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Polat F, Kaya Z, Yaylak B, Onuk T. Comparison of echocardiographic and clinical characteristics in embolic stroke and migraine patients with patent foramen ovale. Echocardiography 2024; 41:e15770. [PMID: 38379240 DOI: 10.1111/echo.15770] [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: 11/08/2023] [Revised: 01/13/2024] [Accepted: 01/16/2024] [Indexed: 02/22/2024] Open
Abstract
BACKGROUND This single-center observational study aimed to compare the echocardiographic and clinical features in patients diagnosed with migraine and embolic stroke of undetermined source (ESUS) who presented with a known patent foramen ovale (PFO). METHODS Two-dimensional and color Doppler images were obtained using various transthoracic echocardiography views for both migraine and ESUS patients. Suspected PFO cases underwent further assessment through contrast echocardiography and transesophageal echocardiography (TEE). High-risk PFO characteristics were evaluated using TEE, and the Risk of Paradoxical Embolism (RoPe) score was calculated. RESULTS The study included 310 participants (age range: 18-60, 73.2% female), with 43.5% diagnosed with migraine and 56.5% with ESUS. Common comorbidities included diabetes (26.1%). High-velocity shunting through the interatrial septum was observed in 35.5% of patients. ESUS patients were older, with higher rates of diabetes and hypertension, while active smoking was more prevalent among migraine patients. Basic echocardiographic parameters were mostly similar, except for elevated pulmonary artery systolic pressure in ESUS. ESUS patients exhibited a greater occurrence of large microbubble passage through the interatrial septum and longer PFO lengths compared to migraine patients. However, the RoPe and High-risk PFO scores were similar between the groups. CONCLUSIONS ESUS patients, characterized by older age and higher rates of diabetes and hypertension, demonstrated increased pulmonary artery pressure, more significant microbubble crossings, and longer PFO lengths. Conversely, migraine patients had a higher prevalence of active smoking. Despite differing clinical profiles, the risk scores for PFO-related embolic events were comparable between the groups. These findings underscore potential distinctions between ESUS and migraine patients with PFO and their implications for management strategies.
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Affiliation(s)
- Fuat Polat
- Department of Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Education Research Hospital, İstanbul, Turkey
| | - Zeynettin Kaya
- Department of Cardiology, Antalya ASV Yaşam Hospital, Antalya, Turkey
| | - Barış Yaylak
- Department of Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Education Research Hospital, İstanbul, Turkey
| | - Tolga Onuk
- Department of Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Education Research Hospital, İstanbul, Turkey
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2
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Chaturvedi A, Moroni F, Axline M, Tomdio A, Mojadidi MK, Gertz Z. Comparative evaluation of intracardiac, transesophageal, and transthoracic echocardiography in the assessment of patent foramen ovale: A retrospective single-center study. Catheter Cardiovasc Interv 2023; 102:1348-1356. [PMID: 37681474 DOI: 10.1002/ccd.30825] [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: 04/23/2023] [Revised: 08/18/2023] [Accepted: 08/24/2023] [Indexed: 09/09/2023]
Abstract
INTRODUCTION Certain patent foramen ovale (PFO) characteristics, such as a large right-to-left shunt (RLS) or atrial septal aneurysm, identify patients who may receive the highest clinical benefit from percutaneous PFO closure. This study aimed to compare intracardiac echocardiography (ICE) with standard echocardiographic imaging in the evaluation of high-risk PFO characteristics and RLS severity in patients with PFO-associated stroke. METHODS We conducted a retrospective review of all patients aged ≥18 years who underwent percutaneous PFO closure for PFO-associated stroke and received all three ultrasound-based cardiac imaging modalities and had interpretable results (N = 51). We then compared RLS severity, high-risk PFO characteristics, and the proportion of patients with a higher likelihood of PFO-associated stroke by ICE versus transthoracic echocardiogram (TTE) and transesophageal echocardiogram (TEE). RESULTS The final cohort had a mean (±SE) age of 48.4 (±1.8) years and was predominantly female (58.8%). ICE was more likely to identify a large RLS versus TTE/TEE combined (66.7% vs. 45.1%; p = 0.03). The use of ICE resulted in significantly more patients being reclassified as having a higher likelihood of PFO-associated stroke (TTE vs. TEE vs. ICE: 10.4% vs. 14.6% vs. 25%; p = 0.03). A high-quality bubble study was found to be the single most important factor associated with identifying a larger RLS across all modalities (ρ [p]; TTE: 0.49 [<0.001], TEE: 0.60 [<0.001], ICE: 0.32 [0.02]). The presence of a hypermobile septum was associated with significantly greater RLS on ICE (ρ [p]: 0.3 [0.03]), especially with poor quality bubble studies (ρ [p]: 0.49 [0.02]). CONCLUSION In this observational study of patients with PFO-associated stroke, ICE detected a large RLS more frequently than TTE and TEE; and reclassified some patients as having a higher likelihood of PFO-associated stroke.
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Affiliation(s)
- Abhishek Chaturvedi
- Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Francesco Moroni
- Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Michael Axline
- Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Anna Tomdio
- Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Mohammad K Mojadidi
- Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Zachary Gertz
- Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA
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3
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Sanchez F, Goudelin M, Evrard B, Vignon P. Prevalence and impact of Eustachian valve on the diagnosis of patent foramen ovale in patients ventilated for an acute respiratory distress syndrome. Crit Care 2023; 27:392. [PMID: 37817233 PMCID: PMC10566137 DOI: 10.1186/s13054-023-04670-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 09/28/2023] [Indexed: 10/12/2023] Open
Affiliation(s)
- Florence Sanchez
- Medical-Surgical Intensive Care Unit, Dupuytren Teaching Hospital, Limoges, France
- Medical Intensive Care Unit, Brive Hospital, Brive-la-Gaillarde, France
| | - Marine Goudelin
- Medical-Surgical Intensive Care Unit, Dupuytren Teaching Hospital, Limoges, France
- Inserm CIC 1435, Dupuytren Teaching Hospital, Limoges, France
| | - Bruno Evrard
- Medical-Surgical Intensive Care Unit, Dupuytren Teaching Hospital, Limoges, France
- Inserm CIC 1435, Dupuytren Teaching Hospital, Limoges, France
| | - Philippe Vignon
- Medical-Surgical Intensive Care Unit, Dupuytren Teaching Hospital, Limoges, France.
- Inserm CIC 1435, Dupuytren Teaching Hospital, Limoges, France.
- Réanimation Polyvalente, CHU Dupuytren, 2 Ave. Martin Luther King, 87000, Limoges, France.
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4
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Song JK. Pearls and Pitfalls in the Transesophageal Echocardiographic Diagnosis of Patent Foramen Ovale. J Am Soc Echocardiogr 2023; 36:895-905.e3. [PMID: 37196905 DOI: 10.1016/j.echo.2023.05.004] [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: 04/28/2023] [Revised: 05/01/2023] [Accepted: 05/02/2023] [Indexed: 05/19/2023]
Abstract
Large randomized controlled trials have shown the benefits of percutaneous closure of patent foramen ovale (PFO) in patients with cryptogenic stroke and PFO. Recent studies have highlighted the clinical significance and prognostic implication of various anatomical features of PFO and the adjacent atrial septum, such as atrial septal aneurysm (ASA), PFO size, large shunt, and hypermobility. Transthoracic echocardiography with contrast study is used for the indirect diagnosis of PFO, as it reveals the passage of the contrast into the left atrium. In contrast, transesophageal echocardiography (TEE) offers a direct demonstration of PFO by measuring its size using the maximum separation distance between the septum primum and septum secundum. Furthermore, TEE enables the acquisition of detailed anatomical features of the adjacent atrial septum including ASA, hypermobility, and PFO tunnel length, which carry significant prognostic implications. Transesophageal echocardiography also facilitates the diagnosis of pulmonary arteriovenous malformation, a relatively rare cause of paradoxical embolism. This review provides evidence for supporting TEE as a useful screening test for patients with cryptogenic stroke to identify suitable candidates for percutaneous device closure of PFO. Additionally, cardiac imaging specialists with proficiency in comprehensive TEE examination should be part of the heart-brain team for proper evaluation of and decision-making in patients with cryptogenic stroke.
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Affiliation(s)
- Jae-Kwan Song
- Professor of Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.
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5
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Hutayanon P, Muengtaweepongsa S. The Role of Transcranial Doppler in Detecting Patent Foramen Ovale. JOURNAL FOR VASCULAR ULTRASOUND 2023; 47:33-39. [DOI: 10.1177/15443167221108512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/03/2023]
Abstract
Air embolic signals detected in the intracranial arteries using transcranial Doppler after intravenous injection of agitated saline bubbles indicate right-to-left cardiac shunting. They prove that emboli from venous sites can bypass the lungs and flow to the intracranial arteries. The Valsalva maneuver immediately after an intravenous injection of agitated saline bubbles helps the air bubbles pass through the shunt. If the air embolic signal appears in the intracranial arteries without the Valsalva maneuver, the shunting is highly significant to the etiology of embolism. Transcranial Doppler to detect air embolic signals after intravenous injection of agitated saline bubbles may not be mandatory to diagnose and treat patent foramen ovale; however, as with echocardiography, transcranial Doppler is considered a noninvasive, convenient, and low-cost investigation. The test should be helpful to confirm the significance of the corresponding patent foramen ovale.
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6
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Millington SJ, Mayo-Malasky H, Koenig S. Agitated Saline Contrast Injection in Patients with Severe Hypoxemia. J Intensive Care Med 2023; 38:479-486. [PMID: 36827332 PMCID: PMC10154990 DOI: 10.1177/08850666231159019] [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: 02/25/2023]
Abstract
The use of agitated saline contrast (ASC) during echocardiographic examinations is a well-established practice, most commonly performed to identify atrial septal abnormalities in the context of stroke. In the intensive care unit, this technique may be employed to identify anatomic right-to-left shunts (either intracardiac or transpulmonary) that may be contributing to hypoxemic respiratory failure. This narrative review will describe the technique of ASC injection, summarize clinical scenarios where it may be useful, and review the strengths and limitations of the tool.
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Affiliation(s)
- Scott J Millington
- Department of Critical Care, University of Ottawa/The Ottawa Hospital, Ottawa, ON Canada
| | - Henry Mayo-Malasky
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 25049Long Island Jewish Medical Center, New Hyde Park, NY, USA
| | - Seth Koenig
- Department of Critical Care, Kent Hospital, Warwick, RI, USA
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7
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Mulloy A, Messika-Zeitoun D, Burwash IG. Detection of Patent Foramen Ovale: Identifying the "Holes" With Contrast-Enhanced Transthoracic Echocardiography. Can J Cardiol 2022; 38:1959-1961. [PMID: 36174914 DOI: 10.1016/j.cjca.2022.09.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 09/22/2022] [Indexed: 12/14/2022] Open
Affiliation(s)
- Andrew Mulloy
- Division of Cardiology, University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - David Messika-Zeitoun
- Division of Cardiology, University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Ian G Burwash
- Division of Cardiology, University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada.
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8
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Zhang H, Liu W, Ma J, Liu H, Li L, Zhou J, Wang S, Li S, Wang W, Wang Y. Pitfalls of Using Imaging Technique in the Presence of Eustachian Valve or Chiari Network: Effects on Right-to-Left Shunt and Related Influencing Factors. Diagnostics (Basel) 2022; 12:diagnostics12102283. [PMID: 36291972 PMCID: PMC9600541 DOI: 10.3390/diagnostics12102283] [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: 08/22/2022] [Revised: 09/12/2022] [Accepted: 09/20/2022] [Indexed: 11/16/2022] Open
Abstract
When patent foramen ovale (PFO) combines with the prominent Eustachian valve or Chiari network (EV/CN), contrast transthoracic echocardiography (cTTE) may miss the diagnosis of PFO. We sought to determine the characteristics of right-to-left shunt (RLS) in PFO patients with prominent EV/CN on cTTE and identify the causal factors of missed diagnosis. We consecutively enrolled 98 patients who suffered from PFO-related stroke and with prominent EV/CN. All patients were divided into the delayed and non-delayed groups according to the characteristics of RLS on cTTE. The characteristics of RLS were compared with those of 42 intrapulmonary shunt patients. The anatomical characteristics of PFO and EV/CN were analyzed in the 98 PFO patients. Upon cTTE, significantly delayed occurrence and longer duration of the RLS in the delayed group were found both at rest and during the Valsalva maneuver, similar to the intrapulmonary shunt. Multivariate logistic analysis revealed that the length of EV/CN (>19 mm) and the diameter of PFO at the left atrium aspect (<1.2 mm) were high-risk factors for missed diagnosis. In conclusion, RLS showed delayed emergence and disappearance in some of the PFO patients with prominent EV/CN. The length of EV/CN and the diameter of PFO may have been related to the missed diagnosis of PFO.
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Affiliation(s)
- Han Zhang
- Department of Cardiac Ultrasound, The Second Hospital of Hebei Medical University, Shijiazhuang 050000, China
| | - Weiwei Liu
- Department of Cardiac Ultrasound, The Second Hospital of Hebei Medical University, Shijiazhuang 050000, China
| | - Jie Ma
- Department of Vascular Surgery, The Second Hospital of Hebei Medical University, Shijiazhuang 050000, China
| | - Huanling Liu
- Department of Cardiac Ultrasound, The Second Hospital of Hebei Medical University, Shijiazhuang 050000, China
| | - Lin Li
- Department of Cardiac Ultrasound, The Second Hospital of Hebei Medical University, Shijiazhuang 050000, China
| | - Jinling Zhou
- Department of Cardiac Ultrasound, The Second Hospital of Hebei Medical University, Shijiazhuang 050000, China
| | - Shanshan Wang
- Department of Cardiac Ultrasound, The Second Hospital of Hebei Medical University, Shijiazhuang 050000, China
| | - Shanshan Li
- Department of Cardiac Ultrasound, The Second Hospital of Hebei Medical University, Shijiazhuang 050000, China
| | - Wei Wang
- Department of Cardiac Ultrasound, The Second Hospital of Hebei Medical University, Shijiazhuang 050000, China
| | - Yueheng Wang
- Department of Cardiac Ultrasound, The Second Hospital of Hebei Medical University, Shijiazhuang 050000, China
- Correspondence: ; Tel.: +86-0311-6600-3733
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9
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Witte LS, el Bouziani A, Straver B, Koch KT, Beijk MA, Caesar L, Tijssen JG, Bouma BJ, de Winter RJ. Atrial Right-to-Left Shunting Does Not Predict PFO Orifice Area in Patients Undergoing Percutaneous PFO Closure. JACC Cardiovasc Interv 2022; 15:2231-2233. [DOI: 10.1016/j.jcin.2022.05.014] [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: 02/11/2022] [Revised: 05/02/2022] [Accepted: 05/10/2022] [Indexed: 10/14/2022]
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10
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Mac Grory B, Ohman EM, Feng W, Xian Y, Yaghi S, Kamel H, Reznik ME. Advances in the management of cardioembolic stroke associated with patent foramen ovale. BMJ 2022; 376:e063161. [PMID: 35140114 DOI: 10.1136/bmj-2020-063161] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Patent foramen ovale (PFO) describes a valve in the interatrial septum that permits shunting of blood or thrombotic material between the atria. PFOs are present in approximately 25% of the healthy population and are not associated with any pathology in the vast majority of cases. However, comparisons between patients with stroke and healthy controls suggest that PFOs may be causative of stroke in certain patients whose stroke is otherwise cryptogenic. Options for the diagnosis of PFO include transthoracic echocardiography, transesophageal echocardiography, and transcranial Doppler ultrasonography. PFOs associated with an interatrial septal aneurysm seem to be more strongly linked to risk of recurrent stroke. Therapeutic options for secondary stroke prevention in the setting of a PFO include antiplatelet therapy, anticoagulation, and percutaneous device closure. Recent randomized clinical trials suggest that percutaneous closure reduces the subsequent risk of stroke in appropriately selected patients, with a large relative benefit but small absolute benefit. Referral for percutaneous PFO closure should therefore be considered in certain patients after a multidisciplinary, patient centered discussion. Areas for future study include structural biomarkers to aid in determining the role of PFO closure in older people with possible PFO associated stroke, the role of direct oral anticoagulants, and very long term outcomes after device closure.
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Affiliation(s)
- Brian Mac Grory
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - E Magnus Ohman
- Duke Clinical Research Institute, Durham, NC, USA
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Wuwei Feng
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
| | - Ying Xian
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Shadi Yaghi
- Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Hooman Kamel
- Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Michael E Reznik
- Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI, USA
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11
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Cho H, Kim T, Song IU, Chung SW. The Prevalence of Microembolic Signals in Transcranial Doppler Sonography With Bubble Test in Acute Ischemic Stroke. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2022; 41:439-446. [PMID: 33885173 DOI: 10.1002/jum.15724] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 03/29/2021] [Accepted: 04/08/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVES Transcranial Doppler ultrasound (TCD) is noninvasive and highly sensitive and specific for the diagnosis of patent foramen ovale (PFO). We evaluated the diagnostic implications of the TCD with a saline agitation test as a routine work-up for ischemic stroke patients. METHODS A TCD bubble study was performed in all consecutive ischemic stroke patients as a routine work-up. We evaluated the prevalence of microembolic signals (MES) for each stroke etiology and the optimal number of MES for predicting the PFO-attributable stroke. RESULTS Subjects (N = 499) with acute ischemic stroke were enrolled. A significant fraction of patients had MES during both normal respiration (5.7-44.4%) and the Valsalva maneuver (19.5-55.6%) across all stroke etiology categories. The optimal MES threshold for the diagnosis of PFO-attributable stroke confirmed by transesophageal echocardiography was 46 MES during the Valsalva maneuver (96% sensitivity and 95% specificity). Applying ≥46 MES during the Valsalva maneuver as a threshold effectively increased the ability to differentially diagnose PFO-attributable stroke from other etiologies. The number of MES during the Valsalva maneuver was negatively correlated with increasing age (r = -.108; P = .016). CONCLUSIONS A significant fraction of patients had right to left shunt across all Trial of ORG 10172 in Acute Stroke Treatment etiologies. A threshold number of MES facilitated the differential diagnosis of PFO-attributable stroke from other etiologies, and the optimal threshold was 46 MES during the Valsalva maneuver.
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Affiliation(s)
- Hyunji Cho
- Department of Neurology, College of Medicine, Incheon St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Taewon Kim
- Department of Neurology, College of Medicine, Incheon St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - In-Uk Song
- Department of Neurology, College of Medicine, Incheon St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Sung-Woo Chung
- Department of Neurology, College of Medicine, Incheon St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
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12
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Germonpré P, Lafère P, Portier W, Germonpré FL, Marroni A, Balestra C. Increased Risk of Decompression Sickness When Diving With a Right-to-Left Shunt: Results of a Prospective Single-Blinded Observational Study (The "Carotid Doppler" Study). Front Physiol 2021; 12:763408. [PMID: 34777020 PMCID: PMC8586212 DOI: 10.3389/fphys.2021.763408] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 10/07/2021] [Indexed: 11/21/2022] Open
Abstract
Introduction: Divers with a patent Foramen Ovale (PFO) have an increased risk for decompression sickness (DCS) when diving with compressed breathing gas. The relative risk increase, however, is difficult to establish as the PFO status of divers is usually only determined after a DCS occurrence. Methods: This prospective, single-blinded, observational study was designed to collect DCS data from volunteer divers after screening for right-to-left shunt (RLS) using a Carotid Doppler test. Divers were blinded to the result of the test, but all received a standardized briefing on current scientific knowledge of diving physiology and “low-bubble” diving techniques; they were then allowed to dive without restrictions. After a mean interval of 8 years, a questionnaire was sent collecting data on their dives and cases of DCS (if any occurred). Results: Data was collected on 148 divers totaling 66,859 dives. There was no significant difference in diving data between divers with or without RLS. Divers with RLS had a 3.02 times higher incidence of (confirmed) DCS than divers without RLS (p = 0.04). When all cases of (confirmed or possible DCS) were considered, the Relative Risk was 1.42 (p = 0.46). DCS occurred mainly in divers who did not dive according to “low-bubble” diving techniques, in both groups. Conclusion: This prospective study confirms that DCS is more frequent in divers with RLS (such as a PFO), with a Relative Risk of 1.42 (all DCS) to 3.02 (confirmed DCS). It appears this risk is linked to diving behavior, more specifically diving to the limits of the adopted decompression procedures.
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Affiliation(s)
- Peter Germonpré
- Centre for Hyperbaric Oxygen Therapy, Military Hospital, Brussels, Belgium.,Divers Alert Network (DAN) Europe Research Division, Roseto, Italy
| | - Pierre Lafère
- Centre for Hyperbaric Oxygen Therapy, Military Hospital, Brussels, Belgium.,Divers Alert Network (DAN) Europe Research Division, Roseto, Italy.,Environmental & Occupational, Ageing (Integrative) Physiology Lab, Haute Ecole Bruxelles-Brabant (HE2B), Auderghem, Belgium
| | - William Portier
- Centre for Hyperbaric Oxygen Therapy, Military Hospital, Brussels, Belgium
| | | | - Alessandro Marroni
- Environmental & Occupational, Ageing (Integrative) Physiology Lab, Haute Ecole Bruxelles-Brabant (HE2B), Auderghem, Belgium
| | - Costantino Balestra
- Divers Alert Network (DAN) Europe Research Division, Roseto, Italy.,Environmental & Occupational, Ageing (Integrative) Physiology Lab, Haute Ecole Bruxelles-Brabant (HE2B), Auderghem, Belgium.,Physical Activity Teaching Unit, Motor Sciences Department, Université Libre de Bruxelles (ULB), Brussels, Belgium
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13
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Van der Giessen H, Wilson LC, Coffey S, Whalley GA. Review: Detection of patient foramen ovale using transcranial Doppler or standard echocardiography. Australas J Ultrasound Med 2020; 23:210-219. [PMID: 34765407 PMCID: PMC8411673 DOI: 10.1002/ajum.12232] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 09/21/2020] [Accepted: 10/02/2020] [Indexed: 11/07/2022] Open
Abstract
A patent foramen ovale (PFO) is a common remnant of fetal circulation present in up to 25% of the worldwide adult population. Paradoxical embolism occurs when venous blood crosses the PFO into the arterial system, bypassing the pulmonary circulation. This allows for the direct passage of microemboli into cerebral blood vessels, increasing the risk of cryptogenic stroke. This review investigates the current diagnostic procedures used to detect and grade a PFO, including transthoracic echocardiography (TTE), transoesophageal echocardiography (TOE) and transcranial Doppler (TCD). Only a few studies have directly compared the use of TTE with TCD for PFO detection but several have compared TTE and TCD independently against the clinical gold standard TOE. Known pitfalls of TTE and TCD are also discussed, including the difficulty of differentiating between intracardiac shunts and intrapulmonary shunts. This review also discusses methods to optimise imaging, such as performing an adequate Valsalva manoeuvre, the role of abdominal compression and the choice of the injection site for the contrast agent and how these may increase the diagnostic success of detecting a right-to-left shunt when prompted by a clinician.
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Affiliation(s)
- Hanna Van der Giessen
- The Department of Medicine, Otago Medical SchoolThe University of OtagoDunedinNew Zealand
| | - Luke C Wilson
- The Department of Medicine, Otago Medical SchoolThe University of OtagoDunedinNew Zealand
| | - Sean Coffey
- The Department of Medicine, Otago Medical SchoolThe University of OtagoDunedinNew Zealand
| | - Gillian A Whalley
- The Department of Medicine, Otago Medical SchoolThe University of OtagoDunedinNew Zealand
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14
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Bernard S, Churchill TW, Namasivayam M, Bertrand PB. Agitated Saline Contrast Echocardiography in the Identification of Intra- and Extracardiac Shunts: Connecting the Dots. J Am Soc Echocardiogr 2020; 34:S0894-7317(20)30615-5. [PMID: 34756394 DOI: 10.1016/j.echo.2020.09.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 09/01/2020] [Accepted: 09/05/2020] [Indexed: 02/08/2023]
Abstract
Agitated saline contrast studies are an essential component of contemporary echocardiography. Agitated saline contrast plays a critical role in the elucidation of intracardiac versus intrapulmonary shunting and can have major therapeutic implications, particularly in light of the evolution of percutaneous treatment options for atrial septal defects or a patent foramen ovale. Despite their perceived simplicity, however, there are numerous pitfalls of these investigations that can occur during their performance and interpretation. As such, the authors review the "bubble study" in identifying intracardiac and extracardiac shunts, including the history of its development, the physics and physiology of contrast enhancement, how to optimally perform and interpret an agitated saline contrast study, and its safety in unique populations.
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Affiliation(s)
- Samuel Bernard
- Cardiac Ultrasound Laboratory, Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
| | - Timothy W Churchill
- Cardiac Ultrasound Laboratory, Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Mayooran Namasivayam
- Cardiac Ultrasound Laboratory, Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Philippe B Bertrand
- Cardiac Ultrasound Laboratory, Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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15
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Montrief T, Alerhand S, Denault A, Scott J. Point-of-care echocardiography for the evaluation of right-to-left cardiopulmonary shunts: a narrative review. Can J Anaesth 2020; 67:1824-1838. [PMID: 32944839 DOI: 10.1007/s12630-020-01813-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 06/10/2020] [Accepted: 06/10/2020] [Indexed: 12/19/2022] Open
Abstract
Right-to-left pulmonary and cardiac shunts (RLS) are important causes of refractory hypoxia in the critically-ill perioperative patient. Using a point-of-care ultrasound (POCUS) agitated saline bubble study for an early diagnosis allows patients with clinically significant RLSs to receive expedited therapy. This narrative review discusses the principles of agitated saline ultrasonography as well as the role of POCUS in detecting the most common RLS types seen in the intensive care unit, including patent foramen ovale, atrial septal defects, and pulmonary arterio-venous malformations. An illustrated discussion of the procedure, as well as shunt-enhancing maneuvers (Valsalva or lung recruitment maneuver with subsequent rapid release) is provided. With the wide dissemination of bedside ultrasound within the perioperative and critical care arena, POCUS practitioners should be knowledgeable of the potential pitfalls leading to both false-positive and false-negative studies. False-positive studies may be due to congenital abnormalities, mischaracterization of intrapulmonary shunts as intracardiac shunts (and vice versa), or evidence of the Valsalva effect. False negatives are typically due to respiratory-phasic variation, performing an inadequate shunt-enhancing maneuver, inadequate injection of agitated saline, or pathophysiologic states of elevated left atrial pressure. Finally, alternative POCUS methods for determining presence of an RLS in patients with poor echocardiographic windows are discussed, with a focus on pulsed-wave Doppler interrogation of arterial signals.
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Affiliation(s)
- Tim Montrief
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Stephen Alerhand
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - André Denault
- Department of Anesthesiology and Critical Care Division, Montreal Heart Institute, Université de Montréal, 5000 Belanger Street, Montreal, QC, H1T 1C8, Canada.
| | - Jeffrey Scott
- Division of Cardiothoracic and Transplant Critical Care, Jackson Health System, Miami Transplant Institute, Miami, FL, USA
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16
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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]
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17
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Tang PT, Cahill T, Rothwell PM, Ormerod OJ, Daniels MJ. Serial Shunt Evaluation Reveals Limitations of Contemporary Screening Studies for Patent Foramen Ovale. JACC Cardiovasc Interv 2020; 13:1269-1270. [PMID: 32438998 PMCID: PMC7254051 DOI: 10.1016/j.jcin.2020.01.210] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 12/17/2019] [Accepted: 01/14/2020] [Indexed: 11/30/2022]
Affiliation(s)
| | | | | | | | - Matthew J. Daniels
- Manchester University NHS Hospitals Trust, Division of Cardiovascular Sciences, Core Technology Facility 3.20, 46 Grafton Street, Manchester, Cheshire M13 9NT, United Kingdom @cardiacpolymath
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18
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Cai Q, Ahmad M. Eustachian valve, interatrial shunt, and paradoxical embolism. Echocardiography 2020; 37:939-944. [DOI: 10.1111/echo.14682] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 04/11/2020] [Accepted: 04/20/2020] [Indexed: 12/19/2022] Open
Affiliation(s)
- Qiangjun Cai
- Division of Cardiology University of Texas Medical Branch Galveston TX USA
| | - Masood Ahmad
- Division of Cardiology University of Texas Medical Branch Galveston TX USA
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19
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Mondal S, Sankova S, Lee K, Sorensen E, Kaczorowski D, Mazzeffi M. Intraoperative and Early Postoperative Management of Patients Undergoing Minimally Invasive Left Ventricular Assist Device Implantation. J Cardiothorac Vasc Anesth 2020; 35:616-630. [PMID: 32505605 DOI: 10.1053/j.jvca.2020.04.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 04/03/2020] [Accepted: 04/09/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Samhati Mondal
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - Susan Sankova
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - Khang Lee
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
| | - Erik Sorensen
- Department of Surgery, Division of Cardiothoracic Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - David Kaczorowski
- Department of Surgery, Division of Cardiothoracic Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Michael Mazzeffi
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD.
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20
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Nagarajarao HS, Ojha CP, Kedar A, Mukherjee D. Patent Foramen Ovale, the Role of Antiplatelet Therapy Alone or Anticoagulant Therapy Alone Versus Device Closure for Cryptogenic Stroke: A Review of the Literature and Current Recommendations. Cardiovasc Hematol Agents Med Chem 2020; 18:135-150. [PMID: 32013839 DOI: 10.2174/1871525718666200203111641] [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: 09/20/2019] [Revised: 11/22/2019] [Accepted: 01/16/2020] [Indexed: 06/10/2023]
Abstract
Cryptogenic stroke and its relation to the Patent Foramen Ovale (PFO) is a long-debated topic. Recent clinical trials have unequivocally established the relationship between cryptogenic strokes and paradoxical embolism across the PFO. This slit-like communication exists in everyone before birth, but most often closes shortly after birth. PFO may persist as a narrow channel of communication between the right and left atria in approximately 25-27% of adults. In this review, we examine the clinical relevance of the PFO with analysis of the latest trials evaluating catheter-based closure of PFO's for cryptogenic stroke. We also review the current evidence examining the use of antiplatelet medications versus anticoagulants for stroke prevention in those patients with PFO who do not qualify for closure per current guidelines.
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Affiliation(s)
- Harsha S Nagarajarao
- Department of Medicine, Texas Tech University of Health Sciences, El Paso, TX, United States
| | - Chandra P Ojha
- Department of Medicine, Texas Tech University of Health Sciences, El Paso, TX, United States
| | - Archana Kedar
- Department of Medicine, Clinical Instructor, University of Louisville, Kentucky, Louisville, Kentucky, United States
| | - Debabrata Mukherjee
- Department of Medicine, Texas Tech University of Health Sciences, El Paso, TX, United States
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21
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Vaidya K, Khandkar C, Celermajer D. Current management aspects in adult congenital heart disease: non-surgical closure of patent foramen ovale. Cardiovasc Diagn Ther 2019; 8:739-753. [PMID: 30740321 DOI: 10.21037/cdt.2018.09.09] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [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 a remnant interatrial communication, best diagnosed with transoesophageal echocardiography (TOE) and bubble study. Although quite common and often asymptomatic, PFO is associated with cryptogenic stroke and migraine. Approximately one-half of patients with a cryptogenic stroke have a PFO, and the dilemma regarding whether or not to proceed with percutaneous device closure, to reduce the risk of future recurrent events due to paradoxical embolism, has been subject to debate for nearly two decades. Despite promising observational data, initial randomised clinical trials failed to demonstrate superiority of closure over medical therapy. However, long-term follow-up data from one of these early trials, combined with two new randomised trials, have provided more evidence for the benefits of closure in selected patients. This new evidence suggests that younger patients with high-risk features such as an atrial septal aneurysm (ASA) or large interatrial shunt are more likely to benefit from PFO closure, after fastidious exclusion of an alternative cause for the index stroke. However, issues which require further clarification include whether anticoagulant therapy is preferable to antiplatelet therapy for medical management, and which particular type of closure device is optimal. Finally, despite promising retrospective observational data suggesting improvement in migraine attacks after PFO closure, high quality evidence is lacking in this regard.
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Affiliation(s)
- Kaivan Vaidya
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia.,Central Clinical School, Faculty of Medicine, University of Sydney, Sydney, Australia
| | - Chinmay Khandkar
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia.,Central Clinical School, Faculty of Medicine, University of Sydney, Sydney, Australia
| | - David Celermajer
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia.,Central Clinical School, Faculty of Medicine, University of Sydney, Sydney, Australia
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22
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Di Biase L, Burkhardt JD, Horton R, Sanchez J, Mohanty P, Mohanty S, Bailey S, Gallinghouse GJ, Natale A, Krishnan SC. Closure of foramen ovale triggered by injury to tunnel surfaces of septum primum and secundum. J Interv Card Electrophysiol 2019; 55:63-71. [DOI: 10.1007/s10840-019-00510-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 01/07/2019] [Indexed: 11/28/2022]
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23
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Neilan TG, Price MC, Sanborn DY, Gainor JF, Chen A. Case 33-2018: A 57-Year-Old Man with Confusion, Fever, Malaise, and Weight Loss. N Engl J Med 2018; 379:1658-1669. [PMID: 30354952 DOI: 10.1056/nejmcpc1802830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Tomas G Neilan
- From the Departments of Medicine (T.G.N., D.Y.S., J.F.G.), Radiology (M.C.P.), and Pathology (A.C.), Massachusetts General Hospital, and the Departments of Medicine (T.G.N., D.Y.S., J.F.G.), Radiology (M.C.P.), and Pathology (A.C.), Harvard Medical School - both in Boston
| | - Melissa C Price
- From the Departments of Medicine (T.G.N., D.Y.S., J.F.G.), Radiology (M.C.P.), and Pathology (A.C.), Massachusetts General Hospital, and the Departments of Medicine (T.G.N., D.Y.S., J.F.G.), Radiology (M.C.P.), and Pathology (A.C.), Harvard Medical School - both in Boston
| | - Danita Y Sanborn
- From the Departments of Medicine (T.G.N., D.Y.S., J.F.G.), Radiology (M.C.P.), and Pathology (A.C.), Massachusetts General Hospital, and the Departments of Medicine (T.G.N., D.Y.S., J.F.G.), Radiology (M.C.P.), and Pathology (A.C.), Harvard Medical School - both in Boston
| | - Justin F Gainor
- From the Departments of Medicine (T.G.N., D.Y.S., J.F.G.), Radiology (M.C.P.), and Pathology (A.C.), Massachusetts General Hospital, and the Departments of Medicine (T.G.N., D.Y.S., J.F.G.), Radiology (M.C.P.), and Pathology (A.C.), Harvard Medical School - both in Boston
| | - Athena Chen
- From the Departments of Medicine (T.G.N., D.Y.S., J.F.G.), Radiology (M.C.P.), and Pathology (A.C.), Massachusetts General Hospital, and the Departments of Medicine (T.G.N., D.Y.S., J.F.G.), Radiology (M.C.P.), and Pathology (A.C.), Harvard Medical School - both in Boston
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24
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Kerut EK, Campbell WF, Hall ME, McMullan MR. Identification of candidates for PFO closure in the echocardiography laboratory. Echocardiography 2018; 35:1860-1867. [PMID: 30303254 DOI: 10.1111/echo.14154] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Revised: 08/21/2018] [Accepted: 09/14/2018] [Indexed: 01/16/2023] Open
Abstract
A patent foramen ovale (PFO) is implicated in several pathologic processes, including that of cryptogenic stroke (cCVA). Recent trials identify "high-risk" PFOs in patients with cCVA as likely to benefit from percutaneous closure. The younger the patient (<60 years old) the more likely a PFO may be attributable to the cCVA. The RoPE Score index helps determine the likelihood that an existing PFO is related to a cCVA. This may help guide the clinician and patient when contemplating percutaneous PFO closure. When evaluating a patient for possible percutaneous closure, one should identify the CVA as a typical ischemic type stroke. In order to "rule-out" other causes of CVA, imaging of the intracranial arteries, cervical, and aortic arch vessels should be performed. Small vessel disease or a lacunar-type infarct should be excluded. To rule out atrial fibrillation, prolonged monitoring should be performed. An index has been developed to determine the probability that a PFO is the causative etiology and calculates the risk of recurrence. This may help guide the clinician and patient in the decision for PFO closure. In addition, one should consider a work-up for a hypercoagulable state. We will obtain an ultrasound of the lower extremities or consider deep pelvic vein thrombosis (prolonged sitting or malignancy). If the closure is to be performed, the Food and Drug Administration (FDA) has approved the Amplatzer PFO Occluder and the GORE Cardioform Septal Occluder for percutaneous closure. These devices are both approved in patients predominately between ages 18 and 60 years with a cCVA due to presumed paradoxical embolism as verified by a neurologist and cardiologist and when other causes of ischemic CVA have been excluded. "High-risk" PFOs appear to achieve the most potential benefit from percutaneous closure.
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Affiliation(s)
- Edmund Kenneth Kerut
- Division of Cardiovascular Diseases, Department of Medicine, University of Mississippi School of Medicine, Jackson, Mississippi.,Heart Clinic of Louisiana, Marrero, Louisiana
| | - William F Campbell
- Division of Cardiovascular Diseases, Department of Medicine, University of Mississippi School of Medicine, Jackson, Mississippi
| | - Michael E Hall
- Division of Cardiovascular Diseases, Department of Medicine, University of Mississippi School of Medicine, Jackson, Mississippi
| | - Michael R McMullan
- Division of Cardiovascular Diseases, Department of Medicine, University of Mississippi School of Medicine, Jackson, Mississippi
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25
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Anantha-Narayanan M, Anugula D, Das G. Patent foramen ovale closure reduces recurrent stroke risk in cryptogenic stroke: A systematic review and meta-analysis of randomized controlled trials. World J Cardiol 2018; 10:41-48. [PMID: 29983901 PMCID: PMC6033706 DOI: 10.4330/wjc.v10.i6.41] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 03/01/2018] [Accepted: 03/20/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate if patent foramen ovale (PFO) closure device reduces the risk of recurrent stroke in patients with cryptogenic stroke.
METHODS We searched five databases - PubMed, EMBASE, Cochrane, CINAHL and Web-of-Science and clinicaltrials.gov from January 2000 to September 2017 for randomized trials comparing PFO closure to medical therapy in cryptogenic stroke. Heterogeneity was determined using Cochrane’s Q statistics. Random effects model was used.
RESULTS Five randomized controlled trials with 3440 patients were included in the analysis. Mean follow-up was 50 ± 20 mo. PFO closure was associated with a 41% reduction in incidence of recurrent strokes when compared to medical therapy alone in patients with cryptogenic stroke [risk ratio (RR): 0.59, 95%CI: 0.40-0.87, P = 0.008]. Atrial fibrillation was higher with device closure when compared to medical therapy alone (RR: 4.97, 95%CI: 2.22-11.11, P < 0.001). There was no difference between the two groups with respect to all-cause mortality, major bleeding or adverse events.
CONCLUSION PFO device closure in appropriately selected patients with moderate to severe right-to-left shunt and/or atrial septal aneurysm shows benefit with respect to recurrent strokes, particularly in younger patients. Further studies are essential to evaluate the impact of higher incidence of atrial fibrillation seen with the PFO closure device on long-term mortality and stroke rates.
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Affiliation(s)
- Mahesh Anantha-Narayanan
- Division of Cardiovascular Disease, Department of Medicine, University of Minnesota, Minneapolis, MN 55455, United States
| | - Dixitha Anugula
- Division of Cardiology, CHI Health Creighton University Medical Center, Omaha, NE 68124, United States
| | - Gladwin Das
- Division of Cardiovascular Disease, Department of Medicine, University of Minnesota, Minneapolis, MN 55455, United States
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26
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Shah AH, Osten M, Benson L, Alnasser S, Bach Y, Vishwanath R, Van De Bruaene A, Shulman H, Navaranjan J, Khan R, Horlick E. Incidence and Outcomes of Positive Bubble Contrast Study Results After Transcatheter Closure of a Patent Foramen Ovale. JACC Cardiovasc Interv 2018; 11:1095-1104. [DOI: 10.1016/j.jcin.2018.03.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 02/05/2018] [Accepted: 03/06/2018] [Indexed: 10/14/2022]
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27
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Hoole SP, Hernández-Sánchez J, Davies WR, McNab DC, Calvert PA, Rana BS, Shapiro LM, Davies MG. Effects of Patent Foramen Ovale Closure on Obstructive Sleep Apnea Syndrome: PCOSA Study. Can J Cardiol 2017; 33:1708-1715. [PMID: 29173609 DOI: 10.1016/j.cjca.2017.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 08/31/2017] [Accepted: 09/01/2017] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Previous studies have shown a higher prevalence of patent foramen ovale (PFO) in patients with obstructive sleep apnea syndrome (OSAS). Right to left shunting through a PFO may be encouraged by the respiratory physiology of OSAS, contributing to the disease pathophysiology. We assessed whether PFO closure would improve respiratory polygraphy parameters compared with baseline measurements in patients with OSAS. METHODS Twenty-six patients with newly diagnosed OSAS and a moderate-large PFO (prevalence, 18% of 143 patients screened) were referred for PFO closure. The oxygen desaturation index (ODI), apnea-hypopnea index (AHI), Epworth Sleepiness Scale (ESS), 6-minute walk test (6MWT), and Sleep Apnea Quality of Life Index (SAQLI) results were compared in these patients at baseline (before continuous positive pressure ventilation [CPAP]) and at 6-month follow-up (after interrupting CPAP for 1 week). RESULTS All PFOs were safely sealed at 6 months, as confirmed by repeated transthoracic echocardiography. The ODI (44.8 [interquartile range (IQR), 31.2-63.5) vs 42.3 [IQR, 34.0-60.8]; P = 0.89) and AHI (47.9 [IQR, 31.5-65.2] vs 42.3 [IQR, 32.1-63]; P = 0.99) did not change after PFO closure nor did the 6MWT, although the ESS (13.0 [IQR, 12.0-16.8] vs 6.0 [IQR, 4.0-8.8]; P < 0.001) and the SAQLI (3.4 [IQR, 2.8-4.3] vs 4.4 [IQR, 3.9-5.3]; P < 0.001) did improve. CONCLUSIONS The prevalence of PFO in OSAS appears to be no higher than that in the general population. Although PFO closure is safe and effective, it did not improve respiratory polygraphy measures of OSAS severity. The improvement in the ESS and SAQLI likely reflect residual benefits from CPAP.
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Affiliation(s)
- Stephen P Hoole
- Cardiology Department, Papworth Hospital, Papworth Everard, United Kingdom.
| | - Jules Hernández-Sánchez
- Papworth Trials Unit Collaboration, Papworth Hospital, Papworth Everard, United Kingdom; MRC Biostatistics Unit, University of Cambridge, School of Clinical Medicine, Cambridge Institute of Public Health, Forvie Site, Cambridge, United Kingdom
| | - William R Davies
- Cardiology Department, Papworth Hospital, Papworth Everard, United Kingdom
| | - Duncan C McNab
- Cardiology Department, Papworth Hospital, Papworth Everard, United Kingdom
| | - Patrick A Calvert
- Cardiology Department, Papworth Hospital, Papworth Everard, United Kingdom
| | - Bushra S Rana
- Cardiology Department, Papworth Hospital, Papworth Everard, United Kingdom
| | - Leonard M Shapiro
- Cardiology Department, Papworth Hospital, Papworth Everard, United Kingdom
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Abstract
With a high prevalence in the general population of approximately 25%, and a prevalence in the cryptogenic stroke population approaching 40%, the propensity of a patent foramen ovale (PFO) to precipitate or enable stroke, especially in young, otherwise healthy individuals, has been the subject of much debate. With proof of concept achieved via imaging modalities documenting thrombus-in-transit, and the development of minimally-invasive percutaneous approaches to closure, multiple observational studies and, more recently, several completed randomized controlled trials have sought to answer the question of when and in whom PFO closure should occur. We describe the historical context of PFO closure and review the observational and randomized control trial evidence in this field, culminating in the recent Food and Drug Administration approval of the first dedicated closure device for PFO. Guidelines and consensus statements are discussed, and a novel treatment algorithm is proposed. Future directions in PFO closure will include new devices, further data from completed and upcoming clinical trials, and potential expansion into other disease states associated with PFO.
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29
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Koh TW. When to use femoral vein injection for diagnosis of patent foramen ovale-Effect of a persistent eustachian valve on right atrial flow patterns during contrast transesophageal echocardiography. Echocardiography 2017; 34:768-772. [PMID: 28299822 DOI: 10.1111/echo.13511] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Contrast echocardiography using agitated saline injected into the antecubital vein is the most common method used for the diagnosis of patent foramen ovale. We describe a case whereby the presence of a persistent eustachian valve and a "negative contrast sign" during contrast transesophageal echocardiography raised suspicion of a false-negative result. Femoral vein injection of contrast successfully demonstrated a patent foramen ovale. Femoral vein injection should be considered if this scenario is recognized because the eustachian valve directs blood preferentially from the inferior vena cava toward the interatrial septum and this route may prove to be more reliable.
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Affiliation(s)
- Tat W Koh
- Department of Cardiology, Barts Heart Centre, London, United Kingdom
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30
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Savino K, Maiello M, Pelliccia F, Ambrosio G, Palmiero P. Patent foramen ovale and cryptogenic stroke: from studies to clinical practice: Position paper of the Italian Chapter, International Society Cardiovascular Ultrasound. Int J Clin Pract 2016; 70:641-8. [PMID: 27384340 DOI: 10.1111/ijcp.12842] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Over the last two decades the interest on patent foramen ovale (PFO) as a cause of cardioembolism in cryptogenic stroke has tremendously increased, thanks to the availability of better techniques to diagnose cardiac right-to-left shunt by ultrasounds and of percutaneous means of PFO treatment with interventional techniques. Many studies have been published that have attempted to define diagnostic methodology, prognosis, and optimal treatment (pharmacological or percutaneous closure) of PFO patients with cryptogenic stroke. Unfortunately, even today, definitive evidence is still lacking, and clinical management is not consistent among cardiologists. AIMS This review aims to evaluate the role of PFO in cryptogenic stroke, the diagnostic accuracy of transcranial Doppler, contrast transthoracic and transesophageal echocardiography in the diagnosis of left-fright shunt and PFO; and discuss the indications to medical treatment and percutaneous closure of PFO. METHODS All studies published in the literature on PFO and cryptogenic stroke are considered and discussed. RESULTS We define an appropriate diagnostic and clinical management of PFO patients with cryptogenic stroke. CONCLUSION After many years of interest on PFO and many concluded studies, there are still no definitive data. However, we are on good track for an appropriate management of PFO patients and cryptogenic stroke.
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Affiliation(s)
- K Savino
- Division of Cardiology - S. Maria della Misericordia Hospital, University of Perugia School of Medicine, Perugia, Italy
| | - M Maiello
- ASL Brindisi, District Cardiology Equipe, Brindisi, Italy
| | - F Pelliccia
- Department Heart and Great Vessels "Attilio Reale", University "La Sapienza" Rome, Rome, Italy
| | - G Ambrosio
- Division of Cardiology - S. Maria della Misericordia Hospital, University of Perugia School of Medicine, Perugia, Italy
| | - P Palmiero
- ASL Brindisi, District Cardiology Equipe, Brindisi, Italy
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31
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Balestra C, Germonpré P. Correlation between Patent Foramen Ovale, Cerebral "Lesions" and Neuropsychometric Testing in Experienced Sports Divers: Does Diving Damage the Brain? Front Psychol 2016; 7:696. [PMID: 27242609 PMCID: PMC4863080 DOI: 10.3389/fpsyg.2016.00696] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 04/26/2016] [Indexed: 11/13/2022] Open
Abstract
SCUBA diving exposes divers to decompression sickness (DCS). There has been considerable debate whether divers with a Patent Foramen Ovale of the heart have a higher risk of DCS because of the possible right-to-left shunt of venous decompression bubbles into the arterial circulation. Symptomatic neurological DCS has been shown to cause permanent damage to brain and spinal cord tissue; it has been suggested that divers with PFO may be at higher risk of developing subclinical brain lesions because of repeated asymptomatic embolization of decompression-induced nitrogen bubbles. These studies however suffer from several methodological flaws, including self-selection bias. We recruited 200 volunteer divers from a recreational diving population who had never suffered from DCS; we then randomly selected 50 of those for further investigation. The selected divers underwent brain Magnetic Resonance Imaging to detect asymptomatic brain lesions, contrast trans-oesophageal echocardiography for PFO, and extensive neuro-psychometric testing. Neuro-psychometry results were compared with a control group of normal subjects and a separate control group for subjects exposed to neurotoxic solvents. Forty two divers underwent all the tests and are included in this report. Grade 2 Patent Foramen Ovale was found in 16 (38%) of the divers; brain Unidentified Bright Objects (UBO's) were found in 5 (11.9%). There was no association between PFO and the presence of UBO's (P = 0.693) or their size (p = 0.5) in divers. Neuropsychometric testing in divers was significantly worse from controls in two tests, Digit Span Backwards (DSB; p < 0.05) and Symbol-Digit-Substitution (SDS; p < 0.01). Compared to subjects exposed to neurotoxic solvents, divers scored similar on DSB and SDS tests, but significantly better on the Simple Reaction Time (REA) and Hand-Eye Coordination (EYE) tests. There was no correlation between PFO, number of UBO's and any of the neuro-psychometric tests. We conclude that for uneventful recreational diving, PFO does not appear to influence the presence of UBO's. Diving by itself seems to cause some decrease of short-term memory and higher cognitive function, including visual-motor skills; this resembles some of the effects of nitrogen narcosis and we suggest that this may be a prolonged effect of diving.
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Affiliation(s)
- Costantino Balestra
- DAN Europe Research DivisionBrussels, Belgium; Faculté des Sciences de la Motricité, Université Libre de BruxellesBrussels, Belgium; Motor Sciences and Physiotherapy, Environmental and Occupational (Integrative) Physiology, Haute Ecole Paul Henri SpaakBrussels, Belgium
| | - Peter Germonpré
- DAN Europe Research DivisionBrussels, Belgium; Center for Hyperbaric Oxygen Therapy, Military Hospital Queen AstridBrussels, Belgium
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Stainback RF, Estep JD, Agler DA, Birks EJ, Bremer M, Hung J, Kirkpatrick JN, Rogers JG, Shah NR. Echocardiography in the Management of Patients with Left Ventricular Assist Devices: Recommendations from the American Society of Echocardiography. J Am Soc Echocardiogr 2015; 28:853-909. [DOI: 10.1016/j.echo.2015.05.008] [Citation(s) in RCA: 202] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Affiliation(s)
- Arjun K Ghosh
- Specialty Registrar in Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London W12 0HS
| | - Ajay Jain
- Consultant Cardiologist at Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, London
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Lunetta M, Costa F, Gattuta ML, Novo S. Transesophageal Contrast Echocardiography is Not Always the Gold Standard Method in the Identification of a Patent Foramen Ovale: A Clinical Case. J Cardiovasc Echogr 2015; 25:86-89. [PMID: 28465942 PMCID: PMC5353415 DOI: 10.4103/2211-4122.166084] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
In the embryo, Eustachian valve is a crescent-shaped membrane extending from the lower margin of the inferior vena cava and the ostium of the coronary sinus into the right atrium toward fossa ovalis and tricuspid valve. At birth, after the functional closure of the foramen ovale, the Eustachian valve loses its function, reducing to an embryo remnant. According to growing evidence, a persistent Eustachian valve is a frequent finding in patients with a patent foramen ovale (PFO). By directing the blood from the inferior cava to the interatrial septum, it may prevent the spontaneous closure of PFO after birth and indirectly predispose to paradoxical embolism. Transesophageal contrast enhanced echocardiography (cTEE) is considered the gold standard to diagnose a PFO in postnatal life, but its accuracy maybe is not so high in the presence of a persistent Eustachian valve. In these cases, color Doppler TEE is more sensitive and simplifies the diagnostic process, reducing the duration of TEE and improving the patient compliance.
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Affiliation(s)
- Monica Lunetta
- Department of Internal Medicine and Specialty, University Hospital of Palermo, Palermo, Italy
| | - Francesco Costa
- Department of Clinical and Experimental Medicine, Cardiology Unit, University Hospital of Messina, Messina, Italy
| | - Marcello La Gattuta
- Department of Radiology, DIBIMEF, University Hospital "P Giaccone", University of Palermo, Palermo, Italy
| | - Salvatore Novo
- Department of Internal Medicine and Specialty, University Hospital of Palermo, Palermo, Italy
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Guidelines for the Cardiac Sonographer in the Performance of Contrast Echocardiography: A Focused Update from the American Society of Echocardiography. J Am Soc Echocardiogr 2014; 27:797-810. [DOI: 10.1016/j.echo.2014.05.011] [Citation(s) in RCA: 170] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Gevorgyan R, Perlowski A, Shenoda M, Mojadidi MK, Agrawal H, Tobis JM. Sensitivity of brachial versus femoral vein injection of agitated saline to detect right-to-left shunts with Transcranial Doppler. Catheter Cardiovasc Interv 2014; 84:992-6. [DOI: 10.1002/ccd.25391] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Revised: 12/11/2013] [Accepted: 01/03/2014] [Indexed: 11/06/2022]
Affiliation(s)
- Rubine Gevorgyan
- David Geffen School of Medicine at UCLA; Department of Medicine; Cardiology, Los Angeles, California
| | - Alice Perlowski
- Department of Medicine; Cardiology; University of Chicago; Chicago Illinois
| | | | - M. Khalid Mojadidi
- David Geffen School of Medicine at UCLA; Department of Medicine; Cardiology, Los Angeles, California
| | - Harsh Agrawal
- David Geffen School of Medicine at UCLA; Department of Medicine; Cardiology, Los Angeles, California
| | - Jonathan M. Tobis
- David Geffen School of Medicine at UCLA; Department of Medicine; Cardiology, Los Angeles, California
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Mojadidi MK, Winoker JS, Roberts SC, Msaouel P, Gevorgyan R, Zolty R. Two-dimensional echocardiography using second harmonic imaging for the diagnosis of intracardiac right-to-left shunt: a meta-analysis of prospective studies. Int J Cardiovasc Imaging 2014; 30:911-23. [PMID: 24740212 DOI: 10.1007/s10554-014-0426-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Accepted: 04/11/2014] [Indexed: 01/17/2023]
Abstract
Right-to-left shunting (RLS), usually through a patent foramen ovale (PFO), has been associated with migraine, cryptogenic stroke and hypoxemia. With emerging observational studies and clinical trials on the subject of PFO, there is a need for accurate diagnosis of PFO in patients being considered for transcatheter closure. While transesophageal echo (TEE) bubble study is the current standard reference for diagnosing PFO, transthoracic echo with second harmonic imaging (TTE-HI) may be a preferable screening test for RLS due to its high accuracy and non-invasiveness. The aim of this meta-analysis was to determine the accuracy of TTE-HI compared to TEE as the reference. A systematic review of Medline, Cochrane and Embase was done for all the prospective studies assessing for intracardiac RLS using TTE-HI compared to TEE as the reference; both TTE-HI and TEE were performed with a contrast agent and a maneuver to provoke RLS in all studies. A total of 15 studies with 1995 patients fulfilled the inclusion criteria. The weighted mean sensitivity and specificity for TTE-HI were 91 and 93 % respectively. Likewise, the positive and negative likelihood ratios were 13.52 and 0.13 respectively. TTE-HI is a reliable, non-invasive test with proficient diagnostic accuracies. The high sensitivity and specificity of TTE-HI make it a useful initial screening test for RLS. If the precise anatomy is required, then TEE can be obtained before scheduling a patient for transcatheter PFO closure.
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Affiliation(s)
- Mohammad Khalid Mojadidi
- Department of Medicine, Montefiore Medical Center and Jacobi Medical Center, Albert Einstein College of Medicine, 1400 Pelham Parkway South, Building 1, Rm 3N1, Bronx, NY, USA,
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Importance of Adequately Performed Valsalva Maneuver to Detect Patent Foramen Ovale during Transesophageal Echocardiography. J Am Soc Echocardiogr 2013; 26:1337-43. [DOI: 10.1016/j.echo.2013.07.016] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Indexed: 02/06/2023]
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Purandare N, Oude Voshaar RC, Burns A, Velupandian UM, McCollum C. Paradoxical embolization: a potential cause of cerebral damage in Alzheimer's disease? Neurol Res 2013; 28:679-84. [PMID: 16945222 DOI: 10.1179/016164106x130425] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND There are considerable overlaps between vascular dementia and Alzheimer's disease (AD), with a suggestion that cerebrovascular disease (CVD) contributes to the neurodegenerative pathology of AD. Paradoxical embolization of venous emboli into the systemic circulation through a venous to arterial circulation shunt (v-aCS), the most commonly a patent foramen ovale (PFO), is known to cause cryptogenic stroke in younger people. We reviewed the potential role of paradoxical embolization in AD. METHODS A review of the literature on paradoxical embolization in neurological disorders and techniques to detect v-aCS and PFO, supplemented by data from our own studies. RESULTS Before our research, the role of paradoxical embolism in dementia had not been studied. The potential role of embolization in cerebral damage was highlighted by studies in patients undergoing coronary artery bypass or carotid surgery. Paradoxical embolization was found to occur in patients with cryptogenic stroke, migraine, decompression sickles and during hip surgery. The methods for detecting v-aCS or PFO had not been standardized. We found 'significant' v-aCS (equivalent to PFO) in 32% of AD patients compared with 22% of controls, but the study was not sufficiently powered to test the statistic significance of this difference. In AD, there was evidence of an association between 'significant' v-aCS and the severity of white matter hyperintensities on magnetic resonance imaging (MRI). CONCLUSION Paradoxical embolization through a v-aCS may be a potentially preventable or treatable cause of CVD in AD.
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Affiliation(s)
- N Purandare
- Division of Psychiatry, Education and Research Center, Wythenshawe Hospital, Wythenshawe, Manchester, M23 9LT, UK.
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Lhéritier G, Legras A, Caille A, Lherm T, Mathonnet A, Frat JP, Courte A, Martin-Lefèvre L, Gouëllo JP, Amiel JB, Garot D, Vignon P. Prevalence and prognostic value of acute cor pulmonale and patent foramen ovale in ventilated patients with early acute respiratory distress syndrome: a multicenter study. Intensive Care Med 2013; 39:1734-42. [PMID: 23860806 DOI: 10.1007/s00134-013-3017-6] [Citation(s) in RCA: 93] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2013] [Accepted: 07/01/2013] [Indexed: 12/26/2022]
Abstract
PURPOSE We sought to determine the prevalence of and factors associated with acute cor pulmonale (ACP) and patent foramen ovale (PFO) at the early phase of acute respiratory distress syndrome (ARDS), and to assess their relation with mortality. METHODS In this prospective multicenter study, 200 patients submitted to protective ventilation for early moderate to severe ARDS [PaO₂/F(I)O₂: 115 ± 39 with F(I)O₂: 1; positive end-expiratory pressure (PEEP): 10.6 ± 3.1 cmH2O] underwent transthoracic (TTE) and transesophageal echocardiography (TEE) <48 h after admission. Echocardiograms were independently interpreted by two experts. Factors associated with ACP, PFO, and 28-day mortality were identified using multivariate regression analysis. RESULTS TEE depicted ACP in 45/200 patients [22.5%; 95% confidence interval (CI) 16.9-28.9%], PFO in 31 patients (15.5%; 95% CI 10.8-21.3%), and both ACP and PFO in 9 patients (4.5%; 95% CI 2.1-8.4%). PFO shunting was small and intermittent in 27 patients, moderate and consistent in 4 patients, and large or extensive in no instances. PaCO₂ >60 mmHg was strongly associated with ACP [odds ratio (OR) 3.70; 95% CI 1.32-10.38; p = 0.01]. No factor was independently associated with PFO, with only a trend for age (OR 2.07; 95% CI 0.91-4.72; p = 0.08). Twenty-eight-day mortality was 23%. Plateau pressure (OR 1.15; 95% CI 1.05-1.26; p < 0.01) and air leaks (OR 5.48; 95% CI 1.30-22.99; p = 0.02), but neither ACP nor PFO, were independently associated with outcome. CONCLUSIONS TEE screening allowed identification of ACP in one-fourth of patients submitted to protective ventilation for early moderate to severe ARDS. PFO shunting was less frequent and never large or extensive. ACP and PFO were not related to outcome.
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Kutty S, Sengupta PP, Khandheria BK. Patent Foramen Ovale. J Am Coll Cardiol 2012; 59:1665-71. [DOI: 10.1016/j.jacc.2011.09.085] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2011] [Revised: 09/09/2011] [Accepted: 09/13/2011] [Indexed: 10/28/2022]
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Mordini FE, Koktzoglou I, Edelman RR. Time-resolved spin-labeled balanced steady-state free precession cineangiography for visualizing intracardiac shunt: technical considerations and clinical feasibility. Magn Reson Med 2012; 68:1798-806. [DOI: 10.1002/mrm.24191] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2011] [Revised: 12/23/2011] [Accepted: 01/05/2012] [Indexed: 11/06/2022]
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Pellaton C, Heinzer R, Michel P, Eeckhout E. Patent foramen ovale and obstructive sleep apnoea: from pathophysiology to diagnosis of a potentially dangerous association. Arch Cardiovasc Dis 2011; 104:242-51. [PMID: 21624791 DOI: 10.1016/j.acvd.2010.12.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2010] [Accepted: 12/14/2010] [Indexed: 11/17/2022]
Abstract
Patent foramen ovale and obstructive sleep apnoea are frequently encountered in the general population. Owing to their prevalence, they may coexist fortuitously; however, the prevalence of patent foramen ovale seems to be higher in patients with obstructive sleep apnoea. We have reviewed the epidemiological data, pathophysiology, and the diagnostic and therapeutic options for both patent foramen ovale and obstructive sleep apnoea. We focus on the interesting pathophysiological links that could explain a potential association between both pathologies and their implications, especially on the risk of stroke.
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Affiliation(s)
- Cyril Pellaton
- Service of cardiology, CHU Vaudois (CHUV), University of Lausanne, 46, rue du Bugnon, 1011 Lausanne, Switzerland
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Pitfalls in diagnosing PFO: characteristics of false-negative contrast injections during transesophageal echocardiography in patients with patent foramen ovales. J Am Soc Echocardiogr 2010; 23:1136-42. [PMID: 20850947 DOI: 10.1016/j.echo.2010.08.004] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2010] [Indexed: 12/16/2022]
Abstract
BACKGROUND Contrast injections during transesophageal echocardiography for patent foramen ovale (PFO) detection may be false negative. The characteristics of false-negative injections were studied retrospectively. METHODS Contrast transesophageal echocardiography was analyzed for the presence or absence of two characteristics: leftward bulging of the interatrial septum and dense contrast filling of the region of the right atrium adjacent to the interatrial septum. RESULTS Two hundred forty-seven injections were administered to 14 patients with PFOs, and 130 (53%) were false negative. The absence of either characteristic during a single injection resulted in low sensitivity for PFO detection of 7%. When the two characteristics were present at the same time, the sensitivity for PFO detection after a single injection was as high as 95%. CONCLUSIONS The simultaneous presence of both leftward bulging of the interatrial septum and dense contrast filling of the region in the right atrium, adjacent to the interatrial septum, is a prerequisite for PFO detection, and if either characteristic is missing, the injection is inconclusive.
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Vale TA, Newton JD, Orchard E, Bhindi R, Wilson N, Ormerod OJ. Prominence of the Eustachian valve in paradoxical embolism. EUROPEAN JOURNAL OF ECHOCARDIOGRAPHY 2010; 12:33-6. [DOI: 10.1093/ejechocard/jeq100] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Schwerzmann M, Meier B. Impact of percutaneous patent foramen ovale closure on migraine course. Interv Cardiol 2010. [DOI: 10.2217/ica.10.6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Di Tullio MR. Patent Foramen Ovale: Echocardiographic Detection and Clinical Relevance in Stroke. J Am Soc Echocardiogr 2010; 23:144-55; quiz 220. [DOI: 10.1016/j.echo.2009.12.008] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Maffe S, Dellavesa P, Zenone F, Paino AM, Paffoni P, Perucca A, Kozel D, Signorotti F, Bielli M, Parravicini U, Pardo NF, Cucchi L, Aymele AG, Zanetta M. Transthoracic second harmonic two- and three-dimensional echocardiography for detection of patent foramen ovale. EUROPEAN JOURNAL OF ECHOCARDIOGRAPHY 2009; 11:57-63. [DOI: 10.1093/ejechocard/jep165] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Lange MC, Zétola VF, Souza AMD, Piovesan ÉJ, Muzzio JA, Germiniani FMB, Werneck LC. Transcranial Doppler for patent foramen ovale screening: is there a good correlation with transesophageal echocardiography? ARQUIVOS DE NEURO-PSIQUIATRIA 2008; 66:785-9. [DOI: 10.1590/s0004-282x2008000600001] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2008] [Accepted: 09/29/2008] [Indexed: 11/22/2022]
Abstract
Right-to-left shunt (RLS) can be identified by contrast-enhanced transcranial Doppler (cTCD) in patent foramen ovale (PFO) patients. AIM: To evaluate cTCD for PFO screening comparing it to cTEE. METHOD: 45 previous cTCD performed for PFO diagnosis and correlated its findings with cTEE. Patients were submitted to a cTCD standardized technique and were divided in two groups according to RLS: Group 1, patients with a positive RLS and Group 2 when RLS was negative. RESULTS: 29 (65%) patients were included in group 1 and 16 (35%) in group 2. PFO confirmation by cTEE was performed in 28 (62%) patients. cTCD had a 92.85% sensitivity, 82.35% specificity, 89.65% positive predictive value and 87.5% negative predictive value when compared to cTEE for PFO diagnosis. CONCLUSION: Standardized technique cTCD allows for RLS visualization in PFO patients with a good correlation with cTEE and can be used as a screening test before cTEE.
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