1
|
Fahy L, Rowe S, Nehme Z, Stub D, Zentner D, James P, Pflaumer A, Connell V, Semsarian C, Ingles J, La Gerche A, Paratz ED. Prevalence of atrial septal defects and patent foramen ovale in a cohort of sudden cardiac death patients undergoing autopsy. J Cardiol 2024; 83:390-393. [PMID: 37734655 DOI: 10.1016/j.jjcc.2023.09.006] [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: 05/29/2023] [Revised: 09/08/2023] [Accepted: 09/13/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Patent foramen ovale (PFO) and atrial septal defects (ASD) have been described in up to 30 % of subjects in autopsy series but contemporary data are scarce. It is important to confirm the prevalence of ASD/PFO in the general population given the potential associated stroke risk and the increasing availability of intervention via PFO closure. METHODS A state-wide prospective out-of-hospital cardiac arrest registry (OHCA) identified all patients aged 1 to 50 years who experienced OHCA in Victoria, Australia from April 2019 to April 2022 and subsequently underwent autopsy with a cardiac cause of death identified. Autopsy was performed including visual description of any ASD and identification of probe patency of foramen ovale. RESULTS A total of 517 patients underwent autopsy in the setting of sudden cardiac death; 36 patients (6.9 %) had a probe-patent foramen ovale, 2 patients (0.4 %) had secundum ASD, and 2 patients (0.4 %) had both a PFO and ASD (1 of whom had undergone percutaneous repair of both lesions). Twelve patients (2.3 %) had a prior history of cerebrovascular accident either recorded on medical history or detected on neuropathological examination; however none of these patients had a PFO or ASD. CONCLUSIONS The combined rate of PFO and ASD in a cohort of 517 patients undergoing autopsy was 7.9 %. None of these patients had experienced a cerebrovascular accident. This rate of PFOs appears lower than earlier reports and raises the possibility that the relative risk of an associated stroke could be higher than previously estimated.
Collapse
Affiliation(s)
- Louise Fahy
- Baker Heart and Diabetes Institute, Prahran, VIC, Australia; Department of Cardiology, St Vincent's Hospital Melbourne, Fitzroy, VIC, Australia.
| | - Stephanie Rowe
- Baker Heart and Diabetes Institute, Prahran, VIC, Australia; Department of Cardiology, St Vincent's Hospital Melbourne, Fitzroy, VIC, Australia
| | - Ziad Nehme
- Ambulance Victoria, Doncaster, VIC, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Dion Stub
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia; Department of Cardiology, Alfred Hospital, Prahran, VIC, Australia
| | - Dominica Zentner
- Department of Cardiology, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Paul James
- Department of Cardiology, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Andreas Pflaumer
- Department of Cardiology, Royal Children's Hospital, Parkville, VIC, Australia; Murdoch Children's Research Institute and University of Melbourne, Parkville, VIC, Australia; Department of Population Genomics, Garvan Institute of Medical Research, Darlinghurst, NSW, Australia
| | - Vanessa Connell
- Department of Cardiology, Royal Children's Hospital, Parkville, VIC, Australia
| | - Christopher Semsarian
- Agnes Ginges Centre for Molecular Cardiology, Centenary Institute and University of Sydney, Sydney, NSW, Australia
| | - Jodie Ingles
- Department of Population Genomics, Garvan Institute of Medical Research, Darlinghurst, NSW, Australia
| | - Andre La Gerche
- Baker Heart and Diabetes Institute, Prahran, VIC, Australia; Department of Cardiology, St Vincent's Hospital Melbourne, Fitzroy, VIC, Australia; Faculty of Medicine, Dentistry and Health Sciences, Melbourne University, Parkville, VIC, Australia
| | - Elizabeth D Paratz
- Baker Heart and Diabetes Institute, Prahran, VIC, Australia; Department of Cardiology, St Vincent's Hospital Melbourne, Fitzroy, VIC, Australia; Faculty of Medicine, Dentistry and Health Sciences, Melbourne University, Parkville, VIC, Australia
| |
Collapse
|
2
|
Lanzone AM, Castelluccio EV, Della Pina P, Boldi E, Lussardi G, Frati G, Gaudio C, Biondi-Zoccai G. Comparative diagnostic accuracy of transcranial Doppler and contrast-enhanced transthoracic echocardiography for the diagnosis of patent foramen ovale and atrial septal defect. Panminerva Med 2024; 66:124-130. [PMID: 38563605 DOI: 10.23736/s0031-0808.24.05123-1] [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: 04/04/2024]
Abstract
BACKGROUND Recognition of right-to-left shunt is crucial in the work-up of patients with suspected patent foramen ovale (PFO) or atrial septal defect (ASD). While transesophageal echocardiography (TEE) remains the gold standard diagnostic tool for the anatomic assessment of PFO/ASD, transcranial Doppler (TCD) and contrast-enhanced transthoracic echocardiogram (CE-TTE) hold the promise of providing minimally invasive yet accurate clinical details. Their comparative accuracy remains however debated. METHODS We conducted a retrospective observational study leveraging our extensive institutional experience with systematic TCD and CE-TTE in patients with suspected PFO/ASD. Several measures of diagnostic test accuracy were computed, with point estimates and 95% confidence intervals, when applicable. RESULTS A total of 1358 patients were included, with age 48±14 years and 772 (58%) women. Tests were performed for diagnostic purposes in 797 (58.6%) and during follow-up in 740 (54.5%). A PFO was eventually diagnosed in 1038 (77.9%) patients, and an ASD in 60 (4.5%). Agreement between TCD and CE-TTE occurred in 1309 (85.2%) cases, with TCD yielding worse findings than CE-TTE in 91 (5.9%) patients, and vice versa in 137 (8.9%), yielding a Cohen kappa of 78.6% (95% CI: 76.3-81.1%) and a highly significant P value at McNemar test (P<0.001). After dichotomization, and using TCD as benchmark, CE-TTE yielded sensitivity 96.9%, specificity 95.1%, area under the curve 92.1%, and P=0.249. Similar findings were obtained when focusing only on diagnostic tests or follow-up ones (Cohen kappa respectively 74.0% [70.2-77.1%], P<0.001 and 80.3% [76.4-84.3%], P<0.001). Notably, Valsalva was necessary to disclose the presence of shunt during TCD in 487 (31.7%) patients and during CE-TTE in 482 (31.4%) cases. Finally, performance of TCD and CE-TTE in a subset of patients eventually undergoing TTE was quite similar. CONCLUSIONS The diagnostic accuracy of CE-TTE appears favorable, and this imaging test may identify patients who may be missed if only TCD is used to screen patients with suspected PFO/ASD. Accordingly, CE-TTE is recommended as an adjunct diagnostic modality for all patients with a high pre-test probability of PFO/ASD and right-to-left shunt.
Collapse
Affiliation(s)
- Alberto M Lanzone
- Division of Cardiology and Coronary Care Unit, San Rocco Clinical Institute, Ome, Brescia, Italy
| | - Emanuele V Castelluccio
- Department of Health Promotion, Mother and Child Care, G. D'Alessandro Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
- Division of Cardiology, Paolo Giaccone University Hospital, Palermo, Italy
| | - Paolo Della Pina
- Division of Cardiology and Coronary Care Unit, San Rocco Clinical Institute, Ome, Brescia, Italy
| | - Emiliano Boldi
- Division of Cardiology and Coronary Care Unit, San Rocco Clinical Institute, Ome, Brescia, Italy
| | | | - Giacomo Frati
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University, Latina, Italy
- IRCCS Neuromed, Pozzilli, Isernia, Italy
| | - Carlo Gaudio
- Department of Clinical, Internal Medicine, Anesthesiological and Cardiovascular Sciences, Sapienza University, Rome, Italy
| | - Giuseppe Biondi-Zoccai
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University, Latina, Italy -
- Mediterranea Cardiocentro, Naples, Italy
| |
Collapse
|
3
|
Ter Schiphorst A, Lippi A, Corti L, Mourand I, Prin P, Agullo A, Cagnazzo F, Macia JC, Arquizan C. In young patients with stroke of undetermined etiology, large vessel occlusions are less frequent in the group with high-risk patent foramen ovale. Rev Neurol (Paris) 2024; 180:539-547. [PMID: 38102053 DOI: 10.1016/j.neurol.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 10/25/2023] [Accepted: 11/15/2023] [Indexed: 12/17/2023]
Abstract
INTRODUCTION Patent foramen ovale (PFO) is present in a significant proportion of young patients with stroke of undetermined etiology, but is not always causal. Therefore, classifications (RoPE, PASCAL) have been developed to determine the probability that PFO is the stroke cause. However, the presence of an initial arterial occlusion as a prediction factor was not studied when these classifications were built. Our aim was to evaluate the presence of arterial occlusion in young patients with stroke of undetermined etiology with/without high-risk PFO. METHODS From a prospectively-built monocentric database, we identified patients aged≥18 to<60-years with strokes of undetermined etiology and complete etiological work-up, including transesophageal echocardiography. We divided patients in two groups: (i) with high-risk PFO [i.e. PFO with large interatrial shunt (>30 microbubbles) or associated with atrial septal aneurysm] and (ii) with low-risk/without PFO. We recorded the presence of arterial occlusion and large vessel occlusion (LVO) in the acute phase. RESULTS We included 96 patients; 55 (57%) had high-risk PFO. Their median age was 48 (40-52) years, and 28 (29%) were women. The percentages of patients with arterial occlusion and with LVO were lower in the high-risk PFO group than in the low-risk/without PFO group: 11 (20%) versus 19 (46%) (P=0.008), and 5 (9%) versus 15 (37%) (P=0.002), respectively. There was no difference in the median RoPE score between groups (P=0.30). CONCLUSION The presence of LVO could represent a "red flag" of PFO causality in stroke of undetermined etiology, and could be implemented in future PFO-related stroke classifications.
Collapse
Affiliation(s)
- A Ter Schiphorst
- Department of Neurology, CHU Gui-de-Chauliac, Montpellier, France.
| | - A Lippi
- Department of Neurology, CHU Gui-de-Chauliac, Montpellier, France
| | - L Corti
- Department of Neurology, CHU Gui-de-Chauliac, Montpellier, France
| | - I Mourand
- Department of Neurology, CHU Gui-de-Chauliac, Montpellier, France
| | - P Prin
- Department of Neurology, CHU Gui-de-Chauliac, Montpellier, France
| | - A Agullo
- Department of Cardiology, CHU Arnaud-de-Villeneuve, Montpellier, France
| | - F Cagnazzo
- Department of Neuroradiology, CHU Gui-de-Chauliac, Montpellier, France
| | - J-C Macia
- Department of Cardiology, CHU Arnaud-de-Villeneuve, Montpellier, France
| | - C Arquizan
- Department of Neurology, CHU Gui-de-Chauliac, Montpellier, France
| |
Collapse
|
4
|
Eltelbany M, Gattani R, Ofosu-Somuah A, Damluji A, Epps KC, Batchelor WB. Transcatheter PFO closure for cryptogenic stroke: current approaches and future considerations. Front Cardiovasc Med 2024; 11:1391886. [PMID: 38832314 PMCID: PMC11144870 DOI: 10.3389/fcvm.2024.1391886] [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: 02/26/2024] [Accepted: 04/15/2024] [Indexed: 06/05/2024] Open
Abstract
Patent Foramen Ovale (PFO) is a common congenital atrial septal defect present in 20%-35% of the general population. Although generally considered a benign anatomic variant, a PFO may facilitate passage of a thrombus from the venous to arterial circulation, thereby resulting in cryptogenic stroke or systemic embolization. A PFO is detected in nearly one half of patients presenting with cryptogenic stroke and often considered the most likely etiology when other causes have been excluded. In this review, we discuss the contemporary role of transcatheter closure of PFO in the treatment of cryptogenic stroke, including devices currently available for commercial use in the United States (Amplatzer PFOTM Occluder and GoreTM Cardioform Septal Occluder) and a novel suture-mediated device (NobleStitchTM EL) under clinical investigation. To provide the best care for cryptogenic stroke patients, practitioners should be familiar with the indications for PFO closure and corresponding treatment options.
Collapse
Affiliation(s)
- Moemen Eltelbany
- Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Raghav Gattani
- Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA, United States
| | - Araba Ofosu-Somuah
- Division of Cardiology, Department of Medicine, University of North Carolina, Chapel Hill, NC, United States
| | - Abdulla Damluji
- Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Kelly C. Epps
- Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| | - Wayne B. Batchelor
- Inova Schar Heart and Vascular, Inova Fairfax Medical Campus, Falls Church, VA, United States
| |
Collapse
|
5
|
Di Paolo M, Mezzetti E, Leoni M, Scatena A, Passino C. Sudden cardiac death during scuba diving: a case report of a patient with unknown hypertrophic cardiomyopathy. Eur Heart J Case Rep 2024; 8:ytae217. [PMID: 38745730 PMCID: PMC11091920 DOI: 10.1093/ehjcr/ytae217] [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: 09/18/2023] [Revised: 04/15/2024] [Accepted: 04/22/2024] [Indexed: 05/16/2024]
Abstract
Background Scuba diving is a recreational activity usually considered at low impact on cardiovascular system. However, when diving, increased ambient pressure exerts several effects on the cardiovascular and pulmonary systems, mainly due to redistribution of peripheral blood into the central circulation. This phenomenon, also known as blood shift, may produce a significant overload on a non-healthy heart. Case summary We present the case of a female patient who experienced sudden cardiac death during scuba diving: post-mortem cardiac magnetic resonance and autopsy revealed that the patient was affected by previously unknown hypertrophic cardiomyopathy. Discussion Diving exposes the body to significant physiological changes that may overstress a diseased heart. This case suggests the need for some cardiovascular exams, such as an echocardiogram or, at least, an electrocardiogram, for screening cardiovascular abnormalities in subjects who wish to practice scuba diving.
Collapse
Affiliation(s)
- Marco Di Paolo
- Department of Surgical Pathology, Medical, Molecular and Critical Area, Institute of Legal Medicine, University of Pisa, Via Roma 55, 56100 Pisa, Italy
| | - Eleonora Mezzetti
- Department of Surgical Pathology, Medical, Molecular and Critical Area, Institute of Legal Medicine, University of Pisa, Via Roma 55, 56100 Pisa, Italy
| | - Matteo Leoni
- Department of Surgical Pathology, Medical, Molecular and Critical Area, Institute of Legal Medicine, University of Pisa, Via Roma 55, 56100 Pisa, Italy
| | - Andrea Scatena
- Department of Surgical Pathology, Medical, Molecular and Critical Area, Institute of Legal Medicine, University of Pisa, Via Roma 55, 56100 Pisa, Italy
| | - Claudio Passino
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant’Anna, Pisa, Italy
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| |
Collapse
|
6
|
Forzano I, Santulli G. Patent Foramen Ovale: The Unresolved Questions. TOP ITALIAN SCIENTISTS JOURNAL 2024; 1:10.62684/DMFZ6956. [PMID: 38585657 PMCID: PMC10995646 DOI: 10.62684/dmfz6956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
Patent Foramen Ovale (PFO) is a remnant of fetal circulation that could be observed in the 25% of the population worldwide. PFO is associated to numerous clinical conditions as migraines, coronary embolization, transient ischemic attacks, and stroke. The main PFO concerns are related to its correlation to stroke, in particular in young adults. Despite the impact on morbidity that PFO could have, to date there is not clear evidence about its management and treatment. In this narrative review our aim is to summarize the more recent evidence in the literature dealing with PFO, in order to provide an updated overview on this topic.
Collapse
Affiliation(s)
- Imma Forzano
- Department of Advanced Biomedical Sciences, Division of Cardiology, "Federico II" University, International Translational Research and Medical Education (ITME) Consortium, Academic Research Unit, 80131, Naples, Italy
| | - Gaetano Santulli
- Department of Advanced Biomedical Sciences, Division of Cardiology, "Federico II" University, International Translational Research and Medical Education (ITME) Consortium, Academic Research Unit, 80131, Naples, Italy
- Department of Medicine (Division of Cardiology), Wilf Family Cardiovascular Research Institute, Albert Einstein College of Medicine, New York City, 10461, NY
| |
Collapse
|
7
|
Badea RȘ, Mihăilă-Bâldea S, Ribigan A, Negrilă A, Grecu N, Marinescu AN, Antochi F, Tiu C, Vinereanu D, Popescu BO. PFO-spectrum disorder: two different cerebrovascular diseases in patients with PFO as detected by AI brain imaging software. Front Neurol 2024; 15:1357348. [PMID: 38440117 PMCID: PMC10909929 DOI: 10.3389/fneur.2024.1357348] [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: 12/17/2023] [Accepted: 02/06/2024] [Indexed: 03/06/2024] Open
Abstract
Background Patent foramen ovale (PFO) is a prevalent cardiac remnant of fetal anatomy that may pose a risk factor for stroke in some patients, while others can present with asymptomatic white matter (WM) lesions. The current study aimed to test the hypothesis that patients with a PFO who have a history of stroke or transient ischemic attack, compared to those without such a history, have a different burden and distribution of cerebral WM hyperintensities. Additionally, we tested the association between PFO morphological characteristics and severity of shunt, and their impact on the occurrence of ischemic cerebral vascular events and on the burden of cerebral WM lesions. Patients and methods Retrospective, case-control study that included patients with PFO confirmed by transesophageal echocardiography. Right-to-left shunt size was assessed using transcranial Doppler ultrasound. Cerebral MRIs were analyzed for all participants using the semi-automated Quantib NDTM software for the objective quantification of WM lesions. WM lesions volume was compared between patients with and without a history of stroke. Additionally, the anatomical characteristics of PFOs were assessed to explore their relation to stroke occurrence and WM lesions volume. Results Of the initial 264 patients diagnosed with PFO, 67 met the inclusion criteria and were included in the analysis. Of them, 62% had a history of PFO-related stroke/TIA. Overall burden of WM lesions, including stroke volume, was not significantly different (p = 0.103). However, after excluding stroke volume, WM lesions volume was significantly higher in patients without stroke (0.27 cm3, IQR 0.03-0.60) compared to those with stroke/TIA (0.08 cm3, IQR 0.02-0.18), p = 0.019. Patients with a history of PFO-related stroke/TIA had a tendency to larger PFO sizes by comparison to those without, in terms of length and height, and exhibited greater right-to-left shunt volumes. Discussion We suggest that PFO may be associated with the development of two distinct cerebrovascular conditions (stroke and "silent" WM lesions), each characterized by unique imaging patterns. Further studies are needed to identify better the "at-risk" PFOs and gain deeper insights into their clinical implications.
Collapse
Affiliation(s)
- Raluca Ștefania Badea
- Department of Neurology, University and Emergency Hospital, Bucharest, Romania
- University of Medicine and Pharmacy Carol Davila, Bucharest, Romania
| | - Sorina Mihăilă-Bâldea
- University of Medicine and Pharmacy Carol Davila, Bucharest, Romania
- Department of Cardiology and Cardiovascular Surgery, University and Emergency Hospital, Bucharest, Romania
| | - Athena Ribigan
- Department of Neurology, University and Emergency Hospital, Bucharest, Romania
- University of Medicine and Pharmacy Carol Davila, Bucharest, Romania
| | - Anca Negrilă
- Department of Neurology, University and Emergency Hospital, Bucharest, Romania
| | - Nicolae Grecu
- Department of Neurology, University and Emergency Hospital, Bucharest, Romania
- University of Medicine and Pharmacy Carol Davila, Bucharest, Romania
| | | | - Florina Antochi
- Department of Neurology, University and Emergency Hospital, Bucharest, Romania
| | - Cristina Tiu
- Department of Neurology, University and Emergency Hospital, Bucharest, Romania
- University of Medicine and Pharmacy Carol Davila, Bucharest, Romania
| | - Dragos Vinereanu
- University of Medicine and Pharmacy Carol Davila, Bucharest, Romania
- Department of Cardiology and Cardiovascular Surgery, University and Emergency Hospital, Bucharest, Romania
| | - Bogdan Ovidiu Popescu
- University of Medicine and Pharmacy Carol Davila, Bucharest, Romania
- Department of Neurology, Colentina Clinical Hospital, Bucharest, Romania
| |
Collapse
|
8
|
Eichelmann A, Kubini R, Nachoski D, Kosinski C, Becker M, Aljalloud A. Patent foramen ovale closure versus drug therapy in patients over 60 years and a follow-up of 5 years. Clin Cardiol 2024; 47:e24251. [PMID: 38445759 PMCID: PMC10915992 DOI: 10.1002/clc.24251] [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: 11/19/2023] [Revised: 02/15/2024] [Accepted: 02/21/2024] [Indexed: 03/07/2024] Open
Abstract
BACKGROUND The advantages of patent foramen ovale (PFO) closure as protection from a recurrence of stroke remains controversial compared to drug therapy, especially in patients over 60 years. HYPOTHESIS The aim of the study is to compare recurrence of stroke in patients over 60 years old with PFO closure versus drug therapy alone. METHODS We included 342 patients over 60 years who suffered a crytopgenic stroke, and were also accepted for a PFO closure. 199 patients refused a PFO closure and were treated with medical therapy alone, whereas 143 patients underwent a PFO closure procedure. RESULTS The mean follow up time was 5.5 ± 1.5 years. All patients in Group B showed persistent shunt in the follow-up period (n = 199, 100%). In Group A, seven patients were diagnosed with residual shunt during echocardiography examination (5%). A new onset of atrial fibrillation occurred in seven patients in Group A (5%) and six patients in Group B (3%), p = .117. Recurrent stroke occurred in 3 patients in Group A (2%) and 11 patients in Group B (6%), p = .021. One patient died of unknown reason (1%) and two patients were lost due to neurological death (1%) in Group B, whereas no patients in Group A died during the follow-up period. CONCLUSION Our results show that strict exclusion of patients over 60 years from PFO closure should be reconsidered. As life expectancies are increasing, patients should be considered for same treatment as younger patients, since the outcomes are improved compared to patients treated with medical therapy alone.
Collapse
Affiliation(s)
| | - Ralf Kubini
- Rhein‐Maas Hospital, Department of CardiologyNephrology and Internal Intensive CareWürselenGermany
| | - Dejan Nachoski
- Rhein‐Maas Hospital, Department of CardiologyNephrology and Internal Intensive CareWürselenGermany
| | | | - Michael Becker
- Rhein‐Maas Hospital, Department of CardiologyNephrology and Internal Intensive CareWürselenGermany
| | - Ali Aljalloud
- Rhein‐Maas Hospital, Department of CardiologyNephrology and Internal Intensive CareWürselenGermany
- Department of Cardiac SurgeryRWTH University Hospital AachenAachenGermany
| |
Collapse
|
9
|
Stoller N, Wertli MM, Haynes AG, Chiolero A, Rodondi N, Panczak R, Aujesky D. Large regional variation in cardiac closure procedures to prevent ischemic stroke in Switzerland a population-based small area analysis. PLoS One 2024; 19:e0291299. [PMID: 38166018 PMCID: PMC10760725 DOI: 10.1371/journal.pone.0291299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 08/23/2023] [Indexed: 01/04/2024] Open
Abstract
BACKGROUND Percutaneous closure of a patent foramen ovale (PFO) or the left atrial appendage (LAA) are controversial procedures to prevent stroke but often used in clinical practice. We assessed the regional variation of these interventions and explored potential determinants of such a variation. METHODS We conducted a population-based analysis using patient discharge data from all Swiss hospitals from 2013-2018. We derived hospital service areas (HSAs) using patient flows for PFO and LAA closure. We calculated age-standardized mean procedure rates and variation indices (extremal quotient [EQ] and systematic component of variation [SCV]). SCV values >5.4 indicate a high and >10 a very high variation. Because the evidence on the efficacy of PFO closure may differ in patients aged <60 years and ≥60 years, age-stratified analyses were performed. We assessed the influence of potential determinants of variation using multilevel regression models with incremental adjustment for demographics, cultural/socioeconomic, health, and supply factors. RESULTS Overall, 2574 PFO and 2081 LAA closures from 10 HSAs were analyzed. The fully adjusted PFO and LAA closure rates varied from 3 to 8 and from 1 to 9 procedures per 100,000 persons per year across HSAs, respectively. The regional variation was high with respect to overall PFO closures (EQ 3.0, SCV 8.3) and very high in patients aged ≥60 years (EQ 4.0, SCV 12.3). The variation in LAA closures was very high (EQ 16.2, SCV 32.1). In multivariate analysis, women had a 28% lower PFO and a 59% lower LAA closure rate than men. French/Italian language areas had a 63% lower LAA closure rate than Swiss German speaking regions and areas with a higher proportion of privately insured patients had a 86% higher LAA closure rate. After full adjustment, 44.2% of the variance in PFO closure and 30.3% in LAA closure remained unexplained. CONCLUSIONS We found a high to very high regional variation in PFO closure and LAA closure rates within Switzerland. Several factors, including sex, language area, and insurance status, were associated with procedure rates. Overall, 30-45% of the regional procedure variation remained unexplained and most probably represents differing physician practices.
Collapse
Affiliation(s)
- Nina Stoller
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Emergency Department, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Maria M. Wertli
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Internal Medicine, Kantonsspital Baden, Baden, Switzerland
| | | | - Arnaud Chiolero
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- School of Population and Global Health, McGill University, Montreal, Canada
- Population Health Laboratory (#PopHealthLab), University of Fribourg, Fribourg, Switzerland
| | - Nicolas Rodondi
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Radoslaw Panczak
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| |
Collapse
|
10
|
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.
Collapse
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
| |
Collapse
|
11
|
Devos P, Guedeney P, Montalescot G. Patent Foramen Ovale Percutaneous Closure: Evolution and Ongoing Challenges. J Clin Med 2023; 13:54. [PMID: 38202061 PMCID: PMC10780039 DOI: 10.3390/jcm13010054] [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: 09/27/2023] [Revised: 11/28/2023] [Accepted: 12/15/2023] [Indexed: 01/12/2024] Open
Abstract
Patent foramen ovale (PFO) concerns nearly a quarter of the general population and incidence may reach up to 50% in patients with cryptogenic stroke. Recent randomized clinical trials confirmed that percutaneous closure of PFO-related stroke reduces the risk of embolic event recurrence. PFO also comes into play in other pathogenic conditions, such as migraine, decompression sickness or platypnea-orthodeoxia syndrome, where the heterogeneity of patients is high and evidence for closure is less well-documented. In this review, we describe the current indications for PFO percutaneous closure and the remaining challenges, and try to provide future directions regarding the technique and its indications.
Collapse
Affiliation(s)
- Perrine Devos
- ACTION Study Group, INSERM UMRS_1166 Institut de Cardiologie (AP-HP), Sorbonne Université, 75005 Paris, France; (P.D.); (P.G.)
| | - Paul Guedeney
- ACTION Study Group, INSERM UMRS_1166 Institut de Cardiologie (AP-HP), Sorbonne Université, 75005 Paris, France; (P.D.); (P.G.)
| | - Gilles Montalescot
- ACTION Study Group, INSERM UMRS_1166 Institut de Cardiologie (AP-HP), Sorbonne Université, 75005 Paris, France; (P.D.); (P.G.)
- Institut de Cardiologie, Centre Hospitalier Universitaire, Pitié-Salpêtrière, 47 Boulevard de l’Hôpital, 75013 Paris, France
| |
Collapse
|
12
|
Zhang L, Zhang H, Zhou X, Zhao J, Wang X. Bibliometric Analysis of Research on Migraine-Stroke Association from 2013 to 2023. J Pain Res 2023; 16:4089-4112. [PMID: 38058980 PMCID: PMC10697147 DOI: 10.2147/jpr.s438745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 11/22/2023] [Indexed: 12/08/2023] Open
Abstract
Background Both migraine and stroke heavily burden individuals, health systems, and society. The migraine-stroke association is of concern and has been studied widely. Our objective is to explore and overview the current research status and emerging trends. Materials and Methods Studies on migraine-stroke association from January 2013 to May 2023 were retrieved and screened from the Web of Science Core Collection (WOSCC) database. Records fulfilling the selection criteria were downloaded and imported into CiteSpace for data mining and visualization. Results A total of 862 papers on migraine-stroke association were included. Annual publications grew slowly. The United States and European countries dominated research in this area. Harvard University published the largest number of articles, while the University of London was most active with other institutions. Ayata Cenk contributed the most articles, while KURTH T and NEUROLOGY were co-cited most. Research hotspots included migraine with aura, ischemic stroke, patent foramen ovale, cortical spreading depolarization, meta-analysis, cross-sectional study, and risk factors. Pathophysiology and small vessel disease represented research frontiers and emerging trends. Conclusion Our study scientifically outlines the migraine-stroke association over the past decade, presenting useful information.
Collapse
Affiliation(s)
- Long Zhang
- First Clinical Medical College, Shandong University of Traditional Chinese Medicine, Jinan, Shandong, People’s Republic of China
- Department of Traditional Chinese Medicine, Zibo TCM-Integrated Hospital, Zibo, Shandong, People’s Republic of China
| | - Hongyan Zhang
- Department of Traditional Chinese Medicine, Shanghai Sixth People’s Hospital, Shanghai, People’s Republic of China
- Shaanxi Key Laboratory of Research on TCM Physical Constitution and Diseases Prevention and Treatment, Shaanxi University of Chinese Medicine, Xianyang, Shaanxi, People’s Republic of China
| | - Xue Zhou
- First Clinical Medical College, Shandong University of Traditional Chinese Medicine, Jinan, Shandong, People’s Republic of China
| | - Jing Zhao
- Experimental Center, Shandong University of Traditional Chinese Medicine, Jinan, Shandong, People’s Republic of China
| | - Xingchen Wang
- Division of Neurology, the Second Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, Shandong, People’s Republic of China
| |
Collapse
|
13
|
Khan IA, Mazhar S. Unintentional Implantation of a Permanent Pacemaker Lead Across a Patent Foramen Ovale Leading to Left Ventricular Pacing. Cureus 2023; 15:e49277. [PMID: 38143598 PMCID: PMC10746920 DOI: 10.7759/cureus.49277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2023] [Indexed: 12/26/2023] Open
Abstract
Unintentional placement of a left ventricular lead through a patent foramen ovale (PFO) is an uncommon and underdiagnosed complication. Normal single- or dual-chamber permanent pacemaker implantation involves placing a lead across the tricuspid valve into the right ventricle. In a very rare case instead of the lead going into the right ventricle, it goes through the PFO and across the mitral valve into the left ventricle (LV) resulting in LV pacing. We describe a case of one of our patients who presented with syncope due to bifascicular block and underwent a dual-chamber pacemaker implantation at a local hospital. He had a background of paroxysmal atrial fibrillation and sarcoidosis. Post-procedure, he was discharged with an inadvertent lead in the LV that was not identified. Abnormal placement of LV leads can result in serious complications including thromboembolism, mitral regurgitation, and left-sided endocarditis. Treatment options include extraction of the lead or anticoagulation.
Collapse
Affiliation(s)
- Ibrar A Khan
- Department of Cardiology, Southend University Hospital, Mid and South Essex NHS Foundation Trust, Southend-on-Sea, GBR
| | - Sajjad Mazhar
- Department of Cardiology, Southend University Hospital, Mid and South Essex NHS Foundation Trust, Southend-on-Sea, GBR
| |
Collapse
|
14
|
Lantz R, Carnes SN. Know the Risk: Stroke With Patent Foramen Ovale. Cureus 2023; 15:e47447. [PMID: 38022170 PMCID: PMC10660138 DOI: 10.7759/cureus.47447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2023] [Indexed: 12/01/2023] Open
Abstract
The presence of patent foramen ovale (PFO) is noted to be higher in patients with a history of cryptogenic stroke, especially in younger patients <55 years old. PFO has shown to be a relatively common occurrence in the population, in 25-30% of individuals. Our case is one of right middle cerebral artery (MCA) infarct due to thromboembolism from a PFO. A 44-year-old white right-handed woman with a history of insulin-dependent diabetes mellitus, hyperlipidemia, hypertension, tobacco abuse, and obesity presented with complaints of new onset headache, dizziness, and left arm and leg heaviness, suspicious for right MCA lesion. She was admitted with stroke-like symptoms, National Institute of Health Stroke Scale (NIHSS) of 8 for left-sided weakness, sensory loss, and ataxia. Computed tomography (CT) head was negative for hemorrhage, and there was no large vessel occlusion on computed tomography angiogram (CTA). She was aspirin-loaded and started on dual antiplatelet therapy (DAPT). Ultimately, brain MRI showed right MCA ischemic stroke, and full stroke assessment showed small PFO on the transthoracic echocardiogram (TTE). She was continued on aspirin and clopidogrel DAPT for 21 days, followed by aspirin monotherapy. Unfortunately, her left-sided deficits did not completely resolve, and she was discharged to rehab. She has had recurrent stroke and is currently considered for PFO repair. A patient's past medical history, last known well time, and exacting symptoms with the NIHSS at onset should be thoroughly obtained at the first medical contact. CT imaging should rule out hemorrhage prior to prompt antiplatelet or thrombolytic administration. In addition, when there are absence of risk factors and the cause remains unknown, it is especially important to obtain TTE with Doppler to assess for right-to-left atrial shunt indicating PFO and potentially contributing thromboembolic etiology. Stroke precautions involving swallow evaluation, aspiration and fall precautions, serial NIH for changes, sequence of imaging, and physical therapy (PT) and occupational therapy (OT) should entail. A stroke neurologist should also be involved at presentation, with the stroke alert protocol shown to improve patient outcomes. Additional risk factors, such as PFO, should also be addressed, often with a multimodal team of providers and careful weight given to the risks and benefits of invasive procedure.
Collapse
Affiliation(s)
- Rebekah Lantz
- Internal Medicine, Miami Valley Hospital, Dayton, USA
| | - Sydney N Carnes
- General Medicine, Wright State Boonshoft School of Medicine, Dayton, USA
| |
Collapse
|
15
|
Ukponmwan EU, Banga S, Kim AG, Qintar M, Abela G. Cryptogenic Stroke Caused by a Newly Diagnosed Patent Foramen Ovale in a Healthy Young Adult. Cureus 2023; 15:e46895. [PMID: 37954786 PMCID: PMC10636518 DOI: 10.7759/cureus.46895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2023] [Indexed: 11/14/2023] Open
Abstract
The foramen ovale serves as an opening between the right and left atria at the site of the fossa ovalis in the fetus during uterine life. During fetal life, it makes it possible for venous blood from the maternal placenta with oxygen and nutrients to bypass the immature fetal lung and get transported to the left side of the heart and onto the systemic circulation. This hole from the right to the left atrium is usually occluded at the time of birth or shortly after birth, due to increased pressures in the left-sided cardiac cavities associated with normal breathing during delivery or shortly afterwards. If the foramen ovale remains open and fails to fuse beyond the first year of life, it is known as a patent foramen ovale (PFO). PFO occurs when, during fetal life, the septum primum and secundum, which develop and overlap normally, fail to fuse at birth. This results in the persistence of communication between the right and left atria. Paradoxical embolism from the right to the left side of the heart can occur through a PFO, causing a cryptogenic stroke or embolic stroke of an undetermined source in an otherwise healthy adult. There was a debate on the long-term benefits of closure. However, data from the randomized evaluation of the recurrent stroke comparing PFO closure to established current standard of care treatment (RESPECT) trial and two randomized trials (patent foramen ovale closure or anticoagulants versus antiplatelet therapy to prevent stroke recurrence (CLOSE) and reduction by dutasteride of prostate cancer events (REDUCE)) have clarified that there is a benefit to closure. In this case report, we describe a patient who presented with cryptogenic stroke, the investigations, imaging modalities for diagnosis of PFO, and procedure for closure. We also describe long-term outcomes and management following closure.
Collapse
Affiliation(s)
| | - Sandeep Banga
- Cardiology, Michigan State University, East Lansing, USA
| | - Andrew G Kim
- Internal Medicine, Michigan State University, East Lansing, USA
| | - Mohammed Qintar
- Cardiology, Human Medicine, Michigan State University, East Lansing, USA
| | - George Abela
- Cardiology, Michigan State University, East Lansing, USA
| |
Collapse
|
16
|
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.
Collapse
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;
| |
Collapse
|
17
|
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.
Collapse
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
| |
Collapse
|
18
|
Karapanayiotides T, Lioutas VA, Rubiera M, Montalescot G, Mitsias P. Editorial: Understanding PFO-associated stroke. Front Neurol 2023; 14:1274123. [PMID: 37693757 PMCID: PMC10491890 DOI: 10.3389/fneur.2023.1274123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 08/14/2023] [Indexed: 09/12/2023] Open
Affiliation(s)
- Theodoros Karapanayiotides
- 2nd Department of Neurology, Aristotle University of Thessaloniki, School of Medicine, Thessaloniki, Greece
| | - Vasileios-Arsenios Lioutas
- Division of Vascular Neurology, Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, United States
| | - Marta Rubiera
- Stroke Unit, Department of Neurology, Hospital Vall d'Hebron, Universitat Autónoma de Barcelona, Badalona, Spain
| | - Gilles Montalescot
- Institut de Cardiologie, Hôpitaux Universitaires Pitié Salpêtrière, Paris, France
| | - Panayiotis Mitsias
- Department of Neurology, School of Medicine, University of Crete, Heraklion, Greece
| |
Collapse
|
19
|
Chen A, Zhu J, Zhu L, Tang Y, Li Y, Zhang Q, Zhao Y, Ma C, Liu X. Neglected intrapulmonary arteriovenous anastomoses: A comparative study of pulmonary right-to-left shunts in patients with patent foramen ovale. Front Cardiovasc Med 2023; 10:1111818. [PMID: 37089892 PMCID: PMC10117845 DOI: 10.3389/fcvm.2023.1111818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 03/16/2023] [Indexed: 04/09/2023] Open
Abstract
ObjectivePulmonary right-to-left shunt (P-RLS) and patent foramen ovale right-to-left shunt (PFO-RLS) often appear in combination, and there are often differences and connections between them. Intrapulmonary arteriovenous anastomoses (IPAVAs), as part of P-RLS, are often overlooked because there are no technologies to detect and identify them. This study aimed to further clarify the incidence and characteristics of P-RLS with the help of contrast transesophageal echocardiography (c-TEE) and contrast transthoracic echocardiography (c-TTE), providing a reference for clinically relevant research and patent foramen ovale (PFO) management disposal decisions.MethodsWe retrospectively investigated 414 subjects who came to our hospital for c-TEE from October 2021 to July 2022, and all subjects completed c-TTE simultaneously. 7 Patients who were newly diagnosed with an atrial septal defect were excluded. Eventually, 407 patients were included in this study. Among them, 157 patients with PFO (58 patients were treated with PFO closure subsequently) and 250 patients without PFO confirmed by c-TEE were finally enrolled. In the process, we observed and analysed the presence of P-RLS.ResultsA total of 407 patients were included in the final analysis and divided into PFO group (N = 157) and non-PFO group (N = 250) according to the results of c-TEE. Whether at rest or after Valsalva maneuver, the incidence of P-RLS was significantly higher under c-TEE than under c-TTE in the two groups (P < 0.001). For both c-TTE and c-TEE, the incidence of P-RLS was slightly higher after Valsalva maneuver than at rest, but the difference was not significant (c-TTE: rest vs. Valsalva maneuver, P = 0.214; c-TEE: rest vs. Valsalva maneuver, P = 0.076). The Valsalva maneuver increased the incidence of P-RLS in the group without PFO, which was more significant in c-TEE (c-TTE: rest vs. Valsalva maneuver, P = 0.591; c-TEE: rest vs. Valsalva maneuver, P = 0.008). In both groups, the P-RLS semiquantitative grading was statistical significance under different states and examinations (P < 0.001).ConclusionThe vast majority of P-RLS are grade 1–2 and are derived from physiological IPAVAs. Even so, attention should be given to the differentiation between P-RLS and PFO-RLS. c-TEE is an effective method to detect P-RLS; however, the recruitments of c-TEE and Valsalva maneuver to P-RLS should be noted.
Collapse
Affiliation(s)
- Anni Chen
- Department of Ultrasound, The First Affiliated Hospital of Shaoxing University, Shaoxing, China
- Department of Ultrasound, Shaoxing People’s Hospital, Shaoxing, China
| | - Jianbo Zhu
- Department of Ultrasound, Shaoxing People’s Hospital, Shaoxing, China
| | - Lei Zhu
- Department of Ultrasound, Shaoxing People’s Hospital, Shaoxing, China
| | - Yunyi Tang
- Department of Ultrasound, Shaoxing People’s Hospital, Shaoxing, China
| | - Yun Li
- Department of Ultrasound, The First Affiliated Hospital of Shaoxing University, Shaoxing, China
- Department of Ultrasound, Shaoxing People’s Hospital, Shaoxing, China
| | - Qi Zhang
- Department of Ultrasound, Shaoxing People’s Hospital, Shaoxing, China
| | - Yeping Zhao
- Department of Ultrasound, Shaoxing People’s Hospital, Shaoxing, China
| | - Caiye Ma
- Department of Ultrasound, Shaoxing People’s Hospital, Shaoxing, China
- Correspondence: Xiatian Liu Caiye Ma
| | - Xiatian Liu
- Department of Ultrasound, The First Affiliated Hospital of Shaoxing University, Shaoxing, China
- Department of Ultrasound, Shaoxing People’s Hospital, Shaoxing, China
- Correspondence: Xiatian Liu Caiye Ma
| |
Collapse
|
20
|
Shi F, Sha L, Li H, Tang Y, Huang L, Liu H, Li X, Li L, Yang W, Kang D, Chen L. Recent progress in patent foramen ovale and related neurological diseases: A narrative review. Front Neurol 2023; 14:1129062. [PMID: 37051056 PMCID: PMC10084837 DOI: 10.3389/fneur.2023.1129062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 02/20/2023] [Indexed: 03/29/2023] Open
Abstract
Patent foramen ovale (PFO) is a common congenital cardiac abnormality when the opening of the interatrial septum is not closed in adulthood. This abnormality affects 25% of the general population. With the development of precision medicine, an increasing number of clinical studies have reported that PFO is closely related to various neurological diseases such as stroke, migraine, obstructive sleep apnea, and decompression syndrome. It has also been suggested that PFO closure could be effective for preventing and treating these neurological diseases. Therefore, increasing attention has been given to the prevention, diagnosis, and treatment of PFO-related neurological diseases. By reviewing existing literature, this article focuses on the pathogenesis, epidemiology, and clinical characteristics of PFO-related neurological diseases, as well as the prevention and treatment of different neurological diseases to discuss, and aims to provide current progress for this field and decision-making evidence for clinical practice.
Collapse
Affiliation(s)
- Fanfan Shi
- Department of Clinical Research Management, West China Hospital, Sichuan University, Chengdu, China
| | - Leihao Sha
- Department of Neurology and Joint Research Institution of Altitude Health, West China Hospital, Sichuan University, Chengdu, China
| | - Hua Li
- Department of Neurology and Joint Research Institution of Altitude Health, West China Hospital, Sichuan University, Chengdu, China
| | - Yusha Tang
- Department of Neurology and Joint Research Institution of Altitude Health, West China Hospital, Sichuan University, Chengdu, China
| | - Litao Huang
- Department of Clinical Research Management, West China Hospital, Sichuan University, Chengdu, China
| | - Huizhen Liu
- Department of Clinical Research Management, West China Hospital, Sichuan University, Chengdu, China
| | - Xu Li
- Department of Clinical Research Management, West China Hospital, Sichuan University, Chengdu, China
| | - Lin Li
- Department of Clinical Research Management, West China Hospital, Sichuan University, Chengdu, China
| | - Wenjie Yang
- Department of Clinical Research Management, West China Hospital, Sichuan University, Chengdu, China
| | - Deying Kang
- Department of Clinical Research Management, West China Hospital, Sichuan University, Chengdu, China
- Department of Evidence-Based Medicine and Clinical Epidemiology, West China Hospital, Sichuan University, Chengdu, China
| | - Lei Chen
- Department of Neurology and Joint Research Institution of Altitude Health, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Lei Chen
| |
Collapse
|
21
|
Uecker NA, Rosenkranz S, Bunck A, Tichelbäcker T. Unexpected paradoxical embolization following catheter-directed thrombectomy with the FlowTriever™ system in a patient with pulmonary embolism: a case report. Eur Heart J Case Rep 2023; 7:ytad074. [PMID: 36895302 PMCID: PMC9991041 DOI: 10.1093/ehjcr/ytad074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 08/09/2022] [Accepted: 02/08/2023] [Indexed: 02/15/2023]
Abstract
Background The optimal therapy for patients suffering from acute pulmonary embolism (PE) classified as intermediate-high risk still needs to be identified. Catheter-directed thrombectomy (CDTE) is a safe procedure to reduce thrombus burden immediately. The lack of randomized trials is one reason: catheter-directed thrombolysis (CDT) has not yet received a clear recommendation in our guidelines. Herein, we report an unexpected event in the course of a patient with PE treated with CDTE using the FlowTriever™ system, the only FDA-approved catheter system for percutaneous mechanical thrombectomy regarding this indication. Case Summary A 57-year-old male presented with dyspnoea at the emergency department of our university hospital. The computed tomography (CT) scan showed bilateral PE, and ultrasound of the left lower limb revealed deep venous thrombosis. According to the current ESC guidelines, he was classified intermediate-high risk. We performed bilateral CDTE. On the first and third day post-intervention, our patient presented neurological deficits. Whereas the first CT scan of the cerebrum remained normal, the CT scan at Day 3 showed demarcated embolic stroke. Further imaging diagnostic gave evidence to an ischemic lesion in the left kidney. Transesophageal echocardiography revealed a patent foramen ovale (PFO) as the origin of paradoxical embolism and thus mechanism of both ischemic lesions. Compliant to the current recommendations, percutaneous PFO closure was performed. Our patient recovered properly without any sequelae. Discussion Whether the deep venous thrombosis is the source of embolization or the catheter-directed retrieval of clots may have transported clot material to the right atrium which further on embolized systemically will remain unclear. Yet, we have to consider it as a potential complication in catheter-directed treatment of PE in patients with a PFO.
Collapse
Affiliation(s)
- Nicola Anne Uecker
- Faculty of Medicine and University Hospital Cologne, Clinic for Internal Medicine III, University of Cologne, Kerpener Str. 62, 50937 Cologne, NRW, Germany
| | - Stephan Rosenkranz
- Faculty of Medicine and University Hospital Cologne, Clinic for Internal Medicine III, University of Cologne, Kerpener Str. 62, 50937 Cologne, NRW, Germany
| | - Alexander Bunck
- Faculty of Medicine and University Hospital Cologne, Department of Radiology, University of Cologne, Kerpener Str. 62, 50937 Cologne, NRW, Germany
| | - Tobias Tichelbäcker
- Faculty of Medicine and University Hospital Cologne, Clinic for Internal Medicine III, University of Cologne, Kerpener Str. 62, 50937 Cologne, NRW, Germany
| |
Collapse
|
22
|
Harrar DB, Sun LR, Segal JB, Lee S, Sansevere AJ. Neuromonitoring in Children with Cerebrovascular Disorders. Neurocrit Care 2023; 38:486-503. [PMID: 36828980 DOI: 10.1007/s12028-023-01689-2] [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: 04/29/2022] [Accepted: 01/31/2023] [Indexed: 02/26/2023]
Abstract
BACKGROUND Cerebrovascular disorders are an important cause of morbidity and mortality in children. The acute care of a child with an ischemic or hemorrhagic stroke or cerebral sinus venous thrombosis focuses on stabilizing the patient, determining the cause of the insult, and preventing secondary injury. Here, we review the use of both invasive and noninvasive neuromonitoring modalities in the care of pediatric patients with arterial ischemic stroke, nontraumatic intracranial hemorrhage, and cerebral sinus venous thrombosis. METHODS Narrative review of the literature on neuromonitoring in children with cerebrovascular disorders. RESULTS Neuroimaging, near-infrared spectroscopy, transcranial Doppler ultrasonography, continuous and quantitative electroencephalography, invasive intracranial pressure monitoring, and multimodal neuromonitoring may augment the acute care of children with cerebrovascular disorders. Neuromonitoring can play an essential role in the early identification of evolving injury in the aftermath of arterial ischemic stroke, intracranial hemorrhage, or sinus venous thrombosis, including recurrent infarction or infarct expansion, new or recurrent hemorrhage, vasospasm and delayed cerebral ischemia, status epilepticus, and intracranial hypertension, among others, and this, is turn, can facilitate real-time adjustments to treatment plans. CONCLUSIONS Our understanding of pediatric cerebrovascular disorders has increased dramatically over the past several years, in part due to advances in the neuromonitoring modalities that allow us to better understand these conditions. We are now poised, as a field, to take advantage of advances in neuromonitoring capabilities to determine how best to manage and treat acute cerebrovascular disorders in children.
Collapse
Affiliation(s)
- Dana B Harrar
- Division of Neurology, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA.
| | - Lisa R Sun
- Divisions of Pediatric Neurology and Vascular Neurology, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - J Bradley Segal
- Division of Child Neurology, Department of Neurology & Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Sarah Lee
- Division of Child Neurology, Department of Neurology & Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Arnold J Sansevere
- Division of Neurology, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| |
Collapse
|
23
|
Multisystemic involvement of post-traumatic fat embolism at a Pediatric Trauma Center: a clinical series and literature review. Eur J Pediatr 2023; 182:1811-1821. [PMID: 36790485 DOI: 10.1007/s00431-023-04869-6] [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: 06/17/2022] [Revised: 02/01/2023] [Accepted: 02/06/2023] [Indexed: 02/16/2023]
Abstract
UNLABELLED Post-traumatic fat embolism syndrome (FES) is a severe complication consequent to bone fractures. The authors describe its clinical features and management in a population of teenagers by detailing demographics, organ involvement, laboratory, and imaging findings, as well as outcome. Moreover, a systematic review of pediatric published case reports of post-traumatic FES is provided. First, a series of eight episodes of post-traumatic FES that occurred in seven patients (median age 16.0 years, IQR 16.0-17.5) admitted to a pediatric intensive care unit (PICU) in an 8-year period was analyzed through a retrospective chart review. Secondly, a systematic research was performed on PUBMED database. Trauma patients ≤ 18 years without comorbidities in a 20-year period (2002-2022) were included in the review. Neurological impairment was present in five out of seven patients, and a patent foramen ovale was found in four cases. Hemodynamic instability requiring vasoactive drugs was recorded in four patients. A severe form of acute respiratory distress syndrome (ARDS) occurred in five cases, with the evidence of hemorrhagic alveolitis in three of them. In the literature review, eighteen cases were examined. Most cases refer to adolescents (median age 17.0 years). More than half of patients experienced two or more long bone fractures (median: 2 fractures). Both respiratory and neurological impairment were common (77.8% and 83.3%, respectively). 88.9% of patients underwent invasive mechanical ventilation and 33.3% of them required vasoactive drugs support. Neurological sequelae were reported in 22.2% of patients. CONCLUSION Post-traumatic FES is an uncommon multi-faceted condition even in pediatric trauma patients, requiring a high level of suspicion. Prognosis of patients who receive prompt support in an intensive care setting is generally favorable. WHAT IS KNOWN •Post-traumatic fat embolism syndrome is a severe condition complicating long bone or pelvic fractures. •Little is known about clinical features and management in pediatric age. WHAT IS NEW •Post-traumatic fat embolism syndrome can cause multiple organ failure, often requiring an intensive care management. •Prompt supportive care contributes to a favorable prognosis.
Collapse
|
24
|
Lim ICZY, Teo YH, Fang JT, Teo YN, Ho JSY, Lee YQ, Chen X, Ong KHX, Leow AST, Ho AFW, Lim Y, Low TT, Kuntjoro I, Yeo LLL, Sia CH, Sharma VK, Tan BYQ. Association of Shunt Size and Long-Term Clinical Outcomes in Patients with Cryptogenic Ischemic Stroke and Patent Foramen Ovale on Medical Management. J Clin Med 2023; 12:jcm12030941. [PMID: 36769589 PMCID: PMC9917737 DOI: 10.3390/jcm12030941] [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: 11/26/2022] [Revised: 01/16/2023] [Accepted: 01/18/2023] [Indexed: 01/27/2023] Open
Abstract
INTRODUCTION Patent foramen ovale (PFO) is a potential source of cardiac embolism in cryptogenic ischemic stroke, but it may also be incidental. Right-to-left shunt (RLS) size may predict PFO-related stroke, but results have been controversial. In this cohort study of medically-managed PFO patients with cryptogenic stroke, we aimed to investigate the association of shunt size with recurrent stroke, mortality, newly detected atrial fibrillation (AF), and to identify predictors of recurrent stroke. METHODS Patients with cryptogenic stroke who screened positive for a RLS using a transcranial Doppler bubble study were included. Patients who underwent PFO closure were excluded. Subjects were divided into two groups: small (Spencer Grade 1, 2, or 3; n = 135) and large (Spencer Grade 4 or 5; n = 99) shunts. The primary outcome was risk of recurrent stroke, and the secondary outcomes were all-cause mortality and newly detected AF. RESULTS The study cohort included 234 cryptogenic stroke patients with medically-managed PFO. The mean age was 50.5 years, and 31.2% were female. The median period of follow-up was 348 (IQR 147-1096) days. The rate of recurrent ischemic stroke was higher in patients with large shunts than in those with small shunts (8.1% vs. 2.2%, p = 0.036). Multivariate analyses revealed that a large shunt was significantly associated with an increased risk of recurrent ischemic stroke [aOR 4.09 (95% CI 1.04-16.0), p = 0.043]. CONCLUSIONS In our cohort of cryptogenic stroke patients with medically managed PFOs, those with large shunts were at a higher risk of recurrent stroke events, independently of RoPE score and left atrium diameter.
Collapse
Affiliation(s)
- Isis Claire Z. Y. Lim
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Level 10, NUHS Tower Block, 1E Kent Ridge Road, Singapore 119228, Singapore
| | - Yao Hao Teo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Level 10, NUHS Tower Block, 1E Kent Ridge Road, Singapore 119228, Singapore
| | - Jun Tao Fang
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Level 10, NUHS Tower Block, 1E Kent Ridge Road, Singapore 119228, Singapore
| | - Yao Neng Teo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Level 10, NUHS Tower Block, 1E Kent Ridge Road, Singapore 119228, Singapore
| | - Jamie S. Y. Ho
- Division of Neurology, Department of Medicine, National University Hospital, Singapore 119074, Singapore
| | - Yong Qin Lee
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Level 10, NUHS Tower Block, 1E Kent Ridge Road, Singapore 119228, Singapore
| | - Xintong Chen
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Level 10, NUHS Tower Block, 1E Kent Ridge Road, Singapore 119228, Singapore
| | - Kathleen Hui-Xin Ong
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Level 10, NUHS Tower Block, 1E Kent Ridge Road, Singapore 119228, Singapore
| | - Aloysius S. T. Leow
- Division of Neurology, Department of Medicine, National University Hospital, Singapore 119074, Singapore
| | - Andrew Fu-Wah Ho
- Department of Emergency Medicine, Singapore General Hospital, Singapore 169608, Singapore
- Pre-Hospital & Emergency Research Centre, Duke-National University of Singapore Medical School, Singapore 169857, Singapore
- Centre for Population Health Research and Implementation, Singhealth Regional Health System, Singapore 168753, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore 117549, Singapore
| | - Yinghao Lim
- Department of Cardiology, National University Heart Centre, Singapore 119074, Singapore
| | - Ting Ting Low
- Department of Cardiology, National University Heart Centre, Singapore 119074, Singapore
| | - Ivandito Kuntjoro
- Department of Cardiology, National University Heart Centre, Singapore 119074, Singapore
| | - Leonard L. L. Yeo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Level 10, NUHS Tower Block, 1E Kent Ridge Road, Singapore 119228, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore 119074, Singapore
| | - Ching-Hui Sia
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Level 10, NUHS Tower Block, 1E Kent Ridge Road, Singapore 119228, Singapore
- Department of Cardiology, National University Heart Centre, Singapore 119074, Singapore
| | - Vijay K. Sharma
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Level 10, NUHS Tower Block, 1E Kent Ridge Road, Singapore 119228, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore 119074, Singapore
- Correspondence: ; Tel.: +65-9138-9555; Fax: +65-6908-2222
| | - Benjamin Y. Q. Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Level 10, NUHS Tower Block, 1E Kent Ridge Road, Singapore 119228, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore 119074, Singapore
| |
Collapse
|
25
|
Zhu J, Chen A, Zhu L, Li Y, Tang Y, Huang Y, Shen H, Jiang Z, Liu X. Calf muscle pump tensing as a novel maneuver to improve the diagnostic performance of detecting patent foramen ovale during transesophageal echocardiography. Front Neurol 2023; 14:1116764. [PMID: 36761345 PMCID: PMC9905729 DOI: 10.3389/fneur.2023.1116764] [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: 12/05/2022] [Accepted: 01/05/2023] [Indexed: 01/26/2023] Open
Abstract
Objective The Valsalva maneuver is the most sensitive provocative maneuver for patent foramen ovale detection. However, nearly half of patients are unable to perform the Valsalva maneuver well. The aim of this study was to investigate the mechanism of action of calf muscle pump tensing (TENSE) as a novel patent foramen ovale (PFO) provocative maneuver and to evaluate the diagnostic value for PFO and the effect on right-to-left shunt volume compared with the Valsalva maneuver. Methods This study prospectively investigated 171 patients who were highly suspected to have PFO clinically. Five patients with atrial septal defects newly diagnosed on transesophageal echocardiography (TEE) were excluded. 166 patients were injected with agitated saline under three provocative maneuvers: Valsalva maneuver, TENSE, and Valsalva + TENSE combined maneuver. The patients were divided into the effective Valsalva group (n = 93) and ineffective Valsalva group (n = 73) according to whether they could perform an effective Valsalva maneuver. TENSE consisted of the straightening of both lower limbs, and when the right atrium was filled with microbubbles, the patient performed instantaneous ankle dorsiflexion movements while maintaining dorsiflexion for 3-5 s. Results Overall, the PFO detection rate of the Valsalva + TENSE combined maneuver (78 [50.1%]) was significantly higher than that of the Valsalva maneuver (51 [30.7%]) and TENSE maneuver (57 [34.3%]) (P < 0.001). In the patients who were able to perform an effective Valsalva maneuver, the PFO detection rate by TENSE was not significantly different from that by the Valsalva maneuver (Valsalva 37/93 [39.8%] vs. TENSE 31/93 [33.3%], P > 0.05), while for the patients who performed an ineffective Valsalva maneuver, the PFO detection rate by the TENSE maneuver was higher than that by the Valsalva maneuver (TENSE 26/73 [35.6%] vs. Valsalva14/73[19.2%], P = 0.017). Conclusion TENSE is a simple and effective provocative maneuver in the diagnosis of PFO using TEE and can assist the Valsalva maneuver. For patients who cannot perform an effective Valsalva maneuver, TENSE can be an alternative to the Valsalva maneuver to some extent.
Collapse
|
26
|
Pivtsova AM, Shchekochikhin DY, Ognerubov DV, Agadzhanyan AA, Bogdanova AA, Makeev MI, Pevzner DV, Merkulov ЕV, Andreev DA, Gilyarov MY. Embolic myocardial infarction associated with patent foramen ovale: a case series. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2023. [DOI: 10.15829/1728-8800-2023-3352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
Abstract
A patent foramen ovale (PFO) is a fairly common mild cardiac defect that causes a shunting across the atrial septum. PFO is also a known risk factor for cryptogenic stroke. Much less frequently, PFO is associated with non-cerebral systemic embolic events. The article describes a case series of paradoxical embolism of the coronary arteries (CA), which caused myocardial infarction (MI). The presence of PFO was confirmed by imaging techniques. Subsequently, the patients underwent successful endovascular closure of the PFO. Thus, paradoxical CA embolism is a rare and underdiagnosed cause of acute MI. It should be considered in patients with MI and a low risk of atherosclerotic coronary artery disease. However, in most cases, it is not possible to verify the source of the embolism. The significance of occluder implantation as one of the treatment tactics requires further clarification.
Collapse
Affiliation(s)
| | | | | | | | | | - M. I. Makeev
- E.I. Chazov National Medical Research Center of Cardiology
| | - D. V. Pevzner
- E.I. Chazov National Medical Research Center of Cardiology
| | - Е. V. Merkulov
- E.I. Chazov National Medical Research Center of Cardiology
| | | | | |
Collapse
|
27
|
SCUBA Diving in Adult Congenital Heart Disease. J Cardiovasc Dev Dis 2023; 10:jcdd10010020. [PMID: 36661915 PMCID: PMC9863475 DOI: 10.3390/jcdd10010020] [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: 11/30/2022] [Revised: 12/29/2022] [Accepted: 01/01/2023] [Indexed: 01/05/2023] Open
Abstract
Conventionally, scuba diving has been discouraged for adult patients with congenital heart disease (ACHD). This restrictive sports advice is based on expert opinion in the absence of high-quality diving-specific studies. However, as survival and quality of life in congenital heart disease (CHD) patients have dramatically improved in the last decades, a critical appraisal whether such restrictive sports advice is still applicable is warranted. In this review, the cardiovascular effects of diving are described and a framework for the work-up for ACHD patients wishing to engage in scuba diving is provided. In addition, diving recommendations for specific CHD diagnostic groups are proposed.
Collapse
|
28
|
Hitzeroth J, van der Bijl P, Michel F, Meel R, Cupido BJ, Klug E. SA Heart consensus statement on closure of patent foramen ovale 2021. Cardiovasc J Afr 2023; 34:35-39. [PMID: 35687070 PMCID: PMC10392800 DOI: 10.5830/cvja-2022-009] [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: 10/23/2021] [Accepted: 02/07/2022] [Indexed: 06/07/2023] Open
Abstract
A patent foramen ovale (PFO) is associated with numerous clinical conditions. The most severe of these is cryptogenic stroke. This consensus statement aims to provide a clinical guideline on which patients should be offered PFO closure.
Collapse
Affiliation(s)
- J Hitzeroth
- Medical School, University of Cape Town, Cape Town, South Africa
| | | | - F Michel
- Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - R Meel
- Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - B J Cupido
- Medical School, University of Cape Town, Cape Town, South Africa
| | - E Klug
- Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| |
Collapse
|
29
|
Copeland H, Knezevic I, Baran DA, Rao V, Pham M, Gustafsson F, Pinney S, Lima B, Masetti M, Ciarka A, Rajagopalan N, Torres A, Hsich E, Patel JK, Goldraich LA, Colvin M, Segovia J, Ross H, Ginwalla M, Sharif-Kashani B, Farr MA, Potena L, Kobashigawa J, Crespo-Leiro MG, Altman N, Wagner F, Cook J, Stosor V, Grossi PA, Khush K, Yagdi T, Restaino S, Tsui S, Absi D, Sokos G, Zuckermann A, Wayda B, Felius J, Hall SA. Donor heart selection: Evidence-based guidelines for providers. J Heart Lung Transplant 2023; 42:7-29. [PMID: 36357275 PMCID: PMC10284152 DOI: 10.1016/j.healun.2022.08.030] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 08/29/2022] [Indexed: 01/31/2023] Open
Abstract
The proposed donor heart selection guidelines provide evidence-based and expert-consensus recommendations for the selection of donor hearts following brain death. These recommendations were compiled by an international panel of experts based on an extensive literature review.
Collapse
Affiliation(s)
- Hannah Copeland
- Department of Cardiovascular and Thoracic Surgery Lutheran Hospital, Fort Wayne, Indiana; Indiana University School of Medicine-Fort Wayne, Fort Wayne, Indiana.
| | - Ivan Knezevic
- Transplantation Centre, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - David A Baran
- Department of Medicine, Division of Cardiology, Sentara Heart Hospital, Norfolk, Virginia
| | - Vivek Rao
- Peter Munk Cardiac Centre Toronto General Hospital, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - Michael Pham
- Sutter Health California Pacific Medical Center, San Francisco, California
| | - Finn Gustafsson
- Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Sean Pinney
- University of Chicago Medicine, Chicago, Illinois
| | - Brian Lima
- Medical City Heart Hospital, Dallas, Texas
| | - Marco Masetti
- Heart Failure and Heart Transplant Unit IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | - Agnieszka Ciarka
- Department of Cardiovascular Diseases, Katholieke Universiteit Leuven, Leuven, Belgium; Institute of Civilisation Diseases and Regenerative Medicine, University of Information Technology and Management, Rzeszow, Poland
| | | | - Adriana Torres
- Los Cobos Medical Center, Universidad El Bosque, Bogota, Colombia
| | | | | | | | | | - Javier Segovia
- Cardiology Department, Hospital Universitario Puerta de Hierro, Universidad Autónoma de Madrid, Madrid, Spain
| | - Heather Ross
- University of Toronto, Toronto, Ontario, Canada; Sutter Health California Pacific Medical Center, San Francisco, California
| | - Mahazarin Ginwalla
- Cardiovascular Division, Palo Alto Medical Foundation/Sutter Health, Burlingame, California
| | - Babak Sharif-Kashani
- Department of Cardiology, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - MaryJane A Farr
- Department of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Luciano Potena
- Heart Failure and Heart Transplant Unit IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | | | | | | | | | | | - Valentina Stosor
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Kiran Khush
- Division of Cardiovascular Medicine, Stanford University, Stanford, California
| | - Tahir Yagdi
- Department of Cardiovascular Surgery, Ege University School of Medicine, Izmir, Turkey
| | - Susan Restaino
- Division of Cardiology Columbia University, New York, New York; New York Presbyterian Hospital, New York, New York
| | - Steven Tsui
- Department of Cardiothoracic Surgery Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Daniel Absi
- Department of Cardiothoracic and Transplant Surgery, University Hospital Favaloro Foundation, Buenos Aires, Argentina
| | - George Sokos
- Heart and Vascular Institute, West Virginia University, Morgantown, West Virginia
| | - Andreas Zuckermann
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Brian Wayda
- Division of Cardiovascular Medicine, Stanford University, Stanford, California
| | - Joost Felius
- Baylor Scott & White Research Institute, Dallas, Texas; Texas A&M University Health Science Center, Dallas, Texas
| | - Shelley A Hall
- Texas A&M University Health Science Center, Dallas, Texas; Division of Transplant Cardiology, Mechanical Circulatory Support and Advanced Heart Failure, Baylor University Medical Center, Dallas, Texas
| |
Collapse
|
30
|
Lee OH, Kim JS. Percutaneous Patent Foramen Ovale Closure After Stroke. Korean Circ J 2022; 52:801-807. [PMID: 36347516 PMCID: PMC9643566 DOI: 10.4070/kcj.2022.0258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 09/26/2022] [Accepted: 10/05/2022] [Indexed: 09/02/2023] Open
Abstract
Percutaneous patent foramen ovale (PFO) closure in patients with a prior PFO-associated stroke showed a risk reduction of the stroke recurrence compared to the medical therapy alone in recent several studies. Nevertheless, optimal patient selection for PFO closure has not been clarified. In this paper, we discuss the characteristics of PFO-associated strokes and discuss the recently published evidence and patient selection for PFO closure in patients with ischemic stroke. The lesions characteristics of PFO-associated stroke are associated with multiple scattered lesion, small sized cerebral cortical lesion, or posterior circulation. Overcoming the failure of early studies in CLOSURE I, PC, and RESPECT trials, PFO closure showed a significant reduction in recurrent stroke in recently published REDUCE, CLOSE, DEFENSE-PRO trials, and long-term follow-up data of RESPECT study. However, considering that PFO closure cannot completely prevent stroke recurrence and that complications including atrial fibrillation, we should be selectively performed in patients with high-risk PFO.
Collapse
Affiliation(s)
- Oh-Hyun Lee
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine and Cardiovascular Center, Yongin Severance Hospital, Yongin, Korea
| | - Jung-Sun Kim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea.
| |
Collapse
|
31
|
Asghar A, Stefanescu Schmidt AC, Sahakyan Y, Horlick EM, Abrahamyan L. Sex differences in baseline profiles and short-term outcomes in patients undergoing closure of patent foramen ovale. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2022; 21:100199. [PMID: 38559747 PMCID: PMC10978392 DOI: 10.1016/j.ahjo.2022.100199] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 08/24/2022] [Indexed: 04/04/2024]
Abstract
Objectives Although sex differences have been emphasized in stroke and congenital heart disease, there has been limited investigation into their role in patent foramen ovale (PFO) closure for secondary prevention of stroke. We aimed to explore differences by sex in baseline profiles, procedural characteristics, and short-term outcomes of patients undergoing transcatheter PFO closure. Methods Data of adult patients undergoing transcatheter PFO closure at the Toronto General Hospital from 1997 to 2017 was retrospectively analyzed. Baseline information included demographic characteristics, medical history, diagnostic, and procedural information, and periprocedural complications. Post-closure outcomes were captured at index hospitalization and during the first follow-up. Results From 1031 patients in the cohort sample, 80.7 % underwent closure for cryptogenic stroke and 44.7 % (n = 461) were females. We observed significant sex-related differences in baseline characteristics; females were younger, less likely to have a history of smoking, and less likely to have several cardiovascular risk factors at baseline (p < 0.05). The median time to first follow-up was 89 days for both groups. Recurrent stroke was observed in 0.1 % and TIA observed in 0.4 % of in the 'cryptogenic stroke/TIA' group; in the 'other indications' group, 1.4 % stroke and no TIA were reported. No significant differences were present between sexes. Conclusions There were no differences in procedural and short-term outcomes between males and females undergoing transcatheter PFO closure, but significant baseline differences in risk factors were identified. There is a critical need for long-term, systematic studies to understand sex and gender differences in the PFO population.
Collapse
Affiliation(s)
- Areeba Asghar
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Ada C. Stefanescu Schmidt
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, UHN, Toronto, Ontario, Canada
| | - Yeva Sahakyan
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, Toronto General Hospital Research Institute, University Health Network (UHN), Toronto, Ontario, Canada
| | - Eric M. Horlick
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, UHN, Toronto, Ontario, Canada
| | - Lusine Abrahamyan
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, Toronto General Hospital Research Institute, University Health Network (UHN), Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, UHN, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
32
|
Testing for Thrombophilia in Young Cryptogenic Stroke Patients: Does the Presence of Patent Foramen Ovale Make a Difference? Medicina (B Aires) 2022; 58:medicina58081056. [PMID: 36013523 PMCID: PMC9416139 DOI: 10.3390/medicina58081056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 07/31/2022] [Accepted: 08/03/2022] [Indexed: 11/30/2022] Open
Abstract
Background and Objectives: The diagnostic value of thrombophilia remains unknown in young patients with patent foramen ovale (PFO) and stroke. In this study we hypothesized that inherited thrombophilias that lead to venous thrombosis are more prevalent in patients with PFO. Materials and Methods: The study included patients of the tertiary center Vilnius University Hospital Santaros Klinikos who had a cryptogenic ischemic stroke between the ages of 18 and 50 between the years 2008 and 2021. Transient ischemic attacks were excluded. Contrast-enhanced transcranial Doppler ultrasound and extensive laboratory testing were performed. Results: The study included 161 cryptogenic stroke patients (mean age 39.2 ± 7.6 years; 54% female), and a right-to-left shunt was found in 112 (69.6%). The mean time between stroke and thrombophilia testing was 210 days (median 98 days). In total, 61 (39.8%) patients were diagnosed with thrombophilia. The most common finding was hyperhomocysteinemia (26.7%), 14.3% of which were genetically confirmed. Two patients (1.2%) were diagnosed with factor V Leiden mutation, three patients (1.9%) with prothrombin G20210A mutation, one patient (0.6%) had a protein C mutation and one patient (0.6%) had a protein S mutation. No antithrombin mutations were diagnosed in our study population. A total of 45.5% of patients with inherited thrombophilia had a right-to-left shunt, while 54.5% did not, p = 0.092. Personal thrombosis anamnesis was positive significantly more often in patients with antiphospholipid syndrome. Conclusions: The hypothesis of the study was rejected since inherited venous thrombophilia was not significantly more common in patients with PFO. Due to the rarity of thrombophilias in general, more research with a larger sample size is required to further verify our findings.
Collapse
|
33
|
Baik M, Shim CY, Gwak SY, Kim YD, Nam HS, Lee HS, Nam CM, Heo JH. Patent foramen ovale and risks of recurrence in stroke of determined etiology. Ann Neurol 2022; 92:596-606. [PMID: 35753038 DOI: 10.1002/ana.26449] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 06/20/2022] [Accepted: 06/23/2022] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Patent foramen ovale (PFO) is often found in stroke patients with determined etiologies. PFO may be the actual cause of stroke in some of them. We determined whether the risk of recurrent ischemic stroke differs with PFO status in stroke patients with determined etiologies. METHODS This study included consecutive patients with stroke of determined etiology who underwent transesophageal echocardiography. We compared the rates of recurrent cerebral infarction in patients with versus without PFO, and according to PFO-Associated Stroke Causal Likelihood (PASCAL) classification. RESULTS Of 2314 included patients, 827 (35.7%) had PFO. During a median follow-up of 4.4 years, cerebral infarction recurred in 202 (8.7%). In multivariate modified Cox regression analyses, recurrence of infarction did not significantly differ between patients with PFO and those without PFO (hazard ratio [HR], 0.86; 95% confidence interval [CI], 0.64-1.17; P = 0.339). Interaction analysis showed a significant effect of PFO in patients < 65 years (adjusted P for interaction = 0.090). PFO was independently associated with a decreased risk of recurrent infarction in patients younger than 65 years (HR, 0.41; 95% CI, 0.20-0.85; adjusted P = 0.016). Patients with probable PFO-associated stroke on the PASCAL classification had a significantly lower risk of recurrent infarction than those without PFO (HR 0.31; 95% CI 0.10-0.97; P=0.044). INTERPRETATION Considering the generally low risk of recurrence in PFO-associated stroke, PFO may be the actual cause of stroke in some patients with determined etiologies, especially younger patients or those with PFO features of probable PFO-associated stroke. This article is protected by copyright. All rights reserved.
Collapse
Affiliation(s)
- Minyoul Baik
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea.,Department of Neurology, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin-si, Gyeonggi-do, South Korea
| | - Chi Young Shim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Seo-Yeon Gwak
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Young Dae Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea.,Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Seoul, South Korea
| | - Hyo Suk Nam
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea.,Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Seoul, South Korea
| | - Hye Sun Lee
- Biostatistics Collaboration Unit, Department of Research Affairs, Yonsei University College of Medicine, Seoul, South Korea
| | - Chung Mo Nam
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Ji Hoe Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea.,Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Seoul, South Korea
| |
Collapse
|
34
|
Del Brutto VJ, Diener HC, Easton JD, Granger CB, Cronin L, Kleine E, Grauer C, Brueckmann M, Toyoda K, Schellinger PD, Lyrer P, Molina CA, Chutinet A, Bladin CF, Estol CJ, Sacco RL. Predictors of Recurrent Stroke After Embolic Stroke of Undetermined Source in the RE-SPECT ESUS Trial. J Am Heart Assoc 2022; 11:e023545. [PMID: 35656979 PMCID: PMC9238731 DOI: 10.1161/jaha.121.023545] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background We sought to determine recurrent stroke predictors among patients with embolic strokes of undetermined source (ESUS). Methods and Results We applied Cox proportional hazards models to identify clinical features associated with recurrent stroke among participants enrolled in RE‐SPECT ESUS (Randomized, Double‐Blind, Evaluation in Secondary Stroke Prevention Comparing the Efficacy and Safety of the Oral Thrombin Inhibitor Dabigatran Etexilate Versus Acetylsalicylic Acid in Patients With Embolic Stroke of Undetermined Source) trial, an international clinical trial evaluating dabigatran versus aspirin for patients with ESUS. During a median follow‐up of 19 months, 384 of 5390 participants had recurrent stroke (annual rate, 4.5%). Multivariable models revealed that stroke or transient ischemic attack before the index event (hazard ratio [HR], 2.27 [95% CI, 1.83–2.82]), creatinine clearance <50 mL/min (HR, 1.69 [95% CI, 1.23–2.32]), male sex (HR, 1.60 [95% CI, 1.27–2.02]), and CHA2DS2‐VASc ≥4 (HR, 1.55 [95% CI, 1.15–2.08] and HR, 1.66 [95% CI, 1.21–2.26] for scores of 4 and ≥5, respectively) versus CHA2DS2‐VASc of 2 to 3, were independent predictors for recurrent stroke. Conclusions In RE‐SPECT ESUS trial, expected risk factors previously linked to other common stroke causes were associated with stroke recurrence. These data help define high‐risk groups for subsequent stroke that may be useful for clinicians and for researchers designing trials among patients with ESUS. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02239120.
Collapse
Affiliation(s)
- Victor J Del Brutto
- Department of Neurology University of Miami Miller School of Medicine Miami FL
| | | | - J Donald Easton
- Department of Neurology University of California San Francisco CA
| | | | - Lisa Cronin
- Boehringer Ingelheim Pharma Burlington Ontario Canada
| | - Eva Kleine
- Boehringer Ingelheim Pharma GmbH & Co. KG Biberach Germany
| | - Claudia Grauer
- Boehringer Ingelheim Pharma GmbH & Co. KG Biberach Germany
| | - Martina Brueckmann
- Boehringer Ingelheim International GmbH Ingelheim Germany.,Faculty of Medicine Mannheim University of Heidelberg Mannheim Germany
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Osaka Japan
| | | | | | | | - Aurauma Chutinet
- Department of Medicine Faculty of Medicine Chulalongkorn UniversityChulalongkorn Stroke CenterKing Chulalongkorn Memorial HospitalThai Red Cross Society Bangkok Thailand
| | | | - Conrado J Estol
- Stroke UnitSanatorio Guemes and Breyna Buenos Aires Argentina
| | - Ralph L Sacco
- Department of Neurology University of Miami Miller School of Medicine Miami FL
| |
Collapse
|
35
|
Sun YE, Na HK, Kwak S, Kim YD, Nam HS, Heo JH. Different Thrombus Histology in a Cancer Patient with Deep Vein Thrombosis and Recurrent Strokes. J Stroke 2022; 24:300-302. [PMID: 35677986 PMCID: PMC9194546 DOI: 10.5853/jos.2021.04140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 02/03/2022] [Indexed: 11/15/2022] Open
Affiliation(s)
- Ye Eun Sun
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Han Kyu Na
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Soomin Kwak
- Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Yonsei University College of Medicine, Seoul, Korea
| | - Young Dae Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
- Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Yonsei University College of Medicine, Seoul, Korea
| | - Hyo Suk Nam
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
- Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Yonsei University College of Medicine, Seoul, Korea
| | - Ji Hoe Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
- Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Yonsei University College of Medicine, Seoul, Korea
- Graduate School of Medical Science, Brain Korea 21 Project, Yonsei University College of Medicine, Seoul, Korea
- Correspondence: Ji Hoe Heo Department of Neurology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea Tel: +82-2-2228-1605 Fax: +82-2-393-0705 E-mail:
| |
Collapse
|
36
|
Vandenberk B, Morillo CA. Atrial Fibrillation after Transcatheter PFO Closure - To Measure Is To Know. Heart Rhythm 2022; 19:1421-1422. [PMID: 35643300 DOI: 10.1016/j.hrthm.2022.05.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 05/23/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Bert Vandenberk
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Carlos A Morillo
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
| |
Collapse
|
37
|
Perera KS, de Sa Boasquevisque D, Rao-Melacini P, Taylor A, Cheng A, Hankey GJ, Lee S, Fabregas JM, Ameriso SF, Field TS, Arauz A, Coutts SB, Arnold M, Mikulik R, Toni D, Mandzia J, Veltkamp RC, Meseguer E, Haeusler KG, Hart RG. Evaluating Rates of Recurrent Ischemic Stroke Among Young Adults With Embolic Stroke of Undetermined Source: The Young ESUS Longitudinal Cohort Study. JAMA Neurol 2022; 79:450-458. [PMID: 35285869 PMCID: PMC8922202 DOI: 10.1001/jamaneurol.2022.0048] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Importance Cryptogenic strokes constitute approximately 40% of ischemic strokes in young adults, and most meet criteria for the embolic stroke of undetermined source (ESUS). Two randomized clinical trials, NAVIGATE ESUS and RESPECT ESUS, showed a high rate of stroke recurrence in older adults with ESUS but the prognosis and prognostic factors among younger individuals with ESUS is uncertain. Objective To determine rates of and factors associated with recurrent ischemic stroke and death and new-onset atrial fibrillation (AF) among young adults. Design, Setting, and Participants This multicenter longitudinal cohort study with enrollment from October 2017 to October 2019 and a mean follow-up period of 12 months ending in October 2020 included 41 stroke research centers in 13 countries. Consecutive patients 50 years and younger with a diagnosis of ESUS were included. Of 576 screened, 535 participants were enrolled after 1 withdrew consent, 41 were found to be ineligible, and 2 were excluded for other reasons. The final follow-up visit was completed by 520 patients. Main Outcomes and Measures Recurrent ischemic stroke and/or death, recurrent ischemic stroke, and prevalence of patent foramen ovale (PFO). Results The mean (SD) age of participants was 40.4 (7.3) years, and 297 (56%) participants were male. The most frequent vascular risk factors were tobacco use (240 patients [45%]), hypertension (118 patients [22%]), and dyslipidemia (109 patients [20%]). PFO was detected in 177 participants (50%) who had transthoracic echocardiograms with bubble studies. Following initial ESUS, 468 participants (88%) were receiving antiplatelet therapy, and 52 (10%) received anticoagulation. The recurrent ischemic stroke and death rate was 2.19 per 100 patient-years, and the ischemic stroke recurrence rate was 1.9 per 100 patient-years. Of the recurrent strokes, 9 (64%) were ESUS, 2 (14%) were cardioembolic, and 3 (21%) were of other determined cause. AF was detected in 15 participants (2.8%; 95% CI, 1.6-4.6). In multivariate analysis, the following were associated with recurrent ischemic stroke: history of stroke or transient ischemic attack (hazard ratio, 5.3; 95% CI, 1.8-15), presence of diabetes (hazard ratio, 4.4; 95% CI, 1.5-13), and history of coronary artery disease (hazard ratio, 10; 95% CI, 4.8-22). Conclusions and Relevance In this large cohort of young adult patients with ESUS, there was a relatively low rate of subsequent ischemic stroke and a low frequency of new-onset AF. Most recurrent strokes also met the criteria for ESUS, suggesting the need for future studies to improve our understanding of the underlying stroke mechanism in this population.
Collapse
Affiliation(s)
- Kanjana S Perera
- Department of Medicine, Neurology, McMaster University, Hamilton, Ontario, Canada.,Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Danielle de Sa Boasquevisque
- Department of Medicine, Neurology, McMaster University, Hamilton, Ontario, Canada.,Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Purnima Rao-Melacini
- Department of Medicine, Neurology, McMaster University, Hamilton, Ontario, Canada.,Department of Statistics, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Amanda Taylor
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Anna Cheng
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Graeme J Hankey
- Medical School, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Western Australia.,Department of Neurology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Sarah Lee
- Department of Neurology & Neurological Sciences, Stanford Stroke Center, Stanford, California.,Stanford Children's Health, Stanford, California
| | - Joan Marti Fabregas
- Department of Neurology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | - Thalia S Field
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Antonio Arauz
- National Institute of Neurology, La Fama, Tlalpan, México
| | - Shelagh B Coutts
- Department of Clinical Neurosciences, University of Calgary, Foothills Medical Calgary, Calgary, Alberta, Canada
| | - Marcel Arnold
- Department of Neurology, University Hospital Bern, Bern, Switzerland
| | - Robert Mikulik
- International Clinical Research Center and Neurology Department, St Anne's University Hospital, Brno, Czech Republic.,Masaryk University, Brno, Czech Republic
| | - Danilo Toni
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Jennifer Mandzia
- Department of Neurosciences, Western University, London, Ontario, Canada
| | - Roland C Veltkamp
- Division of Brain Sciences, Imperial College, The Hammersmith Hospital, London, United Kingdom
| | | | | | - Robert G Hart
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | | |
Collapse
|
38
|
Huber C, Wachter R, Pelz J, Michalski D. Current Challenges and Future Directions in Handling Stroke Patients With Patent Foramen Ovale—A Brief Review. Front Neurol 2022; 13:855656. [PMID: 35572930 PMCID: PMC9103873 DOI: 10.3389/fneur.2022.855656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 03/30/2022] [Indexed: 11/13/2022] Open
Abstract
The role of patent foramen ovale (PFO) in stroke was debated for decades. Randomized clinical trials (RCTs) have shown fewer recurrent events after PFO closure in patients with cryptogenic stroke (CS). However, in clinical practice, treating stroke patients with coexisting PFO raises some questions. This brief review summarizes current knowledge and challenges in handling stroke patients with PFO and identifies issues for future research. The rationale for PFO closure was initially based on the concept of paradoxical embolism from deep vein thrombosis (DVT). However, RCTs did not consider such details, limiting their impact from a pathophysiological perspective. Only a few studies explored the coexistence of PFO and DVT in CS with varying results. Consequently, the PFO itself might play a role as a prothrombotic structure. Transesophageal echocardiography thus appears most appropriate for PFO detection, while a large shunt size or an associated atrial septum aneurysm qualify for a high-risk PFO. For drug-based treatment alone, studies did not find a definite superiority of oral anticoagulation over antiplatelet therapy. Remarkably, drug-based treatment in addition to PFO closure was not standardized in RCTs. The available literature rarely considers patients with transient ischemic attack (TIA), over 60 years of age, and competing etiologies like atrial fibrillation. In summary, RCTs suggest efficacy for closure of high-risk PFO only in a small subgroup of stroke patients. However, research is also needed to reevaluate the pathophysiological concept of PFO-related stroke and establish strategies for older and TIA patients and those with competing risk factors or low-risk PFO.
Collapse
Affiliation(s)
- Charlotte Huber
- Department of Neurology, University of Leipzig, Leipzig, Germany
| | - Rolf Wachter
- Department of Cardiology, University of Leipzig, Leipzig, Germany
| | - Johann Pelz
- Department of Neurology, University of Leipzig, Leipzig, Germany
| | - Dominik Michalski
- Department of Neurology, University of Leipzig, Leipzig, Germany
- *Correspondence: Dominik Michalski
| |
Collapse
|
39
|
Hokanson JS, Ring K, Zhang X. A Survey of Pediatric Cardiologists Regarding Non-emergent Echocardiographic Findings in Asymptomatic Newborns. Pediatr Cardiol 2022; 43:837-843. [PMID: 34999921 DOI: 10.1007/s00246-021-02795-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 11/23/2021] [Indexed: 11/26/2022]
Abstract
Echocardiography is often used to assess for significant heart disease in newborns, but there is little information on how to best manage non-emergent echocardiographic findings in asymptomatic babies. We reviewed the literature regarding the natural history of a patent foramen ovale (PFO), atrial septal defect (ASD), ventricular septal defect (PFO), and patent ductus arteriosus (PDA). We surveyed pediatric cardiologists to determine their recommendations for ten echocardiographic findings (PFO, 3 mm ASD, 6 mm ASD, small muscular VSD, small perimembranous VSD, small PDA with left to right shunting, small PDA with bidirectional shunting, trivial mitral insufficiency, trivial aortic insufficiency, and a normally functioning bicuspid aortic valve) in an asymptomatic one-day old with a heart murmur. These ten findings were set in three clinical contexts (an otherwise normal term baby, a baby born at 34 weeks gestation, and a term baby with trisomy 21). 149 survey responses were evaluated. Follow-up was universally recommended for those babies with a 6 mm ASD, a perimembranous VSD and a bicuspid aortic valve and frequently recommended for newborns with a 3 mm ASD, a small muscular VSD and any PDA. Depending on the context, between 17.5 and 23% of respondents recommended follow-up for an isolated PFO. Follow-up typically included repeat echocardiography. Some form of follow-up, typically with repeat echocardiography was recommended for many asymptomatic day-old newborns who had echocardiographic findings which were unlikely to be clinically significant. Given the wide range of recommendations, a consensus guideline could prove useful to clinicians.
Collapse
Affiliation(s)
- John S Hokanson
- Division of Pediatric Cardiology, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, H6/516c, 600 Highland Ave, Madison, WI, 53792, USA.
| | - Kaitlin Ring
- Department of Agricultural Sciences, University of Wisconsin-Madison, Madison, USA
| | - Xiao Zhang
- Division of Pediatric Cardiology, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, H6/516c, 600 Highland Ave, Madison, WI, 53792, USA
| |
Collapse
|
40
|
Calthrop A, Shabbir A, Raffles M, Hogarth K. Acute neurological deficit with submassive pulmonary emboli. BMJ Case Rep 2022; 15:e247923. [PMID: 35292546 PMCID: PMC8928298 DOI: 10.1136/bcr-2021-247923] [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] [Accepted: 03/01/2022] [Indexed: 11/04/2022] Open
Abstract
Pulmonary embolism (PE) is frequently encountered in the emergency department. Syncope, often as a consequence of impending haemodynamic collapse, is associated with increased mortality. While loss of consciousness owing to cerebral hypoperfusion and reduced left ventricular preload is a common cause of collapse with large volume PE, other syndromes can also cause neurological deficit in thromboembolic disease. Here, we describe a case of a woman in her 60s, presenting to the emergency department with features of high-risk PE. During clinical examination, the patient collapsed and became unresponsive with a Glasgow Coma Scale of 4/15 despite normal haemodynamics. Neurological signs were noted and CT revealed evidence of a large territory cerebral infarction. Further cardiovascular investigations identified a grade 4 patent foramen ovale. We describe a challenging case of established venous thromboembolism complicated by paradoxical embolism, highlighting the importance of thorough clinical examination and investigation and discuss the current evidence base of treatments.
Collapse
Affiliation(s)
| | - Asad Shabbir
- Royal Berkshire NHS Foundation Trust, Reading, UK
| | | | | |
Collapse
|
41
|
Mayerhofer E, Kanz D, Guschlbauer B, Anderson CD, Asmussen A, Grundmann S, Strecker C, Harloff A. Bubble Test and Carotid Ultrasound to Guide Indication of Transesophageal Echocardiography in Young Patients With Stroke. Front Neurol 2022; 13:836609. [PMID: 35309558 PMCID: PMC8931264 DOI: 10.3389/fneur.2022.836609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 01/21/2022] [Indexed: 11/13/2022] Open
Abstract
Background and Purpose Indication of transesophageal echocardiography (TEE) in patients ≤60 years with brain ischemia is uncertain. Methods This prospective double-blinded study included patients with cryptogenic acute ischemic stroke or transient ischemic attack (TIA) ≥18 and ≤60 years. After routine diagnostics, all patients underwent patent foramen ovale (PFO) screening by transcranial Doppler (TCD) bubble test, carotid ultrasound for atherosclerosis screening (intima-media-thickness >0.90 mm or plaques), and TEE. We calculated sensitivity, specificity, positive predictive values (PPV), and negative predictive values (NPV) of the combined non-invasive ultrasound to predict therapy-relevant TEE findings. Results We included 240 consecutive patients (median 51 years, 39% women) of which 68 (28.3%) had both a negative bubble test and no carotid atherosclerosis. Of these, 66 (97.1%) had unremarkable TEE findings; in one patient a small PFO was found and closed subsequently, in another patient a 4.9 mm thick aortic atheroma was found, and double platelet inhibition initiated. Of the other 172 (71.7%) patients, 93 (54%) had PFO and 9 (5.2%) complex aortic plaques. No other therapy-relevant findings were present in both groups. Non-invasive ultrasound had a sensitivity of 98.0%, specificity of 47.8%, NPV of 97.1%, and PPV of 58.1% for therapy-relevant TEE findings. Conclusions Bubble test and carotid ultrasound could be used for the individual decision for/against TEE in patients with cryptogenic stroke ≤60 years. If they are unremarkable, TEE can be omitted with high safety regarding secondary prevention. If bubble test is positive and/or carotid ultrasound shows atherosclerosis, TEE should be carried out if PFO or aortic atheroma are potentially relevant for further patient management.
Collapse
Affiliation(s)
- Ernst Mayerhofer
- Department of Neurology and Neurophysiology, Faculty of Medicine, Medical Center—University of Freiburg, University of Freiburg, Freiburg, Germany
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Dirk Kanz
- Department of Neurology and Neurophysiology, Faculty of Medicine, Medical Center—University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Brigitte Guschlbauer
- Department of Neurology and Neurophysiology, Faculty of Medicine, Medical Center—University of Freiburg, University of Freiburg, Freiburg, Germany
| | | | - Alexander Asmussen
- Department of Cardiology and Angiology I Heart Center, Faculty of Medicine, Medical Center—University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Sebastian Grundmann
- Department of Cardiology and Angiology I Heart Center, Faculty of Medicine, Medical Center—University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Christoph Strecker
- Department of Neurology and Neurophysiology, Faculty of Medicine, Medical Center—University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Andreas Harloff
- Department of Neurology and Neurophysiology, Faculty of Medicine, Medical Center—University of Freiburg, University of Freiburg, Freiburg, Germany
- *Correspondence: Andreas Harloff
| |
Collapse
|
42
|
Liang K, Williams M, Bucciarelli-Ducci C. Cardiac magnetic resonance imaging unmasks presumed embolic myocardial infarction due to patent foramen ovale case report. Eur Heart J Case Rep 2022; 6:ytac029. [PMID: 35146325 PMCID: PMC8824762 DOI: 10.1093/ehjcr/ytac029] [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: 04/30/2021] [Revised: 05/25/2021] [Accepted: 01/10/2022] [Indexed: 11/17/2022]
Abstract
Background Occurrence of paradoxical coronary embolism is reported in up to 10–15% of all myocardial infarctions but embolic infarctions presumed to be as a result of a patent foramen ovale (PFO) are rare. Although rare, it is important to identify these patients as they need appropriate investigations to confirm their diagnosis and guide further treatment. Case summary We present the case of a gentleman with troponin positive chest pain with non-obstructed coronaries on invasive coronary angiogram. Subsequent cardiac magnetic resonance imaging (MRI) demonstrated multi-focal myocardial infarctions in several coronary artery territories. Further investigations including echocardiogram were performed in order to identify a cause and source of the embolic infarctions and led to the diagnosis of patent foramen ovale. The patient was treated as myocardial infarction with non-obstructed coronary arteries most likely due to embolic phenomena in the presence of a PFO. Conclusion Multiple focal infarctions in multiple coronary artery territories should raise the suspicion of an intra-cardiac shunt. Multi-modality imaging with cardiac MRI and echocardiogram is important in correctly identifying any source of emboli and the diagnosis of any intra-cardiac shunt. Whilst PFO closure is a possible treatment for patients, considerations regarding risk stratification and local provisions needs to be taken into account. Patients should be referred to the appropriate subspecialist to ensure suitable long-term follow-up.
Collapse
Affiliation(s)
- Kate Liang
- Department of Cardiology, Bristol Heart Institute, University Hospitals Bristol and Weston NHS Foundation Trust, Upper Maudlin Street, Bristol, BS2 8HW, UK
- Faculty of Translational Health Sciences, Bristol Medical School, University of Bristol, 69 St. Michael’s Hill, Bristol, BS2 8DZ, UK
| | - Matthew Williams
- Department of Cardiology, Bristol Heart Institute, University Hospitals Bristol and Weston NHS Foundation Trust, Upper Maudlin Street, Bristol, BS2 8HW, UK
- Faculty of Translational Health Sciences, Bristol Medical School, University of Bristol, 69 St. Michael’s Hill, Bristol, BS2 8DZ, UK
| | - Chiara Bucciarelli-Ducci
- Department of Cardiology, Royal Brompton and Harefield Hospitals, Guys' and St Thomas NHS Trust
- Faculty of Life Sciences and Medicine, School of Biomedical Engineering and Imaging Sciences, King's College London
| |
Collapse
|
43
|
Pöyhönen P, Kuusisto J, Pirinen J, Räty H, Lehmonen L, Paakkanen R, Martinez-Majander N, Saeed S, Gerdts E, Putaala J, Sinisalo J, Järvinen V. Orientation of the atrial septum to the inferior vena cava may contribute to the persistent patency of the foramen ovale. Cardiology 2022; 147:169-178. [DOI: 10.1159/000522017] [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: 06/05/2021] [Accepted: 01/13/2022] [Indexed: 11/19/2022]
Abstract
Purpose: There is growing evidence that paradoxical embolism through patent foramen ovale (PFO) is a cause for cryptogenic stroke. However, it is still unclear why the foramen ovale fails to close after birth. We studied whether the 3D relations between the atrial septum and the inferior vena cava (IVC) are associated with PFO.
Methods: We recruited 30 patients (18-49 years) with a first-ever cryptogenic stroke and 30 age- and sex-matched stroke-free controls. Using cardiac magnetic resonance (CMR), an approach to evaluate the 3D relations between the atrial septum and the IVC was developed. The presence of interatrial right-to-left shunt was evaluated with transesophageal echocardiography (TEE) in patients and transcranial Doppler in controls.
Results: Of 30 patients, 29 underwent successful TEE, of which 12 (41%) had a shunt. Patients with a shunt had a greater mean 3D angle (γ) between the atrial septal plane and the vector from the orifice of the IVC to the middle of the atrial septum compared with patients without a shunt (45±9° vs. 36±8°, p=0.017). Of 30 controls, 12 (40%) had a shunt and a greater mean γ compared with controls without a shunt (47±8° vs. 37±10°, p=0.007). In a pooled analysis, 24 (41%) of 59 subjects with a shunt had a mean γ of 46±9° compared with subjects without a shunt of 37±9° (p<0.001).
Conclusions: More perpendicular orientation of the atrial septal plane to the orifice of the IVC is associated with PFO, possibly by directing the IVC flow to PFO.
Collapse
|
44
|
Yeh RW, DeFaria Yeh D. Patent Foramen Ovale Closure-Harnessing Clinical Trial Evidence to Inform Individualized Treatment Decisions. JAMA 2021; 326:2265-2267. [PMID: 34905044 DOI: 10.1001/jama.2021.21317] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Robert W Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Doreen DeFaria Yeh
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
45
|
Sun LR, Jordan LC. Cryptogenic Pediatric Ischemic Stroke: What's the Hole Story? Neurology 2021; 97:973-974. [PMID: 34649882 DOI: 10.1212/wnl.0000000000012960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Lisa R Sun
- From the Department of Neurology (L.R.S.), Divisions of Pediatric Neurology and Cerebrovascular Neurology, The Johns Hopkins School of Medicine, Baltimore, MD; and Department of Pediatrics (L.C.J.), Division of Pediatric Neurology, Vanderbilt University Medical Center, Nashville, TN.
| | - Lori C Jordan
- From the Department of Neurology (L.R.S.), Divisions of Pediatric Neurology and Cerebrovascular Neurology, The Johns Hopkins School of Medicine, Baltimore, MD; and Department of Pediatrics (L.C.J.), Division of Pediatric Neurology, Vanderbilt University Medical Center, Nashville, TN
| |
Collapse
|
46
|
Shih EK, Beslow LA, Natarajan SS, Falkensammer CB, Messé SR, Ichord RN. Prevalence of Patent Foramen Ovale in a Cohort of Children With Cryptogenic Ischemic Stroke. Neurology 2021; 97:e2096-e2102. [PMID: 34649876 DOI: 10.1212/wnl.0000000000012892] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 08/30/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES To determine the significance of patent foramen ovale (PFO) in childhood stroke, we compared PFO prevalence, PFO features, and stroke recurrence risk in 25 children with cryptogenic arterial ischemic stroke (AIS), 54 children with AIS from a known etiology, and 209 healthy controls. METHODS We performed a case-control analysis of a 14-year prospectively enrolled single-center cohort of children with AIS who underwent transthoracic echocardiogram (TTE) and compared them to TTEs of otherwise healthy children evaluated for benign cardiac concerns. Stroke patients 29 days to 18 years of age at stroke ictus with confirmed acute AIS on imaging, availability of complete diagnostic studies of stroke risk factors, including TTE images available for central review, and at least 1 follow-up evaluation after index stroke were included. Presence of PFO and high-risk PFO features were assessed by 2 independent, blinded reviewers and compared between groups with the Fisher exact test. Stroke/TIA recurrence risk was determined from Cox proportional hazards models. RESULTS Of 154 children with first-ever AIS, 79 were eligible; 25 had cryptogenic AIS, and 54 had a known cause. PFO prevalence was higher in the cryptogenic group (7, 28%) compared to both the known stroke etiology group (3, 5.6%, p = 0.009) and controls without stroke (24, 11.5%, p = 0.03). There were no significant differences in presence of right-to-left shunt and atrial septal aneurysm. Median follow-up time for entire stroke cohort was 20.9 months. Stroke-free recurrence at 2-years did not differ between children with and without PFO (HR 2.0, 95% CI 0.4-9.3, p = 0.39). DISCUSSION PFO prevalence was higher in children with cryptogenic stroke compared to patients with AIS with known etiology and healthy controls. PFO was not associated with increased recurrence risk. Optimal secondary preventive treatment in children with cryptogenic stroke and PFO remains uncertain and requires further study. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that children with cryptogenic ischemic stroke have an increased frequency of PFO compared to children with ischemic stroke of known etiology and healthy controls.
Collapse
Affiliation(s)
- Evelyn K Shih
- From the Divisions of Neurology (E.K.S., L.A.B., R.N.I.) and Cardiology (S.S.N., C.B.F.), Children's Hospital of Philadelphia, PA; and Departments of Neurology (E.K.S., L.A.B., S.R.M., R.N.I.) and Pediatrics (E.K.S., L.A.B., S.S.N., C.B.F., R.N.I.), University of Pennsylvania, Philadelphia.
| | - Lauren A Beslow
- From the Divisions of Neurology (E.K.S., L.A.B., R.N.I.) and Cardiology (S.S.N., C.B.F.), Children's Hospital of Philadelphia, PA; and Departments of Neurology (E.K.S., L.A.B., S.R.M., R.N.I.) and Pediatrics (E.K.S., L.A.B., S.S.N., C.B.F., R.N.I.), University of Pennsylvania, Philadelphia
| | - Shobha S Natarajan
- From the Divisions of Neurology (E.K.S., L.A.B., R.N.I.) and Cardiology (S.S.N., C.B.F.), Children's Hospital of Philadelphia, PA; and Departments of Neurology (E.K.S., L.A.B., S.R.M., R.N.I.) and Pediatrics (E.K.S., L.A.B., S.S.N., C.B.F., R.N.I.), University of Pennsylvania, Philadelphia
| | - Christine B Falkensammer
- From the Divisions of Neurology (E.K.S., L.A.B., R.N.I.) and Cardiology (S.S.N., C.B.F.), Children's Hospital of Philadelphia, PA; and Departments of Neurology (E.K.S., L.A.B., S.R.M., R.N.I.) and Pediatrics (E.K.S., L.A.B., S.S.N., C.B.F., R.N.I.), University of Pennsylvania, Philadelphia
| | - Steven R Messé
- From the Divisions of Neurology (E.K.S., L.A.B., R.N.I.) and Cardiology (S.S.N., C.B.F.), Children's Hospital of Philadelphia, PA; and Departments of Neurology (E.K.S., L.A.B., S.R.M., R.N.I.) and Pediatrics (E.K.S., L.A.B., S.S.N., C.B.F., R.N.I.), University of Pennsylvania, Philadelphia
| | - Rebecca N Ichord
- From the Divisions of Neurology (E.K.S., L.A.B., R.N.I.) and Cardiology (S.S.N., C.B.F.), Children's Hospital of Philadelphia, PA; and Departments of Neurology (E.K.S., L.A.B., S.R.M., R.N.I.) and Pediatrics (E.K.S., L.A.B., S.S.N., C.B.F., R.N.I.), University of Pennsylvania, Philadelphia
| |
Collapse
|
47
|
Allou A, Baschet L, Sabourin C, Montalscot G, Lorgis L, Iriart X. Cost-effectiveness analysis of patent foramen ovale closure with Amplatzer plus medical therapy compared to medical therapy in patients with a history of stroke in France. J Cardiol 2021; 80:72-79. [PMID: 34772575 DOI: 10.1016/j.jjcc.2021.10.009] [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: 05/20/2021] [Revised: 09/07/2021] [Accepted: 10/13/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND A patent foramen ovale (PFO) is formed when the ovale foramen does not close spontaneously or re-opens leaving the right and left atrium connected. The present study was conducted to analyze the cost-effectiveness of PFO closure with Amplatzer device plus medical therapy (MT) compared to MT alone in the French reimbursement system for PFO patients with a prior history of stroke, using the RESPECT study data. METHODS A multi-state Markov model was used. The analysis was conducted from a collective perspective over a 10-year time horizon with 4% discount applied for costs and health effects. The simulated population included adult patients with PFO. Sub-group analysis was limited to patients with atrial septal aneurysm and/or a large-shunt. Clinical inputs were derived from the RESPECT study and literature. Costs associated with the device, drugs, and management were sourced from literature and national databases. The outcomes of analyses included life-years (LYs), quality-adjusted LYs (QALYs), incremental cost-effectiveness ratio (ICER), and number of recurrent strokes avoided. Scenario and sensitivity analyses were conducted to assess the robustness of the results. RESULTS The use of Amplatzer plus MT provided additional QALYs (0.16) at an incremental cost of 7301€, generating an ICER of 46,288€/QALY for Amplatzer vs. MT alone. In the sub-group analysis, Amplatzer plus MT provided additional QALYs (0.20) at an incremental cost of 5818€, generating an ICER of 28,624€/QALY for Amplatzer plus MT vs. MT alone. Amplatzer plus MT led to lower number of recurrent strokes in comparison to MT alone in both populations. Scenario and sensitivity analyses confirmed the robustness of the results. CONCLUSION Amplatzer plus MT represents a cost-effective treatment option and is associated with lower stroke recurrence compared to MT alone for PFO patients with a prior history of stroke.
Collapse
Affiliation(s)
| | | | | | - Gilles Montalscot
- Sorbonne University, ACTION Study Group, Pitié-Salpêtrière Hospital (AP-HP), Paris, France
| | - Luc Lorgis
- Department of Cardiology, University Hospital, Dijon, France; Laboratory of Cerebro-Vascular Pathophysiology and Epidemiology (PEC2) EA 7460, Dijon, France; University of Burgundy, Dijon, France
| | - Xavier Iriart
- Bordeaux University Hospital (CHU), Department of Pediatric and Adult Congenital Cardiology, Pessac, France; IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France; INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, U1045, Bordeaux, France
| |
Collapse
|
48
|
Chang H, Bae J, Chung TN. A Unique Case of Inferior Vena Cava Aneurysm Complicated with Pulmonary Embolism and Cerebral Infarction. J Cardiovasc Dev Dis 2021; 8:jcdd8110147. [PMID: 34821700 PMCID: PMC8621951 DOI: 10.3390/jcdd8110147] [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: 10/10/2021] [Revised: 10/27/2021] [Accepted: 11/03/2021] [Indexed: 11/16/2022] Open
Abstract
Inferior vena cava (IVC) aneurysms rarely occur. They are commonly detected incidentally since they present with mild or no symptoms. This was the first study to report a fatal case of a saccular IVC aneurysm with pulmonary embolism and cerebral infarction. The patient developed cardiac arrest five minutes after arriving at the emergency department, and spontaneous circulation was restored after two minutes of cardiopulmonary resuscitation. Computed tomography scans of the brain, chest, and abdomen–pelvis were obtained. The patient was diagnosed with a saccular aneurysm of the IVC measuring 8 × 11 cm, massive embolism of both pulmonary arteries, and cerebral infarction. An electroencephalogram, taken on the third day of hospitalization, suggested brain death, and the patient died on the eleventh day of hospitalization. This case report highlights that an IVC aneurysm with pulmonary embolism can be associated with paradoxical emboli-induced cerebral infarction, which is fatal.
Collapse
|
49
|
Ameriso SF. The quest for the identification of pathogenic patent foramen ovale. ARQUIVOS DE NEURO-PSIQUIATRIA 2021; 79:857-858. [PMID: 34706013 DOI: 10.1590/0004-282x-anp-2021-e010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 08/09/2021] [Indexed: 11/22/2022]
Affiliation(s)
- Sebastián Francisco Ameriso
- Fleni, Departamento de Neurología, Buenos Aires, Argentina.,Fleni, Centro Integral de Neurología Vascular, Buenos Aires, Argentina
| |
Collapse
|
50
|
Berrichi S, Bouayed Z, Benbouchta K, Kossir A, Bkiyar H, Ismaili N, Ouafi NE, Housni B. Incidental diagnosis of a large cardiac thrombus swinging through an interatrial communication in a COVID-19 patient: Case report and literature review. Ann Med Surg (Lond) 2021; 71:102967. [PMID: 34691408 PMCID: PMC8524807 DOI: 10.1016/j.amsu.2021.102967] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 10/14/2021] [Accepted: 10/15/2021] [Indexed: 12/13/2022] Open
Abstract
Introduction The hypercoagulability state induced by COVID-19 has been well established and various forms of subsequent thromboembolic events have been reported throughout literature including multiple cases of intracardiac thrombi, four of which in our center alone, this case being the fifth. Case report We report the case of a 38-year-old male with no prior cardiovascular history who -subsequently to a COVID-19 infection-developped a right atrial thrombosis associated to a pulmonary embolism, and in whom cardiography revealed an interatrial communication. Management relied upon curative doses of low molecular weight heparin (LMWH) with favourable outcome. Discussion In our discussion, we lay out the various physiopathological mechanisms incriminated throughout literature in the genesis of a hypercoagulability state distinctive of COVID-19, before highlighting the incidence of an interatrial communication (whether a Potent Foramen Ovale or Atrial Septal Defect) discovered in patients with COVID-19, and the potential paradoxical embolization risks they imply as well as reported cases. A mention of hemostatic parameters monitored was also warranted. Finally we discuss the guidelines in terms of prophylactic and therapeutic anticoagulation in hospitalized patients before discussing cardiac thrombosis's therapeutic options. Conclusion Our case highlights various key points which could change the prognosis of COVID-19 patients, whether related to the underdiagnosis of interatrial abnormalities or with regards to the diagnosis to thromboembolic events, but also the indisputable place of anticoagulation in COVID-19 management. Thromboembolic events complicating COVID-19 have been well described and are attributed to a hypercoagulability state distinctive of COVID-19. A pre-existing Potent Foramen Ovale (PFO) or Atrial septal Defect (ASD) in COVID-19 patients is unknown as only a handful of studies covered the subject. The association of a cardiac thrombosis with a pulmonary embolism and interatrial communication exposes patients to risks of paradoxical embolization and subsequent arterial thrombotic events. Prophylactic and curatrive anticoagulation is unrefutably a key pillar in the management of COVID-19.
Collapse
Affiliation(s)
- Samia Berrichi
- Anesthesia and Resuscitation Department, MOHAMMED VI University Hospital Center, Oujda, Morocco
| | - Zakaria Bouayed
- Anesthesia and Resuscitation Department, MOHAMMED VI University Hospital Center, Oujda, Morocco
| | - Karima Benbouchta
- Cardiology Department, Mohammed VI University Hospital, Oujda, Morocco
| | - Amine Kossir
- Cardiology Department, Mohammed VI University Hospital, Oujda, Morocco
| | - Houssam Bkiyar
- Anesthesia and Resuscitation Department, MOHAMMED VI University Hospital Center, Oujda, Morocco
| | - Nabila Ismaili
- Cardiology Department, Mohammed VI University Hospital, Oujda, Morocco.,Laboratory of Epidemiology, Clinical Research, and Public Health, Faculty of Medicine and Pharmacy, Oujda, Morocco
| | - Noha El Ouafi
- Cardiology Department, Mohammed VI University Hospital, Oujda, Morocco.,Laboratory of Epidemiology, Clinical Research, and Public Health, Faculty of Medicine and Pharmacy, Oujda, Morocco
| | - Brahim Housni
- Anesthesia and Resuscitation Department, MOHAMMED VI University Hospital Center, Oujda, Morocco.,Simulation Center, Faculty of Medicine and Pharmacy, Oujda, Morocco
| |
Collapse
|