Ischaemic stroke with patent foramen ovale

Newly-found channels in the interatrial septum of the heart by dissection, histologic evaluation, and three-dimensional microcomputed tomography

A minute thrombus can pass through a small type of interatrial communication, which can result in a stroke or transient ischemic attack and several associated symptoms. This study sought to investigate a new type of interatrial communication. Thirty-one hearts from embalmed adult cadavers were investigated. Each interatrial channels (IACs) was classified as either an open or obstructed channel according to the connection of each hole on the right and left surfaces of the interatrial septum. Open channels were found in two specimens (6.5%). Both open and obstructed IACs followed tortuous courses through the interatrial septum. On the right surface of the interatrial septum, the hole was usually found adjacent to the left border of the interatrial septum between the opening of the superior vena cava into the right atrium and the superior margin of the fossa ovalis. Conversely, holes on the left surface of the interatrial septum were usually found in the upper and middle parts adjacent to the left border of the interatrial septum. This novel finding is expected to support our understanding of the onset of possible symptoms such as stroke in the absence of classical atrial septal defects.

The Efficacy of Contrast Transthoracic Echocardiography and Contrast Transcranial Doppler for the Detection of Patent Foramen Ovale Related to Cryptogenic Stroke

Background

Patent foramen ovale (PFO) has been linked to the pathophysiology of cryptogenic stroke. Contrast transesophageal echocardiography (cTEE) is the current gold standard for PFO diagnosis, but it has the disadvantage of being semi-invasive and does not exempt from risks. As a diagnostic test, the efficacy of contrast transthoracic echocardiography (cTTE) and contrast transcranial Doppler (cTCD) is controversial. This study is aimed at investigating the efficacy of cTTE and cTCD versus cTEE in PFO detection, exploring a more cost-effective and reliable method for the diagnosis of PFO related to cryptogenic stroke.

Methods

From August 2019 to January 2020, a total of 213 patients with suspected PFO were included in our study. All patients underwent cTEE, cTCD, and cTTE examinations. cTTE3 was named for using a cutoff of 3 beats to detect PFO during cTTE, and cTTE5 represented a cutoff of 5 beats. A cutoff of cTCD grade III was named cTCD III. A cutoff of grade IV was named cTCD IV. cTTE3+cTCD IV was used for the combination of a cutoff of 3 beats during cTTE with grade IV of cTCD. cTTE5+cTCD III combined a cutoff of 5 beats during cTTE with cTCD grade III. Taking cTEE as the gold standard, we compared the sensitivity, specificity, negative likelihood ratio (-LR), and misdiagnosis rate for PFO detection among the above methods.

Results

A total of 161 of 213 (76%) patients had PFO confirmed by cTEE. With the spontaneous Valsalva maneuver, the sensitivity, specificity, negative likelihood ratio (-LR), and misdiagnosis rate of cTTE3 in PFO diagnosis were 60%, 90%, 44%, and 10%, respectively, and those for cTTE5 were 76%, 78%, 31% and 22%, respectively. The sensitivity, specificity, negative likelihood ratio (-LR), and misdiagnosis rate of cTCD III were 80%, 71%, 29%, and 29%, respectively, while those for cTCD IV were 55%, 90%, 49%, and 10%, respectively. When cTTE and cTCD were combined to diagnose PFO, the specificity and misdiagnosis rate were significantly improved, especially cTTE3+cTCD IV, with 100% specificity and a misdiagnosis rate of 0.

Conclusion

cTTE or cTCD can be used for preliminary PFO related to cryptogenic stroke findings. The combination of the two methods can improve the specificity of PFO diagnosis, especially using the cutoff of cTTE3+cTCD IV.

Cardiovascular incidents in male professional football players with negative preparticipation cardiac screening results: an 8-year follow-up

BACKGROUND

Preparticipation cardiac screening of athletes aims to detect cardiovascular disease at an early stage to prevent sudden cardiac arrests and deaths. Few studies have described the cardiovascular outcomes in athletes classified as negative on screening.

OBJECTIVE

To identify cardiovascular incidents in a cohort of male professional football players who were cleared to play after a negative screening result.

METHODS

This is a retrospective 8-year follow-up study of 595 professional male football players in Norway who underwent preparticipation cardiac screening by experienced cardiologists, including electrocardiography (ECG) and echocardiography, in 2008. We performed a media search to identify sudden cardiovascular incidents between January 2008 and February 2016. Incidents were cross-checked with medical records.

RESULTS

Six of the 595 players (1%), all classified as negative on cardiac screening, experienced severe cardiovascular incidents during follow-up. Retrospective review revealed abnormal ECG findings in one case, not recognised at the time of screening. Three players suffered a sudden cardiac arrest (all resuscitated successfully), one a myocardial infarction, one a transient ischaemic attack and one atrial flutter. Three of the players ignored chest pain, paresis, dyspnoea or near-syncope, two completed a match with symptoms before seeking medical assistance, one player's symptoms were misinterpreted and received inappropriate treatment initially, and two players were discharged from hospital without proper follow-up, despite having serious cardiovascular symptoms.

CONCLUSIONS

A comprehensive preparticipation cardiac screening did not identify a subset of 6 of 595 players who experienced subsequent cardiovascular incidents as being at risk. It is important to remind athletes that a normal cardiac screening exam does not protect against all cardiac diseases. Timely reporting of symptoms is essential.