Epidemiology of Patent Foramen Ovale in General Population and in Stroke Patients: A Narrative Review

Cardiac transplantation: A review of current status and emerging innovations

Heart transplantation (HTx) is a life-saving procedure for patients with end-stage heart failure and has undergone remarkable advancements since the first successful transplant in 1967. The introduction of cyclosporine in the 1970s significantly improved patient outcomes, leading to a global increase in transplants, including in India, where the practice has grown despite initial challenges. This review provides an extensive overview of HTx, focusing on current practices, technological advancements, and the ongoing challenges the field faces today. It explores the evolution of surgical techniques, such as minimally invasive and robotic-assisted procedures, and the management of posttransplant rejection through tailored immunosuppressive strategies, including new monoclonal antibodies and personalized therapies. The review also highlights emerging innovations such as mechanical circulatory support devices and xenotransplantation as potential solutions to donor shortages while acknowledging the ethical and logistical challenges these approaches entail. Furthermore, the analysis delves into the implications of using extended-criteria donors and the role of multidisciplinary teams in evaluating absolute and relative contraindications. Despite the progress made, the persistent issues of organ scarcity and ethical concerns underscore the need for ongoing research and innovation to further enhance the efficacy, safety, and accessibility of HTx.

Enhancing the diagnostic efficacy of right-to-left shunt using robot-assisted transcranial Doppler: a quality improvement project

Background

Stroke is the leading cause of adult disability worldwide, with approximately 30% of strokes remaining cryptogenic. One potential important etiology is a patent foramen ovale (PFO), which may contribute to stroke through paradoxical thromboembolism or in situ thromboembolus formation. Recent advancements in robot-assisted transcranial Doppler (raTCD) have shown increased sensitivity in detecting right-to-left shunt (RLS) compared to transthoracic echocardiography (TTE), particularly in detecting the large shunts which are associated with higher stroke risk.

Methods

We conducted a retrospective quality improvement project at our regional stroke center to compare the performance of TTE and raTCD in identifying RLS in ischemic stroke patients. The study involved 148 patients admitted between February 2021 and February 2023. All patients underwent TTE and raTCD with agitated saline bubble contrast, with additional transesophageal echocardiography (TEE) at the treatment team's discretion. The primary metrics analyzed included differences in overall RLS detection and large RLS detection rates for raTCD, TTE and TEE.

Results

raTCD detected RLS in 60.1% of patients compared to 37.2% with TTE (p < 0.001), with a 42.6% detection rate for large shunts on raTCD versus 23.0% on TTE (p < 0.001). The sensitivity and specificity of raTCD were 92 and 87.5%, respectively, compared to 78.57 and 71.43% for TTE, using TEE as the gold standard. Nine patients underwent PFO closure, all correctly identified with large shunts by raTCD, while TTE missed or underestimated the PFO size in 44% of the cases.

Conclusion

raTCD significantly outperforms TTE in detecting RLS and large shunts, suggesting its integration into standard PFO workup protocols may enhance secondary stroke prevention. These findings support the adoption of raTCD as a complementary diagnostic tool alongside TTE and TEE for more accurate PFO detection and risk stratification.

The Etiology and Management of Critical Acute Right Heart Failure

Right ventricular failure contributes to the morbidity and mortality of acute myocardial function, massive pulmonary embolism, and chronic pulmonary hypertension. Understanding how the normal physiology of the right ventricle (RV) is disrupted is integral to managing patients who present with RV decompensation. Therapeutic advances in mechanical circulatory support, pharmacotherapies to reduce afterload, mechanical and chemical lytic therapies for acute pulmonary embolism have improved outcomes of patients by offloading the RV. In this report we provide an overview of the physiology of the RV, medical management (volume optimization, hemodynamic targets, rhythm management), along with critical care-specific topics (induction with mechanical ventilation, sedation strategies, and mechanical circulatory support) and provide a framework for managing patients who present with leveraging principles of preload, contractility, and afterload. Last, because of the complexity of right ventricular failure management, and the complexity of presentation, we also discuss the role of team-based approach (cardiogenic shock and pulmonary embolism response teams), and highlight its benefits at improving outcomes.

"Worse With Sitting": A Case of Severe Hypoxia Due to an Undiscovered Patent Foramen Ovale

Patent foramen ovale (PFO) is a cardiac shunt that results when the foramen ovale fails to close after birth. While it is relatively common, most cases are asymptomatic. The primary clinical implication of PFO is an increased risk of cryptogenic stroke. Accordingly, most literature addresses PFO through the lens of treating/preventing neurological disease. Much less research has been devoted to the minority of patients who suffer pulmonary and cardiovascular symptoms that are directly caused by their PFO. Here, we discuss a case of an elderly female patient presenting with hypoxia requiring high respiratory support, later found to be the result of a large, previously unknown PFO.

Cryptogenic stroke and patent foramen ovale: endeavoring for clarity

This review aims to summarize current knowledge and highlight recent findings on the association between cryptogenic stroke (CS) and patent foramen ovale (PFO). By presenting sometimes conflicting data, the review underscores the necessity for further research to clarify the complex mechanisms behind PFO-related CS and optimize its management. Results from research identifies specific conditions and scores, such as the risk of paradoxical embolism (RoPE) score, that help assess the likelihood of PFO-related cryptogenic stroke and guide treatment decisions. PFO closure has demonstrated substantial benefits in select cases, especially those with high-risk PFO features, though complications such as atrial fibrillation were frequently documented. Biomarker measurements, such as reduced total homocysteine (tHcy) level after PFO closure or high D-dimer levels indicating a higher risk of stroke recurrence, represent newer areas of study with a promising future in medical practice. Cryptogenic stroke (CS) remains a diagnostic challenge. This article reviews the current understanding of PFO-related CS, focusing on the interplay of concomitant pathological conditions, PFO closure, stroke recurrence, and some of the related biomarkers.

Hypercoagulable states in young adults with ischemic stroke in a Stroke Belt state: a retrospective study

We theorize that the southeastern United States has a higher stroke mortality rate and higher recurrent ischemic stroke rate than the rest of the United States due to (1) an increased prevalence of hypercoagulable states among young adults in the region, (2) failure to diagnose hypercoagulable states as the cause of ischemic stroke in young adults, and (3) underutilization of anticoagulation for ischemic stroke secondary prevention in young adults with hypercoagulable states. In an attempt to investigate this hypothesis, we conducted a retrospective chart review of 311 inpatients with first-ever ischemic stroke from age 18 to 55 years at an Oklahoma academic medical center from 1 July 2011 to 30 April 2017. Using Chi-squared test, we compared the stroke etiologic diagnosis of the attending neurologist at discharge-when hypercoagulable profile results were rarely available-to the diagnosis of a vascular neurologist postdischarge who had access to all available etiologic test results. The inpatient neurologists identified the stroke etiology as hypercoagulable state in 79 patients (25.57%) and undetermined etiology in 105 (33.98%). With the benefit of final hypercoagulable profile results, the postdischarge vascular neurologist identified the stroke etiology as hypercoagulable state in 167 (54.22%, 95% CI 48.64-59.70%, p-value <2.2e-16) and undetermined etiology in 28 (9.09%, 95% CI 6.36-12.83%, p-value 1.03e-14). There was no significant change in the proportion of ischemic strokes classified under all other stroke etiologies. We conclude that hypercoagulable states are a common and underrecognized cause of ischemic stroke in young adults in the U.S. Stroke Belt.

Transcatheter Structural Heart Disease Interventions and Concomitant Left Atrial Appendage Occlusion: A State of the Art Review

Atrial fibrillation (AF) is the most common arrhythmia in patients with valvular heart disease, and it can be associated with adverse patient outcomes. However, the need for anticoagulation to counterbalance AF-associated stroke risk may further lead to suboptimal outcomes via increasing bleeding events, especially in high-risk individuals. Because the vast majority of thrombi occur in the left atrial appendage, left atrial appendage occlusion (LAAO) is an established procedure for preventing ischemic stroke in patients with AF, while limiting anticoagulation-related bleeding events. Thus, the concept of combining an index procedure for structural heart disease (SHD) with LAAO seems promising for preventing future stroke events. A combined procedure has been described in aortic stenosis (transcatheter aortic valve implantation + LAAO), mitral regurgitation (transcatheter edge-to-edge repair + LAAO), and atrial septal defects (patent foramen ovale/atrial septal defect + LAAO). Evidence shows that a combined procedure can be safely performed in a "1-stop shop" fashion, without increased rates of procedural adverse events, with the potential to limit bleeding risk and provide prophylaxis against stroke events. This review analyses indications and clinical evidence regarding the safety and efficacy of combined SHD+LAAO procedures, while also providing insights into gaps in knowledge and future directions for the evolution of this field.

Remnants of right venous valve in utero and early postnatal life. Case report and literature review

During fetal life the right valve of the sinus venosus directs oxygenated blood from the inferior vena cava to the left atrium through the foramen ovale, until the regression of the right valve which usually occurs within the 15th week of pregnancy. Incomplete regression of the right venous valve in varying degrees can lead to different types of remnants such as the Eustachian valve, the Chiari Network and Cor Triatriatum Dexter. Prenatal diagnosis of remnants of right venous valve has only rarely been reported in the literature. We present a case of prenatal diagnosis of Chiari Network associated with severe tricuspid regurgitation, further complicated by tachyarrhythmia and signs of fetal heart failure with the appearance of abundant pleural and ascitic effusion. A cesarean section was performed at 32 weeks. After 48 h of life, because of persistence of atrial flutter, an electrical cardioversion was performed. The physical examination 7 months after being discharged showed a normal growth, good condition and persistence of mild tricuspid regurgitation. We also reviewed the available evidence on persistent right venous valve diagnosed in utero or early postnatal life. In conclusion we believe that prenatal recognition is helpful in planning fetal surveillance identifying those newborns at risk of dyspnea, cyanosis or neonatal heart failure.

Sex-Based Differences in Long-Term Outcomes Following Transcatheter Closure of Patent Foramen Ovale for Cryptogenic Stroke

BACKGROUND

Evidence from trials suggests that patent foramen ovale closure is superior to medical therapy alone in reducing stroke recurrence in men but not in women. Evidence from real-world data on the impact of sex on outcomes after patent foramen ovale closure, however, remains scarce. Therefore, the present study aimed to assess sex-based differences in long-term outcomes after transcatheter closure of patent foramen ovale.

METHODS

This was a single-center, retrospective cohort study enrolling patients who underwent transcatheter patent foramen ovale closure to prevent recurrent cerebrovascular events. Detailed information from medical charts was entered into a clinical registry, which has been linked to population-based administrative health databases in Ontario. Procedural, short, and long-term outcomes have been compared by sex.

RESULTS

Of the 783 patients included in the sample, 349 (44.5%) were women and 434 (55.5%) were men. Women were younger and had a higher rate of migraine, while men had a higher prevalence of cardiovascular risk factors. No differences were observed in procedural and 30-day outcomes by sex. At a median follow-up of 14 years, the event rates of recurrent cerebrovascular events, survival, and new-onset atrial fibrillation were not different by sex. In adjusted analysis, men experienced higher rates of pacemaker implantation (hazard ratio, 5.62 [95% CI, 1.57-20.1]).

CONCLUSIONS

No sex-based differences in recurrent cerebrovascular events, survival, or new-onset atrial fibrillation were observed in this study, suggesting equal benefits for both sexes. Future studies should report outcomes by sex to enhance the reproducibility of our findings and help support guideline development.

A patient with unexplained hypoxemia after a fall diagnosed with platypnea orthodeoxia syndrome: approaches to resolving discrepancies between level of hypoxemia and clinical presentation

PURPOSE

Platypnea orthodeoxia syndrome (POS) is a rare cause of hypoxemia. Diagnosis of POS is challenging, requiring a high index of clinical suspicion, special investigations, and collaboration with multiple specialists.

CLINICAL FEATURES

We describe an 86-yr-old male who presented to the emergency department with hip pain after a witnessed fall. He was noted to be hypoxemic at presentation with a peripheral oxygen saturation (SpO2) of 84% on room air, with an inadequate increase in oxygenation after administration of a fractional concentration of inspired oxygen (FIO2) of 1.00. A chest radiograph, computed tomography pulmonary angiogram, and Doppler ultrasound of the liver were unremarkable. In the supine position with an FIO2 of 0.65, his SpO2 and arterial partial pressure of oxygen (PaO2) (96% and 74 mm Hg, respectively) increased significantly relative to the seated position (84% and 50 mm Hg, respectively). Contrast transthoracic echocardiography (TTE) showed a large patent foramen ovale (PFO) with right-to-left shunt. Transthoracic echocardiography showed rotation of the patient's heart, enabling direct alignment of the inferior vena cava with the PFO, creating a large anatomical right-to-left shunt in the seated position. Right heart catheterization confirmed a large PFO with normal right-sided heart pressures. He was treated with a septal occlusion and his SpO2 in the seated position improved immediately. The patient was discharged home without requiring supplemental oxygen.

CONCLUSIONS

Platypnea orthodeoxia syndrome is a rare presentation of hypoxemia. Positional changes in oxygenation are the cardinal feature of POS. Discordance between lung imaging and the severity of hypoxemia should prompt investigation for an intracardiac shunt, which can occur in POS even in the absence of increased right-sided heart pressures. Either contrast TTE or transesophageal echocardiography is necessary to make this diagnosis.

Patent Foramen Ovale Embryology, Anatomy, and Physiology

Patent foramen ovale (PFO) is a common finding in the general population but may lead to serious conditions such as stroke from paradoxical embolism and platypnea orthodeoxia. A thorough understanding of the interatrial septal anatomy along with its assessment by different imaging modalities is critical in performing safe transcatheter PFO closure. Investigating the anatomy and right heart to left heart flows using transesophageal echocardiography or intracardiac echocardiography imaging must be done before undertaking closure of a PFO.

Comparative Effectiveness of Devices for Interventional Patent Foramen Ovale Closure: Insights from a 23-Year Monocentric Analysis

Background/Objectives: Patent foramen ovale (PFO) is a congenital heart defect affecting up to 25% of the population, associated with an increased risk of cryptogenic stroke. Percutaneous PFO closure is a minimally invasive procedure aimed at reducing stroke risk by eliminating the right-to-left shunt. Methods: This monocentric, retrospective study analyzed 716 patients who underwent PFO closure between January 2000 and February 2023. Data collected included demographics, indications for closure, procedural details, and outcomes. Key endpoints were complications at the puncture site, pericardial effusion, recurrent stroke or transient ischemic attack (TIA), thrombi on the device, new-onset atrial fibrillation, and death. Results: The cohort had a mean age of 50.6 ± 12.6 years, with 60.8% female. Four devices were used: Occlutech PFO occluder (n = 106), Amplatzer PFO occluder (n = 227), Gore septal occluder (n = 296), and Cardia PFO-Star (n = 87). The initial procedural success rate was 98.9%, with no significant differences between devices. Complication rates were low across all devices. Residual shunt incidence decreased from 17.9% in 1 month to 3.4% in 12 months. Device-specific complications included late-onset pericardial effusion (p = 0.01), erosions (Cardia PFO-Star), and device thrombus formation (Gore septal occluder). Conclusions: PFO closure is a safe and effective method for preventing recurrent strokes, with high success rates and varying specific complication profiles, depending on the device. Further long-term studies are needed to evaluate newer devices and optimize patient outcomes.

Cardiovascular, autonomic symptoms and quality of life in children with hypermobile Ehlers-Danlos syndrome

Objectives

Hypermobile Ehlers-Danlos syndrome is a connective tissue disorder characterized by joint hypermobility and other systemic manifestations. Cardiovascular, autonomic symptoms and dysautonomia are frequently reported in adults with hypermobile Ehlers-Danlos syndrome and have been shown to have a negative impact on quality of life. However, there is scant literature on autonomic symptoms in pediatric patients with hypermobile Ehlers-Danlos syndrome. This study aims to characterize cardiovascular symptoms and diagnoses in pediatric patients with hypermobile Ehlers-Danlos syndrome and evaluate the impact of autonomic symptoms on quality of life.

Methods

As part of a longitudinal study, a consecutive sample of 70 patients with Ehlers-Danlos syndromes were recruited at routine clinical care visits. Medical history was reviewed, demographics were obtained, and patient-reported outcomes were completed by the patients.

Results

The average age of 70 patients was 15.8 years, and the majority were females (89%) and Caucasian (89%). The most common cardiovascular diagnoses were orthostatic intolerance (59%), dysautonomia (47%), and postural orthostatic tachycardia syndrome (21%). Most patients had an echocardiogram (77%), that was normal (82%). No patients had mitral valve prolapse, and only one patient had mild aortic root dilation (2%). Patient-reported outcomes revealed decreased quality of life associated with autonomic symptoms.

Conclusions

This study shows that most children with hypermobile Ehlers-Danlos syndrome have cardiovascular and autonomic symptoms, which have a negative impact on quality of life. Few patients with hypermobile Ehlers-Danlos syndrome have structural abnormalities on echocardiogram, which suggests that the cardiovascular symptoms experienced by patients are not due to structural cardiovascular disease and possibly reflective of autonomic pathology, though further studies will need to confirm this. This study confirms that cardiovascular and symptoms are prevalent and have a dramatic impact on quality of life in pediatric and young adult patients diagnosed with hypermobile Ehlers-Danlos syndrome.

Symptomatic carotid webs and patent foramen ovale: RoPE score in competing stroke etiologies

BACKGROUND

Patent foramen ovale (PFO)-associated stroke is diagnosed more frequently in young patients with infrequent vascular risk factors and embolic appearing infarcts. The risk of paradoxical embolism (RoPE) score is used to identify PFO-associated stroke. Patients with symptomatic carotid artery web (CaW) share a very similar risk profile and these lesions are frequently overlooked. In this study, we evaluate the RoPE score profile in patients with suspected symptomatic CaW.

METHODS

Retrospective analysis of prospectively collected data of patients with symptomatic CaW as the presumed cause of stroke presenting to 2 comprehensive stroke centers from 2014 to 2021. CaW was diagnosed using computed tomography angiography (CTA) of the neck & head. Shunt study was done using a transthoracic, transesophageal, and/or transcranial-Doppler with bubbles. RoPE score ≥7 was considered high.

RESULTS

Seventy-five patients had stroke from a symptomatic ipsilateral CaW. Mean age was 49.7±11.2 years and 74.7 % were females. Median RoPE score was 7 [5-8], and 52.0 % had a high RoPE score. PFO was detected in 13.3 % of the patients and 20.5 % within the high RoPE score group. Ten percent of the cases would have been misclassified as PFO-associated strokes based on RoPE score.

CONCLUSION

High RoPE scores were observed in the majority of patients with CaW-attributed stroke, and it should not be used to differentiate CaW- versus PFO-associated stroke. Careful extracranial internal carotid artery evaluation for CaW is warranted in cryptogenic strokes, including in PFO positive patients before defining stroke etiology.

Surgical Treatment of Atrial Septal Defects

Atrial septal defects (ASDs) are among the most prevalent congenital cardiac malformations. Closure of the defect and repair of associated cardiac malformations are typically indicated if an ASD is hemodynamically significant or symptomatic. This narrative review aims to summarize key aspects of surgical ASD closures. A non-systematic literature review was conducted to cover surgically relevant aspects of (developmental) anatomy, morphology, and treatment. ASDs result from diverse developmental alterations, leading to subtype-specific associated cardiac malformations, meaning surgical therapy varies accordingly. Presently, surgical repair yields excellent outcomes for all ASD subtypes, with minimally invasive approaches, especially in adults, increasingly employed for ASD closure. Surgical ASD repair is safe with excellent results. However, familiarity with ASD subtypes and typically associated lesions is crucial for optimal patient management.

Efficacy and safety of patent foramen ovale closure for mitigating migraine: a systematic review and meta-analysis of randomized trials and observational studies

Background

Although often asymptomatic, patent foramen ovale (PFO) may cause disabling migraine symptoms. Evidence regarding PFO closure for prevention of migraine is still ambiguous and conflicting.

Objectives

This study aims to analyze the efficacy and safety of PFO closure for mitigating migraine symptoms.

Design

This is a systematic review and meta-analysis of randomized clinical trials (RCTs) and observational studies.

Data sources and methods

A comprehensive search was conducted on the Scopus, Medline, ClinicalTrials.gov, and Cochrane Library databases up until March 12, 2024. This review incorporates literature that examines the comparison between PFO closure and control with outcome data related to migraine. We employed random-effect models to analyze the standardized mean difference (SMD) and odds ratio (OR) for presentation of the outcomes.

Results

A total of five RCTs and six observational studies were incorporated. The results of our meta-analysis showed higher reduction of monthly migraine attacks from baseline (SMD -0.34; 95% CI: -0.51, -0.18, p < 0.0001, I 2 = 19%) and monthly migraine days from baseline (SMD -0.30; 95% CI: -0.53, -0.08, p = 0.009, I 2 = 0%) among PFO closure than control. However, the complete resolution of migraine (especially based on the evidence from RCTs; p = 0.24), HIT-6 score (p = 0.08), and MIDAS score (p = 0.15) did not differ significantly between two groups of intervention. The majority of adverse events reported were atrial fibrillation and access site infection/bleeding that only occurred in small proportions of patients (⩽5%).

Conclusion

This study suggests better efficacy of PFO closure in reducing monthly migraine attacks and days with similar safety profile when compared to control.

Registration

PROSPERO (CRD42023453635).

Severe Hypoxemia Due to Elongation and Shunting of Patent Foramen Ovale After Emergent Repair of Thoracic Aortic Dissection

We document the elongation and shunting of a patent foramen ovale (PFO) after thoracic aortic dissection repair in a 63-year-old man. Initially, a presurgical echocardiogram showed insignificant PFO shunting; however, severe hypoxemia and inability to extubate after thoracic aortic dissection repair necessitated further investigation. A repeat transesophageal echocardiogram after cardiothoracic surgery revealed significant PFO elongation with bidirectional shunting. Subsequent urgent transcatheter PFO closure markedly improved oxygenation, allowing for successful weaning from mechanical ventilation. This case highlights the importance of recognizing dynamic PFO changes after thoracic surgery as a reversible cause of postoperative hypoxemia.

Deep vein thrombosis in patients with stroke or transient ischemic attack presenting with patent foramen ovale: a retrospective observational study

OBJECTIVE

Deep vein thrombosis (DVT) is discussed as a source of embolism for cerebral ischemia in the presence of patent foramen ovale (PFO). However, previous studies reported varying rates of DVT in stroke patients, and recommendations for screening are lacking. This study aimed to characterize patients with stroke or transient ischemic attack (TIA) and concomitant PFO and explore the rate of DVT and associated parameters.

METHODS

Medical records were screened for patients with stroke or TIA and echocardiographic evidence of PFO. Concomitant DVT was identified according to compression ultrasonography of the lower limbs. A variety of demographic, clinical, and laboratory parameters, the RoPE and Wells scores were compared between patients with and without DVT.

RESULTS

Three-hundred-thirty-nine patients (mean age 61.2 ± 15.4 years, 61.1% male) with stroke or TIA and PFO, treated between 01/2015 and 12/2020, were identified. Stroke and TIA patients did not differ for demographic and vascular risk factors. DVT was found in 17 cases out of 217 (7.8%) with compression ultrasonography. DVT was associated with a history of DVT, cancer, previous immobilization, calf compression pain, calf circumference difference, and a few laboratory abnormalities, e.g., increased D-dimer. A multivariate regression model with stepwise backward selection identified the Wells score (odds ratio 35.46, 95%-confidence interval 4.71-519.92) as a significant predictor for DVT.

CONCLUSION

DVT is present in a relevant proportion of patients with cerebral ischemia and PFO, which needs to be considered for the individual diagnostic workup. The Wells score seems suitable for guiding additional examinations, i.e., compression ultrasonography.

Cardiopulmonary haemodynamics in Tibetans and Han Chinese during rest and exercise

During sea-level exercise, blood flow through intrapulmonary arteriovenous anastomoses (IPAVA) in humans without a patent foramen ovale (PFO) is negatively correlated with pulmonary pressure. Yet, it is unknown whether the superior exercise capacity of Tibetans well adapted to living at high altitude is the result of lower pulmonary pressure during exercise in hypoxia, and whether their cardiopulmonary characteristics are significantly different from lowland natives of comparable ancestry (e.g. Han Chinese). We found a 47% PFO prevalence in male Tibetans (n = 19) and Han Chinese (n = 19) participants. In participants without a PFO (n = 10 each group), we measured heart structure and function at rest and peak oxygen uptake (V ̇ O 2 peak ${{\dot{V}}_{{{{\mathrm{O}}}_{\mathrm{2}}}{\mathrm{peak}}}}$ ), peak power output (W ̇ p e a k ${{\dot{W}}_{peak}}$ ), pulmonary artery systolic pressure (PASP), blood flow through IPAVA and cardiac output (Q ̇ T ${{\dot{Q}}_{\mathrm{T}}} $ ) at rest and during recumbent cycle ergometer exercise at 760 Torr (SL) and at 410 Torr (ALT) barometric pressure in a pressure chamber. Tibetans achieved a higherW peak ${W}_{\textit{peak}}$ than Han, and a higherV ̇ O 2 peak ${{\dot{V}}_{{{{\mathrm{O}}}_{\mathrm{2}}}{\mathrm{peak}}}}$ at ALT without differences in heart rate, stroke volume orQ ̇ T ${{\dot{Q}}_{\mathrm{T}}} $ . Blood flow through IPAVA was generally similar between groups. Increases in PASP and total pulmonary resistance at ALT were comparable between the groups. There were no differences in the slopes of PASP plotted as a function ofQ ̇ T ${{\dot{Q}}_{\mathrm{T}}} $ during exercise. In those without PFO, our data indicate that the superior aerobic exercise capacity of Tibetans over Han Chinese is independent of cardiopulmonary features and more probably linked to differences in local muscular oxygen extraction. KEY POINTS: Patent foramen ovale (PFO) prevalence was 47% in Tibetans and Han Chinese living at 2 275 m. Subjects with PFO were excluded from exercise studies. Compared to Han Chinese, Tibetans had a higher peak workload with acute compression to sea level barometric pressure (SL) and acute decompression to 5000 m altitude (ALT). Comprehensive cardiac structure and function at rest were not significantly different between Han Chinese and Tibetans. Tibetans and Han had similar blood flow through intrapulmonary arteriovenous anastomoses (IPAVA) during exercise at SL. Peak pulmonary artery systolic pressure (PASP) and total pulmonary resistance were different between SL and ALT, with significantly increased PASP for Han compared to Tibetans at ALT. No differences were observed between groups at acute SL and ALT.

Ocular Manifestations and Complications of Patent Foramen Ovale: A Narrative Review

Patent foramen ovale (PFO) is a prevalent congenital cardiac anomaly associated with a persistent opening between the atrial septum, allowing communication between the left and right atria. Despite often being asymptomatic, PFO can lead to various clinical presentations, including cryptogenic stroke and other embolic events. Transient visual disturbances, alterations in the visual field, migraine with aura, impaired eye movement and endogenous eye infections may prompt patients to seek ophthalmological consultation. Understanding these diverse clinical scenarios is crucial for early detection, appropriate management and mitigating the morbidity burden associated with PFO. This narrative review aims at examining the spectrum of clinical presentations of ocular pictures associated with PFO. The pathophysiology, diagnosis and treatment methods for PFO will be described, emphasizing the importance of a multidisciplinary approach involving ophthalmologists, cardiologists, neurologists and imaging specialists. In the future, prospective studies and clinical trials are warranted to provide further insights into the preventive role and optimal therapeutic strategies for managing PFO-related ocular complications, ultimately guiding clinical decision making and optimizing patient care.

Cerebral air embolism: neurologic manifestations, prognosis, and outcome

Background

Cerebral air embolism (CAE) is an uncommon medical emergency with a potentially fatal course. We have retrospectively analyzed a set of patients treated with CAE at our comprehensive stroke center and a hyperbaric medicine center. An overview of the pathophysiology, causes, diagnosis, and treatment of CAE is provided.

Results

We retrospectively identified 11 patients with cerebral venous and arterial air emboli that highlight the diversity in etiologies, manifestations, and disease courses encountered clinically. Acute-onset stroke syndrome and a progressive impairment of consciousness were the two most common presentations in four patients each (36%). Two patients (18%) suffered from an acute-onset coma, and one (9%) was asymptomatic. Four patients (36%) were treated with hyperbaric oxygen therapy (HBTO), high-flow oxygen therapy without HBOT was started in two patients (18%), two patients (18%) were in critical care at the time of diagnosis and three (27%) received no additional treatment. CAE was fatal in five cases (46%), caused severe disability in two (18%), mild disability in three (27%), and a single patient had no lasting deficit (9%).

Conclusion

Cerebral air embolism is a dangerous condition that necessitates high clinical vigilance. Due to its diverse presentation, the diagnosis can be missed or delayed in critically ill patients and result in long-lasting or fatal neurological complications. Preventative measures and a proper diagnostic and treatment approach reduce CAE's incidence and impact.

Prevalence of atrial septal defects and patent foramen ovale in a cohort of sudden cardiac death patients undergoing autopsy

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.

Comparative diagnostic accuracy of transcranial Doppler and contrast-enhanced transthoracic echocardiography for the diagnosis of patent foramen ovale and atrial septal defect

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.

In young patients with stroke of undetermined etiology, large vessel occlusions are less frequent in the group with high-risk patent foramen ovale

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.

Transcatheter PFO closure for cryptogenic stroke: current approaches and future considerations

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.

Sudden cardiac death during scuba diving: a case report of a patient with unknown hypertrophic cardiomyopathy

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.

Patent Foramen Ovale: The Unresolved Questions

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.

PFO-spectrum disorder: two different cerebrovascular diseases in patients with PFO as detected by AI brain imaging software

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.

Patent foramen ovale closure versus drug therapy in patients over 60 years and a follow-up of 5 years

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.

Large regional variation in cardiac closure procedures to prevent ischemic stroke in Switzerland a population-based small area analysis

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.

The characteristics and prevalence of patent foramen ovale in Japanese people: a study using material from forensic autopsies

Racial and ethnic differences in the prevalence of patent foramen ovale have been suggested, but there are insufficient data to confirm the situation. Studies have also not investigated detailed morphological changes in the fossa ovalis by age. This study therefore aimed to clarify the characteristics of the fossa ovalis and determine the frequency of patent foramen ovale in Japanese people, using materials from forensic autopsies. A total of 359 hearts were obtained during forensic autopsies (from 223 males and 136 females, aged from 0 to 94 years). Overall, prevalence of patent foramen ovale was 12.5%, but it was significantly higher among those under 20 years old (66.7% in males, 38.5% in females). The area of the fossa ovalis linearly increased with age in both sexes. The prevalence of patent foramen ovale was lower in Japanese adults than previously found in either White or Black people. The ratio of the area of the fossa ovalis to the heart weight was nearly constant.

Approval, Evidence, and "Off-Label" Device Utilization: The Patent Foramen Ovale Closure Story

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.

Patent Foramen Ovale Percutaneous Closure: Evolution and Ongoing Challenges

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.

Bibliometric Analysis of Research on Migraine-Stroke Association from 2013 to 2023

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.

Unintentional Implantation of a Permanent Pacemaker Lead Across a Patent Foramen Ovale Leading to Left Ventricular Pacing

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.

Know the Risk: Stroke With Patent Foramen Ovale

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.

Cryptogenic Stroke Caused by a Newly Diagnosed Patent Foramen Ovale in a Healthy Young Adult

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.

Right-to-Left Shunt Evaluation in Cardiac Patent Foramen Ovale Using Bubble Contrast Transcranial Color-Coded Doppler: A Cryptogenic Stroke Case

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.

Cerebrovascular Events in Older Patients With Patent Foramen Ovale: Current Status and Future Perspectives

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.

Neglected intrapulmonary arteriovenous anastomoses: A comparative study of pulmonary right-to-left shunts in patients with patent foramen ovale

Objective

Pulmonary 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.

Methods

We 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.

Results

A 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 &lt; 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 &lt; 0.001).

Conclusion

The 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.

Recent progress in patent foramen ovale and related neurological diseases: A narrative review

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.

Unexpected paradoxical embolization following catheter-directed thrombectomy with the FlowTriever™ system in a patient with pulmonary embolism: a case report

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.

Neuromonitoring in Children with Cerebrovascular Disorders

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.

Multisystemic involvement of post-traumatic fat embolism at a Pediatric Trauma Center: a clinical series and literature review

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.

Association of Shunt Size and Long-Term Clinical Outcomes in Patients with Cryptogenic Ischemic Stroke and Patent Foramen Ovale on Medical Management

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.

Calf muscle pump tensing as a novel maneuver to improve the diagnostic performance of detecting patent foramen ovale during transesophageal echocardiography

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.

Embolic myocardial infarction associated with patent foramen ovale: a case series

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.

SCUBA Diving in Adult Congenital Heart Disease

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.