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Mattoso AAA, Sena JP, Hotta VT. The Role of Echocardiography in the Assessment of the Interatrial Septum and Patent Foramen Ovale as an Emboligenic Source. Arq Bras Cardiol 2023; 120:e20220903. [PMID: 37909574 PMCID: PMC10586815 DOI: 10.36660/abc.20220903] [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: 02/02/2023] [Revised: 06/07/2023] [Accepted: 07/17/2023] [Indexed: 11/03/2023] Open
Abstract
A comunicação do septo atrial (CIA) representa, aproximadamente, de 6%-10% dos defeitos cardíacos congênitos, com incidência de 1 em 1.500 nascidos vivos.1 Forame oval patente (FOP) é mais comum e está presente em mais de 20%-25% dos adultos.2 Síndromes clínicas associadas a CIA e FOP são variáveis, com implicações abrangendo a medicina pediátrica e adulta, neurologia e cirurgia. O interesse adicional na anatomia do septo interatrial (SIA) aumentou substancialmente nas últimas duas décadas, com evolução simultânea dos procedimentos percutâneos envolvendo cardiopatia estrutural do lado esquerdo e procedimentos eletrofisiológicos. Idealmente, essas intervenções baseadas em cateter requerem rota direta para o átrio esquerdo (AE) através do SIA, necessitando completo entendimento de sua anatomia. Atualmente, tecnologias de imagem sofisticadas e não invasivas como ecocardiografia transesofágica bidimensional (ETE 2D) e tridimensional (ETE 3D), ressonância cardíaca (RMC) e tomografia computadorizada (TC) passaram por um extraordinário desenvolvimento tecnológico, fornecendo detalhes anatômicos das estruturas cardíacas visualizadas em formato 2D e 3D e são essenciais para diagnóstico e tratamento de pacientes com doenças cardíacas. A avaliação da anatomia e anormalidades do SIA, portanto, requer abordagem padronizada e sistemática, integrando modalidades diagnósticas e fornecendo avaliação adequada e uniforme para terapias cirúrgicas e transcateter.
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Affiliation(s)
| | - Joberto Pinheiro Sena
- Hospital Santa IzabelSalvadorBABrasilHospital Santa Izabel – Hemodinâmica, Salvador, BA – Brasil
| | - Viviane Tiemi Hotta
- Instituto do CoraçãoHCFMUSPSão PauloSPBrasilInstituto do Coração HC-FMUSP – Unidade Clinica de Miocardiopatias e Doenças da Aorta, São Paulo, SP – Brasil
- Fleury Medicina e SaúdeSão PauloSPBrasilFleury Medicina e Saúde, São Paulo, SP – Brasil
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2
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Elzanaty AM, Patel N, Sabbagh E, Eltahawy EA. Patent foramen ovale closure in the management of cryptogenic stroke: a review of current literature and guideline statements. Curr Med Res Opin 2021; 37:377-384. [PMID: 33460329 DOI: 10.1080/03007995.2021.1876648] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The management recommendations for patent foramen ovale (PFO) closure in cryptogenic stroke are rapidly evolving. The data has expanded recently with four major trials demonstrating superiority of percutaneous device closure over medical management in preventing cryptogenic stroke recurrence. This paper aims to review the current literature for referring physicians who may encounter patients with patent foramen ovale before referring these patients to stroke specialists and/or interventional cardiologists. METHOD For this Narrative review, we conducted a broad literature search with expert selection of relevant data. Our search included a review of the currently available trials, guideline statements, position papers, cost-effectiveness of device closure data, as well as the impact of device closure on quality of life. RESULTS Most European societies are now in favor of evaluating all patients aged 60 years or younger with recent cryptogenic stroke in the setting of a PFO after careful consideration of the patient's echocardiographic and clinical risk factors. On the other hand, American societies, except for the American Academy of Neurology, have not yet passed official updated recommendations. CONCLUSION PFO closure can be considered for the prevention of recurrent cryptogenic stroke in patients aged ≤60 years after a thorough evaluation and discussion about benefits and potential risks (including but not limited to atrial fibrillation) of the procedure. Accumulating evidence supports prognostic, quality of life, and economic benefit from percutaneous PFO closure with newer generation closure devices in the right subset of patients. HIGHLIGHTS Data from 4 major trials (RESPECT, CLOSE, DEFENSE-PFO, REDUCE) demonstrates the superiority of PFO closure over medical management alone in preventing cryptogenic stroke recurrence. Trials investigated mostly patients ≤60 years old, and therefore results may not be generalizable to the entire population. Further randomized trials evaluating the safety and efficacy of PFO closure in patients older than 60 years are warranted.Atrial fibrillation is one of the most common "occult" causes of cryptogenic stroke and should be excluded by ambulatory electrocardiographic monitoring. It is important to also rule out other causes of stroke, including hypercoagulable states, atherosclerotic lesions, other cardioembolic sources, and arterial dissection.Complications of PFO procedure include new-onset AF, development of scar tissue, risk of aortic root dilation and subsequent erosions, and potential thrombi formation on the device.PFO closure with medical therapy is more cost-effective than medical therapy alone.Patients who underwent PFO closure had lower rates of depression, anxiety, and stress compared to those who did undergo closure.Development of the RoPE score has helped clinicians identify patients with cryptogenic stroke and PFO who might be a candidate for PFO closure. A score of 7, 8, and 9-10 corresponds to a causal risk of 72%, 84%, and 88%, respectively, and defines a subset of patients who may benefit from PFO closure.Current guidelines recommend determining the need for PFO closure on a case-by-case basis, depending on risk factors, in patients age 60 or less with recent cryptogenic stroke in the setting of PFO.
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Affiliation(s)
- Ahmed M Elzanaty
- Department of Internal Medicine, University of Toledo, Toledo, OH, USA
| | - Neha Patel
- Department of Internal Medicine, University of Toledo, Toledo, OH, USA
| | - Ebrahim Sabbagh
- Department of Cardiology, University of Toledo, Toledo, OH, USA
| | - Ehab A Eltahawy
- Department of Cardiology, University of Toledo, Toledo, OH, USA
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3
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Rigatelli G, Zuin M, Dell'Avvocata F, Roncon L, Vassilev D, Nghia N. Light anti-thrombotic regimen for prevention of device thrombosis and/or thrombotic complications after interatrial shunts device-based closure. Eur J Intern Med 2020; 74:42-48. [PMID: 31902564 DOI: 10.1016/j.ejim.2019.12.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 11/28/2019] [Accepted: 12/17/2019] [Indexed: 11/17/2022]
Abstract
AIMS The optimal antiplatelet therapy after atrial septal defect (ASD) or patent foramen ovale device closure (PFO) remain to be established. We evaluated the safety and effectiveness of 6-month 100 mg Aspirin (ASA) regimen in the very long-term follow up after intracardiac echocardiography (ICE) -aided interatrial shunt closure in a large retrospective cohort. METHODS Single-center retrospective analysis which included medical and instrumental data of 789 consecutive patients referred to our institution over a 15 years period due interatrial shunt catheter-based closure. RESULTS Finally, 734 patients were included in the analysis (mean age 46.1 ± 14.6 years, 398 females): ASD and PFO closure were successfully performed in 281 and 453 patients, respectively. Over the follow-up period, no major bleeding events were observed while the rate of minor bleeding events was 0.9%. Tolerance problems were detected in 3.4% of cases (n==28). In 11 patients (1.5%) an abnormal complete blood count was detected and monitored up to normalization. On a mean follow -up of 10.3 ± 3.0 years (range 1-15), 10 patients (1.36%) had a persistent moderate shunt 12 months after closure and maintained Aspirin 100 mg life-long, whereas the remaining 724 suspended the treatment after 6 months. Device thrombosis in ASD and PFO groups were 0% and 0.2%, respectively. A cerebral ischemic event occurred in 0.4% of the entire cohort. CONCLUSIONS A regimen of 100 mg of ASA for six months after ASD/PFO closure appeared to be both safe and effective in preventing device thrombosis and major bleedings.
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Affiliation(s)
- Gianluca Rigatelli
- Section of Adult and Congenital Heart Disease, Cardiovascular Diagnosis and Endoluminal Interventions, Rovigo General Hospital, 45100, Rovigo Italy.
| | - Marco Zuin
- Section of Adult and Congenital Heart Disease, Cardiovascular Diagnosis and Endoluminal Interventions, Rovigo General Hospital, 45100, Rovigo Italy; University of Ferrara, Faculty of Medicine, Ferrara, Italy
| | - Fabio Dell'Avvocata
- Section of Adult and Congenital Heart Disease, Cardiovascular Diagnosis and Endoluminal Interventions, Rovigo General Hospital, 45100, Rovigo Italy
| | - Loris Roncon
- Section of Adult and Congenital Heart Disease, Cardiovascular Diagnosis and Endoluminal Interventions, Rovigo General Hospital, 45100, Rovigo Italy
| | - Dobrin Vassilev
- Department of Cardiology, Alesandrovska University School of Medicine, Sofia, Bulgaria
| | - Nguyen Nghia
- Department of Interventional cardiology, Cho Ray Hospital, Ho Chi Minh City, Vietnam
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4
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Lai JCL, Tse G, Wu WK, Gong M, Bazoukis G, Wong WT, Wong SH, Lampropoulos K, Baranchuk A, Tse LA, Xia Y, Li G, Wong MC, Chan YS, Mu N, Dong M, Liu T. Patent foramen ovale closure versus medical therapy for stroke prevention: A systematic review and meta-analysis of randomized controlled trials. F1000Res 2018; 6:2178. [PMID: 30271571 PMCID: PMC6137413 DOI: 10.12688/f1000research.13444.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/17/2018] [Indexed: 11/20/2022] Open
Abstract
Background: Previous randomized trials on patent foramen ovale (PFO) closure versus medical therapy for stroke prevention were inconclusive. Recently, two new randomized trials and new findings from an extended follow-up of a previous trial have been published on this topic. We conducted a systematic review and meta-analysis of randomized trials comparing PFO closure with medical therapy for stroke prevention. Methods: PubMed and Cochrane Library were searched until 16
th September 2017. The following search terms were used for PubMed: "patent foramen ovale" AND (stroke OR embolism) and "randomized" AND "Trial". For Cochrane Library, the following terms were used: "patent foramen ovale" AND "closure" AND (stroke OR embolism). Results: A total of 91 and 55 entries were retrieved from each database using our search strategy respectively, of which six studies on five trials met the inclusion criteria. This meta-analysis included 1829 patients in the PFO closure arm (mean age: 45.3 years; 54% male) and 1972 patients in the medical therapy arm (mean age: 45.1 years; 51% male). The median follow-up duration was 50 ± 30 months. When compared to medical therapy, PFO closure significantly reduced primary endpoint events with a risk ratio [RR] of 0.60 (95% CI: 0.44-0.83, P < 0.0001;
I2: 15%). It also reduced stroke (RR: 0.50, 95% CI: 0.35-0.73, P < 0.0001;
I2: 32%) despite increasing the risk of atrial fibrillation/flutter (RR: 1.90, 95% CI: 1.23-2.93, P < 0.01;
I2: 43%). However, it did not reduce transient ischemic accident events (0.75; 95% CI: 0.51-1.10, P = 0.14;
I2: 0%), all-cause bleeding (RR: 0.89; 95% CI: 0.44-1.78, P = 0.74;
I2: 51%) or gastrointestinal complications (RR: 0.92; 95% CI: 0.32-2.70, P = 0.88;
I2: 0%). Conclusions: PFO closure significantly reduces risk of stroke when compared to medical treatment and should therefore be considered for stroke prevention in PFO patients.
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Affiliation(s)
- Jenny Chi Ling Lai
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, Hong Kong
- Li Ka Shing Institute of Health Sciences, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Gary Tse
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, Hong Kong
- Li Ka Shing Institute of Health Sciences, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - William K.K. Wu
- Li Ka Shing Institute of Health Sciences, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, Hong Kong
- Department of Anaesthesia and Intensive Care, State Key Laboratory of Digestive Disease, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Mengqi Gong
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular disease, Department of Cardiology, Tianjin Institute of Cardiology, The Second Hospital of Tianjin Medical University, Tianjin, 300211, China
| | - George Bazoukis
- Second Department of Cardiology, Evangelismos General Hospital of Athens, Athens, Greece
| | - Wing Tak Wong
- School of Life Sciences, Chinese University of Hong Kong, Hong Kong, Hong Kong
- State Key Laboratory of Agrobiotechnology, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Sunny Hei Wong
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, Hong Kong
- Li Ka Shing Institute of Health Sciences, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | | | - Adrian Baranchuk
- Division of Cardiology, Kingston General Hospital, Queen’s University, Kingston, ON, Canada
| | - Lap Ah Tse
- JC School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Yunlong Xia
- Department of Cardiovascular Medicine, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Guangping Li
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular disease, Department of Cardiology, Tianjin Institute of Cardiology, The Second Hospital of Tianjin Medical University, Tianjin, 300211, China
| | - Martin C.S. Wong
- JC School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Yat Sun Chan
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, Hong Kong
- Li Ka Shing Institute of Health Sciences, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Nan Mu
- Department of Gynecology and Obstetrics, Yantai Yuhuangding Hospital Affiliated to Qingdao University, Yantai, Shandong, 264000, China
| | - Mei Dong
- Department of Gynecology and Obstetrics, Yantai Yuhuangding Hospital Affiliated to Qingdao University, Yantai, Shandong, 264000, China
| | - Tong Liu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular disease, Department of Cardiology, Tianjin Institute of Cardiology, The Second Hospital of Tianjin Medical University, Tianjin, 300211, China
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Kjeld T, Jørgensen TS, Fornitz G, Roland J, Arendrup HC. Patent foramen ovale and atrial fibrillation as causes of cryptogenic stroke: is treatment with surgery superior to device closure and anticoagulation? A review of the literature. Acta Radiol Open 2018; 7:2058460118793922. [PMID: 30159163 PMCID: PMC6109859 DOI: 10.1177/2058460118793922] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 07/03/2018] [Indexed: 11/30/2022] Open
Abstract
Closure of persistent foramen ovale (PFO) to avoid cryptogenic strokes is performed globally with enthusiasm but lacks prove of efficacy. We present a 79-year-old man who had had a PFO device introduced nine years previously because of cryptogenic strokes presenting as syncopes. The patient was referred from his general practitioner with two new syncopes. Transthoracic echocardiography revealed no cardiac causes of embolism. Transesophageal echocardiography (TEE) revealed a misplaced device like an umbrella in a storm, but no septum defects. Holter revealed seconds-long episodes of atrial fibrillation (AF). The patient was successfully treated with anticoagulation. A literature review showed that: (i) the efficacy of PFO closure devices has not been proven in any trial, but was demonstrated in a meta-analysis comparing three different devices; (ii) PFO devices are rarely controlled by TEE during or after insertion; (iii) residual shunts are detected in up to 45% of cases; (iv) there is an increased rate of post-arrhythmic complications; (v) the risk of AF in congenital heart disease increases with increasing age, with a 13% risk of transient ischemic attacks and stroke; and (vi) surgical treatment of PFO was found to have a 4.1% risk of complications including stroke. The question to be asked is whether device closure of PFO should be avoided, considering that PFO is a congenital heart defect with risks of AF and (cryptogenic) stroke? Heart surgery should be a treatment option for symptomatic PFO.
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Affiliation(s)
- Thomas Kjeld
- 1Department of Cardiothoracic Surgery, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Tem S Jørgensen
- 2Department of Cardiology, University of Copenhagen, Amager Hospital, Copenhagen, Denmark
| | - Gitte Fornitz
- Department of Cardiology, University of Zealand, Slagelse Hospital, Slagelse, Denmark
| | - Jan Roland
- Department of Cardiology, University of Zealand, Slagelse Hospital, Slagelse, Denmark
| | - Henrik C Arendrup
- 1Department of Cardiothoracic Surgery, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
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6
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Musuraca G, Agostoni P, Boldi E, Imperadore F, Terraneo C, Broso GP. Very late migration to and retrieval of an Amplatzer patent foramen ovale occlusion device from the abdominal aortic carrefour. J Cardiovasc Med (Hagerstown) 2018; 19:459-461. [PMID: 29894354 DOI: 10.2459/jcm.0000000000000674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Gerardo Musuraca
- Division of Cardiology, S. Maria del Carmine Hospital, Rovereto, Italy
| | | | - Emiliano Boldi
- Division of Cardiology, Clinica S. Rocco di Franciacorta, Ome
| | | | | | - Giovanni P Broso
- Division of Cardiology, S. Maria del Carmine Hospital, Rovereto, Italy
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Vitarelli A, Gaudio C, Mangieri E, Capotosto L, Tanzilli G, Ricci S, Viceconte N, Placanica A, Placanica G, Ashurov R. Bi-Atrial Function before and after Percutaneous Closure of Atrial Septum in Patients with and without Paroxysmal Atrial Fibrillation: A 2-D and 3-D Speckle Tracking Echocardiographic Study. ULTRASOUND IN MEDICINE & BIOLOGY 2018; 44:1198-1211. [PMID: 29609808 DOI: 10.1016/j.ultrasmedbio.2018.02.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 02/12/2018] [Accepted: 02/26/2018] [Indexed: 06/08/2023]
Abstract
Our aim was to analyze atrial function with 2-D (2-D-STE) and 3-D (3-D-STE) speckle tracking echocardiography in patients with atrial septal devices and paroxysmal atrial fibrillation (PAF). One hundred sixteen patients and a subgroup of 22 patients who developed PAF after device insertion were studied. Left atrial and right atrial peak longitudinal strain and standard deviations of time to peak strain (TPS) were calculated using 2-D-STE. The left atrial/right atrial emptying fraction and expansion index were determined using 3-D-STE. By multivariate analysis, pre-closure 3-D right atrial expansion index, left atrial time to peak strain, and 3-D left atrial expansion index were independently associated with PAF. Compared with the other indices, receiver operating characteristic analysis revealed better diagnostic accuracy for the combination of pre-closure time to peak strain and 3-D expansion index in detecting PAF. Patients with atrial septal devices have pre-existing left and right atrial dilation and dysfunction as assessed by 2-D-STE and 3-D-STE that appear sensitive for the stratification of PAF risk in this population.
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Affiliation(s)
- Antonio Vitarelli
- Deptartments of Cardiology and Medicine, Sapienza University, Rome, Italy.
| | - Carlo Gaudio
- Deptartments of Cardiology and Medicine, Sapienza University, Rome, Italy
| | - Enrico Mangieri
- Deptartments of Cardiology and Medicine, Sapienza University, Rome, Italy
| | - Lidia Capotosto
- Deptartments of Cardiology and Medicine, Sapienza University, Rome, Italy
| | - Gaetano Tanzilli
- Deptartments of Cardiology and Medicine, Sapienza University, Rome, Italy
| | - Serafino Ricci
- Deptartments of Cardiology and Medicine, Sapienza University, Rome, Italy
| | - Nicola Viceconte
- Deptartments of Cardiology and Medicine, Sapienza University, Rome, Italy
| | - Attilio Placanica
- Deptartments of Cardiology and Medicine, Sapienza University, Rome, Italy
| | - Giuseppe Placanica
- Deptartments of Cardiology and Medicine, Sapienza University, Rome, Italy
| | - Rasul Ashurov
- Deptartments of Cardiology and Medicine, Sapienza University, Rome, Italy
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Scacciatella P, Meynet I, Giorgi M, Biava LM, Matranga I, Biasco L, Omedè P, Orzan F, Gaita F. Angiography vs transesophageal echocardiography-guided patent foramen ovale closure: A propensity score matched analysis of a two-center registry. Echocardiography 2018; 35:834-840. [PMID: 29457261 DOI: 10.1111/echo.13842] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES The purpose of this study is to compare the long-term outcomes of patent foramen ovale (PFO) closure using angiography or transesophageal echocardiography as procedural guidance. BACKGROUND The interventional treatment is emerging as a safe and efficient option for patients with high likelihood of PFO-related cryptogenic stroke and high risk of recurrence. The "gold-standard" guidance technique remains an issue. METHODS Two cohorts of patients undergoing PFO closure for cryptogenic stroke in two catheterization laboratories of the same institution, using similar inclusion criteria but different guidance, were compared with propensity score matching. RESULTS A total of 374 patients were enrolled, 161 in Angio-group and 213 in Echo-group. No difference was detected in the procedural complication rate. In Angio-group, radiological exposure (P = .001) and 6-month residual shunt (16.8% vs 8.0%, P = .015) were higher. After a mean follow-up of 41 ± 30 months, 28 patients (7.5%) presented any adverse event (death, recurrent cerebral ischemia, device-related complications, reintervention), with a higher rate in Angio-group (13.0% vs 3.3%, P = .001), mainly due to repeated percutaneous intervention (10.6% vs 1.4%, P = .001). The results were confirmed after propensity score matching (118 patients/group). The rate of recurrent cerebral ischemia was 1.9% and was not significantly different in the two groups. Intra-procedural guidance and atrial septum aneurysm were independent predictors of the composite primary endpoint (OR 1.2, P = .016). CONCLUSIONS The use of intra-procedural transesophageal echocardiography (TEE) guidance for PFO closure allows lower residual shunt rate, radiological exposure, and adverse events, mainly driven by a significant reduction in percutaneous reintervention.
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Affiliation(s)
- Paolo Scacciatella
- Cardiovascular and Thoracic Department, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Ilaria Meynet
- Cardiovascular and Thoracic Department, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Mauro Giorgi
- Cardiovascular and Thoracic Department, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Lorenza M Biava
- Cardiovascular and Thoracic Department, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Ivana Matranga
- Cardiovascular and Thoracic Department, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Luigi Biasco
- Cardiovascular and Thoracic Department, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Pierluigi Omedè
- Cardiovascular and Thoracic Department, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Fulvio Orzan
- Cardiovascular and Thoracic Department, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
| | - Fiorenzo Gaita
- Cardiovascular and Thoracic Department, Azienda Ospedaliera Universitaria Città della Salute e della Scienza di Torino, Turin, Italy
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9
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Lai JCL, Tse G, Wu WK, Gong M, Bazoukis G, Wong WT, Wong SH, Lampropoulos K, Baranchuk A, Tse LA, Xia Y, Li G, Wong MC, Chan YS, Mu N, Dong M, Liu T. Patent foramen ovale closure versus medical therapy for stroke prevention: A systematic review and meta-analysis of randomized controlled trials. F1000Res 2017; 6:2178. [PMID: 30271571 PMCID: PMC6137413 DOI: 10.12688/f1000research.13444.1] [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] [Accepted: 08/17/2018] [Indexed: 10/11/2023] Open
Abstract
Background: Previous randomized trials on patent foramen ovale (PFO) closure versus medical therapy for stroke prevention were inconclusive. Recently, two new randomized trials and new findings from an extended follow-up of a previous trial have been published on this topic. We conducted a systematic review and meta-analysis of randomized trials comparing PFO closure with medical therapy for stroke prevention. Methods: PubMed and Cochrane Library were searched until 16 th September 2017. The following search terms were used for PubMed: "patent foramen ovale" AND (stroke OR embolism) and "randomized" AND "Trial". For Cochrane Library, the following terms were used: "patent foramen ovale" AND "closure" AND (stroke OR embolism). Results: A total of 91 and 55 entries were retrieved from each database using our search strategy respectively, of which six studies on five trials met the inclusion criteria. This meta-analysis included 1829 patients in the PFO closure arm (mean age: 45.3 years; 54% male) and 1972 patients in the medical therapy arm (mean age: 45.1 years; 51% male). The median follow-up duration was 50 ± 30 months. When compared to medical therapy, PFO closure significantly reduced primary endpoint events with a risk ratio [RR] of 0.60 (95% CI: 0.44-0.83, P < 0.0001; I 2: 15%). It also reduced stroke (RR: 0.50, 95% CI: 0.35-0.73, P < 0.0001; I 2: 32%) despite increasing the risk of atrial fibrillation/flutter (RR: 1.90, 95% CI: 1.23-2.93, P < 0.01; I 2: 43%). However, it did not reduce transient ischemic accident events (0.75; 95% CI: 0.51-1.10, P = 0.14; I 2: 0%), all-cause bleeding (RR: 0.89; 95% CI: 0.44-1.78, P = 0.74; I 2: 51%) or gastrointestinal complications (RR: 0.92; 95% CI: 0.32-2.70, P = 0.88; I 2: 0%). Conclusions: PFO closure significantly reduces risk of stroke when compared to medical treatment and should therefore be considered for stroke prevention in PFO patients.
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Affiliation(s)
- Jenny Chi Ling Lai
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, Hong Kong
- Li Ka Shing Institute of Health Sciences, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Gary Tse
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, Hong Kong
- Li Ka Shing Institute of Health Sciences, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - William K.K. Wu
- Li Ka Shing Institute of Health Sciences, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, Hong Kong
- Department of Anaesthesia and Intensive Care, State Key Laboratory of Digestive Disease, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Mengqi Gong
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular disease, Department of Cardiology, Tianjin Institute of Cardiology, The Second Hospital of Tianjin Medical University, Tianjin, 300211, China
| | - George Bazoukis
- Second Department of Cardiology, Evangelismos General Hospital of Athens, Athens, Greece
| | - Wing Tak Wong
- School of Life Sciences, Chinese University of Hong Kong, Hong Kong, Hong Kong
- State Key Laboratory of Agrobiotechnology, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Sunny Hei Wong
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, Hong Kong
- Li Ka Shing Institute of Health Sciences, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | | | - Adrian Baranchuk
- Division of Cardiology, Kingston General Hospital, Queen’s University, Kingston, ON, Canada
| | - Lap Ah Tse
- JC School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Yunlong Xia
- Department of Cardiovascular Medicine, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Guangping Li
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular disease, Department of Cardiology, Tianjin Institute of Cardiology, The Second Hospital of Tianjin Medical University, Tianjin, 300211, China
| | - Martin C.S. Wong
- JC School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Yat Sun Chan
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, Hong Kong
- Li Ka Shing Institute of Health Sciences, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Nan Mu
- Department of Gynecology and Obstetrics, Yantai Yuhuangding Hospital Affiliated to Qingdao University, Yantai, Shandong, 264000, China
| | - Mei Dong
- Department of Gynecology and Obstetrics, Yantai Yuhuangding Hospital Affiliated to Qingdao University, Yantai, Shandong, 264000, China
| | - Tong Liu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular disease, Department of Cardiology, Tianjin Institute of Cardiology, The Second Hospital of Tianjin Medical University, Tianjin, 300211, China
| | - International Health Informatics Study (IHIS) Network
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, Hong Kong
- Li Ka Shing Institute of Health Sciences, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, Hong Kong
- Department of Anaesthesia and Intensive Care, State Key Laboratory of Digestive Disease, Chinese University of Hong Kong, Hong Kong, Hong Kong
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular disease, Department of Cardiology, Tianjin Institute of Cardiology, The Second Hospital of Tianjin Medical University, Tianjin, 300211, China
- Second Department of Cardiology, Evangelismos General Hospital of Athens, Athens, Greece
- School of Life Sciences, Chinese University of Hong Kong, Hong Kong, Hong Kong
- State Key Laboratory of Agrobiotechnology, Chinese University of Hong Kong, Hong Kong, Hong Kong
- Division of Cardiology, Kingston General Hospital, Queen’s University, Kingston, ON, Canada
- JC School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong, Hong Kong
- Department of Cardiovascular Medicine, First Affiliated Hospital of Dalian Medical University, Dalian, China
- Department of Gynecology and Obstetrics, Yantai Yuhuangding Hospital Affiliated to Qingdao University, Yantai, Shandong, 264000, China
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10
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Saver JL, Carroll JD, Thaler DE, Smalling RW, MacDonald LA, Marks DS, Tirschwell DL. Long-Term Outcomes of Patent Foramen Ovale Closure or Medical Therapy after Stroke. N Engl J Med 2017; 377:1022-1032. [PMID: 28902590 DOI: 10.1056/nejmoa1610057] [Citation(s) in RCA: 619] [Impact Index Per Article: 88.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Whether closure of a patent foramen ovale reduces the risk of recurrence of ischemic stroke in patients who have had a cryptogenic ischemic stroke is unknown. METHODS In a multicenter, randomized, open-label trial, with blinded adjudication of end-point events, we randomly assigned patients 18 to 60 years of age who had a patent foramen ovale (PFO) and had had a cryptogenic ischemic stroke to undergo closure of the PFO (PFO closure group) or to receive medical therapy alone (aspirin, warfarin, clopidogrel, or aspirin combined with extended-release dipyridamole; medical-therapy group). The primary efficacy end point was a composite of recurrent nonfatal ischemic stroke, fatal ischemic stroke, or early death after randomization. The results of the analysis of the primary outcome from the original trial period have been reported previously; the current analysis of data from the extended follow-up period was considered to be exploratory. RESULTS We enrolled 980 patients (mean age, 45.9 years) at 69 sites. Patients were followed for a median of 5.9 years. Treatment exposure in the two groups was unequal (3141 patient-years in the PFO closure group vs. 2669 patient-years in the medical-therapy group), owing to a higher dropout rate in the medical-therapy group. In the intention-to-treat population, recurrent ischemic stroke occurred in 18 patients in the PFO closure group and in 28 patients in the medical-therapy group, resulting in rates of 0.58 events per 100 patient-years and 1.07 events per 100 patient-years, respectively (hazard ratio with PFO closure vs. medical therapy, 0.55; 95% confidence interval [CI], 0.31 to 0.999; P=0.046 by the log-rank test). Recurrent ischemic stroke of undetermined cause occurred in 10 patients in the PFO closure group and in 23 patients in the medical-therapy group (hazard ratio, 0.38; 95% CI, 0.18 to 0.79; P=0.007). Venous thromboembolism (which comprised events of pulmonary embolism and deep-vein thrombosis) was more common in the PFO closure group than in the medical-therapy group. CONCLUSIONS Among adults who had had a cryptogenic ischemic stroke, closure of a PFO was associated with a lower rate of recurrent ischemic strokes than medical therapy alone during extended follow-up. (Funded by St. Jude Medical; RESPECT ClinicalTrials.gov number, NCT00465270 .).
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Affiliation(s)
- Jeffrey L Saver
- From the University of California, Los Angeles (UCLA), Ronald Reagan UCLA Medical Center, Los Angeles (J.L.S.); University of Colorado, Denver, and University of Colorado Hospital, Aurora (J.D.C.), and South Denver Cardiology, Swedish Medical Center, Littleton (L.A.M.) - all in Colorado; Tufts University, Tufts Medical Center, Boston (D.E.T.); University of Texas, Memorial Hermann Heart and Vascular Institute, Houston (R.W.S.); Medical College of Wisconsin, Milwaukee (D.S.M.); and University of Washington, Seattle (D.L.T.)
| | - John D Carroll
- From the University of California, Los Angeles (UCLA), Ronald Reagan UCLA Medical Center, Los Angeles (J.L.S.); University of Colorado, Denver, and University of Colorado Hospital, Aurora (J.D.C.), and South Denver Cardiology, Swedish Medical Center, Littleton (L.A.M.) - all in Colorado; Tufts University, Tufts Medical Center, Boston (D.E.T.); University of Texas, Memorial Hermann Heart and Vascular Institute, Houston (R.W.S.); Medical College of Wisconsin, Milwaukee (D.S.M.); and University of Washington, Seattle (D.L.T.)
| | - David E Thaler
- From the University of California, Los Angeles (UCLA), Ronald Reagan UCLA Medical Center, Los Angeles (J.L.S.); University of Colorado, Denver, and University of Colorado Hospital, Aurora (J.D.C.), and South Denver Cardiology, Swedish Medical Center, Littleton (L.A.M.) - all in Colorado; Tufts University, Tufts Medical Center, Boston (D.E.T.); University of Texas, Memorial Hermann Heart and Vascular Institute, Houston (R.W.S.); Medical College of Wisconsin, Milwaukee (D.S.M.); and University of Washington, Seattle (D.L.T.)
| | - Richard W Smalling
- From the University of California, Los Angeles (UCLA), Ronald Reagan UCLA Medical Center, Los Angeles (J.L.S.); University of Colorado, Denver, and University of Colorado Hospital, Aurora (J.D.C.), and South Denver Cardiology, Swedish Medical Center, Littleton (L.A.M.) - all in Colorado; Tufts University, Tufts Medical Center, Boston (D.E.T.); University of Texas, Memorial Hermann Heart and Vascular Institute, Houston (R.W.S.); Medical College of Wisconsin, Milwaukee (D.S.M.); and University of Washington, Seattle (D.L.T.)
| | - Lee A MacDonald
- From the University of California, Los Angeles (UCLA), Ronald Reagan UCLA Medical Center, Los Angeles (J.L.S.); University of Colorado, Denver, and University of Colorado Hospital, Aurora (J.D.C.), and South Denver Cardiology, Swedish Medical Center, Littleton (L.A.M.) - all in Colorado; Tufts University, Tufts Medical Center, Boston (D.E.T.); University of Texas, Memorial Hermann Heart and Vascular Institute, Houston (R.W.S.); Medical College of Wisconsin, Milwaukee (D.S.M.); and University of Washington, Seattle (D.L.T.)
| | - David S Marks
- From the University of California, Los Angeles (UCLA), Ronald Reagan UCLA Medical Center, Los Angeles (J.L.S.); University of Colorado, Denver, and University of Colorado Hospital, Aurora (J.D.C.), and South Denver Cardiology, Swedish Medical Center, Littleton (L.A.M.) - all in Colorado; Tufts University, Tufts Medical Center, Boston (D.E.T.); University of Texas, Memorial Hermann Heart and Vascular Institute, Houston (R.W.S.); Medical College of Wisconsin, Milwaukee (D.S.M.); and University of Washington, Seattle (D.L.T.)
| | - David L Tirschwell
- From the University of California, Los Angeles (UCLA), Ronald Reagan UCLA Medical Center, Los Angeles (J.L.S.); University of Colorado, Denver, and University of Colorado Hospital, Aurora (J.D.C.), and South Denver Cardiology, Swedish Medical Center, Littleton (L.A.M.) - all in Colorado; Tufts University, Tufts Medical Center, Boston (D.E.T.); University of Texas, Memorial Hermann Heart and Vascular Institute, Houston (R.W.S.); Medical College of Wisconsin, Milwaukee (D.S.M.); and University of Washington, Seattle (D.L.T.)
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11
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Retrieval of Embolized Amplatzer Patent Foramen Ovale Occlusion Device: Issues Related to Late Recognition. Case Rep Cardiol 2017; 2017:9894215. [PMID: 28567311 PMCID: PMC5439245 DOI: 10.1155/2017/9894215] [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: 01/29/2017] [Accepted: 03/27/2017] [Indexed: 11/18/2022] Open
Abstract
Embolization of a percutaneous patent foramen ovale (PFO) closure device is a rare but serious complication. While early, periprocedural device embolization can normally be managed with snare and percutaneous retrieval, late embolization requires a different management strategy due to inability of the device to deform to allow passage into a large caliber sheath. We present a case of asymptomatic device embolization recognized six months following implantation and discuss the challenges encountered in successfully retrieving the device.
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12
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Clinically apparent long-term electric disturbances in the acute and very long-term of patent foramen ovale device-based closure. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2017; 18:118-122. [DOI: 10.1016/j.carrev.2016.10.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Revised: 10/25/2016] [Accepted: 10/25/2016] [Indexed: 11/22/2022]
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13
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Rigatelli G, Pedon L, Zecchel R, Dell'Avvocata F, Carrozza A, Zennaro M, Mazza A, Zuin M, Russo M, Zanchetta M. Long-Term Outcomes and Complications of Intracardiac Echocardiography-Assisted Patent Foramen Ovale Closure in 1,000 Consecutive Patients. J Interv Cardiol 2016; 29:530-538. [DOI: 10.1111/joic.12325] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Gianluca Rigatelli
- Section of Adult Congenital and Adult Heart Disease; Cardiovascular Diagnosis and Endoluminal Interventions; Rovigo General Hospital; Rovigo Italy
- Department of Cardiovascular Disease; Cittadella General Hospital; Padua Italy
| | - Luigi Pedon
- Department of Cardiovascular Disease; Cittadella General Hospital; Padua Italy
| | - Roberto Zecchel
- Department of Cardiovascular Disease; Cittadella General Hospital; Padua Italy
| | - Fabio Dell'Avvocata
- Section of Adult Congenital and Adult Heart Disease; Cardiovascular Diagnosis and Endoluminal Interventions; Rovigo General Hospital; Rovigo Italy
| | - Antonio Carrozza
- Department of Cardiovascular Disease; Cittadella General Hospital; Padua Italy
| | - Marco Zennaro
- Department of Cardiovascular Disease; Cittadella General Hospital; Padua Italy
| | - Alberto Mazza
- Department of Medical Sciences; Rovigo General Hospital; Rovigo Italy
| | - Marco Zuin
- Section of Adult Congenital and Adult Heart Disease; Cardiovascular Diagnosis and Endoluminal Interventions; Rovigo General Hospital; Rovigo Italy
| | - Monia Russo
- Department of NeuroSciences; Rovigo General Hospital; Rovigo Italy
| | - Mario Zanchetta
- Department of Cardiovascular Disease; Cittadella General Hospital; Padua Italy
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14
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Scalise F, Auguadro C, Sorropago G, Sorropago A, Novelli E, Finizio M, Specchia G. Long-Term Contrast Echocardiography and Clinical Follow-Up after Percutaneous Closure of Patent Foramen Ovale Using Two Different Atrial Septal Occluder Devices. J Interv Cardiol 2016; 29:406-13. [PMID: 27338839 DOI: 10.1111/joic.12314] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION Percutaneous patent foramen ovale (PFO) closure by means of a septal occluder device (SOD) is a well-known therapeutic strategy for the secondary prevention of paradoxical embolic neurological events. The aim of this study was to provide long-term echocardiographic and clinical follow-up data on patients who had undergone percutaneous PFO closure with 2 different SOD. METHODS We selected 2 groups of patients treated with 2 different SOD: Group A: 52 patients with an Amplatzer(®) PFO Occluder and Group B: 49 patients with a Figulla Flex(®) device. All patients underwent follow-up Bubble Test Transthoracic Echocardiography (BTTE) and clinical examination. The results were compared with those recently reported in a group of patients with similar characteristics, but that had been treated conservatively, which acted as a control group. RESULTS The mean follow-up after PFO closure was 53 months. The Amplatzer(®) PFO Occluder and the Figulla Flex were used in 52 (51.5%) and 49 (48.5%) of patients, respectively. We found no significant difference in the rate of effective PFO closure between the devices: Amplatzer 91.4%, Figulla 93.9% (P = 0.71). One patient (1.0%) suffered a recurrent neurologic event. BTTE was positive (BTTE+) in 8 patients (8%), 5 with an Amplatzer, and 3 with a Figulla device (P = 0.516). Only 1 patient with BTTE+ had a recurrent TIA (12.5%). No significant relationship was found between device dimensions and BTTE+ (P = 0.062). In the control group (163 patients), the recurrence of neurologic events was 9.2% (15 events), that was significantly higher in respect to the patients who had undergone percutaneous closure of the PFO. CONCLUSIONS Percutaneous PFO closure was associated with a remarkably low risk of recurrent embolic neurological events, and no long-term device-related major complications. No statistically significant difference emerged between the 2 different SODs regarding BTTE positivity. Long-term follow-up showed that the recurrence of neurological events has been significantly higher in the group treated in a conservative way.
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Affiliation(s)
- Filippo Scalise
- Department of Interventional Cardiology, Policlinico di Monza, Monza, Italy
| | - Carla Auguadro
- Department of Interventional Cardiology, Policlinico di Monza, Monza, Italy
| | - Giovanni Sorropago
- Department of Interventional Cardiology, Policlinico di Monza, Monza, Italy
| | - Antonio Sorropago
- Department of Interventional Cardiology, Policlinico di Monza, Monza, Italy
| | | | - Marica Finizio
- Department of Interventional Cardiology, Policlinico di Monza, Monza, Italy
| | - Giuseppe Specchia
- Department of Interventional Cardiology, Policlinico di Monza, Monza, Italy
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15
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Alcántara-Carmona S, Valdivia de la Fuente M, Pérez-Redondo M, Balandín-Moreno B, Villanueva-Fernández H, Ortega-López A. Late cardiac perforation following percutaneous sealing of a permeable foramen ovale. Med Intensiva 2016; 40:389-90. [PMID: 26856954 DOI: 10.1016/j.medin.2015.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Revised: 11/17/2015] [Accepted: 11/28/2015] [Indexed: 11/18/2022]
Affiliation(s)
- S Alcántara-Carmona
- Servicio de Medicina Intensiva, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, España.
| | - M Valdivia de la Fuente
- Servicio de Medicina Intensiva, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, España
| | - M Pérez-Redondo
- Servicio de Medicina Intensiva, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, España
| | - B Balandín-Moreno
- Servicio de Medicina Intensiva, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, España
| | - H Villanueva-Fernández
- Servicio de Medicina Intensiva, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, España
| | - A Ortega-López
- Servicio de Medicina Intensiva, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, España
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