[Patent foramen ovale: conservative or surgical therapy?]

Transoesophageal Echocardiography in Patients with Stroke and Low Risk of Embolic Etiology

Transoesophageal echocardiography (TEE) is currently the gold standard in the diagnosis of cardiac sources of embolization and the frequently discussed question is whether all patients with suspected embolic stroke should be screened by TEE. Based on the results of transthoracic echocardiography (TTE), we determined the significance of TEE in patients with ischemic stroke with low risk of embolic etiology. We made a retrospective evaluation of TEE examination in the period from 1st January 2000 to 31st December 2003 in patients with ischemic stroke and sinus rhythm and normal left ventricular function. TEE examination was done in 159 patients. A quarter of the patients had pathological findings in the heart: left atrial thrombus in nine (5.7%), spontaneous echocontrast in left atrium in 14 (8.8%), patent foramen ovale in 16 (10%) and other findings in seven (4.4%) patients. The finding of the thrombus or echocontrast in the left atrium correlated with the size of the left atrium and it was proved in the patients with left atrium of size above 39 mm. On the contrary, patent foramen ovale was found in younger patients (70 vs. 59 years). Our results have shown that TEE is of low relevance to patients with a normal transthoracic echocardiogram.

Calcification of human vascular smooth muscle cells: associations with osteoprotegerin expression and acceleration by high-dose insulin

Arterial medial calcifications occur often in diabetic individuals as part of the diabetic macroangiopathy. The pathogenesis is unknown, but the presence of calcifications predicts risk of cardiovascular events. We examined the effects of insulin on calcifying smooth muscle cells in vitro and measured the expression of the bone-related molecule osteoprotegerin (OPG). Human vascular smooth muscle cells (VSMCs) were grown from aorta from kidney donors. Induction of calcification was performed with beta-glycerophosphate. The influence of insulin (200 microU/ml or 1,000 microU/ml) on calcification was judged by measuring calcium content in the cell layer and by von Kossa staining. OPG was measured in the medium by ELISA. Histochemistry was used for determination of alkaline phosphatase (ALP). Bone sialoprotein (BSP) and OPG mRNA expressions were done by RT-PCR. beta-Glycerophosphate was able to induce calcification in human smooth muscle cells from a series of donors after variable time in culture. Decreased OPG amounts were observed from the cells during the accelerated calcification phase. High dose of insulin (1,000 microU/ml) accelerated the calcification, whereas lower concentrations (200 microU/ml) did not. Calcified cells expressed ALP and BSP activity in high levels. In conclusion, high concentration of insulin enhances in vitro-induced calcification in VSMCs. Altered OPG levels during the calcification raise the possibility that OPG may have a potent function in regulating the calcification process or it may represent a consequence of mineralization. Effects of insulin and modulations by OPG on the calcification process in arterial cells may play a role in the development of calcifications as part of the diabetic macroangiopathy.

Surgical Closure of Combined Symptomatic Patent Foramen Ovale and Atrial Septum Aneurysm for Prevention of Recurrent Cerebral Emboli

BACKGROUND

Patients with patent foramen ovale (PFO) have an undefined but certainly considerable risk of repeated cerebral ischemia due to paradoxical embolism. Especially, if a cerebrovascular event has already occurred and the combination with an atrial septum aneurysm (ASA) is present this risk increases tremendously. The aim of this study was to demonstrate that surgical closure of PFO in combination with an ASA is safe and useful in preventing recurrent strokes.

METHODS

Ten patients with previous cerebral ischemia, proven by CT or MRI, and PFO in combination with an ASA were prospectively scheduled for surgical closure. Patients with extracardiac sources of embolic disease were excluded from this study. However, one patient suffered from a hypercoagulability syndrome.

RESULTS

All patients (mean age 35.5 +/- 19.1 years) underwent direct suture of the PFO and plication of the ASA with the aid of cardiopulmonary bypass and cardioplegic arrest (n = 3) or ventricular fibrillation (n = 7). Mean operation time was 123.1 +/- 20.2 minutes; mean bypass time was 34.5 +/- 9.9 minutes. There was no mortality or significant postoperative morbidity. Mean hospital stay was 5.1 +/- 1.5 days. During a follow-up of >4 years, no recurrent stroke or transient ischemic attack occurred and no patient received anticoagulation therapy.

CONCLUSION

Our data suggest that surgical closure of PFO in combination with ASA in patients with previous stroke is safe and efficacious to prevent recurrent strokes and avoids lifelong anticoagulation.

The serum protein alpha 2-Heremans-Schmid glycoprotein/fetuin-A is a systemically acting inhibitor of ectopic calcification

Ectopic calcification is a frequent complication of many degenerative diseases. Here we identify the serum protein alpha2-Heremans-Schmid glycoprotein (Ahsg, also known as fetuin-A) as an important inhibitor of ectopic calcification acting on the systemic level. Ahsg-deficient mice are phenotypically normal, but develop severe calcification of various organs on a mineral and vitamin D-rich diet and on a normal diet when the deficiency is combined with a DBA/2 genetic background. This phenotype is not associated with apparent changes in calcium and phosphate homeostasis, but with a decreased inhibitory activity of the Ahsg-deficient extracellular fluid on mineral formation. The same underlying principle may contribute to many calcifying disorders including calciphylaxis, a syndrome of severe systemic calcification in patients with chronic renal failure. Taken together, our data demonstrate a critical role of Ahsg as an inhibitor of unwanted mineralization and provide a novel therapeutic concept to prevent ectopic calcification accompanying various diseases.

Cardiac perforation following transcatheter PFO closure

From December 1998 to August 2001, transcatheter closure of patent foramen ovale (PFO) with an Amplatzer PFO occluder has been successfully performed in our center in 102 patients without severe complications. We are reporting the first known case of cardiac perforation by an Amplatzer PFO occluder.

Transcatheter closure of patent foramen ovale in patients with cerebral ischemia

OBJECTIVES

The present study was conducted to determine the safety of the transcatheter closure of a patent foramen ovale (PFO) in patients with cryptogenic cerebral ischemia and the midterm follow-up of recurrent thromboembolic events after interventional PFO closure.

BACKGROUND

Current therapeutic options for stroke prevention in patients with PFO and a history of thromboembolic events include chronic antithrombotics and more invasive treatments such as surgical closure or minor invasive transcatheter permanent closure of the PFO. Promising preliminary and pilot data with the Amplatzer Septal Occluder or the PFO-Star Occluder have been reported. Systematic and long-term data are still missing.

METHODS

A total of 276 consecutive patients with a PFO and a history of at least one thromboembolic event were recruited in four medical centers and underwent percutaneous PFO closure with the PFO-Star device. Follow-up data were analyzed over an average of 15.1 months, equivalent to 345 patient-years.

RESULTS

The implantation was successful in all 276 patients. Peri-interventional reversible complications included transient ST-segment elevations (1.8%) and transient ischemic attack (TIA) (0.8%). Two devices have been removed surgically. During follow-up the annual recurrence rate of thromboembolic events was 1.7% for TIA, 0% for stroke and 0% for peripheral emboli.

CONCLUSIONS

Interventional PFO closure with the PFO-Star device appears to be a reliable and promising technique resulting in a low recurrence rate of thromboembolic events, especially stroke in patients with a history of cryptogenic ischemia presumably due to paradoxical embolization. To our knowledge, this is the largest coherent and prospective study for interventional PFO closure.