1
|
Onorato EM, Alamanni F, Monizzi G, Mastrangelo A, Bartorelli AL. Case Report: Persistent residual shunt after a first percutaneous PFO closure followed by minimally invasive surgical failure: third time is a charm. Front Cardiovasc Med 2024; 11:1367515. [PMID: 39015678 PMCID: PMC11249728 DOI: 10.3389/fcvm.2024.1367515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 06/12/2024] [Indexed: 07/18/2024] Open
Abstract
Background Even though the optimal management of a moderate or large residual shunt following patent foramen ovale (PFO) closure is open to question, recent data confirmed that it is associated with an increased risk of stroke recurrence. Case summary A 48-year-old woman, a migraineur with visual aura, was diagnosed with a PFO associated with a huge multifenestrated atrial septal aneurysm (mfASA) and a moderate right-to-left shunt, detectable only after a Valsalva maneuver on contrast-transthoracic echocardiography. Brain magnetic resonance imaging showed a 1-mm silent white matter lesion in the right frontal lobe. Although the indication was not supported by guidelines, a transcatheter PFO closure was performed at another center with implantation of a large, equally sized, double-disc device (Figulla UNI 33/33 mm). At 6-month follow-up, a 2D/3D transesophageal echocardiography (TEE) color Doppler showed incorrect orientation of the device, which was not parallel to the interatrial septum, with two discs failing to capture the aortic muscular rim and partially protruding in the right atrium; furthermore, a 4 mm × 7 mm ASA fenestration was documented with a residual bidirectional shunt. Thereafter, the same team performed a minimally invasive cardiac surgery under femoro-femoral cardiopulmonary bypass; however, the procedure proved ineffective and was complicated by postoperative pericarditis with pericardial effusion, requiring further rehospitalization 1 month later due to persistent pericarditis, bilateral pleuritis, phrenic nerve palsy, and atrial flutter, which was treated with amiodarone. The patient asked for a second opinion, and our multidisciplinary heart team decided to offer a percutaneous redo intervention. An uneventful implantation of a regular PFO occluder (Figulla Flex II 16/18 mm) across the septal defect was performed successfully. Twelve-month follow-up with 2D TTE color Doppler and contrast transcranial Doppler showed correct position and good interaction between the two devices, with no residual shunt. Discussion In addition to the incorrect indication for PFO closure and the failure of minimally invasive surgery, the procedural mishap in this case could have been due to the inappropriate implantation of the first large device within the tunnel. It would have been better to deploy the same large device in the most central fenestration, covering the PFO and a greater part of the remaining mfASA at the same time.
Collapse
Affiliation(s)
- Eustaquio M. Onorato
- University Cardiology Department, I.R.C.C.S. Ospedale Galeazzi- Sant’Ambrogio, Milan, Italy
| | - Francesco Alamanni
- University Cardiac Surgery Department, I.R.C.C.S. Ospedale Galeazzi- Sant’Ambrogio, Milan, Italy
| | - Giovanni Monizzi
- University Cardiology Department, I.R.C.C.S. Ospedale Galeazzi- Sant’Ambrogio, Milan, Italy
| | - Angelo Mastrangelo
- University Cardiology Department, I.R.C.C.S. Ospedale Galeazzi- Sant’Ambrogio, Milan, Italy
| | - Antonio Luca Bartorelli
- University Cardiology Department, I.R.C.C.S. Ospedale Galeazzi- Sant’Ambrogio, Milan, Italy
- Department of Biomedical and Clinical Sciences, “Luigi Sacco”, University of Milan, Milan, Italy
| |
Collapse
|
2
|
Nakayama R, Takaya Y, Akagi T, Takemoto R, Haruna M, Nakashima M, Miki T, Nakagawa K, Toh N, Nakamura K. Relationship between patent foramen ovale anatomical features and residual shunt after patent foramen ovale closure. Cardiovasc Interv Ther 2024; 39:200-206. [PMID: 38265606 DOI: 10.1007/s12928-023-00979-y] [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: 08/21/2023] [Accepted: 11/27/2023] [Indexed: 01/25/2024]
Abstract
Transcatheter closure of patent foramen ovale (PFO) is an effective strategy for preventing recurrence of paradoxical embolism. However, PFO closure is often associated with residual shunt, which is a risk of recurrent stroke. This study aimed to evaluate the relationship between the anatomical features of PFO and residual shunt. The degree of residual shunt and its relationship with the anatomical features of PFO were evaluated in 106 patients who underwent PFO closure at our institution between March 2011 and January 2022 and in whom contrast transthoracic echocardiography was performed 1 year later. The mean PFO tunnel length was 9.3 ± 3.6 mm and the mean PFO height was 3.2 ± 2.2 mm. Atrial septal aneurysm (ASA) was found in 37 patients. After PFO closure, residual shunt was observed in 28 patients (grade 1, n = 8; grade 2, n = 16; grade 3, n = 3; grade 4, n = 1). Univariate logistic analysis identified ASA to be associated with residual shunt (odds ratio 2.78, 95% confidence interval 1.14 to 6.79; p = 0.024). There was no association of residual shunt with the size of the PFO, the length of PFO tunnel, or the size of the device used for closure. Two of four patients with a large residual shunt of grade 3 or grade 4 were found to have device size mismatch. Residual shunt after PFO closure was observed in a quarter of patients and was related to the presence of ASA. A few patients had a large residual shunt due to the device size mismatch.
Collapse
Affiliation(s)
- Rie Nakayama
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Yoichi Takaya
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan.
| | - Teiji Akagi
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Rika Takemoto
- Division of Medical Support, Okayama University Hospital, Okayama, Japan
| | - Madoka Haruna
- Division of Medical Support, Okayama University Hospital, Okayama, Japan
| | - Mitsutaka Nakashima
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Takashi Miki
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Koji Nakagawa
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Norihisa Toh
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| | - Kazufumi Nakamura
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558, Japan
| |
Collapse
|
3
|
Randhawa S, Mehta JL, Dhar G. Percutaneous Patent Foramen Ovale Closure: Stroke and Beyond. Curr Cardiol Rev 2024; 20:77-86. [PMID: 38485682 DOI: 10.2174/011573403x276984240304044109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 01/13/2024] [Accepted: 01/20/2024] [Indexed: 07/20/2024] Open
Abstract
Over 750,000 individuals suffer from stroke annually in the United States, with 87% of these strokes being ischemic in nature. Roughly 40% of ischemic strokes occur in individuals 60 years of age or under. A quarter of all ischemic strokes have no identifiable cause despite extensive workup and are deemed cryptogenic in nature. Patent Foramen Ovales (PFO) has been postulated in stroke causation by either paradoxical embolization or platelet activation in the tunnel of the defect. The incidence of PFO is reported to be 15-25% in the general population but rises to 40% in patients with cryptogenic stroke. While the initial trials evaluating PFO closures were non-revealing, subsequent long-term follow-ups, as well as recent trials evaluating PFO closures in cryptogenic stroke patients 60 years of age or under, demonstrated the superiority of percutaneous closure compared to medical therapy alone, leading to FDA approval of PFO closure devices. In this review, we review the diagnosis of PFO, postulated stroke mechanisms, literature supporting PFO closure, patient selection for percutaneous closure, procedural considerations, and associated procedural complications.
Collapse
Affiliation(s)
- Sandeep Randhawa
- Division of Cardiology, The University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Jawahar L Mehta
- Division of Cardiology, The University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Gaurav Dhar
- Division of Cardiology, The University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| |
Collapse
|
4
|
Devos P, Guedeney P, Montalescot G. Patent Foramen Ovale Percutaneous Closure: Evolution and Ongoing Challenges. J Clin Med 2023; 13:54. [PMID: 38202061 PMCID: PMC10780039 DOI: 10.3390/jcm13010054] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 11/28/2023] [Accepted: 12/15/2023] [Indexed: 01/12/2024] Open
Abstract
Patent foramen ovale (PFO) concerns nearly a quarter of the general population and incidence may reach up to 50% in patients with cryptogenic stroke. Recent randomized clinical trials confirmed that percutaneous closure of PFO-related stroke reduces the risk of embolic event recurrence. PFO also comes into play in other pathogenic conditions, such as migraine, decompression sickness or platypnea-orthodeoxia syndrome, where the heterogeneity of patients is high and evidence for closure is less well-documented. In this review, we describe the current indications for PFO percutaneous closure and the remaining challenges, and try to provide future directions regarding the technique and its indications.
Collapse
Affiliation(s)
- Perrine Devos
- ACTION Study Group, INSERM UMRS_1166 Institut de Cardiologie (AP-HP), Sorbonne Université, 75005 Paris, France; (P.D.); (P.G.)
| | - Paul Guedeney
- ACTION Study Group, INSERM UMRS_1166 Institut de Cardiologie (AP-HP), Sorbonne Université, 75005 Paris, France; (P.D.); (P.G.)
| | - Gilles Montalescot
- ACTION Study Group, INSERM UMRS_1166 Institut de Cardiologie (AP-HP), Sorbonne Université, 75005 Paris, France; (P.D.); (P.G.)
- Institut de Cardiologie, Centre Hospitalier Universitaire, Pitié-Salpêtrière, 47 Boulevard de l’Hôpital, 75013 Paris, France
| |
Collapse
|
5
|
Katsianos E, Oikonomou E, Kalogeras K, Manousaki A, Kalantzis C, Pantelidis P, Vavuranakis MA, Aggeli K, Siasos G, Tsioufis C, Vavuranakis M. Residual Right-to-Left-Shunt Following Transcatheter Patent Foramen Ovale Closure: The Role of Antithrombotic Treatment. Curr Pharm Des 2022; 28:3305-3312. [PMID: 36306457 DOI: 10.2174/1381612829666221028095839] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 09/26/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND Transcatheter closure of patent foramen ovale (PFO) is a highly effective therapy for patients with left circulation thromboembolism, not attributable to other conditions. OBJECTIVES This retrospective cohort study investigates the impact of baseline foramen ovale anatomy on the severity of the postclosure shunt. METHODS Patients with PFO, who underwent percutaneous closure, were followed up for at least 5 years postimplantation. Patients were classified into two groups based on the presence of high-risk features of the baseline PFO anatomy. At the follow-up follow-up, residual right-to-left shunt was assessed for the high and non-highrisk anatomy groups, via transcranial Doppler at rest and after performing the Valsalva maneuver, with the injection of agitated saline. RESULTS 38 patients were examined after a mean follow-up period of 9 ± 3 years after implantation. After retrospective evaluation of the baseline transthoracic and transesophageal echo studies, 14 patients with high-risk PFO anatomy were identified. The degree of the residual right-to-left shunt, as assessed by the number of microbubbles was higher in the high-risk PFO anatomy group compared to the non-high-risk group, both at rest [1.50 (IQR: 0.00-3.25) vs. 0.00 (IQR: 0.00-0.00), p < 0.001] and post-Valsalva maneuver [7.50 (IQR: 1.50- 10.25) vs. 0.00 (IQR: 0.00-3.75), p = 0.003]. Furthermore, in the high-risk group, more microbubbles were detected at rest (p = 0.008) and post-Valsalva (p = 0.002) in subjects without antiplatelet treatment compared to subjects on prolonged antiplatelet therapy. CONCLUSION Baseline PFO anatomy affects the severity of the residual right-to-left shunt. Prolonged antiplatelet therapy may benefit patients with high-risk anatomical features.
Collapse
Affiliation(s)
- Efstratios Katsianos
- 3rd Cardiology Clinic, National and Kapodistrian University of Athens, Medical School, Sotiria Chest Disease Hospital, Athens. Greece
| | - Evangelos Oikonomou
- 3rd Cardiology Clinic, National and Kapodistrian University of Athens, Medical School, Sotiria Chest Disease Hospital, Athens. Greece.,1st Cardiology Clinic, National and Kapodistrian University of Athens, Medical School, "Hippokration" General Hospital, Athens, Greece
| | - Konstantinos Kalogeras
- 3rd Cardiology Clinic, National and Kapodistrian University of Athens, Medical School, Sotiria Chest Disease Hospital, Athens. Greece
| | - Alexandra Manousaki
- 1st Cardiology Clinic, National and Kapodistrian University of Athens, Medical School, "Hippokration" General Hospital, Athens, Greece
| | - Charalambos Kalantzis
- 1st Cardiology Clinic, National and Kapodistrian University of Athens, Medical School, "Hippokration" General Hospital, Athens, Greece
| | - Panteleimon Pantelidis
- 3rd Cardiology Clinic, National and Kapodistrian University of Athens, Medical School, Sotiria Chest Disease Hospital, Athens. Greece
| | | | - Konstantina Aggeli
- 3rd Cardiology Clinic, National and Kapodistrian University of Athens, Medical School, Sotiria Chest Disease Hospital, Athens. Greece
| | - Gerasimos Siasos
- 3rd Cardiology Clinic, National and Kapodistrian University of Athens, Medical School, Sotiria Chest Disease Hospital, Athens. Greece.,1st Cardiology Clinic, National and Kapodistrian University of Athens, Medical School, "Hippokration" General Hospital, Athens, Greece
| | - Costas Tsioufis
- 1st Cardiology Clinic, National and Kapodistrian University of Athens, Medical School, "Hippokration" General Hospital, Athens, Greece
| | - Manolis Vavuranakis
- 3rd Cardiology Clinic, National and Kapodistrian University of Athens, Medical School, Sotiria Chest Disease Hospital, Athens. Greece.,1st Cardiology Clinic, National and Kapodistrian University of Athens, Medical School, "Hippokration" General Hospital, Athens, Greece
| |
Collapse
|
6
|
Gaetti G, Beneduce A, La Fauci D, Scardoni A, Chiappa F, Bellini L, Franzin M, Natale AM, Marras P, Ranieri P, Signorelli C, Bossi E, Ferrario L, Foglia E, Montorfano M, Odone A. Suture-Mediated Patent Foramen Ovale Closure Using the NobleStitch EL: Results from a Hospital-Based HTA. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19137863. [PMID: 35805522 PMCID: PMC9266135 DOI: 10.3390/ijerph19137863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 06/18/2022] [Accepted: 06/24/2022] [Indexed: 11/17/2022]
Abstract
(1) Background: Patent foramen ovale (PFO) is a congenital abnormality present in up to 25% of the general population, and it is a relevant cause of cryptogenic stroke. We applied the hospital-based HTA model (AdHopHTA) to conduct a multidimensional assessment of NobleStitch EL, an innovative suture-mediated PFO closure device. We compared it to Amplatzer PFO Occluder (APO) to provide evidence to inform technologies’ governance in hospital settings. (2) Methods: For each AdHopHTA dimension we: systematically retrieved available evidence from the literature applying the PRISMA guidelines and then analyzed original clinical and cost data of a NobleStitch EL device at San Raffaele research hospital in Milan (Italy). The economic dimension was analyzed through activity-based costing and a cost analysis. We conducted semi-structured interviews with selected healthcare professionals to explore the organizational, legal, social, and ethical impact. (3) Results: A single study was included for the NobleStitch EL, with 10 for APO. Both literature data and original data showed comparable safety. Efficacy data analysis found that the PFO closure was at 89% for NobleStitch EL vs. 89–97% for APO. APO has a better impact on the budget and minor process costs. Consulted experts reported that the organizational impact of NobleStitch EL in the short and the long run as null, albeit a better impact under the social and the ethical aspects. (4) Conclusion: We suggest that there is inadequate evidence to conclude the relative efficacy of NobleStitch EL as compared to APO. Nevertheless, this report shows a good safety profile and higher costs for NobleStitch EL, with no organizational or legal impact. Further studies in selected population are recommended.
Collapse
Affiliation(s)
- Giovanni Gaetti
- School of Public Health, Vita-Salute San Raffaele University, 20132 Milan, Italy; (G.G.); (A.S.); (F.C.); (L.B.); (E.B.)
| | - Alessandro Beneduce
- Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (A.B.); (M.M.)
| | - Dario La Fauci
- HTA Committee, IRCCS San Raffaele Hospital, 20132 Milan, Italy; (D.L.F.); (M.F.); (A.M.N.); (P.M.); (P.R.); (C.S.)
| | - Alessandro Scardoni
- School of Public Health, Vita-Salute San Raffaele University, 20132 Milan, Italy; (G.G.); (A.S.); (F.C.); (L.B.); (E.B.)
| | - Federica Chiappa
- School of Public Health, Vita-Salute San Raffaele University, 20132 Milan, Italy; (G.G.); (A.S.); (F.C.); (L.B.); (E.B.)
| | - Lorenzo Bellini
- School of Public Health, Vita-Salute San Raffaele University, 20132 Milan, Italy; (G.G.); (A.S.); (F.C.); (L.B.); (E.B.)
| | - Michela Franzin
- HTA Committee, IRCCS San Raffaele Hospital, 20132 Milan, Italy; (D.L.F.); (M.F.); (A.M.N.); (P.M.); (P.R.); (C.S.)
| | - Anna Maria Natale
- HTA Committee, IRCCS San Raffaele Hospital, 20132 Milan, Italy; (D.L.F.); (M.F.); (A.M.N.); (P.M.); (P.R.); (C.S.)
| | - Paola Marras
- HTA Committee, IRCCS San Raffaele Hospital, 20132 Milan, Italy; (D.L.F.); (M.F.); (A.M.N.); (P.M.); (P.R.); (C.S.)
| | - Paolo Ranieri
- HTA Committee, IRCCS San Raffaele Hospital, 20132 Milan, Italy; (D.L.F.); (M.F.); (A.M.N.); (P.M.); (P.R.); (C.S.)
| | - Carlo Signorelli
- HTA Committee, IRCCS San Raffaele Hospital, 20132 Milan, Italy; (D.L.F.); (M.F.); (A.M.N.); (P.M.); (P.R.); (C.S.)
| | - Eleonora Bossi
- School of Public Health, Vita-Salute San Raffaele University, 20132 Milan, Italy; (G.G.); (A.S.); (F.C.); (L.B.); (E.B.)
| | - Lucrezia Ferrario
- Centre for Research on Health Economics, Social and Health Care Management, Carlo Cattaneo-LIUC University, 21053 Castellanza, Italy; (L.F.); (E.F.)
| | - Emanuela Foglia
- Centre for Research on Health Economics, Social and Health Care Management, Carlo Cattaneo-LIUC University, 21053 Castellanza, Italy; (L.F.); (E.F.)
| | - Matteo Montorfano
- Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (A.B.); (M.M.)
| | - Anna Odone
- HTA Committee, IRCCS San Raffaele Hospital, 20132 Milan, Italy; (D.L.F.); (M.F.); (A.M.N.); (P.M.); (P.R.); (C.S.)
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, 27100 Pavia, Italy
- Correspondence:
| |
Collapse
|
7
|
Iskander B, Anwer F, Oliveri F, Fotios K, Panday P, Arcia Franchini AP, Hamid P. Amplatzer Patent Foramen Ovale Occluder Device-Related Complications. Cureus 2022; 14:e23756. [PMID: 35402119 PMCID: PMC8980243 DOI: 10.7759/cureus.23756] [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: 09/12/2021] [Accepted: 04/01/2022] [Indexed: 11/05/2022] Open
Abstract
Patent foramen ovale (PFO) is a standard variant that is present in 25% of the whole adult population. In a certain population, PFO can lead to cerebrovascular accidents. Mechanism of cerebrovascular accidents can be by paradoxical embolization from the right circulation or in situ thrombosis. Diagnosis of a PFO-responsible cerebrovascular accident is based on a thorough work-up to exclude other possible etiologies and detect PFO on trans-thoracic or trans-esophageal echocardiography with bubble study and/or Doppler. Over the last few years, multiple studies have supported that percutaneous PFO closure is superior to medical therapy in the secondary prevention of cerebrovascular accidents. However, numerous adverse events have been linked to PFO closure devices in general compared to medical therapy as new-onset atrial fibrillation, residual shunt, device-related thrombus, bleeding, deep vein thrombosis, pulmonary embolism, and inter-atrial septal erosions. Amplatzer device is one of the PFO occluder devices approved by the FDA. Device-related adverse events have been addressed by comparing the Amplatzer device with other PFO occluder devices. Based on the new data, we expect to see more complications related to PFO closure in the coming few years. We reviewed different studies that looked at the PFO closure-related complications and the trials comparing adverse events in the Amplatzer PFO occluder device compared to other devices. Amplatzer PFO occluder device is either superior or non-statistically different from other PFO occluder devices related to new-onset atrial fibrillation and residual shunt. More studies are needed to address the other less common adverse events. Since many of the device-related complications appear many years after device placement, a long-term follow-up is recommended.
Collapse
|
8
|
Cho KK, Khanna S, Lo P, Cheng D, Roy D. Persistent pathology of the patent foramen ovale: a review of the literature. Med J Aust 2021; 215:89-93. [PMID: 34218432 DOI: 10.5694/mja2.51141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 12/14/2020] [Accepted: 12/15/2020] [Indexed: 11/17/2022]
Abstract
A patent foramen ovale (PFO) is an interatrial shunt, with a prevalence of 20-34% in the general population. While most people do not have secondary manifestations of a PFO, some reported sequelae include ischaemic stroke, migraine, platypnoea-orthodeoxia syndrome and decompression illness. Furthermore, in some cases, PFO closure should be considered for patients before neurosurgery and for patients with concomitant carcinoid syndrome. Recent trials support PFO closure for ischaemic stroke patients with high risk PFOs and absence of other identified stroke mechanisms. While PFOs can be associated with migraine with auras, with some patients reporting symptomatic improvement after closure, the evidence from randomised controlled trials is less clear in supporting the use of PFO closure for migraine treatment. PFO closure for other indications such as platypnoea-orthodeoxia syndrome, decompression illness and paradoxical embolism are based largely on case series with good clinical outcomes. PFO closure can be performed as a day surgical intervention with high procedural success and low risk of complications.
Collapse
Affiliation(s)
- Kenneth K Cho
- St Vincent's Hospital Sydney, Sydney, NSW.,Western Sydney University, Sydney, NSW
| | - Shaun Khanna
- St Vincent's Hospital Sydney, Sydney, NSW.,University of New South Wales, Sydney, NSW
| | - Phillip Lo
- St Vincent's Hospital Sydney, Sydney, NSW
| | | | - David Roy
- St Vincent's Hospital Sydney, Sydney, NSW.,University of New South Wales, Sydney, NSW
| |
Collapse
|
9
|
D'Andrea A, Dweck MR, Holte E, Fontes-Carvalho R, Cameli M, Aboumarie HS, Diener HC, Haugaa KH. EACVI survey on the management of patients with patent foramen ovale and cryptogenic stroke. Eur Heart J Cardiovasc Imaging 2021; 22:135-141. [PMID: 33346351 PMCID: PMC7822641 DOI: 10.1093/ehjci/jeaa318] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 11/05/2020] [Indexed: 11/14/2022] Open
Abstract
AIMS The European Association of Cardiovascular Imaging (EACVI) Scientific Initiatives Committee performed a global survey to evaluate the current practice for the assessment and management of patients with suspected patent foramen ovale (PFO) and cryptogenic stroke. METHODS AND RESULTS In total, 79 imaging centres from 34 countries across the world responded to the survey, which comprised 17 questions. Most non-invasive investigations for PFO were widely available in the responding centres, with the exception of transcranial colour Doppler which was only available in 70% of sites, and most commonly performed by neurologists. Standard transthoracic echocardiography, with or without bubbles, was considered the first-level test for suspected PFO in the majority of the centres, whereas transoesophageal echocardiography was an excellent second-level modality. Most centres would rule out atrial fibrillation (AF) as a source of embolism in all patients with cryptogenic stroke (63%), with the remainder reserving investigation for patients with multiple AF risk factors (33%). Cardiac magnetic resonance was the preferred tool for identifying other unusual aetiologies, like cardiac masses or thrombi. After PFO closure, there was variation in the use of antiplatelet therapy: a quarter recommended treatment for life, while only 12% recommended 5 years as stipulated in the guidelines (12%). Antibiotic prophylaxis prior to dental or endoscopic procedures was not recommended in 41% of centres, contrary to what the guidelines recommended. CONCLUSION Our survey revealed a variable adherence to the current recommendations for the diagnosis and management of patients with cryptogenic stroke and PFO. Efforts should focus on optimizing and standardizing diagnostic tests and treatment of this condition.
Collapse
Affiliation(s)
- Antonello D'Andrea
- Department of Cardiology, Umberto I_ Hospital, Luigi Vanvitelli University - Nocera Inferiore (ASL Salerno), Viale San Francesco - 84014 Caserta, Italy
| | - Marc R Dweck
- BHF Centre for Cardiovascular Science, Department of Cardiology, University of Edinburgh, Edinburgh, EH16 4SB, UK
| | - Espen Holte
- Department of Cardiology, St. Olavs Hospital, Postboks 3250 Torgarden, 7006 Trondheim, Norway
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology NTNU, Trondheim, PO Box 8905, 7491 Trondheim, Norway
| | - Ricardo Fontes-Carvalho
- Cardiovascular Research and Development Unit, Department of Physiology and Cardiothoracic Surgery, Faculty of Medicine, University of Porto, Al. Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
| | - Matteo Cameli
- Department of Cardiovascular Diseases, University of Siena, Policlinico Le Scotte, Viale Bracci 16, 53100 Siena, Italy
| | - Hatem Soliman Aboumarie
- Department of Cardiology - Harefield Hospital, Royal Brompton and Harefield NHS Foundation Trust, UB9 6JH London, UK
| | - Hans Christoph Diener
- Department of Neurology - Medical Faculty of the University Duisburg-Essen—Institute for Medical Informatics, Biometry and Epidemiology, Hufelandstraße, 26, 45147 Essen, Germany
| | - Kristina H Haugaa
- Department of Cardiology, Oslo University Hospital, Postboks 4950 Nydalen, 0424 Oslo, Norway
- Department of Cardiology - Institute for Clinical Medicine, University of Oslo, Postboks 1171 Blindern, 0318 Oslo, Norway
| |
Collapse
|
10
|
Drakopoulou M, Soulaidopoulos S, Stathogiannis K, Oikonomou G, Papanikolaou A, Toutouzas K, Tousoulis D. Antiplatelet and Antithrombotic Therapy After Patent Foramen Oval and Atrial Septal Defect Closure. Curr Pharm Des 2021; 26:2769-2779. [PMID: 32338207 DOI: 10.2174/1385272824999200427083838] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 05/18/2020] [Indexed: 12/18/2022]
Abstract
Pathologies of the atrial septum include different interatrial communications varying from patent foramen ovale (PFO) to actual defects. Atrial septal defects (ASDs) may be localized within the fossa ovalis such as the secundum type ASD or outside the region of fossa ovalis, such as the ostium primum defect and sinus venosus defect. Over the last decades, the percutaneous closure of interatrial shunts has become a feasible and safe method. During these procedures, the delicate balance between thrombotic risk, device sealing process and bleeding risk is crucial. In this review, we sought to describe current available data on the antiplatelet and antithrombotic management of patients after percutaneous ASD or PFO closure.
Collapse
Affiliation(s)
- Maria Drakopoulou
- First Department of Cardiology, Hippokration Hospital, Medical School of Athens University, Athens, Greece
| | - Stergios Soulaidopoulos
- First Department of Cardiology, Hippokration Hospital, Medical School of Athens University, Athens, Greece
| | - Konstantinos Stathogiannis
- First Department of Cardiology, Hippokration Hospital, Medical School of Athens University, Athens, Greece
| | - Georgios Oikonomou
- First Department of Cardiology, Hippokration Hospital, Medical School of Athens University, Athens, Greece
| | - Aggelos Papanikolaou
- First Department of Cardiology, Hippokration Hospital, Medical School of Athens University, Athens, Greece
| | - Konstantinos Toutouzas
- First Department of Cardiology, Hippokration Hospital, Medical School of Athens University, Athens, Greece
| | - Dimitrios Tousoulis
- First Department of Cardiology, Hippokration Hospital, Medical School of Athens University, Athens, Greece
| |
Collapse
|
11
|
Microtransesophageal Echocardiographic Guidance during Percutaneous Interatrial Septal Closure without General Anaesthesia. J Interv Cardiol 2020; 2020:1462140. [PMID: 32982607 PMCID: PMC7492935 DOI: 10.1155/2020/1462140] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 07/30/2020] [Accepted: 08/31/2020] [Indexed: 11/23/2022] Open
Abstract
Objective To study the safety and efficacy of microtransesophageal echocardiography (micro-TEE) and TEE during percutaneous atrial septal defect (ASD) and patent foramen ovale (PFO) closure. Background TEE has proven to be safe during ASD and PFO closure under general anaesthesia. Micro-TEE makes it possible to perform these procedures under local anaesthesia. We are the first to describe the safety and efficacy of micro-TEE for percutaneous closure. Methods All consecutive patients who underwent ASD and PFO closure between 2013 and 2018 were included. The periprocedural complications were registered. Residual shunts were diagnosed using transthoracic contrast echocardiography (TTCE). All data were compared between the use of TEE or micro-TEE within the ASD and PFO groups separately. Results In total, 82 patients underwent ASD closure, 46 patients (49.1 ± 15.0 years) with TEE and 36 patients (47.8 ± 12.1 years) using micro-TEE guidance. Median device diameter was, respectively, 26 mm (range 10–40 mm) and 27 mm (range 10–35 mm). PFO closure was performed in 120 patients, 55 patients (48.6 ± 9.2 years, median device diameter 25 mm, range 23–35 mm) with TEE and 65 patients (mean age 51.0 ± 11.8 years, median device diameter 27 mm, range 23–35 mm) using micro-TEE. There were no major periprocedural complications, especially no device embolizations within all groups. Six months after closure, there was no significant difference in left-to-right shunt after ASD closure and no significant difference in right-to-left shunt after PFO closure using TEE or micro-TEE. Conclusion Micro-TEE guidance without general anaesthesia during percutaneous ASD and PFO closure is as safe as TEE, without a significant difference in the residual shunt rate after closure.
Collapse
|
12
|
Harb SC, Huded CP. Structural Interventions and Procedural Imaging. JACC Cardiovasc Interv 2020; 13:2121-2123. [DOI: 10.1016/j.jcin.2020.06.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 06/30/2020] [Indexed: 01/10/2023]
|
13
|
Deng W, Yin S, McMullin D, Inglessis-Azuaje I, Elmariah S, Hung J, Lo EH, Palacios IF, Buonanno FS, Ning M. Residual Shunt After Patent Foramen Ovale Closure and Long-Term Stroke Recurrence: A Prospective Cohort Study. Ann Intern Med 2020; 172:717-725. [PMID: 32422058 PMCID: PMC10021023 DOI: 10.7326/m19-3583] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Residual shunt is observed in up to 25% of patients after patent foramen ovale (PFO) closure, but its long-term influence on stroke recurrence currently is unknown. OBJECTIVE To investigate the association of residual shunt after PFO closure with the incidence of recurrent stroke and transient ischemic attack (TIA). DESIGN Prospective cohort study comparing stroke or TIA recurrence in patients with and without residual shunt after PFO closure. SETTING Single hospital center. PARTICIPANTS 1078 consecutive patients (mean age, 49.3 years) with PFO-attributable cryptogenic stroke who were undergoing percutaneous PFO closure were followed for up to 11 years. MEASUREMENTS Residual shunt was evaluated by transthoracic echocardiography with saline contrast. Primary outcome was a composite of the first recurrent ischemic stroke or TIA after PFO closure. RESULTS Compared with complete closure, the presence of residual shunt after PFO closure was associated with an increased incidence of recurrent stroke or TIA: 2.32 versus 0.75 events per 100 patient-years (hazard ratio [HR], 3.05 [95% CI, 1.65 to 5.62]; P < 0.001). This result remained robust after adjustment for important covariates, namely age; study period; device; presence of atrial septal aneurysm, hypertension, hyperlipidemia, diabetes, hypercoagulability, or hypermobile septum; and medication use (HR, 3.01 [CI, 1.59 to 5.69]; P < 0.001). Further stratification based on shunt size revealed that moderate or large residual shunts were associated with a higher risk for stroke or TIA recurrence (HR, 4.50 [CI, 2.20 to 9.20]; P < 0.001); the result for small residual shunts was indeterminate (HR, 2.02 [CI, 0.87 to 4.69]; P = 0.102). LIMITATION Nonrandomized study with potential unmeasured confounding. CONCLUSION Among patients undergoing PFO closure to prevent future stroke, the presence of residual shunt, particularly a moderate or large residual shunt, was associated with an increased risk for stroke or TIA recurrence. PRIMARY FUNDING SOURCE National Institutes of Health.
Collapse
Affiliation(s)
- Wenjun Deng
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (W.D., S.Y., D.M., I.I., S.E., J.H., E.H.L., I.F.P., F.S.B., M.N.)
| | - Shanye Yin
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (W.D., S.Y., D.M., I.I., S.E., J.H., E.H.L., I.F.P., F.S.B., M.N.)
| | - David McMullin
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (W.D., S.Y., D.M., I.I., S.E., J.H., E.H.L., I.F.P., F.S.B., M.N.)
| | - Ignacio Inglessis-Azuaje
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (W.D., S.Y., D.M., I.I., S.E., J.H., E.H.L., I.F.P., F.S.B., M.N.)
| | - Sammy Elmariah
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (W.D., S.Y., D.M., I.I., S.E., J.H., E.H.L., I.F.P., F.S.B., M.N.)
| | - Judy Hung
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (W.D., S.Y., D.M., I.I., S.E., J.H., E.H.L., I.F.P., F.S.B., M.N.)
| | - Eng H Lo
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (W.D., S.Y., D.M., I.I., S.E., J.H., E.H.L., I.F.P., F.S.B., M.N.)
| | - Igor F Palacios
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (W.D., S.Y., D.M., I.I., S.E., J.H., E.H.L., I.F.P., F.S.B., M.N.)
| | - Ferdinando S Buonanno
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (W.D., S.Y., D.M., I.I., S.E., J.H., E.H.L., I.F.P., F.S.B., M.N.)
| | - MingMing Ning
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (W.D., S.Y., D.M., I.I., S.E., J.H., E.H.L., I.F.P., F.S.B., M.N.)
| |
Collapse
|
14
|
Arfaras-Melainis A, Palaiodimos L, Mojadidi MK. Transcatheter Closure of Patent Foramen Ovale: Randomized Trial Update. Interv Cardiol Clin 2019; 8:341-356. [PMID: 31445719 DOI: 10.1016/j.iccl.2019.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
A patent foramen ovale (PFO) is found in about one-quarter of all adults, but the prevalence increases to approximately half of those with a history of a so-called cryptogenic stroke. The true efficacy of PFO closure for prevention of recurrent paradoxical embolism has been debated for years, as the early 3 randomized trials did not show a statistically significant benefit of PFO closure over standard-of-care medical therapy. However, 3 recent randomized trials along with the long-term follow-up data from the largest early trial demonstrated superiority of device closure for secondary stroke prevention.
Collapse
Affiliation(s)
- Angelos Arfaras-Melainis
- Second Cardiology Department, National and Kapodistrian University of Athens, Attikon University Hospital, 1 Rimini Street, Haidari, Athens 12462, Greece
| | - Leonidas Palaiodimos
- Department of Medicine, Division of Hospital Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467, USA.
| | - Mohammad K Mojadidi
- Division of Cardiology, Department of Medicine, Virginia Commonwealth University, 1101 East Marshall Street, Richmond, VA 23298, USA
| |
Collapse
|
15
|
Abstract
Patent foramen ovale (PFO), an embryonic remnant of the fetal circulation, is present in 20-25% of adults. Although recent observational studies and clinical trials have established the link between PFO-mediated right-to-left shunting with cryptogenic stroke and migraine with aura, the role of a PFO in exacerbating hypoxemic medical conditions (ie, sleep apnea, chronic obstructive pulmonary disease, pulmonary hypertension, platypnea-orthodeoxia, pulmonary arteriovenous malformation, high-altitude pulmonary edema, and exercise desaturation) remains less understood. PFO-mediated hypoxemia occurs when deoxygenated venous blood from the right atrium enters and mixes with oxygenated arterial blood in the left atrium. Patients with an intracardiac right-to-left shunt may have profound hypoxemia out of proportion to underlying primary lung disease, even in the presence of normal right-sided pressures. The presence of right-to-left cardiac shunting can exacerbate the degree of hypoxemia in patients with underlying pulmonary disorders. In a subset of these patients, percutaneous PFO closure may result in marked improvement in dyspnea and hypoxemia. This review discusses the association between PFO-mediated right-to-left shunting with medical conditions associated with hypoxemia and explores the role of percutaneous PFO closure in alleviating the hypoxemia.
Collapse
|
16
|
Pristipino C, Sievert H, D'Ascenzo F, Mas JL, Meier B, Scacciatella P, Hildick-Smith D, Gaita F, Toni D, Kyrle P, Thomson J, Derumeaux G, Onorato E, Sibbing D, Germonpré P, Berti S, Chessa M, Bedogni F, Dudek D, Hornung M, Zamorano J. European position paper on the management of patients with patent foramen ovale. General approach and left circulation thromboembolism. EUROINTERVENTION 2019; 14:1389-1402. [PMID: 30141306 DOI: 10.4244/eij-d-18-00622] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/03/2023]
|
17
|
Collado FMS, Poulin MF, Murphy JJ, Jneid H, Kavinsky CJ. Patent Foramen Ovale Closure for Stroke Prevention and Other Disorders. J Am Heart Assoc 2018; 7:e007146. [PMID: 29910192 PMCID: PMC6220531 DOI: 10.1161/jaha.117.007146] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Fareed Moses S Collado
- Division of Cardiology, Department of Medicine, Rush University Medical Center, Chicago, IL
| | - Marie-France Poulin
- Division of Cardiology, Department of Medicine, Rush University Medical Center, Chicago, IL
| | - Joshua J Murphy
- Division of Cardiology, Department of Medicine, Rush University Medical Center, Chicago, IL
| | - Hani Jneid
- Division of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Clifford J Kavinsky
- Division of Cardiology, Department of Medicine, Rush University Medical Center, Chicago, IL
| |
Collapse
|
18
|
Susuri N, Obeid S, Ulmi M, Siontis G, Wahl A, Windecker S, Nietlispach F, Meier B, Praz F. Second transcatheter closure for residual shunt following percutaneous closure of patent foramen ovale. EUROINTERVENTION 2017; 13:858-866. [DOI: 10.4244/eij-d-17-00061] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
19
|
Cheli M, Canepa M, Brunelli C, Bezante GP, Favorini S, Rollando D, Sivori G, Viani E, Finocchi C, Balbi M. Recurrent and Residual Shunts After Patent Foramen Ovale Closure: Results From a Long-Term Transcranial Doppler Study. J Interv Cardiol 2016; 28:600-8. [PMID: 26643006 DOI: 10.1111/joic.12255] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES Assess the evolution of right-to-left shunt (RLS) after transcatheter patent foramen ovale (PFO) closure. BACKGROUND Despite the high number of interventional procedures performed worldwide, limited systematic data on the long-term abolition of RLS after percutaneous closure are available. METHODS All patients treated at our Institution between February 2001 and July 2009 were included in this single center, prospective study, and were asked to repeat late contrast transcranial Doppler (cTCD). Rate of complete closure, residual RLS (i.e., a shunt that persists after closure), and recurrent RLS (i.e., a shunt that reappears after a previous negative cTCD) was assessed. RESULTS Long-term follow-up was completed in 120 patients (56% male). RLS was still detectable 4.9 ± 2.3 years (range 1.3-10.3) after the procedure in 55 patients; 20 (17%) had residual RLS and 35 (29%) had recurrent RLS. Multivariate analysis revealed that significant predictors of residual RLS included post-procedural shunt at transesophageal echocardiography (OR 3.07, 95%CI 0.97-9.7), use of a bigger device (35 vs 25 mm, OR 3.85, 95%CI 1.22-12.2) and length of follow-up (OR 0.75, 95%CI 0.57-0.98), while only length of follow-up (OR 0.77, 95%CI 0.62-0.95) was associated with recurrent RLS. Neurological recurrences (1 stroke, 6 transient ischemic attacks) were equally distributed between the groups. CONCLUSION A significant number of recurrent and residual shunts may be observed by cTCD up to 5 years after PFO closure. Management of late RLSs includes periodic re-evaluation, exclusion of device-induced complications or secondary sources of RLS, and optimization of antithrombotic treatment with or without a second intervention.
Collapse
Affiliation(s)
- Martino Cheli
- Cardiology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Marco Canepa
- Cardiology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy.,Longitudinal Studies Section, Translational Gerontology Branch, NIA/NIH, Baltimore, Maryland
| | - Claudio Brunelli
- Cardiology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Gian Paolo Bezante
- Cardiology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Serena Favorini
- Cardiology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Daniela Rollando
- Cardiology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Giorgia Sivori
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics and Maternal-Childhood Sciences, University of Genoa, Genoa, Italy
| | - Erica Viani
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics and Maternal-Childhood Sciences, University of Genoa, Genoa, Italy
| | - Cinzia Finocchi
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics and Maternal-Childhood Sciences, University of Genoa, Genoa, Italy
| | - Manrico Balbi
- Cardiology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| |
Collapse
|
20
|
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.
Collapse
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
| |
Collapse
|
21
|
Rovera C, Biasco L, Orzan F, Belli R, Omedè P, Gaita F. Percutaneous implantation of a second device in patients with residual right-to-left shunt after patent foramen ovale closure. J Interv Cardiol 2014; 27:548-54. [PMID: 25421752 DOI: 10.1111/joic.12162] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION The management of patients with residual right-to-left shunt (rRLS) after percutaneous patent foramen ovale (PFO) closure is debated. The aim of this study was to define the incidence of moderate-to-large rRLS and to report the feasibility, safety and long-term clinical outcome of transcatheter closure of rRLS. METHODS AND RESULTS From June 2000 to March 2013, 322 subjects underwent percutaneous PFO closure. In 39 patients (12.1%) with moderate-to-large rRLS on transcranial Doppler (TCD) and/or transesophageal echocardiogram a second cardiac catheterization was performed with the aim of completing the closure. A second closure device was implanted in 21 patients (53.8%). In the remaining 18 (46.2%), a second device was not delivered for the following reasons: in 13 (72.2%) no residual passage could be crossed, in 5 (27.8%) the residual shunt was deemed to be negligible. No complications occurred. After the second procedure, complete closure was proved by TCD in 16/21 (76.2%) subjects. One patient received a third device. During follow-up (41 ± 19 months), no cerebrovascular ischemic accidents occurred. CONCLUSION A second percutaneous PFO occlusion device can be safely implanted in patients with significant rRLS. However, a moderate-to-large rRLS on TCD and/or TEE may not necessarily represent a significant risk of further paradoxical embolization.
Collapse
Affiliation(s)
- Chiara Rovera
- Department of Medical Sciences, Division of Cardiology, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | | | | | | | | | | |
Collapse
|
22
|
Vitarelli A, Mangieri E, Capotosto L, Tanzilli G, D'Angeli I, Toni D, Azzano A, Ricci S, Placanica A, Rinaldi E, Mukred K, Placanica G, Ashurov R. Echocardiographic findings in simple and complex patent foramen ovale before and after transcatheter closure. Eur Heart J Cardiovasc Imaging 2014; 15:1377-85. [PMID: 25139906 DOI: 10.1093/ehjci/jeu143] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS Percutaneous closure of patent foramen ovale (PFO) in cryptogenic cerebrovascular events is an alternative to medical therapy. The interpretation of residual shunts after implantation of different devices for PFO with different morphologies is controversial. METHODS AND RESULTS Transcatheter PFO closure was performed in 123 patients with a history of ≥1 paradoxical embolism using three different devices: Amplatzer (n = 46), Figulla Occlutech (n = 41), and Atriasept Cardia (n = 36). Fifty-six patients presented with simple PFO and 67 patients had complex morphologies. All patients were studied with contrast enhanced transesophageal echocardiography (TEE) before interventional procedure and thereafter at 1 and 6 months and every 6-12 months in case of incomplete closure. Definite closure was confirmed in at least two consecutive TEE studies. Various PFO morphologies were identified by TEE before device implantation. The device size to PFO diameter ratio was significantly increased in patients with complex PFO compared with those patients with a simple PFO morphology (P < 0.05). The difference between the closure rate of S-PFO and C-PFO concerning each device type was significant (Amplatzer P = 0.0027, Figulla P = 0.0043, and Atriasept P < 0.01). The mean follow-up period was 3.4 years (median 2.7 years) with a cerebrovascular re-event rate of 2.4% per year. In three patients, thrombi were detected in the 6-month TEE controls and resolved after medical therapy. In three other patients, the implantation of an adjunctive device was necessary for residual shunt. CONCLUSION In our series of patients, the closure rate was dependent on PFO morphology more than occluder size and type. An adjunctive device was implanted in selected cases.
Collapse
Affiliation(s)
| | | | | | | | | | - Danilo Toni
- Sapienza University, Via Lima 35, Rome 00198, Italy
| | | | | | | | | | | | | | | |
Collapse
|
23
|
Cardiac Procedures to Prevent Stroke: Patent Foramen Ovale Closure/Left Atrial Appendage Occlusion. Can J Cardiol 2014; 30:87-95. [DOI: 10.1016/j.cjca.2013.11.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Revised: 11/12/2013] [Accepted: 11/12/2013] [Indexed: 11/20/2022] Open
|