Patent foramen ovale, systemic embolization and closure

Can Visual Function Be Affected by an Open Foramen Ovale?

The authors present a relatively rare finding of pathological changes in the visual field, the emergence of homonymous hemianopia, in connection with trauma and paradoxical embolism in a subsequently diagnosed open foramen ovale in a 56-year-old otherwise healthy patient. Cardiac source of embolism is a significant etiology of vascular embolization. The important group is the so-called paradoxical embolism, which occurs when a blood clot (embolus) is carried from the venous side of circulation to the arterial side via foramen ovale patens, what can manifests as ischemic stroke. Foramen ovale patens becomes a risk factor for the stroke development only if there is a peripheral source of embolism and at the same time there is a hemodynamically significant right-left short circuit. Therefore, screening for the causes of cryptogenic stroke should include not only the detection of foramen ovale patens but also evaluation of the peripheral venous system, coagulation parameters and hemodynamic severity of a right-left shunt. Neuroophthalmological aspects related to the described issues are discussed.

Incidentally detected small fistula flows in pulmonary artery by colour Doppler: echocardiographic findings and follow-up results

Abnormal small fistulous flows in the pulmonary artery were detected on routine transthoracic echocardiography in asymptomatic patients by colour Doppler echocardiography. The most likely diagnosis is small coronary artery-pulmonary artery fistulas. We evaluated the clinical, echocardiographic, and follow-up findings of 101 patients. The mean age at first echocardiographic evaluation was 4.3 ± 4.2 years. In 79 (78.2%) of the patients, fistula flow in the pulmonary artery was diagnosed at the first presentation and the remaining 22 patients (21.8%) were diagnosed between the 2nd and 10th examination. The echocardiography indication was cardiac murmur in 42 (41.6%), routine cardiac control in 30 (29.7%), additional CHD in 14 (13.8%), non-specific chest pain in 11 (10.9%), suspicion of inflammatory heart disease in 2 (2%), and syncope in 2 (2%) patients. In 70 (69.3%) patients, fistulous flow was located in the anterior aspect of the main pulmonary artery, in 23 (22.8%) patients on the aortic side of the pulmonary artery and in 8 (7.9%) patients on the right pulmonary artery. Additional cardiac anomalies were ventricular septal defect in 8, patent ductus arteriosus in 6, atrial septal defect in 5, mitral valve prolapse in 4, coarctation of aorta in 4, bicuspid aortic valve in 3, and Kawasaki syndrome in 1 patient. Sixty-four patients (63.3%) were followed during a mean of 52.6 ± 43.7 months. Spontaneous closure was detected in only three patients; the others remained almost unchanged during the follow-up. Since the fistulas are thin and hemodynamically insignificant, echocardiography is an appropriate method to monitor these patients without performing any invasive diagnostic procedures for the fistula source.

Patent foramen ovale and obstructive sleep apnoea: from pathophysiology to diagnosis of a potentially dangerous association

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.

Intermittent cyanosis due to prominent eustachian valve in a newborn infant

A full-term neonate presented with cyanosis only when sleeping, which was considered due to a prominent eustachian valve, directing blood flow from the inferior vena cava to the left atrium through the foramen ovale resulting in interatrial right-to-left shunting. In addition to the anatomical features, hemodynamic features shortly after birth, such as patent foramen ovale and high pulmonary vascular resistance, were also probably involved in the mechanism responsible for the patient's cyanosis. This case may provide insight into differential diagnosis for cyanotic infants.

[Patent foramen ovale percutaneous closure: indications, techniques and results]

A patent foramen ovale is almost physiological (15% of the population) but can be associated with some pathological situations in which its closure can be considered. The only medical indication currently accepted is a right-left shunt without elevation of the right pulmonary pressure, whose most famous pattern is the rare platypnea-orthodeoxie syndrome. PFO may be responsible for diving decompression accidents. Before taking the decision of closing a PFO, each situation must be discussed on a case to case basis. In spite of the possible link between some kinds of migraine and PFO, according to current knowledge, there is no evidence of the efficiency of PFO closure in this situation. The secondary prevention of a cryptogenic ischaemic cerebrovascular attack on a young person with a PFO associated to a membranous septum aneurysm, is the most commonly considered indication, but we lack valid data for this indication. The PFO closing procedure is well codified and its success rate is close to 100%, with rare major complications. Residual permeability within the prosthesis ensuring the closure of the PFO decreases gradually to get under 15% after six months. The clinical result is often dramatic when treating right-left shunts. As far as the secondary prevention of cryptogenic ischaemic cerebro vascular attacks in young people is concerned, there might be some clinical benefit, but we are waiting for the results of ongoing randomized and scheduled studies.

Patent foramen ovale: a new disease?

Patent foramen ovale is a frequent remnant of the fetal circulation. Affecting approximately 25% of the adult population. Its recognition, evaluation and treatment has attracted increasing interest as the importance and frequency of its implication in several pathologic processes, including ischemic stroke secondary to paradoxic embolism, the platypnea-orthodeoxia syndrome, decompression sickness (DCS) (an occupational hazard for underwater divers and high altitude aviators and astronauts) and migraine headache, has become better understood. Echocardiographic techniques have emerged as the principle means for diagnosis and assessment of PFO, in particular contrast echocardiography and transcranial Doppler. Its treatment remains controversial with a general tendency to propose a percutaneous closure among the symptomatic patients.

The 5-Year Projection on the Future of Interventional Cardiology

Interventional cardiology has revolutionized modern cardiovascular care not only with the introduction of new approaches to the treatment of coronary artery disease, but also with the development of new invasive approaches to electrophysiologic procedures and the treatment of noncoronary vascular beds. This revolution continues to gather speed. Creative solutions continue to be proposed, evaluated, and then brought to the patient care arena. Issues remain, but these identify opportunities for continuing improvement.

Transcatheter closure of an atrial septal defect in a dog

Atrial septal defect, while rare in dogs, can result in severe clinical signs. Surgical correction of atrial septal defect requires open-heart surgery. Transcatheter closure techniques provide minimally invasive surgical alternatives.

Patent foramen ovale: The never-ending story

Several uncontrolled studies suggested a relationship between patent foramen ovale (PFO) and stroke. But recent data indicate that previous studies may overestimate the association between PFO and stroke. First, among patients who have had a cryptogenic stroke under treatment (with either warfarin or aspirin), the main data from the French PFO/atrial septal aneurysm (ASA) and PICSS (Patent Foramen Ovale in Cryptogenic Stroke Study), analyzed separately and in combination, indicate that PFO alone does not announce a significantly increased risk of recurrent stroke or death. But a small increase or decrease in risk cannot be excluded by this meta-analysis. Second, the data concerning the association between PFO and ASA are not clear and variable: the French PFO/ASA study found a significantly increased risk of recurrent stroke in patients with cryptogenic stroke and an association between PFO and ASA when treated medically. In contrast, PICSS found no association between the combined PFO-ASA with stroke or death, but the two populations had meaningful differences. Patients in the PICSS were much older than those in the French PFO/ASA study and had more risk factors for stroke, such as hypertension, diabetes, and history of prior stroke. Third, there were inadequate data to conclude about ASA alone. Possible practice recommendations could come from this meta-analysis: the evidence indicates that the risk of recurrent stroke or death is not different for patients with a PFO who underwent cryptogenic stroke compared to patients without a PFO who underwent a cryptogenic stroke under treatment with either aspirin or warfarin. But aspirin is more preferable (300 mg/d). However, it seems that the association between PFO and ASA confers an increased risk of recurrent stroke in medically treated patients who are less than 55 years of age. This subgroup of younger stroke patients may benefit from other treatments, such as the percutaneous closure of PFO or mini-invasive surgery to a lesser extent, but their efficacy and safety are not yet assessed by large randomized trials. However, we must also keep in mind that some stroke patients with PFO are psychologically attached to their PFO and prefer to close it.