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Eichelmann A, Kubini R, Nachoski D, Kosinski C, Becker M, Aljalloud A. Patent foramen ovale closure versus drug therapy in patients over 60 years and a follow-up of 5 years. Clin Cardiol 2024; 47:e24251. [PMID: 38445759 PMCID: PMC10915992 DOI: 10.1002/clc.24251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 02/15/2024] [Accepted: 02/21/2024] [Indexed: 03/07/2024] Open
Abstract
BACKGROUND The advantages of patent foramen ovale (PFO) closure as protection from a recurrence of stroke remains controversial compared to drug therapy, especially in patients over 60 years. HYPOTHESIS The aim of the study is to compare recurrence of stroke in patients over 60 years old with PFO closure versus drug therapy alone. METHODS We included 342 patients over 60 years who suffered a crytopgenic stroke, and were also accepted for a PFO closure. 199 patients refused a PFO closure and were treated with medical therapy alone, whereas 143 patients underwent a PFO closure procedure. RESULTS The mean follow up time was 5.5 ± 1.5 years. All patients in Group B showed persistent shunt in the follow-up period (n = 199, 100%). In Group A, seven patients were diagnosed with residual shunt during echocardiography examination (5%). A new onset of atrial fibrillation occurred in seven patients in Group A (5%) and six patients in Group B (3%), p = .117. Recurrent stroke occurred in 3 patients in Group A (2%) and 11 patients in Group B (6%), p = .021. One patient died of unknown reason (1%) and two patients were lost due to neurological death (1%) in Group B, whereas no patients in Group A died during the follow-up period. CONCLUSION Our results show that strict exclusion of patients over 60 years from PFO closure should be reconsidered. As life expectancies are increasing, patients should be considered for same treatment as younger patients, since the outcomes are improved compared to patients treated with medical therapy alone.
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Affiliation(s)
| | - Ralf Kubini
- Rhein‐Maas Hospital, Department of CardiologyNephrology and Internal Intensive CareWürselenGermany
| | - Dejan Nachoski
- Rhein‐Maas Hospital, Department of CardiologyNephrology and Internal Intensive CareWürselenGermany
| | | | - Michael Becker
- Rhein‐Maas Hospital, Department of CardiologyNephrology and Internal Intensive CareWürselenGermany
| | - Ali Aljalloud
- Rhein‐Maas Hospital, Department of CardiologyNephrology and Internal Intensive CareWürselenGermany
- Department of Cardiac SurgeryRWTH University Hospital AachenAachenGermany
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Low CE, Teo YN, Teo YH, Lim ICZ, Rana S, Lee YQ, Chen X, Fang JT, Lam HH, Ong K, Yang J, Kuntjoro I, Low TT, Lee EC, Sharma VK, Yeo LL, Sia CH, Tan BY, Lim Y. Propensity-score matched analysis of patent foramen ovale closure in real-world study cohort with cryptogenic ischemic stroke. J Stroke Cerebrovasc Dis 2023; 32:107407. [PMID: 37804781 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107407] [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: 07/20/2023] [Revised: 09/27/2023] [Accepted: 10/02/2023] [Indexed: 10/09/2023] Open
Abstract
INTRODUCTION Patent foramen ovale (PFO) occurs in 25% of the general population and in 40% of cryptogenic ischemic stroke patients. Recent trials support PFO closure in selected patients with cryptogenic stroke. We examined the outcomes of transcatheter PFO closure in a real-world study cohort with cryptogenic stroke. METHODS Consecutive ischemic stroke patients who were classified as cryptogenic on the TOAST aetiology and diagnosed with a PFO were included. All patients underwent either transcatheter PFO closure or medical therapy. A 2:1 propensity score matching by sex and Risk-of-Paradoxical-Embolism (RoPE) score was performed. Multivariable regression models adjusted for sex and RoPE score. RESULTS Our cohort comprised 232 patients with mean age 44.3 years (SD 10.8) and median follow-up 1486.5 days. 33.2% were female. PFO closure (n=84) and medical therapy (n=148) groups were well-matched with <10% mean-difference in sex and RoPE score. Two patients in the treated group (2.4%) and seven in the control group (4.7%) had a recurrent ischemic stroke event. Multivariable Cox regression demonstrated a hazard-ratio of 0.26 (95%CI 0.03-2.13, P=0.21) for PFO closure compared to control. The incidence of atrial fibrillation (AF) detected post-PFO closure was similar between the treated and control (1.19% vs 1.35%, multivariable logistic regression odds-ratio 0.90, 95%CI 0.04-9.81, P=0.94). There were no major periprocedural complications documented. The difference in restricted mean survival-time free from stroke at two years between treated and control was 26.2 days (95%CI 5.52-46.85, P=0.013). CONCLUSIONS In this Asian cohort, we report a low incidence of ischemic stroke recurrence and new-onset AF in patients who underwent PFO closure. When compared to the medical therapy group, there was no significant difference in the incidence of stroke recurrence and new-onset AF. Further studies involving larger real-world cohorts are warranted to identify patients who are more likely to benefit from PFO closure.
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Affiliation(s)
- Chen Ee Low
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yao Neng Teo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yao Hao Teo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Isis Claire Zy Lim
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Sounak Rana
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yong Qin Lee
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Xintong Chen
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Jun Tao Fang
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Hsin Hui Lam
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Kathleen Ong
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Joanna Yang
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Ivandito Kuntjoro
- Department of Cardiology, National University Heart Centre, 5 Lower Kent Ridge Road, Singapore 119074, Singapore
| | - Ting Ting Low
- Department of Cardiology, National University Heart Centre, 5 Lower Kent Ridge Road, Singapore 119074, Singapore
| | - Edward Cy Lee
- Department of Cardiology, National University Heart Centre, 5 Lower Kent Ridge Road, Singapore 119074, Singapore
| | - Vijay K Sharma
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Leonard Ll Yeo
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Ching Hui Sia
- Department of Cardiology, National University Heart Centre, 5 Lower Kent Ridge Road, Singapore 119074, Singapore
| | - Benjamin Yq Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Yinghao Lim
- Department of Cardiology, National University Heart Centre, 5 Lower Kent Ridge Road, Singapore 119074, Singapore.
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3
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Farjat‐Pasos JI, Guedeney P, Houde C, Alperi A, Robichaud M, Côté M, Montalescot G, Rodés‐Cabau J. Sex Differences in Patients With Cryptogenic Cerebrovascular Events Undergoing Transcatheter Closure of Patent Foramen Ovale. J Am Heart Assoc 2023; 12:e030359. [PMID: 37776218 PMCID: PMC10727268 DOI: 10.1161/jaha.123.030359] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 07/18/2023] [Indexed: 10/02/2023]
Abstract
Background Scarce data exist on sex differences in patients with cryptogenic cerebrovascular events undergoing patent foramen ovale (PFO) closure. This study aimed to determine the sex differences in clinical profile, procedural characteristics, and long-term outcomes of patients with cryptogenic cerebrovascular events undergoing PFO closure. Methods and Results A retrospective cohort was used, including 1076 consecutive patients undergoing PFO closure because of a cryptogenic cerebrovascular event. Patients were divided into 2 groups: 469 (43.6%) women and 607 (56.4%) men. The median follow-up was 3 years (interquartile range, 2-8 years). Women were younger (46±13 versus 50±12 years; P<0.01) and had a higher risk of paradoxical embolism score (6.9±1.7 versus 6.6±1.6; P<0.01). Procedural characteristics and postprocedural antithrombotic therapy were similar. At follow-up, there were no differences in atrial fibrillation (women versus men: 0.47 versus 0.97 per 100 patient-years; incidence rate ratio [IRR], 0.55 [95% CI, 0.27-1.11]; P=0.095; adjusted P=0.901), stroke (0.17 versus 0.07 per 100 patient-years; IRR, 2.58 [95% CI, 0.47-14.1]; P=0.274; adjusted P=0.201), or transient ischemic attack (0.43 versus 0.18 per 100 patient-years; IRR, 2.58 [95% CI, 0.88-7.54]; P=0.084; adjusted P=0.121); nevertheless, women exhibited a higher incidence of combined ischemic cerebrovascular events (0.61 versus 0.26 per 100 patient-years; IRR, 2.58 [95% CI, 1.04-6.39]; P=0.041; adjusted P=0.028) and bleeding events (1.04 versus 0.45 per 100 patient-years; IRR, 2.82 [95% CI, 1.41-5.65]; P=0.003; adjusted P=0.004). Conclusions Compared with men, women with cryptogenic cerebrovascular events undergoing PFO closure were younger and had a higher risk of paradoxical embolism score. After a median follow-up of 3 years, there were no differences in stroke events, but women exhibited a higher rate of combined (stroke and transient ischemic attack) cerebrovascular events and bleeding complications. Additional studies are warranted to clarify sex-related outcomes after PFO closure further.
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Affiliation(s)
| | - Paul Guedeney
- Sorbonne Université, ACTION Study Group, INSERM UMRS_1166 Institut de Cardiologie (AP‐HP)ParisFrance
| | - Christine Houde
- Centre Hospitalier Universitaire de QuebecLaval UniversityQuebec CityQuebecCanada
| | - Alberto Alperi
- Quebec Heart and Lung Institute, Laval UniversityQuebec CityQuebecCanada
| | - Mathieu Robichaud
- Quebec Heart and Lung Institute, Laval UniversityQuebec CityQuebecCanada
| | - Mélanie Côté
- Quebec Heart and Lung Institute, Laval UniversityQuebec CityQuebecCanada
| | - Gilles Montalescot
- Sorbonne Université, ACTION Study Group, INSERM UMRS_1166 Institut de Cardiologie (AP‐HP)ParisFrance
| | - Josep Rodés‐Cabau
- Quebec Heart and Lung Institute, Laval UniversityQuebec CityQuebecCanada
- Centre Hospitalier Universitaire de QuebecLaval UniversityQuebec CityQuebecCanada
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Patel U, Dengri C, Pielykh D, Baskar A, Tar MI, Patel G, Patel N, Kothari N, Selvam SA, Sharma AM, Venkata VS, Shah S, Mahmood SN, Peela AS. Secondary Prevention of Cryptogenic Stroke and Outcomes Following Surgical Patent Foramen Ovale Closure Plus Medical Therapy vs. Medical Therapy Alone: An Umbrella Meta-Analysis of Eight Meta-Analyses Covering Seventeen Countries. Cardiol Res 2023; 14:342-350. [PMID: 37936625 PMCID: PMC10627369 DOI: 10.14740/cr1526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 08/09/2023] [Indexed: 11/09/2023] Open
Abstract
Background Cryptogenic stroke (CS) is an exclusion diagnosis that accounts for 10-40% of all ischemic strokes. Patent foramen ovale (PFO) is found in 66% of patients with CS, while having a prevalence of 25-30% in the general population. The primary aim was to evaluate the risk of recurrent stroke following surgical PFO closure plus medical therapy vs. medical therapy alone amongst CS, an embolic stroke of undetermined source (ESUS), or transient ischemic attack (TIA). The secondary aim was to evaluate new-onset non-valvular atrial fibrillation, mortality, and major bleeding. Methods We conducted an umbrella meta-analysis using PRISMA guidelines on English studies comparing surgical PFO closure plus medical therapy versus medical therapy alone for managing CS. We extracted data on interventions and outcomes and used random-effects models with generic inverse variance to calculate relative risks (RRs) with 95% confidence intervals for outcome calculations. Results A comprehensive search yielded 54,729 articles on CS and 65,001 on surgical PFO closure, with 1,591 studies focusing on PFO closure and medical therapy for secondary CS, ESUS, or TIA prevention. After excluding non-meta-analyses, 52 eligible meta-analyses were identified, and eight studies were selected for outcome evaluation, excluding non-English, non-human, and studies before January 2019 as of August 31, 2021. Among a total of 41,880 patients, 14,942 received PFO closure + medical therapy, while 26,938 patients received medical therapy alone. Our umbrella meta-analysis showed that PFO closure plus medical therapy had a 64% lower risk of recurrent strokes than medical therapy alone (pooled RR: 0.36). PFO closure plus medical therapy was associated with 4.94 times higher risk of atrial fibrillation. There was no difference in the risk of death or bleeding between both groups. Conclusion In patients with CS, PFO closure, in addition to medical therapy, reduces the risk of recurrence. More research is needed to assess the efficacy of early closure as well as specific risk profiles that would benefit from early intervention to reduce the burden of stroke.
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Affiliation(s)
- Urvish Patel
- Department of Neurology and Public Health, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- These authors contributed equally to the article
| | - Chetna Dengri
- Department of Neurology, Cleveland Clinic Florida, Weston, FL 33331, USA
- These authors contributed equally to the article
| | - David Pielykh
- Odessa National Medical University, Valikhovskiy Lane 2, Odessa 65000, Ukraine
| | - Aakash Baskar
- K.A.P. Viswanatham Government Medical College, Musiri, Trichy, Tamilnadu 621006, India
| | - Muhammad Imtiaz Tar
- Touro University Nevada College of Osteopathic Medicine, Henderson, NV 89014, USA
| | | | - Neel Patel
- Department of Public Health, Icahn School of Medicine at Mount Sinai, New York, NY 10029 USA
| | - Nishel Kothari
- Dartmouth Hitchcock Medical Center, Lebanon, NH 03766, USA
| | - Renu
- Department of Medicine, Sarojini Naidu Medical College, Agra, Uttar Pradesh 282003, India
| | - Sri Abirami Selvam
- Department of Internal Medicine, St Mary Medical Center, Langhorne, PA 19047, USA
| | - Amit Munshi Sharma
- Department of Medicine, Geisinger Commonwealth School of Medicine, Scranton, PA 18510, USA
| | | | - Shamik Shah
- Department of Neurology, Stormont Vail Health, Topeka, KS, USA
| | - Syed Nazeer Mahmood
- Department of Medicine, Section of Pulmonary/Critical Care, MedStar Washington Hospital Center, Washington, DC 5333, USA
| | - Appala Suman Peela
- Department of Family Medicine, UNC Health Southeastern, Lumberton, NC 28358, USA
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Yang J, Lei WR, Wang JW, Xiao ZZ, Sun CP, Lin XF, Zheng SY, Zhu P. Transesophageal echocardiography-guided percutaneous closure of the patent foramen ovale only uses the sheath. Cardiovasc Diagn Ther 2023; 13:728-735. [PMID: 37675091 PMCID: PMC10478018 DOI: 10.21037/cdt-22-513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 05/17/2023] [Indexed: 09/08/2023]
Abstract
Background Percutaneous closure of the patent foramen ovale (PFO) is primarily guided by fluoroscopy in the catheter room, during which procedure both the guidewire and sheath need to pass through the PFO. We performed PFO closure using a transesophageal echocardiography (TEE)-guided approach and only the sheath was passed through the PFO during the procedure. This study aimed to evaluate the feasibility and safety of PFO closure using this technique. Methods A retrospective observational study was performed. A total of 117 consecutive adult patients underwent percutaneous PFO closure without fluoroscopy, under the sole guidance of TEE in our hospital between December 2018 and December 2021. The data of each patient consisted of preoperative, operative, and postoperative variables collected. The primary outcome is that the occluder was successfully released. The secondary outcomes included perioperative and follow-up transthoracic echocardiography (TTE), Headache impact test-6 (HIT-6) score and clinical symptoms. Results Transvenous PFO closure under TEE guidance was successful in all cases. The sample consisted of 93 females and 24 males with an average age of 42.3±7.8 years. There were 28 patients with preoperative cerebral infarction [Risk of Paradoxical Embolism (RoPE) score >6 points] and 89 patients with migraine. All patients underwent a preoperative TEE to confirm the presence of PFO, and contrast-enhanced transcranial Doppler (c-TCD) acoustic contrast suggested grades 3 to 4. The average time of surgery for patients (puncture to removal of the sheath) was 32 minutes. Three cases of vagus nerve reflex manifestations during surgery and two cases of transient ventricular arrhythmia all improved after symptomatic treatment. There were no instances of metal allergy, hemolysis, or other acute vascular procedural complications. For all 89 patients with migraine, significant relief or resolution was achieved during the first six-month follow-up (P<0.001). Conclusions As a monotherapy, percutaneous closure of PFO guided by TEE where only the sheath passes through the PFO during the operation is an effective procedure with a high success rate and a low complication rate.
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Affiliation(s)
- Jie Yang
- Department of Cardiovascular Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Wen-Rui Lei
- Department of Cardiovascular Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jun-Wei Wang
- Department of Cardiovascular Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Ze-Zhou Xiao
- Department of Cardiovascular Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Chun-Ping Sun
- Department of Cardiovascular Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xue-Feng Lin
- Department of Cardiovascular Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Shao-Yi Zheng
- Department of Cardiovascular Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Peng Zhu
- Department of Cardiovascular Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
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Patent Foramen Ovale and Cryptogenic Stroke: Integrated Management. J Clin Med 2023; 12:jcm12051952. [PMID: 36902748 PMCID: PMC10004032 DOI: 10.3390/jcm12051952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 02/13/2023] [Accepted: 02/27/2023] [Indexed: 03/06/2023] Open
Abstract
Patent foramen ovale (PFO) is a common cardiac abnormality with a prevalence of 25% in the general population. PFO has been associated with the paradoxical embolism causing cryptogenic stroke and systemic embolization. Results from clinical trials, meta-analyses, and position papers support percutaneous PFO device closure (PPFOC), especially if interatrial septal aneurysms coexist and in the presence of large shunts in young patients. Remarkably, accurately evaluating patients to refer to the closure strategy is extremely important. However, the selection of patients for PFO closure is still not so clear. The aim of this review is to update and clarify which patients should be considered for closure treatment.
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Percutaneous Patent Foramen Ovale Closure in Patients with Cryptogenic Stroke or Transient Ischemic Attack: A Retrospective Study. BIOMED RESEARCH INTERNATIONAL 2022; 2022:2614225. [PMID: 35178445 PMCID: PMC8844344 DOI: 10.1155/2022/2614225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 12/06/2021] [Indexed: 11/17/2022]
Abstract
Background Patent foramen ovale (PFO) is associated with cryptogenic stroke (CS). Transcatheter closure of PFO is superior to pharmacotherapy for patients with CS or transient ischemic attack (TIA). More evidence is needed to evaluate the efficacy and safety of PFO closure in Chinese patients. Methods This study enrolled ten CS patients and two TIA patients (mean age of 40.8 ± 9.7 y), including seven males (58%) and five females (42%) who underwent PFO closure in our center from January 2017 to July 2019. Baseline data, imaging data, and RoPE (Risk of Paradoxical Embolism) score were collected retrospectively. The preprocedural assessment and percutaneous transcatheter PFO closure were described in detail. The perioperative complications and follow-ups were recorded from all patients. Results Among ten patients with CS, eight patients had a RoPE score of >6 and two patients had a RoPE score of 6. MRI confirmed multiple infarcts in seven cases, and infarct involving the cortex in nine cases. Abnormal ECG was found in three patients and abnormal Echo in four patients. Right-to-left shunt (RLS) was detected in all the patients by cTCD or cTTE. To be specific, RLS was observed in nine of the ten TEE-detected patients. No case had PFO complicated with atrial septal aneurysm (ASA). The success rate of PFO closure was 91.6%. No serious perioperative complications were observed. During a mean time of 26.5 ± 8 months (15-41 months) of follow-up, no recurrent cerebral infarction, TIA, or thromboembolism were detected in postoperative patients. Conclusions PFO closure is safe and effective in the treatment of Chinese patients with CS or TIA.
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Sun H, Zhou C, Xu L, Xu T. A meta-analysis of the association of atrial septal abnormalities and atrial vulnerability. Medicine (Baltimore) 2021; 100:e27165. [PMID: 34477173 PMCID: PMC8416013 DOI: 10.1097/md.0000000000027165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 08/19/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND The mechanism of cryptogenic stroke (CS) in patients with atrial septal abnormalities remains unclear, and the increased incidence of atrial vulnerability may be one of the reasons. We performed this meta-analysis to clarify the association between atrial septal abnormalities and atrial vulnerability, and to provide evidence-based basis for the prevention and mechanism of CS. METHODS We systematically searched for studies on the association between atrial septal abnormalities and atrial vulnerability, and pooled available data on types of atrial septal abnormalities, types of atrial vulnerability, and methods of atrial vulnerability detection. The primary endpoints were the occurrence of atrial arrhythmias or P wave abnormalities. Random-effects models were used to calculate odds ratios (OR) and 95% confidence intervals (CI). RESULTS Twelve case-control studies were eligible. Compared with the control group, patients with atrial septal abnormalities had a higher risk of atrial vulnerability (OR: 1.93; 95% CI: 1.13-3.30, P = .02). Data based on stroke patients showed that the group with atrial septal abnormalities had a higher risk of atrial vulnerability than the control group (OR: 2.00; 95% CI: 1.13-3.53, P = .02). However, there was no significant difference in the incidence of atrial vulnerability between the 2 groups of nonstroke patients. Subgroup analysis showed that although atrial septal abnormality increased the risk of atrial vulnerability in the subgroup of atrial septal aneurysm (OR: 1.68; 95% CI: 0.47-5.95, P = .42), the subgroup of atrial fibrillation (AF)/atrial fluster (OR: 1.81; 95% CI: 0.94-3.46, P = .07) and the subgroup of subcutaneous recording system (OR: 1.33; 95% CI: 0.68-2.61, P = .41), the difference was not statistically significant. CONCLUSIONS Atrial septal abnormalities can increase the risk of atrial vulnerability, and atrial arrhythmia caused by atrial septal abnormalities may be one of the mechanisms of CS.
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9
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Pristipino C, Germonpré P, Toni D, Sievert H, Meier B, D'Ascenzo F, Berti S, Onorato E, Bedogni F, Mas JL, Scacciatella P, Hildick-Smith D, Gaita F, Kyrle P, Thomson J, Derumeaux G, Sibbing D, Chessa M, Hornung M, Zamorano J, Dudek D. European position paper on the management of patients with patent foramen ovale. Part II - Decompression sickness, migraine, arterial deoxygenation syndromes and select high-risk clinical conditions. EUROINTERVENTION 2021; 17:e367-e375. [PMID: 33506796 PMCID: PMC9724983 DOI: 10.4244/eij-d-20-00785] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Patent foramen ovale (PFO) is implicated in the pathogenesis of a number of medical conditions but to date only one official position paper related to left circulation thromboembolism has been published. This interdisciplinary paper, prepared with the involvement of eight European scientific societies, reviews the available evidence and proposes a rationale for decision making for other PFO-related clinical conditions. In order to guarantee a strict evidence-based process, we used a modified grading of recommendations, assessment, development, and evaluation (GRADE) methodology. A critical qualitative and quantitative evaluation of diagnostic and therapeutic procedures was performed, including assessment of the risk/benefit ratio. The level of evidence and the strength of the position statements were weighed and graded according to predefined scales. Despite being based on limited and observational or low-certainty randomised data, a number of position statements were made to frame PFO management in different clinical settings, along with suggestions for new research avenues. This interdisciplinary position paper, recognising the low or very low certainty of existing evidence, provides the first approach to several PFO-related clinical scenarios beyond left circulation thromboembolism and strongly stresses the need for fresh high-quality evidence on these topics.
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Affiliation(s)
- Christian Pristipino
- San Filippo Neri - ASL Roma 1 Hospital, Via Alessandro Poerio 140, 00152 Rome, Italy
| | | | - Danilo Toni
- Hospital Policlinico Umberto I, Sapienza University, Rome, Italy
| | - Horst Sievert
- CardioVascular Center Frankfurt (CVC Frankfurt), Frankfurt, Germany,Anglia Ruskin University, Chelmsford, United Kingdom,University California San Francisco (UCSF), San Francisco, CA, USA
| | | | - Fabrizio D'Ascenzo
- Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | | | | | | | - Jean-Louis Mas
- Hôpital Sainte-Anne, Université Paris Descartes, Paris, France
| | | | - David Hildick-Smith
- Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, United Kingdom
| | - Fiorenzo Gaita
- Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | | | | | | | - Dirk Sibbing
- Privatklinik Lauterbacher Mühle am Ostersee, Iffeldorf and Ludwig-Maximilians-Universität (LMU) München, Munich, Germany
| | - Massimo Chessa
- IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Marius Hornung
- CardioVascular Center Frankfurt (CVC Frankfurt), Frankfurt, Germany
| | | | - Dariusz Dudek
- Jagiellonian University Medical College, Krakow, Poland,Maria Cecilia Hospital, GVM Care & Research, Cotignola (RA), Italy
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Kheiri B, Simpson TF, Osman M, Golwala H, Radaideh Q, Dalouk K, Stecker EC, Zahr F, Nazer B, Rahmouni H. Meta-Analysis of Secondary Prevention of Cryptogenic Stroke. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 21:1285-1290. [PMID: 32151594 DOI: 10.1016/j.carrev.2020.01.016] [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: 11/03/2019] [Revised: 01/13/2020] [Accepted: 01/22/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Cryptogenic stroke and embolic stroke of undetermined source (ESUS) are a frequently encountered categories of ischemic stroke with an uncertain cause. METHODS We analyzed all randomized clinical trials (RCTs) that evaluated antithrombotic therapy and patent foramen ovale (PFO) closure in cryptogenic stroke and/or ESUS. We calculated aggregate hazard ratios (HRs) using direct and network meta-analysis. The primary outcome was recurrent ischemic stroke. RESULTS Ten RCTs with a total of 16,876 patients, randomizing 32,143 patient-years of follow-up (mean age 61.2 ± 13.5 with 39.2% female) were identified. Anticoagulation therapy was associated with significantly reduced recurrent ischemic stroke compared with antiplatelet therapy (HR = 0.66; [95% confidence interval (CI) = 0.47-0.94]). Meta-regression analysis showed significantly reduced recurrent stroke with longer duration of therapy, and significantly increased events with advanced age. Significant interactions were observed based on the presence of PFO, stroke type, and anticoagulant used. There were no significant differences with regard to the composite ischemic outcome, transient ischemic attack, any death, major bleeding, or intracranial bleeding. In the network meta-analysis, compared to antiplatelet therapy, warfarin (HR = 0.31; [95% credible interval (CrI) = 0.12-0.68]) and PFO closure (HR = 0.14; 95% CrI = 0.05-0.31]) were associated with significantly reduced recurrent ischemic stroke. In rank order, PFO closure was associated with the best outcome, followed by warfarin. CONCLUSIONS Among patients with cryptogenic stroke, anticoagulation therapy, as compared with antiplatelet therapy is associated with lower rate of recurrent stroke. The small sample size and high heterogeneity with regards to bleeding outcomes require further large trials. In patients with PFO, closure and warfarin are associated with the lowest rates of recurrent stroke.
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Affiliation(s)
- Babikir Kheiri
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA.
| | - Timothy F Simpson
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
| | - Mohammed Osman
- Division of Cardiology, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Harsh Golwala
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
| | - Qais Radaideh
- Midwest Cardiovascular Research Foundation, Davenport, Iowa, IA, USA
| | - Khidir Dalouk
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
| | - Eric C Stecker
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
| | - Firas Zahr
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
| | - Babak Nazer
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
| | - Hind Rahmouni
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
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Anderson G, Ebersole D, Covington D, Denoble PJ. The effectiveness of risk mitigation interventions in divers with persistent (patent) foramen ovale. Diving Hyperb Med 2019; 49:80-87. [PMID: 31177513 DOI: 10.28920/dhm49.2.80-87] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Accepted: 03/12/2019] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Persistent (patent) foramen ovale (PFO) is a recognized risk for decompression sickness (DCS) in divers, which may be mitigated by conservative diving or by PFO closure. Our study aimed to compare the effectiveness of these two risk mitigation interventions. METHODS This was a prospective study on divers who tested positive for PFO or an atrial septal defect (ASD) and either decided to continue diving without closure ('conservative group'), or to close their PFO/ASD and continue diving ('closure group'). Divers' characteristics, medical history, history of diving and history of DCS were reported at enrollment and annually after that. The outcome measures were the incidence rate of DCS, frequency and intensity of diving activities, and adverse events of closure. RESULTS Divers in both groups dived less and had a lower incidence rate of confirmed DCS than before the intervention. In the closure group (n = 42) the incidence rate of confirmed DCS decreased significantly. Divers with a large PFO experienced the greatest reduction in total DCS. In the conservative group (n = 23), the post-intervention decrease in confirmed DCS incidence rate was not significant. Of note, not all divers returned to diving after closure. Seven subjects reported mild adverse events associated with closure; one subject reported a serious adverse event. CONCLUSIONS PFO closure should be considered on an individual basis. In particular, individuals who are healthy, have a significant DCS burden, a large PFO or seek to pursue advanced diving may benefit from closure.
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Affiliation(s)
| | | | - Derek Covington
- Department of Anesthesiology, University of Florida, Gainesville FL, USA
| | - Petar J Denoble
- Divers Alert Network, Durham NC, USA.,Corresponding author: Petar J Denoble, Divers Alert Network, 6 West Colony Place, Durham, NC 27705, USA,
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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]
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