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Khan M, Miller M, Mccarthy P, Tsai JP, Merhi W, Berkompas D, Wees N, Khan NI, Ahrar A, Evans E, Dahu M, Gauri A, Moelker T, Chalfoun N, Min J. Multidisciplinary Approach to Patent Foramen Ovale Closure for Cryptogenic Stroke: Brain-Heart Board Experience. Neurol Clin Pract 2024; 14:e200319. [PMID: 38826798 PMCID: PMC11141343 DOI: 10.1212/cpj.0000000000200319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 03/11/2024] [Indexed: 06/04/2024]
Abstract
Background and Objectives Patent foramen ovale (PFO) is present in approximately 25% of adult population. The prevalence of PFO is high in patients with cryptogenic stroke suggesting paradoxical embolism. PFO closure in carefully selected patients is an effective secondary preventive strategy in these patients. We report predictors of management recommendations by the multidisciplinary Board and their impact on outcomes. Methods Brain-Heart Board comprises vascular and interventional neurology and cardiology subspecialties (structural, electrophysiology, and cardiac imaging). Adult patients referred to the Board for consideration of PFO closure between October 2017 to March 2021 were included in this retrospective cohort analysis. Demographics, comorbid conditions, risk of paradoxical embolism (RoPE) score, event frequencies (transient ischemic attack [TIA] or stroke, intracranial hemorrhage [ICH], post-PFO closure cardiac arrhythmias), and modified Rankin Scale (mRS) at 1 year were compared between the groups (PFO closure vs medical management). Multivariable logistic regression was used to identify factors associated with management recommendation and chi-square tests to test differences in outcomes for patients according to management. Results Two hundred seventy patients (229 stroke; 41 TIA) were discussed by the Board for PFO closure. 119 (44.0%) patients were recommended for PFO closure of which 117 (98.3%) had evidence of ischemic infarct on imaging. In univariate analysis, age was similar (50 ± 11.9 vs 52 ± 12.8, p = 0.17), but RoPE score was higher in closure as compared with the medical management group (6 [IQR 5-7] vs 5 [IQR 4-7], p < 0.05). In multivariable analysis, TIA as the index event was an independent predictor of Board recommendation against PFO closure (OR 0.05, 95% CI 0.01-0.19, p < 0.05). Event frequency was low in both cohorts (5.9% vs 4.8%, p > 0.05) and comprised cardiac arrhythmias (6 cases of atrial fibrillation and 1 ICH in closure group; 1 TIA and 1 recurrent stroke in medical management group). Excellent functional outcome (mRS 0-1) was similar in both cohorts (66.3% vs 70.7%, p > 0.05) at 1 year. Discussion Multidisciplinary Brain-Heart Board provides a clinical practice model of collaborative care to ensure proper patient selection for PFO closure. TIA as the index event is associated with recommendation of medical management by the multidisciplinary Brain-Heart Board.
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Affiliation(s)
- Muhib Khan
- Division of Neurology (MK, MM, PM, NW, NIK, AA, EE, JM), Neuroscience Institute, Spectrum Health, Grand Rapids; Michigan State University (MK, MM, PM, JPT, WM, DB, NW, NIK, AA, MD, AG, NC, JM), Grand Rapids; Department of Neurology (MK), Mayo Clinic, Rochester, MN; Division of Neurosurgery (JPT), Neuroscience Institute, Grand Rapids; and Division of Cardiology (WM, DB, MD, AG, TM, NC), Heart and Vascular Institute, Spectrum Health, Grand Rapids, MI
| | - Malgorzata Miller
- Division of Neurology (MK, MM, PM, NW, NIK, AA, EE, JM), Neuroscience Institute, Spectrum Health, Grand Rapids; Michigan State University (MK, MM, PM, JPT, WM, DB, NW, NIK, AA, MD, AG, NC, JM), Grand Rapids; Department of Neurology (MK), Mayo Clinic, Rochester, MN; Division of Neurosurgery (JPT), Neuroscience Institute, Grand Rapids; and Division of Cardiology (WM, DB, MD, AG, TM, NC), Heart and Vascular Institute, Spectrum Health, Grand Rapids, MI
| | - Philip Mccarthy
- Division of Neurology (MK, MM, PM, NW, NIK, AA, EE, JM), Neuroscience Institute, Spectrum Health, Grand Rapids; Michigan State University (MK, MM, PM, JPT, WM, DB, NW, NIK, AA, MD, AG, NC, JM), Grand Rapids; Department of Neurology (MK), Mayo Clinic, Rochester, MN; Division of Neurosurgery (JPT), Neuroscience Institute, Grand Rapids; and Division of Cardiology (WM, DB, MD, AG, TM, NC), Heart and Vascular Institute, Spectrum Health, Grand Rapids, MI
| | - Jenny P Tsai
- Division of Neurology (MK, MM, PM, NW, NIK, AA, EE, JM), Neuroscience Institute, Spectrum Health, Grand Rapids; Michigan State University (MK, MM, PM, JPT, WM, DB, NW, NIK, AA, MD, AG, NC, JM), Grand Rapids; Department of Neurology (MK), Mayo Clinic, Rochester, MN; Division of Neurosurgery (JPT), Neuroscience Institute, Grand Rapids; and Division of Cardiology (WM, DB, MD, AG, TM, NC), Heart and Vascular Institute, Spectrum Health, Grand Rapids, MI
| | - William Merhi
- Division of Neurology (MK, MM, PM, NW, NIK, AA, EE, JM), Neuroscience Institute, Spectrum Health, Grand Rapids; Michigan State University (MK, MM, PM, JPT, WM, DB, NW, NIK, AA, MD, AG, NC, JM), Grand Rapids; Department of Neurology (MK), Mayo Clinic, Rochester, MN; Division of Neurosurgery (JPT), Neuroscience Institute, Grand Rapids; and Division of Cardiology (WM, DB, MD, AG, TM, NC), Heart and Vascular Institute, Spectrum Health, Grand Rapids, MI
| | - Duane Berkompas
- Division of Neurology (MK, MM, PM, NW, NIK, AA, EE, JM), Neuroscience Institute, Spectrum Health, Grand Rapids; Michigan State University (MK, MM, PM, JPT, WM, DB, NW, NIK, AA, MD, AG, NC, JM), Grand Rapids; Department of Neurology (MK), Mayo Clinic, Rochester, MN; Division of Neurosurgery (JPT), Neuroscience Institute, Grand Rapids; and Division of Cardiology (WM, DB, MD, AG, TM, NC), Heart and Vascular Institute, Spectrum Health, Grand Rapids, MI
| | - Nabil Wees
- Division of Neurology (MK, MM, PM, NW, NIK, AA, EE, JM), Neuroscience Institute, Spectrum Health, Grand Rapids; Michigan State University (MK, MM, PM, JPT, WM, DB, NW, NIK, AA, MD, AG, NC, JM), Grand Rapids; Department of Neurology (MK), Mayo Clinic, Rochester, MN; Division of Neurosurgery (JPT), Neuroscience Institute, Grand Rapids; and Division of Cardiology (WM, DB, MD, AG, TM, NC), Heart and Vascular Institute, Spectrum Health, Grand Rapids, MI
| | - Nadeem I Khan
- Division of Neurology (MK, MM, PM, NW, NIK, AA, EE, JM), Neuroscience Institute, Spectrum Health, Grand Rapids; Michigan State University (MK, MM, PM, JPT, WM, DB, NW, NIK, AA, MD, AG, NC, JM), Grand Rapids; Department of Neurology (MK), Mayo Clinic, Rochester, MN; Division of Neurosurgery (JPT), Neuroscience Institute, Grand Rapids; and Division of Cardiology (WM, DB, MD, AG, TM, NC), Heart and Vascular Institute, Spectrum Health, Grand Rapids, MI
| | - Asad Ahrar
- Division of Neurology (MK, MM, PM, NW, NIK, AA, EE, JM), Neuroscience Institute, Spectrum Health, Grand Rapids; Michigan State University (MK, MM, PM, JPT, WM, DB, NW, NIK, AA, MD, AG, NC, JM), Grand Rapids; Department of Neurology (MK), Mayo Clinic, Rochester, MN; Division of Neurosurgery (JPT), Neuroscience Institute, Grand Rapids; and Division of Cardiology (WM, DB, MD, AG, TM, NC), Heart and Vascular Institute, Spectrum Health, Grand Rapids, MI
| | - Elizabeth Evans
- Division of Neurology (MK, MM, PM, NW, NIK, AA, EE, JM), Neuroscience Institute, Spectrum Health, Grand Rapids; Michigan State University (MK, MM, PM, JPT, WM, DB, NW, NIK, AA, MD, AG, NC, JM), Grand Rapids; Department of Neurology (MK), Mayo Clinic, Rochester, MN; Division of Neurosurgery (JPT), Neuroscience Institute, Grand Rapids; and Division of Cardiology (WM, DB, MD, AG, TM, NC), Heart and Vascular Institute, Spectrum Health, Grand Rapids, MI
| | - Musa Dahu
- Division of Neurology (MK, MM, PM, NW, NIK, AA, EE, JM), Neuroscience Institute, Spectrum Health, Grand Rapids; Michigan State University (MK, MM, PM, JPT, WM, DB, NW, NIK, AA, MD, AG, NC, JM), Grand Rapids; Department of Neurology (MK), Mayo Clinic, Rochester, MN; Division of Neurosurgery (JPT), Neuroscience Institute, Grand Rapids; and Division of Cardiology (WM, DB, MD, AG, TM, NC), Heart and Vascular Institute, Spectrum Health, Grand Rapids, MI
| | - Andre Gauri
- Division of Neurology (MK, MM, PM, NW, NIK, AA, EE, JM), Neuroscience Institute, Spectrum Health, Grand Rapids; Michigan State University (MK, MM, PM, JPT, WM, DB, NW, NIK, AA, MD, AG, NC, JM), Grand Rapids; Department of Neurology (MK), Mayo Clinic, Rochester, MN; Division of Neurosurgery (JPT), Neuroscience Institute, Grand Rapids; and Division of Cardiology (WM, DB, MD, AG, TM, NC), Heart and Vascular Institute, Spectrum Health, Grand Rapids, MI
| | - Tarah Moelker
- Division of Neurology (MK, MM, PM, NW, NIK, AA, EE, JM), Neuroscience Institute, Spectrum Health, Grand Rapids; Michigan State University (MK, MM, PM, JPT, WM, DB, NW, NIK, AA, MD, AG, NC, JM), Grand Rapids; Department of Neurology (MK), Mayo Clinic, Rochester, MN; Division of Neurosurgery (JPT), Neuroscience Institute, Grand Rapids; and Division of Cardiology (WM, DB, MD, AG, TM, NC), Heart and Vascular Institute, Spectrum Health, Grand Rapids, MI
| | - Nagib Chalfoun
- Division of Neurology (MK, MM, PM, NW, NIK, AA, EE, JM), Neuroscience Institute, Spectrum Health, Grand Rapids; Michigan State University (MK, MM, PM, JPT, WM, DB, NW, NIK, AA, MD, AG, NC, JM), Grand Rapids; Department of Neurology (MK), Mayo Clinic, Rochester, MN; Division of Neurosurgery (JPT), Neuroscience Institute, Grand Rapids; and Division of Cardiology (WM, DB, MD, AG, TM, NC), Heart and Vascular Institute, Spectrum Health, Grand Rapids, MI
| | - Jiangyong Min
- Division of Neurology (MK, MM, PM, NW, NIK, AA, EE, JM), Neuroscience Institute, Spectrum Health, Grand Rapids; Michigan State University (MK, MM, PM, JPT, WM, DB, NW, NIK, AA, MD, AG, NC, JM), Grand Rapids; Department of Neurology (MK), Mayo Clinic, Rochester, MN; Division of Neurosurgery (JPT), Neuroscience Institute, Grand Rapids; and Division of Cardiology (WM, DB, MD, AG, TM, NC), Heart and Vascular Institute, Spectrum Health, Grand Rapids, MI
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