septal puncture area. Front Cardiovasc Med 2024; 10:1301412. [PMID: 38250032 PMCID: PMC10796624 DOI: 10.3389/fcvm.2023.1301412] [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: 09/24/2023] [Accepted: 12/18/2023] [Indexed: 01/23/2024] Open
Abstract
Purpose To evaluate a noval bilateral asymmetric single-rivet occluder with reserved interatrial septal puncture area for treating patent foramen ovale (PFO). Materials and methods The study established a pig model of patent foramen ovale (PFO) by puncturing the oval fossa and then performing high-pressure balloon dilation. A specially designed bilateral asymmetric occluder for the reserved interatrial septal puncture area was then. used to close the PFO through catheter-based intervention. The pigs were kept for 3 months before undergoing a second catheter-based intervention, involving interatrial septal puncture using a newly developed occluder in the reserved interatrial septal puncture area. During 6 months, the experimental pigs underwent assessment using digital subtraction angiography (DSA), echocardiography, and histological evaluation. Results A patent foramen ovale (PFO) model was successfully established in 6 pigs using the puncture atrial septum high-pressure balloon dilation method. The diameter of the unclosed PFO was measured (3.56 ± 0.25 mm). Using the newly developed occluder device, all 6 pigs with unclosed PFO underwent successful catheter-based closure surgeries, with intraoperative and postoperative transesophageal echocardiography showing excellent device positioning and complete closure without residual shunting. After 3 months of implantation, the catheter-based interatrial septal puncture was performed through the reserved interatrial septal puncture area, and all procedures were successful. Immediately following euthanasia, a histological examination revealed intact and undamaged occluder devices with visible puncture holes in the reserved interatrial septal puncture area. No fracture of the nitinol wire was observed, and the surface of the occluder device showed coverage of endothelial and connective tissues. Utilizing a bilateral asymmetric single-rivet occluder device implanted through the reserved interatrial septal puncture area has proven effective in closing PFO. After implantation, the occluder device allows subsequent interatrial septal puncture procedures through the reserved area. Conclusion The novel occluder device demonstrated excellent closure performance, biocompatibility, and puncturability in the experiment. This indicates the feasibility of conducting further catheter-based interventions on the interatrial septum.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Haibin Jiang
- Department of Cardiology, Wuxi No.2 People's Hospital (Jiangnan University Medical Center), Wuxi, Jiangsu, China
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14
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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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15
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Taha A, Ali S, Atti L, Duhan S, Elseidy S, Khir F, Keisham B, Aziz S, Spaseski M, Erdem S, ElJack A, Almas T, Uppal D, Ali S, Alraies MC. Cardiovascular Outcomes and Readmissions of Atrial Fibrillation Among Patent Foramen Ovale Occluder Device Recipients: A Propensity Matched National Readmission Study. Curr Probl Cardiol 2024; 49:102115. [PMID: 37802160 DOI: 10.1016/j.cpcardiol.2023.102115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 09/30/2023] [Indexed: 10/08/2023]
Abstract
Patent foramen ovale (PFO) occluder devices are increasingly utilized in minimally invasive procedures used to treat cryptogenic stroke. Data on the impact of Atrial Fibrillation (AF) among PFO occluder device recipients are limited. The Nationwide Readmissions Database was queried between 2016 and 2019 to identify PFO patients with and without AF. The 2 groups were compared using propensity score matching (PSM) and multivariate regression models. The outcomes included in-hospital mortality, acute kidney injury (AKI), Mechanical circulatory support use (MCS), Cardiogenic shock (CS), acute ischemic stroke, bleeding, and other cardiovascular outcomes. Statistical analysis was performed using STATA v. 17. Out of 6508 Weighted hospitalizations for PFO occluder device procedure over the study period, 877 (13.4%) had AF compared to 5631 (86.6%) who did not. On adjusted analysis, PFO with AF group had higher rates of MCS (PSM, 4.5% vs 2.2 %, P value = 0.011) and SCA (PSM, 7.6% vs 4.6 %, P value = 0.015) compared to PFO with no AF. There was no statistically significant difference in the rate of in-hospital mortality (PSM, 5.4% vs 6.4 %, P value = 0.39), CS (PSM, 8.3% vs 5.9 %, P value = 0.075), AKI (PSM, 32.4% vs 32.3 %, P value = 0.96), bleeding (PSM, 2.08% vs 1.3%, P value = 0.235) or the readmission rates among both cohorts. Additionally, AF was associated with higher hospital length of stay (9.5 ± 13.2 vs 8.2 ± 24.3 days, P-value = 0.012) and total cost ($66,513 ± $80,922 vs $52,013±$125,136, 0.025, P-value = 0.025) compared to PFO without AF. AF among PFO occluder device recipients is associated with increased adverse outcomes, including MCS use and SCA, with no difference in mortality and readmission rates among both cohorts. Long-term follow-up needs further studies.
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Affiliation(s)
- Amro Taha
- Department of Internal Medicine, Weiss Memorial Hospital, Chicago, IL
| | - Shafaqat Ali
- Department of Internal Medicine, Louisiana State University, Shreveport, LA
| | - Lalitsiri Atti
- Department of Internal Medicine, Sparrow Hospital-Michigan State University, MI
| | - Sanchit Duhan
- Department of Internal Medicine, Sinai Hospital of Baltimore, Baltimore, MD
| | - Sheref Elseidy
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY
| | - Fadi Khir
- Department of Internal Medicine, Weiss Memorial Hospital, Chicago, IL
| | - Bijeta Keisham
- Department of Internal Medicine, Sinai Hospital of Baltimore, Baltimore, MD
| | - Sundal Aziz
- Department of Medicine, Khyber Medical University, Peshawar, Pakistan
| | - Maja Spaseski
- Department of Internal Medicine, Weiss Memorial Hospital, Chicago, IL
| | - Saliha Erdem
- Department of Internal Medicine, Wayne State University, Detroit Medical Center, MI
| | - Ammar ElJack
- Department of Cardiology, Baylor Scott and White Health, Heart Hospital Plano, TX
| | - Talal Almas
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Dipan Uppal
- Department of Cardiology, Cleveland Clinic, FL
| | - Shehzad Ali
- Department of Internal Medicine, Weiss Memorial Hospital, Chicago, IL
| | - M Chadi Alraies
- Department of Cardiology, Detroit Medical Center; Detroit, MI.
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16
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Goldsweig AM, Deng Y, Yao X, Desai NR, Cohen DJ, Aronow HD, Messé S, Ross JS, Lansky AJ, Savitz ST. Approval, Evidence, and "Off-Label" Device Utilization: The Patent Foramen Ovale Closure Story. Circ Cardiovasc Qual Outcomes 2024; 17:e010200. [PMID: 38189127 PMCID: PMC10844981 DOI: 10.1161/circoutcomes.123.010200] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 09/27/2023] [Indexed: 01/09/2024]
Abstract
BACKGROUND Following regulatory approval, medical devices may be used "off-label." Patent foramen ovale (PFO) closure is indicated to reduce recurrent stroke but has been proposed for other indications, including migraine, transient ischemic attack, and diving decompression illness. We sought to evaluate PFO closure rates and indications relative to the timing of regulatory approval and publication of key randomized trials. METHODS We performed a retrospective cohort study using the OptumLabs Data Warehouse of US commercial insurance enrollees from 2006 to 2019. We quantified PFO closure among individuals with ≥2 years of preprocedure coverage to establish indications, classified hierarchically as stroke/systemic embolism, migraine, transient ischemia attack, or other. RESULTS We identified 5315 patients undergoing PFO closure (51.8% female, 29.2%≥60 years old), which increased from 4.75 per 100 000 person-years in 2006 to 6.60 per 100 000 person-years in 2019. Patients aged ≥60 years accounted for 29.2% of closures. Procedure volumes corresponded weakly with supportive clinical publications and device approval. Among patients with PFO closure, 58.6% underwent closure for stroke/systemic embolism, 10.2% for transient ischemia attack, 8.8% for migraine, and 22.4% for other indications; 17.6% of patients had atrial fibrillation at baseline; and 11.9% developed atrial fibrillation postprocedure. Those aged ≥60 years and male were less likely to undergo closure for migraine than stroke/systemic embolism. CONCLUSIONS From 2006 to 2019, PFO closure use was consistently low and corresponded weakly with clinical trial publications and regulatory status. Nearly half of patients underwent PFO closure for indications unapproved by the Food and Drug Administration. Regulators and payers should coordinate mechanisms to promote utilization for approved indications to ensure patient safety and should facilitate clinical trials for other possible indications.
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Affiliation(s)
- Andrew M. Goldsweig
- Department of Cardiovascular Medicine, Baystate Medical
Center, Springfield, MA, USA
| | - Yihong Deng
- Kern Center for the Science of Health Care Delivery and
Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Xiaoxi Yao
- Kern Center for the Science of Health Care Delivery and
Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Nihar R. Desai
- Section of Cardiovascular Medicine, Yale University, New
Haven, CT, USA
| | - David J. Cohen
- Cardiovascular Research Foundation, New York, NY, USA, and
St. Francis Hospital and Heart Center, Roslyn, NY, USA
| | - Herbert D. Aronow
- Department of Cardiovascular Medicine, Henry Ford Health
System, Detroit, MI, USA
| | - Steven Messé
- Department of Neurology, Hospital of the University of
Pennsylvania, Philadelphia, PA, USA
| | - Joseph S. Ross
- Section of General Medicine, Department of Internal
Medicine, Yale School of Medicine, and Department of Health Policy and Management,
Yale School of Public Health, New Haven, CT, USA
| | | | - Samuel T. Savitz
- Kern Center for the Science of Health Care Delivery and
Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
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Randhawa S, Mehta JL, Dhar G. Percutaneous Patent Foramen Ovale Closure: Stroke and Beyond. Curr Cardiol Rev 2024; 20:77-86. [PMID: 38485682 PMCID: PMC11284695 DOI: 10.2174/011573403x276984240304044109] [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: 09/10/2023] [Revised: 01/13/2024] [Accepted: 01/20/2024] [Indexed: 07/20/2024] Open
Abstract
Over 750,000 individuals suffer from stroke annually in the United States, with 87% of these strokes being ischemic in nature. Roughly 40% of ischemic strokes occur in individuals 60 years of age or under. A quarter of all ischemic strokes have no identifiable cause despite extensive workup and are deemed cryptogenic in nature. Patent Foramen Ovales (PFO) has been postulated in stroke causation by either paradoxical embolization or platelet activation in the tunnel of the defect. The incidence of PFO is reported to be 15-25% in the general population but rises to 40% in patients with cryptogenic stroke. While the initial trials evaluating PFO closures were non-revealing, subsequent long-term follow-ups, as well as recent trials evaluating PFO closures in cryptogenic stroke patients 60 years of age or under, demonstrated the superiority of percutaneous closure compared to medical therapy alone, leading to FDA approval of PFO closure devices. In this review, we review the diagnosis of PFO, postulated stroke mechanisms, literature supporting PFO closure, patient selection for percutaneous closure, procedural considerations, and associated procedural complications.
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Affiliation(s)
- Sandeep Randhawa
- Division of Cardiology, The University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Jawahar L. Mehta
- Division of Cardiology, The University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Gaurav Dhar
- Division of Cardiology, The University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
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Low CE, Teo YN, Teo YH, Lim ICZ, Rana S, Lee YQ, Chen X, Fang JT, Lam HH, Ong K, Yang J, Kuntjoro I, Low TT, Lee EC, Sharma VK, Yeo LL, Sia CH, Tan BY, Lim Y. Propensity-score matched analysis of patent foramen ovale closure in real-world study cohort with cryptogenic ischemic stroke. J Stroke Cerebrovasc Dis 2023; 32:107407. [PMID: 37804781 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107407] [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: 07/20/2023] [Revised: 09/27/2023] [Accepted: 10/02/2023] [Indexed: 10/09/2023] Open
Abstract
INTRODUCTION Patent foramen ovale (PFO) occurs in 25% of the general population and in 40% of cryptogenic ischemic stroke patients. Recent trials support PFO closure in selected patients with cryptogenic stroke. We examined the outcomes of transcatheter PFO closure in a real-world study cohort with cryptogenic stroke. METHODS Consecutive ischemic stroke patients who were classified as cryptogenic on the TOAST aetiology and diagnosed with a PFO were included. All patients underwent either transcatheter PFO closure or medical therapy. A 2:1 propensity score matching by sex and Risk-of-Paradoxical-Embolism (RoPE) score was performed. Multivariable regression models adjusted for sex and RoPE score. RESULTS Our cohort comprised 232 patients with mean age 44.3 years (SD 10.8) and median follow-up 1486.5 days. 33.2% were female. PFO closure (n=84) and medical therapy (n=148) groups were well-matched with <10% mean-difference in sex and RoPE score. Two patients in the treated group (2.4%) and seven in the control group (4.7%) had a recurrent ischemic stroke event. Multivariable Cox regression demonstrated a hazard-ratio of 0.26 (95%CI 0.03-2.13, P=0.21) for PFO closure compared to control. The incidence of atrial fibrillation (AF) detected post-PFO closure was similar between the treated and control (1.19% vs 1.35%, multivariable logistic regression odds-ratio 0.90, 95%CI 0.04-9.81, P=0.94). There were no major periprocedural complications documented. The difference in restricted mean survival-time free from stroke at two years between treated and control was 26.2 days (95%CI 5.52-46.85, P=0.013). CONCLUSIONS In this Asian cohort, we report a low incidence of ischemic stroke recurrence and new-onset AF in patients who underwent PFO closure. When compared to the medical therapy group, there was no significant difference in the incidence of stroke recurrence and new-onset AF. Further studies involving larger real-world cohorts are warranted to identify patients who are more likely to benefit from PFO closure.
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Affiliation(s)
- Chen Ee Low
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yao Neng Teo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yao Hao Teo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Isis Claire Zy Lim
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Sounak Rana
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yong Qin Lee
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Xintong Chen
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Jun Tao Fang
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Hsin Hui Lam
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Kathleen Ong
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Joanna Yang
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Ivandito Kuntjoro
- Department of Cardiology, National University Heart Centre, 5 Lower Kent Ridge Road, Singapore 119074, Singapore
| | - Ting Ting Low
- Department of Cardiology, National University Heart Centre, 5 Lower Kent Ridge Road, Singapore 119074, Singapore
| | - Edward Cy Lee
- Department of Cardiology, National University Heart Centre, 5 Lower Kent Ridge Road, Singapore 119074, Singapore
| | - Vijay K Sharma
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Leonard Ll Yeo
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Ching Hui Sia
- Department of Cardiology, National University Heart Centre, 5 Lower Kent Ridge Road, Singapore 119074, Singapore
| | - Benjamin Yq Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Yinghao Lim
- Department of Cardiology, National University Heart Centre, 5 Lower Kent Ridge Road, Singapore 119074, Singapore.
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19
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Ntiloudi D, Rammos S, Karakosta M, Kalesi A, Kasinos N, Giannakoulas G. Arrhythmias in Patients with Congenital Heart Disease: An Ongoing Morbidity. J Clin Med 2023; 12:7020. [PMID: 38002634 PMCID: PMC10672721 DOI: 10.3390/jcm12227020] [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: 10/07/2023] [Revised: 11/04/2023] [Accepted: 11/08/2023] [Indexed: 11/26/2023] Open
Abstract
With the aging of congenital heart disease (CHD) patients, the burden of arrhythmias is expanding. Atrial arrhythmias, especially intra-atrial reentrant tachycardia and atrial fibrillation, are the most prevalent forms of arrhythmia. Managing comorbidities, such as obesity, using pharmacotherapy, including antiarrhythmics and anticoagulants, and ablation therapy has become the cornerstone of arrhythmia management. Ventricular tachycardias are also not rare; however, except for tetralogy of Fallot patients, recommendations for the use of implantable cardioverter defibrillators for primary prevention in other CHD patients are still not well established. Patients with CHD might also present with atrioventricular blockages because of their anatomy or following a surgical procedure. The scope of this article is to review the current knowledge and discuss the future directions regarding arrhythmia management in CHD patients.
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Affiliation(s)
- Despoina Ntiloudi
- Department of Cardiology, Tzaneio General Hospital of Piraeus, 185 36 Piraeus, Greece; (M.K.); (A.K.); (N.K.)
- Echocardiography Training Center of Tzaneio ‘D. Beldekos’, 185 36 Piraeus, Greece
| | - Spyridon Rammos
- Department of Pediatric Cardiology and Adult Congenital Heart Disease, “Onassis” Cardiac Surgery Center, 176 74 Athens, Greece;
| | - Maria Karakosta
- Department of Cardiology, Tzaneio General Hospital of Piraeus, 185 36 Piraeus, Greece; (M.K.); (A.K.); (N.K.)
- Echocardiography Training Center of Tzaneio ‘D. Beldekos’, 185 36 Piraeus, Greece
| | - Alkistis Kalesi
- Department of Cardiology, Tzaneio General Hospital of Piraeus, 185 36 Piraeus, Greece; (M.K.); (A.K.); (N.K.)
- Echocardiography Training Center of Tzaneio ‘D. Beldekos’, 185 36 Piraeus, Greece
| | - Nearchos Kasinos
- Department of Cardiology, Tzaneio General Hospital of Piraeus, 185 36 Piraeus, Greece; (M.K.); (A.K.); (N.K.)
- Echocardiography Training Center of Tzaneio ‘D. Beldekos’, 185 36 Piraeus, Greece
| | - George Giannakoulas
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, 546 36 Thessaloniki, Greece;
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20
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Aerospace Medicine Clinic. Aerosp Med Hum Perform 2023; 94:864-867. [PMID: 37891716 DOI: 10.3357/amhp.6257.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2023]
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21
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Patel RB, Reddy VY, Komtebedde J, Wegerich SW, Sekaric J, Swarup V, Walton A, Laurent G, Chetcuti S, Rademann M, Bergmann M, McKenzie S, Bugger H, Bruno RR, Herrmann HC, Nair A, Gupta DK, Lim S, Kapadia S, Gordon R, Vanderheyden M, Noel T, Bailey S, Gertz ZM, Trochu JN, Cutlip DE, Leon MB, Solomon SD, van Veldhuisen DJ, Auricchio A, Shah SJ. Atrial Fibrillation Burden and Atrial Shunt Therapy in Heart Failure With Preserved Ejection Fraction. JACC. HEART FAILURE 2023; 11:1351-1362. [PMID: 37480877 DOI: 10.1016/j.jchf.2023.05.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/12/2023] [Accepted: 05/17/2023] [Indexed: 07/24/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) is a common comorbidity in patients with heart failure with preserved ejection fraction (HFpEF) and in heart failure with mildly reduced ejection fraction (HFmrEF). OBJECTIVES This study sought to describe AF burden and its clinical impact among individuals with HFpEF and HFmrEF who participated in a randomized clinical trial of atrial shunt therapy (REDUCE LAP-HF II [A Study to Evaluate the Corvia Medical, Inc IASD System II to Reduce Elevated Left Atrial Pressure in Patients with Heart Failure]) and to evaluate the effect of atrial shunt therapy on AF burden. METHODS Study investigators characterized AF burden among patients in the REDUCE LAP-HF II trial by using ambulatory cardiac patch monitoring at baseline (median patch wear time, 6 days) and over a 12-month follow-up (median patch wear time, 125 days). The investigators determined the association of baseline AF burden with long-term clinical events and examined the effect of atrial shunt therapy on AF burden over time. RESULTS Among 367 patients with cardiac monitoring data at baseline and follow-up, 194 (53%) had a history of AF or atrial flutter (AFL), and median baseline AF burden was 0.012% (IQR: 0%-1.3%). After multivariable adjustment, baseline AF burden ≥0.012% was significantly associated with heart failure (HF) events (HR: 2.00; 95% CI: 1.17-3.44; P = 0.01) both with and without a history of AF or AFL (P for interaction = 0.68). Adjustment for left atrial reservoir strain attenuated the baseline AF burden-HF event association (HR: 1.71; 95% CI: 0.93-3.14; P = 0.08). Of the 367 patients, 141 (38%) had patch-detected AF during follow-up without a history of AF or AFL. Atrial shunt therapy did not change AF incidence or burden during follow-up. CONCLUSIONS In HFpEF and HFmrEF, nearly 40% of patients have subclinical AF by 1 year. Baseline AF burden, even at low levels, is associated with HF events. Atrial shunt therapy does not affect AF incidence or burden. (A Study to Evaluate the Corvia Medical, Inc IASD System II to Reduce Elevated Left Atrial Pressure in Patients with Heart Failure [REDUCE LAP-HF II]; NCT03088033).
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Affiliation(s)
- Ravi B Patel
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA; Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Illinois, USA
| | - Vivek Y Reddy
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | | | | | | | - Gabriel Laurent
- Department of Cardiology, Dijon University Hospital, Dijon, France
| | - Stanley Chetcuti
- Division of Cardiology, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Matthias Rademann
- Department of Cardiology, University of Giessen, Bad Nauheim, Germany
| | - Martin Bergmann
- Department of Interventional Cardiology, Cardiologicum, Hamburg, Germany
| | - Scott McKenzie
- School of Medicine, University of Queensland, The Prince Charles Hospital, Brisbane, Australia
| | - Heiko Bugger
- Division of Cardiology, Medical University of Graz, Graz, Austria
| | - Raphael Romano Bruno
- Division of Cardiology, Pulmonology, and Vascular Medicine, Faculty of Medicine, University Hospital Dusseldorf, Heinrich-Heine-University Dusseldorf, Dusseldorf, Germany
| | - Howard C Herrmann
- Division of Cardiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ajith Nair
- Division of Cardiology, Baylor College of Medicine, Houston, Texas, USA
| | - Deepak K Gupta
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Scott Lim
- Division of Cardiology, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Samir Kapadia
- Division of Cardiology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Robert Gordon
- Division of Cardiology, NorthShore University Health System, Evanston, Illinois, USA
| | | | - Thomas Noel
- Southern Medical Group, P.A., Tallahassee, Florida, USA
| | - Steven Bailey
- Division of Cardiology, Louisiana State University School of Medicine, Baton Rouge, Louisiana, USA
| | - Zachary M Gertz
- Division of Cardiology, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Jean-Noël Trochu
- Nantes Université, CHU Nantes, CNRS, INSERM, l'institut du thorax, Nantes, France
| | - Donald E Cutlip
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Martin B Leon
- Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York, New York, USA
| | - Scott D Solomon
- Division of Cardiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Dirk J van Veldhuisen
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Angelo Auricchio
- Division of Cardiology, Ticino Cardiocentro Institute, Lugano, Switzerland
| | - Sanjiv J Shah
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
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22
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Ji MH, Seoung YH. Right-to-Left Shunt Evaluation in Cardiac Patent Foramen Ovale Using Bubble Contrast Transcranial Color-Coded Doppler: A Cryptogenic Stroke Case. Healthcare (Basel) 2023; 11:2655. [PMID: 37830692 PMCID: PMC10572775 DOI: 10.3390/healthcare11192655] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 09/23/2023] [Accepted: 09/28/2023] [Indexed: 10/14/2023] Open
Abstract
Traditional diagnosis of patent foramen ovale (PFO) in the heart has involved the use of transcranial Doppler (TCD). However, TCD is essentially a blind test that cannot directly visualize the location of blood vessels. Since TCD relies on qualitative assessments by examiners, there is room for errors, such as misalignment of the ultrasound's angle of incidence with the actual blood vessels. This limitation affects the reproducibility and consistency of the examination. In this study, we presented an alternative approach for assessing right-to-left shunt (RLS) associated with PFO using contrast transcranial color-coded Doppler (C-TCCD) with bubble contrast. The patient under consideration had been diagnosed with an ischemic stroke through imaging, but the subsequent cardiac work-up failed to determine the cause. Employing C-TCCD for RLS screening revealed a confirmed RLS of Spencer's three grades. Subsequently, transesophageal echocardiography (TEE) was conducted to evaluate PFO risk factors, confirming an 8 mm PFO size, a 21 mm tunnel length, a hypermobile interatrial septum, and persistent RLS. The calculated high-risk PFO score was 4 points, categorizing it as a very high risk PFO. This case underscores the importance of C-TCCD screening in detecting RLS associated with PFO, especially in cryptogenic stroke patients, when identifying the underlying cause of ischemic stroke becomes challenging.
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Affiliation(s)
- Myeong-Hoon Ji
- Department of Radiological Science, College of Health and Medical Sciences, Cheongju University, Cheongju 28503, Republic of Korea;
- The Korean Registry for Diagnostic Medical Sonography (KRDMS), Daejeon 35041, Republic of Korea
| | - Youl-Hun Seoung
- Department of Radiological Science, College of Health and Medical Sciences, Cheongju University, Cheongju 28503, Republic of Korea;
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23
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Skibsted CV, Korsholm K, Pedersen L, Bonnesen K, Nielsen-Kudsk JE, Schmidt M. Long-term risk of atrial fibrillation or flutter after transcatheter patent foramen ovale closure: a nationwide Danish study. Eur Heart J 2023; 44:3469-3477. [PMID: 37279491 DOI: 10.1093/eurheartj/ehad305] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 04/20/2023] [Accepted: 05/08/2023] [Indexed: 06/08/2023] Open
Abstract
AIMS Transcatheter closure of patent foramen ovale (PFO) is the recommended stroke prevention treatment in patients ≤60 years with cryptogenic ischemic stroke and PFO. Atrial fibrillation or flutter (AF) is a known potential procedure-related complication, but long-term risk of developing AF remains unknown. This paper studied the long-term risk of developing AF following PFO closure. METHODS AND RESULTS A Danish nationwide cohort study was conducted. During 2008-2020, this study identified a PFO closure cohort, a PFO diagnosis cohort without PFO closure, and a general population comparison cohort matched 10:1 to the PFO closure cohort on age and sex. The outcome was first-time AF diagnosis. Risk of AF and multivariable-adjusted hazard ratio (HR) of the association between PFO closure or PFO diagnosis and AF were calculated. A total of 817 patients with PFO closure, 1224 with PFO diagnosis, and 8170 matched individuals were identified. The 5 year risk of AF was 7.8% [95% confidence interval (CI): 5.5-10] in the PFO closure cohort, 3.1% (95% CI: 2.0-4.2) in the PFO diagnosis cohort, and 1.2% (95% CI: 0.8-1.6) in the matched cohort. The HR of AF comparing PFO closure with PFO diagnosis was 2.3 (95% CI: 1.3-4.0) within the first 3 months and 0.7 (95% CI: 0.3-1.7) thereafter. The HR of AF comparing PFO closure with the matched cohort was 51 (95% CI: 21-125) within the first 3 months and 2.5 (95% CI: 1.2-5.0) thereafter. CONCLUSION Patent foramen ovale closure was not associated with any substantial increased long-term risk of developing AF beyond the well-known procedure-related short-term risk.
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Affiliation(s)
- Christian Valdemar Skibsted
- Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Allé 43-45, 8200 Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus University Hospital A1001, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Kasper Korsholm
- Department of Clinical Medicine, Aarhus University, Aarhus University Hospital A1001, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Lars Pedersen
- Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Allé 43-45, 8200 Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus University Hospital A1001, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Kasper Bonnesen
- Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Allé 43-45, 8200 Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus University Hospital A1001, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Jens Erik Nielsen-Kudsk
- Department of Clinical Medicine, Aarhus University, Aarhus University Hospital A1001, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Morten Schmidt
- Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Allé 43-45, 8200 Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus University Hospital A1001, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
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24
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Badoz M, Derimay F, Serzian G, Besutti M, Rioufol G, Frey P, Guenancia C, Ecarnot F, Meneveau N, Chopard R. Incidence of atrial fibrillation in cryptogenic stroke with patent foramen ovale closure: protocol for the prospective, observational PFO-AF study. BMJ Open 2023; 13:e074584. [PMID: 37699623 PMCID: PMC10503323 DOI: 10.1136/bmjopen-2023-074584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 08/25/2023] [Indexed: 09/14/2023] Open
Abstract
INTRODUCTION After closure of patent foramen ovale (PFO) due to stroke, atrial fibrillation (AF) occurs in up to one in five patients. However, data are sparse regarding the possible pre-existence of AF in these patients prior to PFO closure, and about recurrence of AF in the long term after the procedure. No prospective study to date has investigated these topics in patients with implanted cardiac monitor (ICM). The PFO-AF study (registered with ClinicalTrials.gov under the number NCT04926142) will investigate the incidence of AF occurring within 2 months after percutaneous closure of PFO in patients with prior stroke. AF will be identified using systematic ICM. Secondary objectives are to assess incidence and burden of AF in the 2 months prior to, and up to 2 years after PFO closure. METHODS AND ANALYSIS Prospective, multicentre, observational study including 250 patients with an indication for PFO closure after stroke, as decided by interdisciplinary meetings with cardiologists and neurologists. Patients will undergo implantation of a Reveal Linq device (Medtronic). Percutaneous PFO closure will be performed 2 months after device implantation. Follow-up will include consultation, ECG and reading of ICM data at 2, 12 and 24 months after PFO closure. The primary endpoint is occurrence of AF at 2 months, defined as an episode of AF or atrial tachycardia/flutter lasting at least 30 s, and recorded by the ICM and/or any AF or atrial tachycardia/flutter documented on ECG during the first 2 months of follow-up. ETHICS AND DISSEMINATION The study was approved by the Ethics Committee 'Comité de Protection des Personnes (CPP) Sud-Méditerranéen III' on 2 June 2021 and registered with ClinicalTrials.gov (NCT04926142). Findings will be presented in national and international congresses and peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT04926142.
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Affiliation(s)
- Marc Badoz
- Department of Cardiology, Besançon Regional University Hospital Center, Besancon, Bourgogne-Franche-Comté, France
- Université de Franche-Comté, Besancon, Bourgogne-Franche-Comté, France
| | - François Derimay
- Interventional Cardiology, Hospices Civils de Lyon, Lyon, France
| | - Guillaume Serzian
- Department of Cardiology, Besançon Regional University Hospital Center, Besancon, Bourgogne-Franche-Comté, France
| | - Matthieu Besutti
- Department of Cardiology, Besançon Regional University Hospital Center, Besancon, Bourgogne-Franche-Comté, France
| | - Gilles Rioufol
- Interventional Cardiology, Hospices Civils de Lyon, Lyon, France
| | - Pierre Frey
- Department of Cardiology, Centre Hospitalier Annecy Genevois, Epagny Metz-Tessy, France
| | | | - Fiona Ecarnot
- Department of Cardiology, Besançon Regional University Hospital Center, Besancon, Bourgogne-Franche-Comté, France
- Université de Franche-Comté, Besancon, Bourgogne-Franche-Comté, France
| | - Nicolas Meneveau
- Department of Cardiology, Besançon Regional University Hospital Center, Besancon, Bourgogne-Franche-Comté, France
- Université de Franche-Comté, Besancon, Bourgogne-Franche-Comté, France
| | - Romain Chopard
- Department of Cardiology, Besançon Regional University Hospital Center, Besancon, Bourgogne-Franche-Comté, France
- Université de Franche-Comté, Besancon, Bourgogne-Franche-Comté, France
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25
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Farjat-Pasos JI, Chamorro A, Lanthier S, Robichaud M, Mengi S, Houde C, Rodés-Cabau J. Cerebrovascular Events in Older Patients With Patent Foramen Ovale: Current Status and Future Perspectives. J Stroke 2023; 25:338-349. [PMID: 37813671 PMCID: PMC10574307 DOI: 10.5853/jos.2023.01599] [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: 05/15/2023] [Revised: 08/18/2023] [Accepted: 08/21/2023] [Indexed: 10/11/2023] Open
Abstract
Patent foramen ovale (PFO) closure, along with medical therapy, has emerged as the therapeutic gold standard in younger (<60-year-old) patients with a PFO-related stroke for preventing recurrent events. However, PFO management guidelines lack definite recommendations for older (>60 years) patients with a PFO-related cerebrovascular event, a complex group of patients who were mostly excluded from PFO closure clinical trials. Nevertheless, several studies have shown a higher prevalence of PFO among older patients with cryptogenic stroke, and its presence has been associated with an increased risk of recurrent events. Furthermore, older patients exhibit a higher prevalence of high-risk PFO anatomical features, present inherent age-related risk factors that might increase the risk of paradoxical embolism through a PFO, and have a higher incidence of ischemic events after a PFO-related event. Additionally, observational studies have shown the safety and preliminary efficacy of PFO closure in older PFO-related stroke patients. Yet, higher rates of recurrent cerebrovascular events and new-onset atrial fibrillation were observed in some studies among older patients compared to their younger counterparts. After careful case-by-case evaluation, including the assessment of hidden potential cardioembolic sources of a cryptogenic stroke other than PFO, transcatheter PFO closure might be a safe and effective therapeutic option for preventing recurrent thromboembolic events in patients >60 years with a high-risk PFO-associated stroke. Ongoing trials will provide important insights into the role of PFO closure in the elderly population.
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Affiliation(s)
- Julio I. Farjat-Pasos
- Department of Cardiology, Quebec Heart & Lung Institute, Laval University, Quebec City, Canada
| | - Angel Chamorro
- Department of Neuroscience, Hospital Clinic, University of Barcelona, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Sylvain Lanthier
- Neurovascular Program and Research Center, Montreal Sacre Coeur Hospital; Montreal, Canada
| | - Mathieu Robichaud
- Department of Cardiology, Quebec Heart & Lung Institute, Laval University, Quebec City, Canada
| | - Siddhartha Mengi
- Department of Cardiology, Quebec Heart & Lung Institute, Laval University, Quebec City, Canada
| | - Christine Houde
- Department of Pediatric Cardiology, Laval University Hospital Center, Quebec City, Canada
| | - Josep Rodés-Cabau
- Department of Cardiology, Quebec Heart & Lung Institute, Laval University, Quebec City, Canada
- Department of Research & Innovation, Clínic Barcelona, Barcelona, Spain
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26
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Jiang H, Cao S, Wang R, Wang S, He Z, Xu X, Yang C, Liu X. In vivo study of a reserved atrial septal puncture area patent foramen ovale occluder. Cardiol Young 2023; 33:1581-1586. [PMID: 36065734 DOI: 10.1017/s1047951122002827] [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: 11/07/2022]
Abstract
PURPOSE After patent foramen ovale interventional closure, puncture of the interatrial septum through the occluder is difficult but sometimes needed for further interventional treatment. This paper presents findings from an in vivo experimental study of a reserved atrial septal puncture area patent foramen ovale occluder. MATERIALS AND METHODS A patent foramen ovale model was established in canines using trans-septal puncture of the fossa ovale and high-pressure balloon dilation. Then, patent foramen ovale closure was performed with a reserved atrial septal puncture area and all canines were raised for 3 months. Then, the occluder was crossed and left atrial angiography was performed on the septal area with the occluder. Finally, DSA angiography, echocardiography, and histology were used to evaluate the performance and feasibility of the reserved atrial septal puncture area. RESULTS A patent foramen ovale model was successfully established in 10 canines using the atrial septal puncture method. The average diameter of the patent foramen ovale was 3.77 ±0.19 mm, and the patent foramen ovale was successfully closed in all canines using a reserved atrial septal puncture area. As assessed using transoesophageal echocardiography, the new occluder exhibited an ideal position and was occluded entirely without a residual shunt intraoperatively and postoperatively. A 100% success rate of atrial septum puncture was achieved across the new occluder. The occluders were completely endothelialised 3 months post-implantation. CONCLUSIONS The reserved atrial septal puncture area was effective in patent foramen ovale closure and exhibited positive sealing performance and biological compatibility. Trans-septal puncture was feasible and effective after reserved atrial septal puncture area patent foramen ovale closure.
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Affiliation(s)
- Haibin Jiang
- Department of Cardiology, Wuxi NO. 2 People's Hospital, Nanjing Medical University, Wuxi 214000, Jiangsu, China
| | - Suyan Cao
- Department of Cardiology, Wuxi NO. 2 People's Hospital, Nanjing Medical University, Wuxi 214000, Jiangsu, China
| | - Renrong Wang
- Department of Cardiology, Wuxi NO. 2 People's Hospital, Nanjing Medical University, Wuxi 214000, Jiangsu, China
| | - Shuya Wang
- Department of Cardiology, Wuxi NO. 2 People's Hospital, Nanjing Medical University, Wuxi 214000, Jiangsu, China
| | - Ziqian He
- Department of Cardiology, Wuxi NO. 2 People's Hospital, Nanjing Medical University, Wuxi 214000, Jiangsu, China
| | - Xin Xu
- Department of Cardiology, Wuxi NO. 2 People's Hospital, Nanjing Medical University, Wuxi 214000, Jiangsu, China
| | - Chengjian Yang
- Department of Cardiology, Wuxi NO. 2 People's Hospital, Nanjing Medical University, Wuxi 214000, Jiangsu, China
| | - Xiaoxiao Liu
- Department of Cardiology, Wuxi NO. 2 People's Hospital, Nanjing Medical University, Wuxi 214000, Jiangsu, China
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Sha L, Li Y, Zhang Y, Tang Y, Li B, Chen Y, Chen L. Heart-brain axis: Association of congenital heart abnormality and brain diseases. Front Cardiovasc Med 2023; 10:1071820. [PMID: 37063948 PMCID: PMC10090520 DOI: 10.3389/fcvm.2023.1071820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 03/13/2023] [Indexed: 03/31/2023] Open
Abstract
Brain diseases are a major burden on human health worldwide, and little is known about how most brain diseases develop. It is believed that cardiovascular diseases can affect the function of the brain, and many brain diseases are associated with heart dysfunction, which is called the heart-brain axis. Congenital heart abnormalities with anomalous hemodynamics are common treatable cardiovascular diseases. With the development of cardiovascular surgeries and interventions, the long-term survival of patients with congenital heart abnormalities continues to improve. However, physicians have reported that patients with congenital heart abnormalities have an increased risk of brain diseases in adulthood. To understand the complex association between congenital heart abnormalities and brain diseases, the paper reviews relevant clinical literature. Studies have shown that congenital heart abnormalities are associated with most brain diseases, including stroke, migraine, dementia, infection of the central nervous system, epilepsy, white matter lesions, and affective disorders. However, whether surgeries or other interventions could benefit patients with congenital heart abnormalities and brain diseases remains unclear because of limited evidence.
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Affiliation(s)
- Leihao Sha
- Department of Neurology, Joint Research Institution of Altitude Health, West China Hospital, Sichuan University, Chengdu, China
| | - Yajiao Li
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Yunwu Zhang
- Fujian Provincial Key Laboratory of Neurodegenerative Disease and Aging Research, Institute of Neuroscience, School of Medicine, Xiamen University, Xiamen, China
| | - Yusha Tang
- Department of Neurology, Joint Research Institution of Altitude Health, West China Hospital, Sichuan University, Chengdu, China
| | - Baichuan Li
- Department of Neurology, Joint Research Institution of Altitude Health, West China Hospital, Sichuan University, Chengdu, China
| | - Yucheng Chen
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Lei Chen
- Department of Neurology, Joint Research Institution of Altitude Health, West China Hospital, Sichuan University, Chengdu, China
- Correspondence: Lei Chen
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Lucà F, Pino PG, Parrini I, Di Fusco SA, Ceravolo R, Madeo A, Leone A, La Mair M, Benedetto FA, Riccio C, Oliva F, Colivicchi F, Gulizia MM, Gelsomino S. Patent Foramen Ovale and Cryptogenic Stroke: Integrated Management. J Clin Med 2023; 12:1952. [PMID: 36902748 PMCID: PMC10004032 DOI: 10.3390/jcm12051952] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 02/13/2023] [Accepted: 02/27/2023] [Indexed: 03/06/2023] Open
Abstract
Patent foramen ovale (PFO) is a common cardiac abnormality with a prevalence of 25% in the general population. PFO has been associated with the paradoxical embolism causing cryptogenic stroke and systemic embolization. Results from clinical trials, meta-analyses, and position papers support percutaneous PFO device closure (PPFOC), especially if interatrial septal aneurysms coexist and in the presence of large shunts in young patients. Remarkably, accurately evaluating patients to refer to the closure strategy is extremely important. However, the selection of patients for PFO closure is still not so clear. The aim of this review is to update and clarify which patients should be considered for closure treatment.
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Affiliation(s)
- Fabiana Lucà
- Cardiology Department, Grande Ospedale Metropolitano, GOM, AO Bianchi Melacrino Morelli, 89129 Reggio di Calabria, Italy
| | - Paolo G. Pino
- Cardiology Department, San Camillo Forlanini Hospital, 00152 Rome, Italy
| | - Iris Parrini
- Cardiology Department, Mauriziano Hospital, 10128 Torino, Italy
| | - Stefania Angela Di Fusco
- Clinical and Rehabilitation Cardiology Department, San Filippo Neri Hospital, ASL Roma 1, 00135 Roma, Italy
| | - Roberto Ceravolo
- Cardiology Unit, Giovanni Paolo II Hospital, 88046 Lamezia, Italy
| | | | - Angelo Leone
- Ospedale Santissima Annunziata, 87100 Cosenza, Italy
| | - Mark La Mair
- Cardiothoracic Department, Brussels University Hospital, 1090 Jette, Belgium
| | - Francesco Antonio Benedetto
- Cardiology Department, Grande Ospedale Metropolitano, GOM, AO Bianchi Melacrino Morelli, 89129 Reggio di Calabria, Italy
| | - Carmine Riccio
- Division of Clinical Cardiology, A.O.R.N. ‘Sant’Anna e San Sebastiano’, 81100 Caserta, Italy
| | - Fabrizio Oliva
- De Gasperis Cardio Center, Niguarda Hospital, 20162 Milano, Italy
| | - Furio Colivicchi
- Clinical and Rehabilitation Cardiology Department, San Filippo Neri Hospital, ASL Roma 1, 00135 Roma, Italy
| | | | - Sandro Gelsomino
- Cardiothoracic Department, Maastricht University, 6211 LK Maastrich, The Netherlands
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Stefanescu Schmidt AC, Abrahamyan L, Muthuppalaniappan A, Gorocica Romero R, Ephrem G, Everett K, Lee DS, Osten M, Benson LN, Horlick EM. Outcomes of Patent Foramen Ovale Transcatheter Closure: Should a Short Aortic Rim Preclude Closure? JACC. ADVANCES 2023; 2:100257. [PMID: 38938308 PMCID: PMC11198134 DOI: 10.1016/j.jacadv.2023.100257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 11/10/2022] [Accepted: 12/13/2022] [Indexed: 06/29/2024]
Abstract
Background The risk of erosion of an atrial septal closure device, in particular the Amplatzer Septal Occluder, has been described as higher in patients with a short aortic rim. Similar concern has been applied to patent foramen ovale (PFO) closure devices, but there are only rare reported cases of erosion. It may be that smaller devices are chosen due to fear of device erosion in PFO patients when this is not necessarily an issue. Objectives The authors aimed to assess outcomes after PFO closure with the Amplatzer PFO device in patients with a short (<9 mm) aortic rim. Methods We performed a retrospective analysis of PFO closure for any indication, between 2006 and 2017 at a quaternary center. Preprocedural transesophageal echocardiographic parameters including the aortic rim were remeasured. Long-term outcomes were obtained by linkage to provincial administrative databases. Results Over the study period, 324 patients underwent PFO closure with the Amplatzer PFO device, with a mean age of 49.8 years; 61% had a short aortic rim (<9 mm). The most common indication was cryptogenic stroke (72%); those with longer aortic distance were more likely to have a non-stroke indication for closure, diabetes (15% vs 6.5%, P = 0.04), and heart failure (15.7% vs 4%, P < 0.001). Over a median 7 years of follow-up, there were no cases of device erosion or embolization requiring cardiac surgery. Conclusions In a large cohort with long-term administrative follow-up (1,394 patient-years), implantation of an Amplatzer PFO device was performed safely even in patients with a short aortic rim.
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Affiliation(s)
- Ada C. Stefanescu Schmidt
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
- Heart Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Lusine Abrahamyan
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, Toronto General Hospital, Toronto, Ontario, Canada
| | - Annamalar Muthuppalaniappan
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
- Gleneagles Hospital Penang, Pulau Pinang, Malaysia
| | - Ricardo Gorocica Romero
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
- Mexican Institution of Social Security, UMAE No. 1, Merida, Yucatan, Mexico
| | - Georges Ephrem
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
- Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | | | | | - Mark Osten
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Leland N. Benson
- Division of Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Eric M. Horlick
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
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Testa L, Popolo Rubbio A, Squillace M, Albano F, Cesario V, Casenghi M, Tarantini G, Pagnotta P, Ielasi A, Popusoi G, Paloscia L, Durante A, Maffeo D, Meucci F, Valentini G, Ussia GP, Cioffi P, Cortese B, Sangiorgi G, Contegiacomo G, Bedogni F. Patent foramen ovale occlusion with the Cocoon PFO Occluder. The PROS-IT collaborative project. Front Cardiovasc Med 2023; 9:1064026. [PMID: 36712245 PMCID: PMC9875285 DOI: 10.3389/fcvm.2022.1064026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 12/20/2022] [Indexed: 01/12/2023] Open
Abstract
Background The Cocoon patent foramen ovale (PFO) Occluder is a new generation nitinol alloy double-disk device coated with nanoplatinum, likely useful in patients with nickel hypersensitivity. Early results and mid-term outcomes of this device in percutaneous PFO closure are missing. Aims To assess the preliminary efficacy and safety profile of PFO closure with Cocoon device in an Italian multi-center registry. Methods This is a prospective registry of 189 consecutive adult patients treated with the Cocoon PFO Occluder at 15 Italian centers from May 2017 till May 2020. Patients were followed up for 2 years. Results Closure of the PFO with Cocoon Occluder was carried out successfully in all patients, with complete closure without residual shunt in 94.7% of the patients and minimal shunt in 5.3%. Except from a case of paroxysmal supraventricular tachycardia and a major vascular bleeding, no procedural and in-hospital device-related complications occurred. No patient developed cardiac erosions, allergic reactions to nickel, or any other major complications during the follow-up. During the follow-up period, 2 cases of new-onset atrial fibrillation occurred within thirty-day. Conclusions Percutaneous closure of PFO with Cocoon Occluder provided satisfactory procedural and mid-term clinical follow-up results in a real-world registry.
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Affiliation(s)
- Luca Testa
- Department of Cardiology, IRCCS Policlinico San Donato, Milan, Italy
| | | | - Mattia Squillace
- Department of Cardiology, IRCCS Policlinico San Donato, Milan, Italy
| | - Flavio Albano
- Department of Cardiology, IRCCS Policlinico San Donato, Milan, Italy
| | - Vincenzo Cesario
- Department of Cardiology, IRCCS Policlinico San Donato, Milan, Italy
| | - Matteo Casenghi
- Department of Cardiology, IRCCS Policlinico San Donato, Milan, Italy
| | - Giuseppe Tarantini
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Paolo Pagnotta
- Cardio Center, Humanitas Research Hospital, Milan, Italy
| | - Alfonso Ielasi
- Clinical and Interventional Cardiology Unit, Istituto Clinico Sant'Ambrogio, Milan, Italy
| | - Grigore Popusoi
- Interventional Cardiology Service, Montevergine Clinic, Mercogliano, Italy
| | | | | | | | - Francesco Meucci
- Structural Interventional Cardiology, Careggi University Hospital, Florence, Italy
| | - Giuliano Valentini
- Cardiology Intensive Care Unit and Cath Lab, Ospedale Civile SS. Filippo e Nicola, L'Aquila, Italy
| | - Gian Paolo Ussia
- Unit of Cardiovascular Science, Department of Medicine, Campus Bio-Medico University, Rome, Italy
| | - Paolo Cioffi
- Department of Cardiology, Cardiac Cath Lab, Città di Alessandria Institute, Alessandria, Italy
| | | | - Giuseppe Sangiorgi
- Department of Biomedicine and Prevention, Tor Vergata University of Rome, Rome, Italy
| | - Gaetano Contegiacomo
- Department of Interventional Cardiology, Anthea Hospital, GVM Care and Research, Bari, Italy
| | - Francesco Bedogni
- Department of Cardiology, IRCCS Policlinico San Donato, Milan, Italy
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Krittanawong C, Yue B, Khawaja M, Kumar A, Virk HUH, Wang Z, Hanif S, Khalid U, Denktas AE, Kavinsky CJ, Volpi JJ, Jneid H. Readmission in patients undergoing percutaneous patent foramen ovale closure in the United States. Int J Cardiol 2023; 370:143-148. [PMID: 36356694 DOI: 10.1016/j.ijcard.2022.10.135] [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] [Received: 08/09/2022] [Revised: 09/18/2022] [Accepted: 10/16/2022] [Indexed: 11/09/2022]
Abstract
Current estimates suggest that a patent foramen ovale (PFO) may exist in up to 25% of the general population and is a potential risk factor for embolic, ischemic stroke. PFO closure complications include bleeding, need for procedure-related surgical intervention, pulmonary emboli, device malpositioning, new onset atrial arrhythmias, and transient atrioventricular block. Rates of PFO closure complications at a national level in the Unites States remain unknown. To address this, we performed a contemporary nationwide study using the 2016 and 2017 Nationwide Readmissions Database (NRD) to identify patterns of readmissions after percutaneous PFO closure. In conclusion, our study showed that following PFO closure, the most common complications were atrial fibrillation/atrial flutter followed by acute heart failure syndrome, supraventricular tachycardia and acute myocardial infarction.
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Affiliation(s)
- Chayakrit Krittanawong
- Michael E. DeBakey VA Medical Center, Houston, TX, USA; Section of Cardiology, Baylor School of Medicine, Houston, TX, USA.
| | - Bing Yue
- Department of Cardiology, Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Muzamil Khawaja
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Anirudh Kumar
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Hafeez Ul Hassan Virk
- Harrington Heart & Vascular Institute, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Zhen Wang
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA; Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Sana Hanif
- Griffin Hospital, Department of Cardiology, CT, USA
| | - Umair Khalid
- Michael E. DeBakey VA Medical Center, Houston, TX, USA; Section of Cardiology, Baylor School of Medicine, Houston, TX, USA
| | - Ali E Denktas
- Michael E. DeBakey VA Medical Center, Houston, TX, USA; Section of Cardiology, Baylor School of Medicine, Houston, TX, USA
| | | | - John J Volpi
- Department of Neurology, Houston Methodist Neurological Institute, TX, USA
| | - Hani Jneid
- John Sealey Centennial Chair in Cardiology, Chief of Cardiology, The University of Texas Medical Branch, TX, USA
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32
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Karagianni A, Mandalenakis Z, Papadopoulos S, Dellborg M, Eriksson P. Long-term outcome after closure of an atrial shunt in patients aged 60 years or older with ischemic stroke: A nationwide, registry-based, case-control study. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2023. [DOI: 10.1016/j.ijcchd.2022.100438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
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Guedeney P, Laredo M, Zeitouni M, Hauguel-Moreau M, Wallet T, Elegamandji B, Alamowitch S, Crozier S, Sabben C, Deltour S, Obadia M, Benyounes N, Collet JP, Rouanet S, Hammoudi N, Silvain J, Montalescot G. Supraventricular Arrhythmia Following Patent Foramen Ovale Percutaneous Closure. JACC Cardiovasc Interv 2022; 15:2315-2322. [PMID: 36008269 DOI: 10.1016/j.jcin.2022.07.044] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 07/21/2022] [Accepted: 07/27/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND Randomized studies have reported low rates of atrial fibrillation (AF) after patent foramen ovale (PFO) closure (<6%) but have relied on patient-reported symptomatic episodes, so the true incidence and timing of AF after PFO closure remain unknown. OBJECTIVES The aim of this study was to prospectively determine the incidence, timing, and determinants of supraventricular arrhythmia following PFO closure on the basis of loop recorder monitoring. METHODS Cardiac monitoring was proposed to all patients after PFO closure from June 2018 to October 2021 at a single center by means of implantable loop recorder monitoring in patients considered at higher risk for AF (age ≥ 55 years, associated cardiovascular risk factors, prior palpitations, or documented supraventricular ectopic activity) or 4-week external loop recorder monitoring in other patients. The primary endpoint was the incidence of AF, atrial flutter, or supraventricular tachycardia lasting >30 seconds within 28 days of the procedure. Determinants of the primary endpoint were assessed using a stepwise logistic regression model. RESULTS A total of 225 patients were included. The primary endpoint occurred in 47 patients (20.9%), including 13 (9.9%) and 24 (28.9%) among patients monitored with external loop recorders and implantable loop recorders, respectively. Overall, the median delay from procedure to arrhythmia was 14.0 days (IQR: 6.5-19.0 days), and one-half of these patients reported symptomatic episodes. Determinants of the primary endpoint were older age (adjusted OR: 1.67 per 10-year increase; 95% CI: 1.18-2.36), device left disc diameter ≥25 mm (adjusted OR: 2.67; 95% CI: 1.19-5.98) and male sex (adjusted OR: 4.78; 95% CI: 1.96-11.66). CONCLUSIONS Using loop recorder monitoring for ≥28 days, supraventricular arrhythmia was diagnosed in 1 in 5 patients, with a median delay of 14 days, suggesting that this postprocedural event has so far been underestimated.
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Affiliation(s)
- Paul Guedeney
- Sorbonne Université, ACTION Study Group, INSERM UMRS_1166 Institut de Cardiologie, Pitié Salpêtrière (AP-HP), Paris, France
| | - Mikael Laredo
- Sorbonne Université, ACTION Study Group, INSERM UMRS_1166 Institut de Cardiologie, Pitié Salpêtrière (AP-HP), Paris, France
| | - Michel Zeitouni
- Sorbonne Université, ACTION Study Group, INSERM UMRS_1166 Institut de Cardiologie, Pitié Salpêtrière (AP-HP), Paris, France
| | - Marie Hauguel-Moreau
- INSERM U-1018, Department of Cardiology, Ambroise Paré Hospital, Assistance Publique-Hôpitaux de Paris, Boulogne, France
| | - Thomas Wallet
- Sorbonne Université, ACTION Study Group, INSERM UMRS_1166 Institut de Cardiologie, Pitié Salpêtrière (AP-HP), Paris, France
| | - Benjamin Elegamandji
- Sorbonne Université, ACTION Study Group, INSERM UMRS_1166 Institut de Cardiologie, Pitié Salpêtrière (AP-HP), Paris, France
| | - Sonia Alamowitch
- Sorbonne Université, Service des Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpétrière, AP-HP, Paris, France
| | - Sophie Crozier
- Sorbonne Université, Service des Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpétrière, AP-HP, Paris, France
| | - Candice Sabben
- Rothschild Foundation Hospital, Neurology Department, Paris, France
| | - Sandrine Deltour
- Neurology Department, Raymond-Poincaré Hospital (AP-HP), Garches, France
| | - Michaël Obadia
- Rothschild Foundation Hospital, Neurology Department, Paris, France
| | - Nadia Benyounes
- Cardiology Department, Rothschild Foundation Hospital, Paris, France
| | - Jean-Philippe Collet
- Sorbonne Université, ACTION Study Group, INSERM UMRS_1166 Institut de Cardiologie, Pitié Salpêtrière (AP-HP), Paris, France
| | - Stéphanie Rouanet
- Statistician Unit, StatEthic, ACTION Study Group, Levallois-Perret, France
| | - Nadjib Hammoudi
- Sorbonne Université, ACTION Study Group, INSERM UMRS_1166 Institut de Cardiologie, Pitié Salpêtrière (AP-HP), Paris, France
| | - Johanne Silvain
- Sorbonne Université, ACTION Study Group, INSERM UMRS_1166 Institut de Cardiologie, Pitié Salpêtrière (AP-HP), Paris, France
| | - Gilles Montalescot
- Sorbonne Université, ACTION Study Group, INSERM UMRS_1166 Institut de Cardiologie, Pitié Salpêtrière (AP-HP), Paris, France.
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Alperi A, Guedeney P, Horlick E, Nombela-Franco L, Freixa X, Pascual I, Mesnier J, Houde C, Abrahamyan L, Montalescot G, Rodés-Cabau J. Transcatheter Closure of Patent Foramen Ovale in Older Patients With Cryptogenic Thromboembolic Events. Circ Cardiovasc Interv 2022; 15:e011652. [PMID: 35735021 DOI: 10.1161/circinterventions.121.011652] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND The main randomized trials evaluating patent foramen ovale (PFO) closure after a presumed PFO-associated stroke excluded patients older than 60 years. We aimed to evaluate the early- and long-term clinical outcomes of transcatheter PFO closure in older (>60 years) patients with a cryptogenic ischemic event. METHODS This is a multicenter study including consecutive patients older than 60 years (mean age, 67±5 years) who had a PFO closure following a presumed PFO-related ischemic event. Patients ≤60 years old (mean age, 44±10 years) served as the control group. The primary end point was the occurrence of stroke, transient ischemic attack, or peripheral embolism over the follow-up period. New-onset atrial fibrillation was a secondary end point. RESULTS A total of 388 and 883 patients >60 and ≤60 years old were included, respectively. Procedural success rate was high (99.9%), and procedural-related complications low (<2%) in both groups. After a median follow-up of 3 (1-8) years, older patients exhibited an incidence of stroke/transient ischemic attack/peripheral embolism of 1.6 events per 100 patient-years (stroke: 0.6 events per 100 patient-years), lower than that expected according to the risk of paradoxical embolism score (observed-to-expected ratio, 0.31 [95% CI, 0.11-0.91]). However, the event rate in older patients was higher than that observed in their younger counterparts (incidence rate ratio, 4.7 [95% CI, 2.36-9.8]). De novo atrial fibrillation after the procedure was more frequent in older patients (2.66 per 100 patient-years versus 0.49 per 100 patient-years, P<0.001). CONCLUSIONS In patients older than 60 years with a presumed PFO-related ischemic event, PFO closure was safe and associated with a relatively low incidence of recurrent ischemic events after a median follow-up of 3 years compared with historical cohorts of patients who did not undergo PFO closure. However, a higher risk of recurrent cerebrovascular events was observed in older patients compared to their younger counterparts. Randomized trials are warranted in this population.
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Affiliation(s)
- Alberto Alperi
- Quebec Heart and Lung Institute, Laval University, Quebec City, Canada (A.A., J.M., J.R.-C.).,Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain (A.A., I.P.)
| | - Paul Guedeney
- Institut de Cardiologie, Groupe Hospitalier Pitié-Salpetrière, Paris, France (P.G., G.M.)
| | - Eric Horlick
- Department of Cardiology, Toronto General Hospital, University of Toronto, Canada (E.H., L.A.)
| | - Luis Nombela-Franco
- Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (L.N.-F.)
| | - Xavier Freixa
- Institut Clínic Cardiovascular, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain (X.F., J.R.-C.)
| | - Isaac Pascual
- Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain (A.A., I.P.)
| | - Jules Mesnier
- Quebec Heart and Lung Institute, Laval University, Quebec City, Canada (A.A., J.M., J.R.-C.)
| | - Christine Houde
- Centre Hospitalier Universitaire de Quebec, Quebec City' Canada (C.H., J.R.-C.)
| | - Lusine Abrahamyan
- Department of Cardiology, Toronto General Hospital, University of Toronto, Canada (E.H., L.A.)
| | - Gilles Montalescot
- Institut de Cardiologie, Groupe Hospitalier Pitié-Salpetrière, Paris, France (P.G., G.M.)
| | - Josep Rodés-Cabau
- Quebec Heart and Lung Institute, Laval University, Quebec City, Canada (A.A., J.M., J.R.-C.).,Institut Clínic Cardiovascular, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain (X.F., J.R.-C.).,Centre Hospitalier Universitaire de Quebec, Quebec City' Canada (C.H., J.R.-C.)
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Kavinsky CJ, Szerlip M, Goldsweig AM, Amin Z, Boudoulas KD, Carroll JD, Coylewright M, Elmariah S, MacDonald LA, Shah AP, Spies C, Tobis JM, Messé SR, Senerth E, Falck-Ytter Y, Babatunde I, Morgan RL. SCAI Guidelines for the Management of Patent Foramen Ovale. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2022; 1:100039. [PMID: 39131947 PMCID: PMC11307505 DOI: 10.1016/j.jscai.2022.100039] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 08/13/2024]
Abstract
Background Patent foramen ovale (PFO) is a vestigial congenital cardiovascular structure present in around 25% of adults. In most cases, PFO is entirely benign and requires no treatment. However, it may cause serious complications under certain circumstances. Objective These evidence-based guidelines from the Society for Cardiovascular Angiography and Interventions (SCAI) aim to support patients, clinicians, and other stakeholders in decisions about management of PFO. Methods SCAI convened a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. The Evidence Foundation, a registered 501(c)(3) nonprofit organization, provided methodological support for the guideline-development process. Following the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, the guideline panel formulated and prioritized clinical questions in population, intervention, comparison, outcome (PICO) format. A separate technical review team of clinical and methodological experts conducted systematic reviews of the evidence, synthesized data, and graded the certainty of the evidence across outcomes. The guideline panel then reconvened to formulate recommendations and supporting remarks informed by the results of the technical review and additional contextual factors described in the GRADE evidence-to-decision framework. Results The panel agreed on 13 recommendations to address variations on 5 clinical scenarios. Conclusions Key recommendations address patient selection for PFO closure in the prevention of recurrent PFO-associated stroke, including populations not commonly included in randomized studies, and scenarios where the PFO closure might serve a role in the prevention of other outcomes such as migraine headaches and decompression illness. The panel has also identified future research priorities to advance the field.
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Affiliation(s)
| | - Molly Szerlip
- Baylor Scott & White The Heart Hospital, Plano, Texas
| | | | - Zahid Amin
- AdventHealth Medical Group, Orlando, Florida
| | | | - John D. Carroll
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | | | | | | | | | - Christian Spies
- Sutter Health Palo Alto Medical Foundation, Burlingame, California
| | | | - Steven R. Messé
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Emily Senerth
- Society for Cardiovascular Angiography & Interventions, Washington, DC
| | - Yngve Falck-Ytter
- Case Western Reserve University/VA Northeast Ohio Healthcare System, Cleveland, Ohio
| | | | - Rebecca L. Morgan
- Department of Health Research Methods, McMaster University, Hamilton, Ontario, Canada
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36
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Krishnamurthy Y, Ben-Ami J, Robbins BT, Sommer RJ. Incidence and time course of atrial fibrillation following patent foramen ovale closure. Catheter Cardiovasc Interv 2022; 100:219-224. [PMID: 35652162 DOI: 10.1002/ccd.30247] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 05/17/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVES Determine the true incidence and time course of atrial fibrillation (AF) after patent foramen ovale closure (PFOc) using implantable loop recorders (ILR) placed during cryptogenic stroke evaluation. BACKGROUND Published trials report a 2%-6.6% incidence of postimplant atrial fibrillation (PIAF) after PFOc, which is probably a gross underestimation, as only patients presenting in AF were captured. Episodes of paroxysmal and silent AF would have been missed. METHODS Of 761 patients who underwent PFOc at a single center between January 2016 and December 2020, 35 patients had an ILR implanted before PFOc, without documentation of AF, and had ≥1 month of monitoring post-PFOc. The incidence, onset, and conclusion of AF episodes were determined from a review of patient records. RESULTS The mean duration of ILR monitoring was 54.6 ± 39.4 weeks after PFOc. AF occurred in 13/35 (37%) patients. PFOc patients who developed PIAF were older than those who did not (62 ± 11 vs. 52 ± 14 years, p = 0.03). In 12/13, the initial PIAF event occurred within 4 weeks of PFOc, with the greatest frequency around 2 weeks and conclusion by 12 weeks in all. No recurrent strokes occurred during ILR monitoring. CONCLUSION The actual incidence of PIAF was far greater than previously reported and was significantly associated with older age at PFOc. The timing of PIAF onset and termination were consistent with a postimplant inflammatory mechanism. The higher actual PIAF incidence underscores its low stroke potential in this population. A larger prospective trial is required to validate these preliminary results.
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Affiliation(s)
- Yamini Krishnamurthy
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Johanna Ben-Ami
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Barbara T Robbins
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Robert J Sommer
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
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Lip GYH, Lane DA, Lenarczyk R, Boriani G, Doehner W, Benjamin LA, Fisher M, Lowe D, Sacco RL, Schnabel R, Watkins C, Ntaios G, Potpara T. OUP accepted manuscript. Eur Heart J 2022; 43:2442-2460. [PMID: 35552401 PMCID: PMC9259378 DOI: 10.1093/eurheartj/ehac245] [Citation(s) in RCA: 54] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 03/11/2022] [Accepted: 04/27/2022] [Indexed: 11/12/2022] Open
Abstract
The management of patients with stroke is often multidisciplinary, involving various specialties and healthcare professionals. Given the common shared risk factors for stroke and cardiovascular disease, input may also be required from the cardiovascular teams, as well as patient caregivers and next-of-kin. Ultimately, the patient is central to all this, requiring a coordinated and uniform approach to the priorities of post-stroke management, which can be consistently implemented by different multidisciplinary healthcare professionals, as part of the patient ‘journey’ or ‘patient pathway,’ supported by appropriate education and tele-medicine approaches. All these aspects would ultimately aid delivery of care and improve patient (and caregiver) engagement and empowerment. Given the need to address the multidisciplinary approach to holistic or integrated care of patients with heart disease and stroke, the European Society of Cardiology Council on Stroke convened a Task Force, with the remit to propose a consensus on Integrated care management for optimizing the management of stroke and associated heart disease. The present position paper summarizes the available evidence and proposes consensus statements that may help to define evidence gaps and simple practical approaches to assist in everyday clinical practice. A post-stroke ABC pathway is proposed, as a more holistic approach to integrated stroke care, would include three pillars of management:
A: Appropriate Antithrombotic therapy. B: Better functional and psychological status. C: Cardiovascular risk factors and Comorbidity optimization (including lifestyle changes).
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Affiliation(s)
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Radosław Lenarczyk
- Division of Medical Sciences in Zabrze, Department of Cardiology, Congenital Heart Diseases and Electrotherapy, The Medical University of Silesia, Silesian Center of Heart Diseases, Curie-Sklodowska Str 9, 41-800 Zabrze, Poland
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Wolfram Doehner
- BIH Center for Regenerative Therapies (BCRT) and Department of Internal Medicine and Cardiology (Virchow Klinikum), German Centre for Cardiovascular Research (DZHK) partner site Berlin and Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Laura A Benjamin
- Laboratory of Molecular and Cell Biology, University College London National Hospital for Neurology and Neurosurgery, Queen Square, London
| | - Marc Fisher
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Deborah Lowe
- Wirral University Teaching Hospital NHS Foundation Trust, Wirral CH49 5PE, UK
| | - Ralph L Sacco
- UM Clinical & Translational Science Institute, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Renate Schnabel
- University Heart & Vascular Center Hamburg Eppendorf, German Center for Cardiovascular Research (DZHK) partner site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Caroline Watkins
- Faculty of Health and Care, University of Central Lancashire, Preston PR1 2HE, UK
| | - George Ntaios
- Department of Internal Medicine, School of Health Sciences, Faculty of Medicine, University of Thessaly, Larissa, Greece
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Parsons IT, Nicol ED, Holdsworth D, Guettler N, Rienks R, Davos CH, Halle M, Parati G. Cardiovascular risk in high-hazard occupations: the role of occupational cardiology. Eur J Prev Cardiol 2021; 29:702-713. [PMID: 34918040 DOI: 10.1093/eurjpc/zwab202] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 11/10/2021] [Accepted: 11/12/2021] [Indexed: 12/20/2022]
Abstract
Work is beneficial for health, but many individuals develop cardiovascular disease (CVD) during their working lives. Occupational cardiology is an emerging field that combines traditional cardiology sub-specialisms with prevention and risk management unique to specific employment characteristics and conditions. In some occupational settings incapacitation through CVD has the potential to be catastrophic due to the nature of work and/or the working environment. These are often termed 'hazardous' or 'high-hazard' occupations. Consequently, many organizations that employ individuals in high-hazard roles undertake pre-employment medicals and periodic medical examinations to screen for CVD. The identification of CVD that exceeds predefined employer (or regulatory body) risk thresholds can result in occupational restriction, or disqualification, which may be temporary or permanent. This article will review the evidence related to occupational cardiology for several high-hazard occupations related to aviation and space, diving, high altitude, emergency workers, commercial transportation, and the military. The article will focus on environmental risk, screening, surveillance, and risk management for the prevention of events precipitated by CVD. Occupational cardiology is a challenging field that requires a broad understanding of general cardiology, environmental, and occupational medicine principles. There is a current lack of consensus and contemporary evidence which requires further research. Provision of evidence-based, but individualized, risk stratification and treatment plans is required from specialists that understand the complex interaction between work and the cardiovascular system. There is a current lack of consensus and contemporary evidence in occupational cardiology and further research is required.
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Affiliation(s)
- Iain T Parsons
- Academic Department of Military Medicine, Research and Clinical Innovation, Royal Centre for Defence Medicine, Birmingham, UK.,School of Cardiovascular Medicine and Sciences, King's College London, London, UK
| | - Edward D Nicol
- Academic Department of Military Medicine, Research and Clinical Innovation, Royal Centre for Defence Medicine, Birmingham, UK.,Faculty of Medicine, Imperial College, London, UK.,Department of Cardiology, Royal Brompton Hospital, London, UK
| | - David Holdsworth
- Academic Department of Military Medicine, Research and Clinical Innovation, Royal Centre for Defence Medicine, Birmingham, UK
| | - Norbert Guettler
- Department of Internal Medicine and Cardiology, German Air Force Centre of Aerospace Medicine, Fuerstenfeldbruck, Germany
| | - Rienk Rienks
- CardioExpert, Outpatient Clinic for Sports and Occupational Cardiology, Amsterdam, The Netherlands
| | - Constantinos H Davos
- Division of Cardiovascular Research, Cardiovascular Laboratory, Biomedical Research Foundation, Academy of Athens, Athens, Greece
| | - Martin Halle
- Department of Prevention and Sports Medicine, University Hospital Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.,Department of Cardiovascular Research, DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Gianfranco Parati
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.,Department of Cardiology, Istituto Auxologico Italiano, IRCCS, San Luca Hospital, Milan, Italy
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Andersen A, Matzen KL, Andersen G, Settergren M, Sjostrand C, Iversen HK, Roine RO, Hildick-Smith D, Spence JD, Rhodes JF, Kasner SE, Sondergaard L, Nielsen-Kudsk JE. Atrial fibrillation after closure of patent foramen ovale in the REDUCE clinical study. Catheter Cardiovasc Interv 2021; 99:1551-1557. [PMID: 34773685 DOI: 10.1002/ccd.30019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 10/27/2021] [Accepted: 11/04/2021] [Indexed: 11/07/2022]
Abstract
OBJECTIVES To describe the occurrence of postprocedural atrial fibrillation (AF) among patients with cryptogenic stroke undergoing patent foramen ovale (PFO) closure in the REDUCE clinical study and analyze for potential risk factors for the development of postprocedural AF. BACKGROUND AF is an adverse event that might potentially counterbalance the stroke prevention benefit from PFO closure. Data on AF after transcatheter PFO closure are sparse. METHODS We evaluated data from patients having PFO closure (Gore HELEX or Gore Cardioform Septal Occluder) in the REDUCE clinical trial (n = 408) in at post hoc explorative analysis. Median follow-up was 5.0 years. RESULTS AF occurred in 30 patients (7.4%) after PFO closure with a total of 34 AF events. Most were reported as non-serious (68%), detected within 45 days post-procedure (79%), and resolved within 2 weeks of onset (63%). One subject with AF had recurrent stroke. Postprocedural AF occurred more frequently among subjects with higher age and large device sizes. Male sex was the only independent predictor of postprocedural AF. We found no association between the type of occluder (HELEX or Gore Cardioform Septal Occluder) or PFO anatomical characteristics and post-procedural AF. CONCLUSION In the REDUCE clinical study, postprocedural atrial fibrillation was mostly early onset, transient and with no later recurrence. Postprocedural AF occurred more frequently among patients with higher age and larger devices. Male sex was the only independent predictor of postprocedural AF.
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Affiliation(s)
- Asger Andersen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Grethe Andersen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Magnus Settergren
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | | | - Helle K Iversen
- Department of Neurology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Risto O Roine
- Department of Clinical Neurosciences, Turku University Hospital and University of Turku, Turku, Finland
| | - David Hildick-Smith
- Department of Cardiology, Sussex Cardiac Centre, Brighton & Sussex University Hospitals, Brighton, UK
| | - John David Spence
- Stroke Prevention & Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, Ontario, Canada
| | - John F Rhodes
- Department of Cardiology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Scott E Kasner
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lars Sondergaard
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Contemporary Management of Patent Foramen Ovale: A Multinational Survey on Cardiologists' Perspective. J Interv Cardiol 2021; 2021:6955791. [PMID: 34602869 PMCID: PMC8449721 DOI: 10.1155/2021/6955791] [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: 04/21/2021] [Accepted: 08/18/2021] [Indexed: 11/18/2022] Open
Abstract
Objectives The purpose of our survey is to analyze the clinical approach used by interventional and imaging cardiologists to diagnose, treat, and follow-up patients with PFO-related left circulation thromboembolism in different parts of the world with particular emphasis on adherence to current guidelines. Background Firm guidelines do not cover many aspects of PFO-related patient care. Consequently, very disparate approaches exist among clinicians in the real-world. Methods A 24-item electronic questionnaire was sent directly to experienced cardiology specialists practicing at consultant/attending positions directly involved in PFO closure management in the United States, United Kingdom, Gulf countries, and other countries. There were no unanswered questions. Responses were recorded between October 2019 and July 2020. Results Seventy-one responses were obtained: 31 from the UK, 19 from the US, 16 from Gulf countries, 2 from Poland, and 1 response from Australia, Italy, and Switzerland. The overall response rate was 76%. Significant differences between regions were noted in the duration of ECG monitoring during the diagnostic process, PFO closure for left circulation thromboembolism other than stroke/transient ischemic attack, and intraoperative use of intracardiac echocardiography. A similar pattern was noted in the lack of routine screening for thrombophilia and the use of the long-term single antiplatelet therapy. Conclusions The study shows a vast spectrum of opinions on the optimal approach to PFO closure with significant differences between the US, UK, and Gulf countries. The results stress the need for systematic, high-quality data on the diagnostic work-up and follow-up strategies to inform the standardized approach.
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Roina Y, Auber F, Hocquet D, Herlem G. ePTFE-based biomedical devices: An overview of surgical efficiency. J Biomed Mater Res B Appl Biomater 2021; 110:302-320. [PMID: 34520627 DOI: 10.1002/jbm.b.34928] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 07/26/2021] [Accepted: 08/01/2021] [Indexed: 12/19/2022]
Abstract
Polytetrafluoroethylene (PTFE) is a ubiquitous material used for implants and medical devices in general because of its high biocompatibility and inertness: blood vessel, heart, table jawbone, nose, eyes, or abdominal wall can benefit from its properties in case of disease or injury. Its expanded version, ePTFE is an improved version of PTFE with better mechanical properties, which extends its medical applications. A material as frequently used as ePTFE with these exceptional properties deserves a review of its main uses, developments, and possibility of improvements. In this systematic review, we examined clinical trials related to ePTFE-based medical devices from the literature. Then, we excluded all trials using ePTFE as a control to test other devices. ePTFE-coated stents, hemodialysis and bypass grafts, guided bone and tissue regeneration membranes, hernia and heart repair and other devices are reviewed. The rates of success using these devices and their efficiency compared to other materials used for the same purposes are reported. ePTFE appears to be more or just as efficient compared to them. Some success rates remain low, suggesting the need of improvement ePTFE for medical applications.
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Affiliation(s)
- Yaëlle Roina
- Nanomedicine Lab EA4662, Bat. E, Université de Franche-Comté, UFR Sciences & Techniques, Besançon Cedex, France
| | - Frédéric Auber
- Nanomedicine Lab EA4662, Bat. E, Université de Franche-Comté, UFR Sciences & Techniques, Besançon Cedex, France
| | - Didier Hocquet
- Hygiène Hospitalière, UMR CNRS 6249, Université de Bourgogne Franche-Comté, Besançon, France
| | - Guillaume Herlem
- Nanomedicine Lab EA4662, Bat. E, Université de Franche-Comté, UFR Sciences & Techniques, Besançon Cedex, France
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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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