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Reeder G, Herrmann J. Editorial commentary: PFO device closure: Knot or not? Trends Cardiovasc Med 2024; 34:414-415. [PMID: 38081491 DOI: 10.1016/j.tcm.2023.12.002] [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] [Received: 12/06/2023] [Accepted: 12/06/2023] [Indexed: 01/08/2024]
Affiliation(s)
- Guy Reeder
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA.
| | - Joerg Herrmann
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA
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Khan M, Miller M, Mccarthy P, Tsai JP, Merhi W, Berkompas D, Wees N, Khan NI, Ahrar A, Evans E, Dahu M, Gauri A, Moelker T, Chalfoun N, Min J. Multidisciplinary Approach to Patent Foramen Ovale Closure for Cryptogenic Stroke: Brain-Heart Board Experience. Neurol Clin Pract 2024; 14:e200319. [PMID: 38826798 PMCID: PMC11141343 DOI: 10.1212/cpj.0000000000200319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 03/11/2024] [Indexed: 06/04/2024]
Abstract
Background and Objectives Patent foramen ovale (PFO) is present in approximately 25% of adult population. The prevalence of PFO is high in patients with cryptogenic stroke suggesting paradoxical embolism. PFO closure in carefully selected patients is an effective secondary preventive strategy in these patients. We report predictors of management recommendations by the multidisciplinary Board and their impact on outcomes. Methods Brain-Heart Board comprises vascular and interventional neurology and cardiology subspecialties (structural, electrophysiology, and cardiac imaging). Adult patients referred to the Board for consideration of PFO closure between October 2017 to March 2021 were included in this retrospective cohort analysis. Demographics, comorbid conditions, risk of paradoxical embolism (RoPE) score, event frequencies (transient ischemic attack [TIA] or stroke, intracranial hemorrhage [ICH], post-PFO closure cardiac arrhythmias), and modified Rankin Scale (mRS) at 1 year were compared between the groups (PFO closure vs medical management). Multivariable logistic regression was used to identify factors associated with management recommendation and chi-square tests to test differences in outcomes for patients according to management. Results Two hundred seventy patients (229 stroke; 41 TIA) were discussed by the Board for PFO closure. 119 (44.0%) patients were recommended for PFO closure of which 117 (98.3%) had evidence of ischemic infarct on imaging. In univariate analysis, age was similar (50 ± 11.9 vs 52 ± 12.8, p = 0.17), but RoPE score was higher in closure as compared with the medical management group (6 [IQR 5-7] vs 5 [IQR 4-7], p < 0.05). In multivariable analysis, TIA as the index event was an independent predictor of Board recommendation against PFO closure (OR 0.05, 95% CI 0.01-0.19, p < 0.05). Event frequency was low in both cohorts (5.9% vs 4.8%, p > 0.05) and comprised cardiac arrhythmias (6 cases of atrial fibrillation and 1 ICH in closure group; 1 TIA and 1 recurrent stroke in medical management group). Excellent functional outcome (mRS 0-1) was similar in both cohorts (66.3% vs 70.7%, p > 0.05) at 1 year. Discussion Multidisciplinary Brain-Heart Board provides a clinical practice model of collaborative care to ensure proper patient selection for PFO closure. TIA as the index event is associated with recommendation of medical management by the multidisciplinary Brain-Heart Board.
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Affiliation(s)
- Muhib Khan
- Division of Neurology (MK, MM, PM, NW, NIK, AA, EE, JM), Neuroscience Institute, Spectrum Health, Grand Rapids; Michigan State University (MK, MM, PM, JPT, WM, DB, NW, NIK, AA, MD, AG, NC, JM), Grand Rapids; Department of Neurology (MK), Mayo Clinic, Rochester, MN; Division of Neurosurgery (JPT), Neuroscience Institute, Grand Rapids; and Division of Cardiology (WM, DB, MD, AG, TM, NC), Heart and Vascular Institute, Spectrum Health, Grand Rapids, MI
| | - Malgorzata Miller
- Division of Neurology (MK, MM, PM, NW, NIK, AA, EE, JM), Neuroscience Institute, Spectrum Health, Grand Rapids; Michigan State University (MK, MM, PM, JPT, WM, DB, NW, NIK, AA, MD, AG, NC, JM), Grand Rapids; Department of Neurology (MK), Mayo Clinic, Rochester, MN; Division of Neurosurgery (JPT), Neuroscience Institute, Grand Rapids; and Division of Cardiology (WM, DB, MD, AG, TM, NC), Heart and Vascular Institute, Spectrum Health, Grand Rapids, MI
| | - Philip Mccarthy
- Division of Neurology (MK, MM, PM, NW, NIK, AA, EE, JM), Neuroscience Institute, Spectrum Health, Grand Rapids; Michigan State University (MK, MM, PM, JPT, WM, DB, NW, NIK, AA, MD, AG, NC, JM), Grand Rapids; Department of Neurology (MK), Mayo Clinic, Rochester, MN; Division of Neurosurgery (JPT), Neuroscience Institute, Grand Rapids; and Division of Cardiology (WM, DB, MD, AG, TM, NC), Heart and Vascular Institute, Spectrum Health, Grand Rapids, MI
| | - Jenny P Tsai
- Division of Neurology (MK, MM, PM, NW, NIK, AA, EE, JM), Neuroscience Institute, Spectrum Health, Grand Rapids; Michigan State University (MK, MM, PM, JPT, WM, DB, NW, NIK, AA, MD, AG, NC, JM), Grand Rapids; Department of Neurology (MK), Mayo Clinic, Rochester, MN; Division of Neurosurgery (JPT), Neuroscience Institute, Grand Rapids; and Division of Cardiology (WM, DB, MD, AG, TM, NC), Heart and Vascular Institute, Spectrum Health, Grand Rapids, MI
| | - William Merhi
- Division of Neurology (MK, MM, PM, NW, NIK, AA, EE, JM), Neuroscience Institute, Spectrum Health, Grand Rapids; Michigan State University (MK, MM, PM, JPT, WM, DB, NW, NIK, AA, MD, AG, NC, JM), Grand Rapids; Department of Neurology (MK), Mayo Clinic, Rochester, MN; Division of Neurosurgery (JPT), Neuroscience Institute, Grand Rapids; and Division of Cardiology (WM, DB, MD, AG, TM, NC), Heart and Vascular Institute, Spectrum Health, Grand Rapids, MI
| | - Duane Berkompas
- Division of Neurology (MK, MM, PM, NW, NIK, AA, EE, JM), Neuroscience Institute, Spectrum Health, Grand Rapids; Michigan State University (MK, MM, PM, JPT, WM, DB, NW, NIK, AA, MD, AG, NC, JM), Grand Rapids; Department of Neurology (MK), Mayo Clinic, Rochester, MN; Division of Neurosurgery (JPT), Neuroscience Institute, Grand Rapids; and Division of Cardiology (WM, DB, MD, AG, TM, NC), Heart and Vascular Institute, Spectrum Health, Grand Rapids, MI
| | - Nabil Wees
- Division of Neurology (MK, MM, PM, NW, NIK, AA, EE, JM), Neuroscience Institute, Spectrum Health, Grand Rapids; Michigan State University (MK, MM, PM, JPT, WM, DB, NW, NIK, AA, MD, AG, NC, JM), Grand Rapids; Department of Neurology (MK), Mayo Clinic, Rochester, MN; Division of Neurosurgery (JPT), Neuroscience Institute, Grand Rapids; and Division of Cardiology (WM, DB, MD, AG, TM, NC), Heart and Vascular Institute, Spectrum Health, Grand Rapids, MI
| | - Nadeem I Khan
- Division of Neurology (MK, MM, PM, NW, NIK, AA, EE, JM), Neuroscience Institute, Spectrum Health, Grand Rapids; Michigan State University (MK, MM, PM, JPT, WM, DB, NW, NIK, AA, MD, AG, NC, JM), Grand Rapids; Department of Neurology (MK), Mayo Clinic, Rochester, MN; Division of Neurosurgery (JPT), Neuroscience Institute, Grand Rapids; and Division of Cardiology (WM, DB, MD, AG, TM, NC), Heart and Vascular Institute, Spectrum Health, Grand Rapids, MI
| | - Asad Ahrar
- Division of Neurology (MK, MM, PM, NW, NIK, AA, EE, JM), Neuroscience Institute, Spectrum Health, Grand Rapids; Michigan State University (MK, MM, PM, JPT, WM, DB, NW, NIK, AA, MD, AG, NC, JM), Grand Rapids; Department of Neurology (MK), Mayo Clinic, Rochester, MN; Division of Neurosurgery (JPT), Neuroscience Institute, Grand Rapids; and Division of Cardiology (WM, DB, MD, AG, TM, NC), Heart and Vascular Institute, Spectrum Health, Grand Rapids, MI
| | - Elizabeth Evans
- Division of Neurology (MK, MM, PM, NW, NIK, AA, EE, JM), Neuroscience Institute, Spectrum Health, Grand Rapids; Michigan State University (MK, MM, PM, JPT, WM, DB, NW, NIK, AA, MD, AG, NC, JM), Grand Rapids; Department of Neurology (MK), Mayo Clinic, Rochester, MN; Division of Neurosurgery (JPT), Neuroscience Institute, Grand Rapids; and Division of Cardiology (WM, DB, MD, AG, TM, NC), Heart and Vascular Institute, Spectrum Health, Grand Rapids, MI
| | - Musa Dahu
- Division of Neurology (MK, MM, PM, NW, NIK, AA, EE, JM), Neuroscience Institute, Spectrum Health, Grand Rapids; Michigan State University (MK, MM, PM, JPT, WM, DB, NW, NIK, AA, MD, AG, NC, JM), Grand Rapids; Department of Neurology (MK), Mayo Clinic, Rochester, MN; Division of Neurosurgery (JPT), Neuroscience Institute, Grand Rapids; and Division of Cardiology (WM, DB, MD, AG, TM, NC), Heart and Vascular Institute, Spectrum Health, Grand Rapids, MI
| | - Andre Gauri
- Division of Neurology (MK, MM, PM, NW, NIK, AA, EE, JM), Neuroscience Institute, Spectrum Health, Grand Rapids; Michigan State University (MK, MM, PM, JPT, WM, DB, NW, NIK, AA, MD, AG, NC, JM), Grand Rapids; Department of Neurology (MK), Mayo Clinic, Rochester, MN; Division of Neurosurgery (JPT), Neuroscience Institute, Grand Rapids; and Division of Cardiology (WM, DB, MD, AG, TM, NC), Heart and Vascular Institute, Spectrum Health, Grand Rapids, MI
| | - Tarah Moelker
- Division of Neurology (MK, MM, PM, NW, NIK, AA, EE, JM), Neuroscience Institute, Spectrum Health, Grand Rapids; Michigan State University (MK, MM, PM, JPT, WM, DB, NW, NIK, AA, MD, AG, NC, JM), Grand Rapids; Department of Neurology (MK), Mayo Clinic, Rochester, MN; Division of Neurosurgery (JPT), Neuroscience Institute, Grand Rapids; and Division of Cardiology (WM, DB, MD, AG, TM, NC), Heart and Vascular Institute, Spectrum Health, Grand Rapids, MI
| | - Nagib Chalfoun
- Division of Neurology (MK, MM, PM, NW, NIK, AA, EE, JM), Neuroscience Institute, Spectrum Health, Grand Rapids; Michigan State University (MK, MM, PM, JPT, WM, DB, NW, NIK, AA, MD, AG, NC, JM), Grand Rapids; Department of Neurology (MK), Mayo Clinic, Rochester, MN; Division of Neurosurgery (JPT), Neuroscience Institute, Grand Rapids; and Division of Cardiology (WM, DB, MD, AG, TM, NC), Heart and Vascular Institute, Spectrum Health, Grand Rapids, MI
| | - Jiangyong Min
- Division of Neurology (MK, MM, PM, NW, NIK, AA, EE, JM), Neuroscience Institute, Spectrum Health, Grand Rapids; Michigan State University (MK, MM, PM, JPT, WM, DB, NW, NIK, AA, MD, AG, NC, JM), Grand Rapids; Department of Neurology (MK), Mayo Clinic, Rochester, MN; Division of Neurosurgery (JPT), Neuroscience Institute, Grand Rapids; and Division of Cardiology (WM, DB, MD, AG, TM, NC), Heart and Vascular Institute, Spectrum Health, Grand Rapids, MI
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Mirza AA, Saad MZ, Bittla P, Paidimarri SP, Ayuthu S, Chauhan YD, Khan S. A Detailed Systematic Review Comparing Patent Foramen Ovale Closure vs Medical Therapy for the Prevention of Recurrent Cryptogenic Stroke. Cureus 2024; 16:e65632. [PMID: 39205754 PMCID: PMC11357720 DOI: 10.7759/cureus.65632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2024] [Accepted: 07/29/2024] [Indexed: 09/04/2024] Open
Abstract
Cryptogenic stroke refers to a type of ischemic stroke with no identifiable cause despite extensive diagnostic testing. Patent foramen ovale (PFO) treatment modality for the prevention of cryptogenic stroke has been controversial. We undertook this systematic review to compare the efficacy of PFO closure versus medical therapy in preventing recurrent cryptogenic stroke and to provide insight into the most effective treatment modality. Inclusion criteria included patients who had PFO, papers written in English language or had translation available, and papers focusing on medical therapy including drug and surgical treatment for PFO for the prevention of recurrent stroke. Exclusion criteria included articles in which full text could not be obtained and articles in which only one treatment modality was mentioned, either surgical closure or drug therapy. The databases used were PubMed, Cochrane, Embase, and ClinicalTrials.gov. We conducted a bias assessment through the modified Jadad scale for randomized controlled trials (RCTs) and AMSTAR.Ca for meta-analysis and systematic review. The literature search identified a total of 277 papers. After screening, 12 papers were selected for the review. Among these, five were RCTs, five were meta-analyses, one was a systematic review, and one was a systematic review with network meta-analysis. The RCTs included a total of 3,336 participants, while the meta-analyses included 21,813 participants. These finalized papers examined the outcomes of PFO closure compared to medical therapy in preventing recurrent strokes.
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Affiliation(s)
- Amna A Mirza
- Medicine, Ziauddin Medical College, Karachi, PAK
| | - Moyal Z Saad
- Internal Medicine, Jinnah Medical and Dental College, Karachi, PAK
| | | | | | - Shriya Ayuthu
- Medicine, Kamineni Institute of Medical Sciences, Nalgonda, IND
| | - Yashkumar D Chauhan
- Medicine, Smt. Nathiba Hargovandas Lakhmichand (NHL) Municipal Medical College, Ahmedabad, IND
| | - Safeera Khan
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology (CIBNP), Fairfield, USA
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Steiner K, Sjöberg G, Damlin A, Settergren M, Verouhis D. Same-day discharge after percutaneous closure of persistent foramen ovale using intracardiac echocardiography and the Gore Septal Occluder. Front Cardiovasc Med 2024; 11:1408543. [PMID: 38993520 PMCID: PMC11238211 DOI: 10.3389/fcvm.2024.1408543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 06/11/2024] [Indexed: 07/13/2024] Open
Abstract
Aim Periprocedural and postinterventional care of patients undergoing closure of patent foramen ovale (PFO) varies significantly across care providers. Same-day discharge (SDD) after transcatheter interventions is an evolving concept. This study aimed to assess the same-day discharge rate and incidence of complications in patients undergoing PFO closure with intracardiac echocardiography (ICE) using the Gore®Cardioform Septal Occluder (GSO) device. The secondary aim was to analyse the efficacy of femoral vein closure with Perclose ProGlide. Methods Patients who underwent PFO closure with the GSO device at a university hospital in Stockholm, Sweden, were retrospectively included between March 1, 2017, and June 30, 2020, all with cryptogenic stroke as the indication for the procedure. All patients underwent PFO closure with conscious sedation and local anaesthesia. The indication for all patients was a cryptogenic stroke. Periprocedural imaging was performed using ICE and fluoroscopy in all patients. Patient characteristics and periprocedural data were collected from patient charts. Patients were kept on bed rest for 4-6 h post-intervention. Transthoracic echocardiography and clinical examination, including groin status, were performed before discharge. No clinical routine follow-up was performed the day following the intervention. Clinical follow-up was done by phone call two weeks after the procedure, and echocardiographic follow-up was done after 12 months. Data were analysed using linear and logistic regression models. Results In total, 262 patients were included, of which 246 (94%) had SDD. 166 patients (63%) received the ProGlide™ system for femoral vein access closure. Post-procedural arrhythmias occurred in 17 (6%) patients, and vascular complications in 9 patients (3%). The overall closure rate at follow-up was 98.5%. 25 out of 264 patients (9.5%) had to be readmitted within the first eight weeks after PFO closure, 16 due to atrial fibrillation warranting electric cardioversion, one due to an arteriovenous fistula that was operated, four due to chest pain/pain at the access site, and four patients developed fever. There was no difference in SDD among patients who received ProGlide™ vs. patients who did not receive ProGlide™. Conclusion SDD appears safe after transcatheter PFO closure with the GSO device with high procedural success rates. Low rates of complications and readmissions make the intervention suitable for this patient-friendly and cost-effective concept.
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Affiliation(s)
- Kristoffer Steiner
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Department of Paediatric Cardiology, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Gunnar Sjöberg
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Department of Paediatric Cardiology, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Anna Damlin
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
- Unit of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Magnus Settergren
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
- Unit of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Dinos Verouhis
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
- Unit of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
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Erdem S, Taha A, Patel N, Patel DA, Titus A, Harmouch KM, Bahar Y, Duhan S, Keisham B, Syed M, Avalon JC, Sattar Y, Alraies MC. Impact of frailty index on cardiovascular outcomes and readmissions of patent foramen ovale closure procedure: a propensity matched national analysis. AMERICAN JOURNAL OF CARDIOVASCULAR DISEASE 2024; 14:188-195. [PMID: 39021524 PMCID: PMC11249661 DOI: 10.62347/ptmd5117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 04/24/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND Transcatheter patent foramen ovale (PFO) occluder device is a procedure mostly performed to prevent secondary stroke as a result of paradoxical emboli traversing an intracardiac defect into the systemic circulation. The complications and outcomes following the procedure remain poorly studied. We aimed to investigate morbidity and mortality associated with occluder device procedures using hospital frailty index score stratification. METHODS The Nationwide Readmission Database was employed to identify patients admitted for PFO closure from 2016 to 2020. Two groups divided by index frailty score were compared to report adjusted odds ratio (aOR) for primary and secondary cardiovascular outcomes. Outcomes included in-hospital mortality, acute kidney injury, acute ischemic stroke, and post-procedure bleeding. Statistical analysis was performed using STATA v.17. RESULTS Of the 2,063 total patients who underwent the procedure, 45% possessed intermediate to high frailty scores while the other 55% had low frailty scores. The first cohort had higher odds of in-hospital mortality (aOR 6.3, 95% CI 2.05-19.5), acute kidney injury (aOR 17.6, 95% CI 9.5-32.5), and stroke (aOR 3.05, 95% CI 1.5-5.8) than the second cohort. There was no difference in the incidence of post-procedural bleeding and cardiac tamponade and 30/90/180-day readmission rates between the two cohorts. Hospitalizations in the first cohort were associated with a higher median length of stay and total cost. CONCLUSION High to intermediate frailty scores may predict an increased risk of in-hospital mortality in patients undergoing PFO occluder device procedures.
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Affiliation(s)
- Saliha Erdem
- Department of Internal Medicine, Wayne State University School of MedicineDetroit, MI, USA
| | - Amro Taha
- Department of Internal Medicine, Weiss Memorial HospitalChicago, IL, USA
| | - Neel Patel
- Department of Internal Medicine, New York Medical College/Landmark Medical CenterWoonsocket, RI, USA
| | | | - Anoop Titus
- Department of Internal Medicine, Saint Vincent HospitalWorcester, MA, USA
| | - Khaled M Harmouch
- Department of Internal Medicine, Wayne State University School of MedicineDetroit, MI, USA
| | | | - Sanchit Duhan
- Department of Internal Medicine, Sinai HospitalBaltimore, MD, USA
| | - Bijeta Keisham
- Department of Medicine, Weifang Medical UniversityWeifang, China
| | - Moinuddin Syed
- Department of Cardiology, Boston UniversityBoston, MA, USA
| | - Juan Carlo Avalon
- Department of Cardiology, West Virginia UniversityMorgantown, WV, USA
| | - Yasar Sattar
- Department of Cardiology, West Virginia UniversityMorgantown, WV, USA
| | - M Chadi Alraies
- Cardiovascular Institute, Detroit Medical CenterDetroit, MI, USA
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Shehata A, Nasser A, Mohsen A, Anwar Samaan A, Mostafa A, Hassan M. Prevalence and characteristics of patent foramen ovale in a sample of Egyptian population: a computed tomography study. Egypt Heart J 2024; 76:73. [PMID: 38856789 PMCID: PMC11164847 DOI: 10.1186/s43044-024-00504-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 05/31/2024] [Indexed: 06/11/2024] Open
Abstract
BACKGROUND The reported prevalence of patent foramen ovale (PFO) in the general population is variable. It ranges between 8.6 and 42% according to the population studied and the imaging technique used. We aim to prospectively assess the prevalence and characteristics of PFO and interatrial septum (IAS) abnormalities as well as the related clinical manifestations in a sample of Egyptian population. RESULTS This study comprised 1000 patients who were referred for CT coronary angiography (CTCA). Mean age was 52.5 ± 10.9 years. The prevalence of PFO among the studied population was 16.3%; closed PFO (grade I) 44.2%, open PFO (grade II) 50.9%, and open PFO with jet (grade III) 4.9%. Anatomical high-risk PFO features-defined as the presence of at least 2 or more of the following (diameter ≥ 2 mm, length ≥ 10 mm, septal aneurysm "ASA", or redundant septum)-were found in 51.5% of PFOs' population. Other IAS abnormalities as redundant septum (8.6%), ASA (5.3%), Bachmann's bundle (4.5%), microaneurysm (2.6%), and atrial septal defect (ASD) (0.4%) were detected. There was a lower rate of coexistence of ASA with PFO (p = 0.031). Syncope was significantly higher in patients with PFO compared to those without PFO (6.7% vs. 1.6%, p = 0.001). Stroke, transient ischaemic attacks (TIA), and dizziness were similar in both groups. TIA, dizziness, and syncope were significantly higher in patients with IAS abnormalities including PFO compared to those without IAS abnormalities. Syncope was also significantly higher in PFO with high-risk anatomical features compared to those with non-high-risk PFO population (p = 0.02). CONCLUSION The prevalence of PFO in our study was approximately 16.3%, almost half of them showed anatomical high-risk features for stroke. Dizziness, syncope and TIA were significantly higher in patients with IAS abnormalities including PFO.
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Affiliation(s)
- Ahmed Shehata
- Cardiology Department, Cairo University, Giza, Egypt
| | | | - Ahmed Mohsen
- Cardiology Department, Cairo University, Giza, Egypt
| | - Amir Anwar Samaan
- Cardiology Department, Cairo University, Giza, Egypt
- Cardiology Department, AlNas Hospital, Qalyubia, Egypt
| | - Amir Mostafa
- Cardiology Department, Cairo University, Giza, Egypt
- Cardiology Department, AlNas Hospital, Qalyubia, Egypt
| | - Mohamed Hassan
- Cardiology Department, Cairo University, Giza, Egypt.
- Cardiology Department, AlNas Hospital, Qalyubia, Egypt.
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Apostolos A, Tsiachris D, Drakopoulou M, Trantalis G, Oikonomou G, Ktenopoulos N, Simopoulou C, Katsaros O, Tsalamandris S, Aggeli C, Tsivgoulis G, Tsioufis C, Toutouzas K. Atrial Fibrillation After Patent Foramen Ovale Closure: Incidence, Pathophysiology, and Management. J Am Heart Assoc 2024; 13:e034249. [PMID: 38639354 PMCID: PMC11179870 DOI: 10.1161/jaha.124.034249] [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: 01/01/2024] [Accepted: 02/06/2024] [Indexed: 04/20/2024]
Abstract
This comprehensive review explores the incidence, pathophysiology, and management of atrial fibrillation (AF) following percutaneous closure of patent foramen ovale (PFO). Although AF is considered a common adverse event post PFO closure, its incidence, estimated at <5%, varies based on monitoring methods. The review delves into the challenging task of precisely estimating AF incidence, given subclinical AF and diverse diagnostic approaches. Notably, a temporal pattern emerges, with peak incidence around the 14th day after closure and a subsequent decline after the 45th day, mimicking general population AF trends. The pathophysiological mechanisms behind post PFO closure AF remain elusive, with proposed factors including local irritation, device-related interference, tissue stretch, and nickel hypersensitivity. Management considerations encompass rhythm control, with flecainide showing promise, and anticoagulation tailored to individual risk profiles. The authors advocate for a personalized approach, weighing factors like age, comorbidities, and device characteristics. Notably, postclosure AF is generally considered benign, often resolving spontaneously within 45 days, minimizing thromboembolic risks. Further studies are required to refine understanding and provide evidence-based guidelines.
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Affiliation(s)
- Anastasios Apostolos
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
| | - Dimitrios Tsiachris
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
| | - Maria Drakopoulou
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
| | - Georgios Trantalis
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
| | - Georgios Oikonomou
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
| | - Nikolaos Ktenopoulos
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
| | - Chrysavgi Simopoulou
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
| | - Odysseas Katsaros
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
| | - Sotirios Tsalamandris
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
| | - Constantina Aggeli
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
| | - Georgios Tsivgoulis
- Second Department of Neurology, Medical SchoolNational and Kapodistrian University of Athens, Attikon University Hospital of AthensAthensGreece
| | - Costas Tsioufis
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
| | - Konstantinos Toutouzas
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
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Eichelmann A, Kubini R, Nachoski D, Kosinski C, Becker M, Aljalloud A. Patent foramen ovale closure versus drug therapy in patients over 60 years and a follow-up of 5 years. Clin Cardiol 2024; 47:e24251. [PMID: 38445759 PMCID: PMC10915992 DOI: 10.1002/clc.24251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 02/15/2024] [Accepted: 02/21/2024] [Indexed: 03/07/2024] Open
Abstract
BACKGROUND The advantages of patent foramen ovale (PFO) closure as protection from a recurrence of stroke remains controversial compared to drug therapy, especially in patients over 60 years. HYPOTHESIS The aim of the study is to compare recurrence of stroke in patients over 60 years old with PFO closure versus drug therapy alone. METHODS We included 342 patients over 60 years who suffered a crytopgenic stroke, and were also accepted for a PFO closure. 199 patients refused a PFO closure and were treated with medical therapy alone, whereas 143 patients underwent a PFO closure procedure. RESULTS The mean follow up time was 5.5 ± 1.5 years. All patients in Group B showed persistent shunt in the follow-up period (n = 199, 100%). In Group A, seven patients were diagnosed with residual shunt during echocardiography examination (5%). A new onset of atrial fibrillation occurred in seven patients in Group A (5%) and six patients in Group B (3%), p = .117. Recurrent stroke occurred in 3 patients in Group A (2%) and 11 patients in Group B (6%), p = .021. One patient died of unknown reason (1%) and two patients were lost due to neurological death (1%) in Group B, whereas no patients in Group A died during the follow-up period. CONCLUSION Our results show that strict exclusion of patients over 60 years from PFO closure should be reconsidered. As life expectancies are increasing, patients should be considered for same treatment as younger patients, since the outcomes are improved compared to patients treated with medical therapy alone.
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Affiliation(s)
| | - Ralf Kubini
- Rhein‐Maas Hospital, Department of CardiologyNephrology and Internal Intensive CareWürselenGermany
| | - Dejan Nachoski
- Rhein‐Maas Hospital, Department of CardiologyNephrology and Internal Intensive CareWürselenGermany
| | | | - Michael Becker
- Rhein‐Maas Hospital, Department of CardiologyNephrology and Internal Intensive CareWürselenGermany
| | - Ali Aljalloud
- Rhein‐Maas Hospital, Department of CardiologyNephrology and Internal Intensive CareWürselenGermany
- Department of Cardiac SurgeryRWTH University Hospital AachenAachenGermany
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9
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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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10
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Scalera S, Pizzuto A, Marchese P, Santoro G. Percutaneous closure of 'complex' multi-fenestrated atrial septal aneurysm in visceral situs inversus using a multi-device approach: a case report. Eur Heart J Case Rep 2023; 7:ytad467. [PMID: 37942352 PMCID: PMC10629585 DOI: 10.1093/ehjcr/ytad467] [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: 03/13/2023] [Revised: 09/05/2023] [Accepted: 09/18/2023] [Indexed: 11/10/2023]
Abstract
Background Percutaneous closure is nowadays still deemed challenging in patent forame ovale (PFO) associated to multi-fenestrated atrial septal aneurysm (ASA). This anatomic arrangement is still considered a significant risk factor for recurrence of paradoxical embolism. Theoretically, transcatheter approach could be theoretically even more complex in the case of dextrocardia and visceral situs inversus. Case summary A 59-year-old man with history of migraine with aura and multiple cryptogenic strokes was referred for percutaneous closure of a PFO with associated ASA. He had been previously submitted to repeat attempt of percutaneous closure with not self-centering and self-centering devices that failed due to unfavorable anatomic characteristics (dextrocardia with situs viscerum inversus, huge ASA, multiple fenestrations, large PFO). Based on this "complex" anatomy, a sequential 2-step interventional approach aiming to reduce size and mobility of the atrial septal aneurysm with a suture-based approach (Noblestich™ EL, HeartStitch, Fountain Valley, CA, USA) and to close any eventual accessory fenestrations with a not self-centering occluding device was planned. At the end of the procedure, the ASA completely disappeared and no residual shunt was imaged at TEE bubble test. Discussion We describe a very rare case of symptomatic ASA-PFO in dextrocardia with situs viscerum inversus as well as an innovative approach to treat such complex anatomic setting by using the suture-based closure of a PFO to reduce size and mobility of an ASA in order to deploy dedicated not-self-centering occluding devices.
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Affiliation(s)
- Silvia Scalera
- Pediatric Cardiology and GUCH Unit, Heart Hospital ‘G. Pasquinucci’, National Research Council-Tuscany Foundation ‘G. Monasterio’, Via Aurelia Sud, Massa 54100, Italy
| | - Alessandra Pizzuto
- Pediatric Cardiology and GUCH Unit, Heart Hospital ‘G. Pasquinucci’, National Research Council-Tuscany Foundation ‘G. Monasterio’, Via Aurelia Sud, Massa 54100, Italy
| | - Pietro Marchese
- Pediatric Cardiology and GUCH Unit, Heart Hospital ‘G. Pasquinucci’, National Research Council-Tuscany Foundation ‘G. Monasterio’, Via Aurelia Sud, Massa 54100, Italy
| | - Giuseppe Santoro
- Pediatric Cardiology and GUCH Unit, Heart Hospital ‘G. Pasquinucci’, National Research Council-Tuscany Foundation ‘G. Monasterio’, Via Aurelia Sud, Massa 54100, Italy
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11
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Alkhouli M, Van Houten HK, Yao X, Holmes DR. Effectiveness of Transcatheter Closure of Patent Foramen Ovale in Clinical Practice. J Am Heart Assoc 2023; 12:e030321. [PMID: 37489748 PMCID: PMC10492997 DOI: 10.1161/jaha.123.030321] [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: 03/24/2023] [Accepted: 06/28/2023] [Indexed: 07/26/2023]
Abstract
Background Transcatheter closure of patent foramen ovale (PFO) has reduced the risk of recurrent stroke in patients with cryptogenic strokes in randomized clinical trials. Whether PFO closure in clinical practice is associated with similar benefit remains unknown. Methods and Results We identified patients with PFO and a history of ischemic stroke or transient ischemic attack who were treated with PFO closure or medical therapy in the OptumLabs database. The primary end point was recurrent ischemic stroke or systemic embolization. Secondary outcomes included mortality, all stroke, transient ischemic attack, and major bleeding. A total of 6668 propensity-matched patients were included (PFO closure n=4111; medical therapy n=2557). The incidence of stroke or systemic embolization per 100 person-years was 2.38 after PFO cohort and 2.99 with medical therapy (hazard ratio [HR], 0.85 [95% CI, 0.68-1.05], P=0.13). Mortality was lower in the PFO closure cohort (1.78 versus 2.59 per 100 person-years: HR, 0.69 [95% CI, 0.55-0.87], P=0.002). Falsification end points showed that this difference is unlikely to be completely explained by residual confounders. There were no significant differences between the groups in secondary end points including intracranial hemorrhage and major bleeding except for an increase in nonintracranial hemorrhage bleeding among patients treated with oral anticoagulation (1.42 versus 2.16 per 100 person-years: HR, 0.69 [95% CI, 0.48-0.99], P=0.043). The main end point was consistent in subanalyses including patients <60 years of age, patients with prior stroke, and those treated after the publication of the positive PFO trials in 2017. Conclusions In contemporary US practice, PFO closure is not associated with lower rates of recurrent ischemic stroke or systemic embolization compared with medical therapy. Potential reasons for this discrepancy warrant further investigation.
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Affiliation(s)
| | - Holly K. Van Houten
- Robert D. and Patricia E. Kern Center for the Science of Health Care DeliveryMayo ClinicRochesterMNUSA
- OptumLabsEden PrairieMNUSA
| | - Xiaoxi Yao
- Department of Cardiovascular MedicineMayo ClinicRochesterMNUSA
- OptumLabsEden PrairieMNUSA
| | - David R. Holmes
- Department of Cardiovascular MedicineMayo ClinicRochesterMNUSA
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12
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Lucà F, Pino PG, Parrini I, Di Fusco SA, Ceravolo R, Madeo A, Leone A, La Mair M, Benedetto FA, Riccio C, Oliva F, Colivicchi F, Gulizia MM, Gelsomino S. Patent Foramen Ovale and Cryptogenic Stroke: Integrated Management. J Clin Med 2023; 12:1952. [PMID: 36902748 PMCID: PMC10004032 DOI: 10.3390/jcm12051952] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 02/13/2023] [Accepted: 02/27/2023] [Indexed: 03/06/2023] Open
Abstract
Patent foramen ovale (PFO) is a common cardiac abnormality with a prevalence of 25% in the general population. PFO has been associated with the paradoxical embolism causing cryptogenic stroke and systemic embolization. Results from clinical trials, meta-analyses, and position papers support percutaneous PFO device closure (PPFOC), especially if interatrial septal aneurysms coexist and in the presence of large shunts in young patients. Remarkably, accurately evaluating patients to refer to the closure strategy is extremely important. However, the selection of patients for PFO closure is still not so clear. The aim of this review is to update and clarify which patients should be considered for closure treatment.
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Affiliation(s)
- Fabiana Lucà
- Cardiology Department, Grande Ospedale Metropolitano, GOM, AO Bianchi Melacrino Morelli, 89129 Reggio di Calabria, Italy
| | - Paolo G. Pino
- Cardiology Department, San Camillo Forlanini Hospital, 00152 Rome, Italy
| | - Iris Parrini
- Cardiology Department, Mauriziano Hospital, 10128 Torino, Italy
| | - Stefania Angela Di Fusco
- Clinical and Rehabilitation Cardiology Department, San Filippo Neri Hospital, ASL Roma 1, 00135 Roma, Italy
| | - Roberto Ceravolo
- Cardiology Unit, Giovanni Paolo II Hospital, 88046 Lamezia, Italy
| | | | - Angelo Leone
- Ospedale Santissima Annunziata, 87100 Cosenza, Italy
| | - Mark La Mair
- Cardiothoracic Department, Brussels University Hospital, 1090 Jette, Belgium
| | - Francesco Antonio Benedetto
- Cardiology Department, Grande Ospedale Metropolitano, GOM, AO Bianchi Melacrino Morelli, 89129 Reggio di Calabria, Italy
| | - Carmine Riccio
- Division of Clinical Cardiology, A.O.R.N. ‘Sant’Anna e San Sebastiano’, 81100 Caserta, Italy
| | - Fabrizio Oliva
- De Gasperis Cardio Center, Niguarda Hospital, 20162 Milano, Italy
| | - Furio Colivicchi
- Clinical and Rehabilitation Cardiology Department, San Filippo Neri Hospital, ASL Roma 1, 00135 Roma, Italy
| | | | - Sandro Gelsomino
- Cardiothoracic Department, Maastricht University, 6211 LK Maastrich, The Netherlands
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13
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Laghlam D, Coroyer L, Martial PJ, Estagnasie P, Squara P, Nguyen LS. Risk factors and complications associated with intra-operative or post-operative identification of a PFO in cardiac surgery patients: A cohort study. Front Neurol 2023; 13:1057479. [PMID: 36703625 PMCID: PMC9871930 DOI: 10.3389/fneur.2022.1057479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 12/13/2022] [Indexed: 01/12/2023] Open
Abstract
Introduction It is unknown whether patent foramen ovale (PFO) reopening in the peri-operative setting of cardiac surgery affects the risk for stroke and post-operative outcomes. Methods We performed a single-center, retrospective study based on a prospectively collected database in a tertiary cardiac surgery center. Using logistic regression, we assessed risk factors of PFO finding around surgery and subsequent clinical complications. Results Between January 2007 and July 2019, 11034 patients who underwent cardiac surgery in our center were included. A total of 233 patients (2.1%) presented a finding of PFO including 138 per-operative disclosures and 95 post-operative finding for hypoxemia. In the whole cohort, the mean age was 68.4 ± 11.5 years including 73.9% of men. Post-operative PFO finding was associated with more ischemic strokes compared with per-operative finding and control group [7(7.4%) vs. 3(2.2%) vs. 236(2.2), respectively; p = 0.003]. Moreover, patients with post-operative PFO reopening experienced a higher rate of pneumonia, reintubation, and longer length of stay in the ICU. Post-operative reopening of PFO, but not per-operative finding, was independently associated with ischemic strokes {adjusted odds-ratio = 3.5, 95% confidence interval (CI) [1.6-7.8]; p = 0.002}. Other variables associated with stroke incidence included age, mitral valve surgery, and ascending aorta surgery. Per- or post-operative PFO closure was associated with reduced adverse respiratory outcomes and a trend of the lower cerebral ischemic event. Conclusion Patent foramen ovale finding incidence in peri-operative cardiac surgery care was rare (2%) but post-operative finding of PFO was associated with a increased risk of ischemic strokes, worsened respiratory outcomes, and prolonged hospitalization.
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14
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Kolokathis K, Thomopoulos C, Tsioufis K. Net clinical benefit of PFO closure versus medical treatment in patients with cryptogenic stroke: A systematic review and meta-analysis. Hellenic J Cardiol 2022; 70:46-52. [PMID: 36584788 DOI: 10.1016/j.hjc.2022.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 12/02/2022] [Accepted: 12/23/2022] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The ideal treatment for patent foramen ovale (PFO) in patients with cryptogenic stroke remains controversial and is being evaluated. The objective of this study was to evaluate the net clinical benefit (NCB) between PFO closure and medical treatment. METHODS We searched three electronic databases from inception until January 2022. The primary outcomes were the NCB-1, defined as the cumulative incidence of stroke, major bleeding, atrial fibrillation/flutter, and serious procedural or device complications; the NCB-2 and NCB-3 were defined as NCB1 but using a weighted factor of 0.5 and 0.25 for atrial fibrillation/flutter events, respectively. We also evaluated each component outcome of NCB as a secondary outcome. Risk ratios (RR) and 95% confidence intervals (CI) of each outcome were calculated (random-effects model). RESULTS Our analysis included six RCTs (n = 3750 patients). The rates of NCB-1, NCB-2, and NCB-3 were not different between PFO closure and medical treatment. The heterogeneity between trials was low to moderate. Stroke showed a significant relative decrease of 44% (95% CI, 21-60%), favoring the PFO closure arm. Atrial fibrillation/flutter increased by 4.04 times (95% CI, 1.57-8.89) in the PFO closure compared with the medical treatment group. In a meta-regression analysis, the reduction in NCB-1 with PFO closure increased as the proportion of patients treated with the Amplatzer device increased (p = 0.02), and the reduction in NCB-1, NCB-2, and NCB-3 with PFO closure increased as the proportion of patients treated with substantial PFO size increased (p = 0.03). CONCLUSION The NCB between PFO closure and medical treatment was not different, suggesting individualized treatment to maximize benefit.
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Affiliation(s)
- Konstantinos Kolokathis
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
| | | | - Konstantinos Tsioufis
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece.
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15
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Tejada García J, Lara Lezama LB, de la Fuente Blanco R, Pérez de Prado A, Benavente Fernández L, Rico Santos M, Fernández Couto MD, Naya Ríos L, Couso Pazó I, Alba PV, Redondo-Robles L, López Mesonero L, Arias-Rivas S, Santamaría Cadavid M, Tejada Meza H, Horna Cañete L, Azkune Calle I, Pinedo Brochado A, García Sánchez JM, Caballero Romero I, Freijo Guerrero MM, Luna Rodríguez A, de Lera-Alfonso M, Arenillas Lara JF, Pérez Lázaro C, Navarro Pérez MP, Martínez Zabaleta M. Selection of patients for percutaneous closure in nonlacunar cryptogenic stroke associated with patent foramen ovale. Data from the NORDICTUS cooperative registry. Neurologia 2022:S2173-5808(22)00145-6. [PMID: 36347422 DOI: 10.1016/j.nrleng.2022.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 09/15/2022] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION There is an extending use of percutaneous closure of patent foramen ovale (PFO) as therapy for PFO-associated cryptogenic strokes. The aim of our study was to investigate the clinical practice of percutaneous closure of PFO and to analyse the variables for decision-making on the selection of patients for this procedure. METHOD A prospective observational multicentric survey was conducted using all the cases of cryptogenic stroke/transient ischaemic attack associated with PFO recorded in the NORDICTUS hospital registry during the period 2018-2021. Clinical data, radiological patterns, echocardiogram data and factors related to PFO-associated stroke (thromboembolic disease and paradoxical embolism criteria) were recorded. The indication for closure was analysed according to age (≤/> 60 years) and the characteristics of the PFO. RESULTS In the group ≤ 60 years (n = 488), 143 patients (29.3%) underwent PFO closure. The most influential variables for this therapy were detection of a high-risk PFO (OR 4.11; IC 2.6-6.5, P < .001), criteria for paradoxical embolism (OR 2.61; IC 1.28-5.28; P = .008) and previous use of antithrombotics (OR 2.67; IC 1.38-5.18; P = .009). In the > 60 years group (n = 124), 24 patients had PFO closure (19%). The variables related to this option were history of pulmonary thromboembolism, predisposition to thromboembolic disease, paradoxical embolism criteria, and high-risk PFO. CONCLUSIONS The detection of a high-risk PFO (large shunt, shunt with associated aneurysm) is the main criterion for a percutaneous closure-based therapy. Other conditions to consider in the eligibility of patients are the history of thromboembolic disease, paradoxical embolism criteria or the previous use of antithrombotics.
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Affiliation(s)
- J Tejada García
- Unidad de Ictus, Sección de Neurología, Complejo Asistencial Universitario de León, León, Spain.
| | - L B Lara Lezama
- Unidad de Ictus, Sección de Neurología, Complejo Asistencial Universitario de León, León, Spain
| | - R de la Fuente Blanco
- Unidad de Ictus, Sección de Neurología, Complejo Asistencial Universitario de León, León, Spain
| | - A Pérez de Prado
- Servicio de Cardiología, Complejo Asistencial Universitario de León, León, Spain
| | - L Benavente Fernández
- Unidad de Ictus, Sevicio de Neurología, Hospital Universitario Central de Asturias, Spain
| | - M Rico Santos
- Unidad de Ictus, Sevicio de Neurología, Hospital Universitario Central de Asturias, Spain
| | - M D Fernández Couto
- Servicio de Neurología, Complejo Hospitalario Universitario de A Coruña, Spain
| | - L Naya Ríos
- Servicio de Neurología, Complejo Hospitalario Universitario de A Coruña, Spain
| | - I Couso Pazó
- Unidad de Ictus, Complejo Hospitalario Universitario de Vigo, Spain
| | - P V Alba
- Unidad de Ictus, Complejo Hospitalario Universitario de Vigo, Spain
| | - L Redondo-Robles
- Servicio de Neurología, Complejo Asistencial Universitario de Salamanca, Spain
| | - L López Mesonero
- Servicio de Neurología, Complejo Asistencial Universitario de Salamanca, Spain
| | - S Arias-Rivas
- Servicio de Neurología, Complejo Hospitalario Universitario de Santiago, Spain
| | | | - H Tejada Meza
- Sección de Neurovascular, Servicio de Neurología, Hospital Universitario Miguel Servet, Grupo de Investigación en Neurociencias, Instituto de Investigación Sanitaria (IIS) Aragón, Spain
| | - L Horna Cañete
- Servicio de Neurología, Hospital Galdakao-Usansolo (Bizkaia), Spain
| | - I Azkune Calle
- Servicio de Neurología, Hospital Galdakao-Usansolo (Bizkaia), Spain
| | | | - J M García Sánchez
- Servicio de Neurología, Hospital Universitario de Basurto-OSI Bilbao, Spain
| | - I Caballero Romero
- Servicio de Neurología, Hospital Universitario de Basurto-OSI Bilbao, Spain
| | - M M Freijo Guerrero
- Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, Enfermedades Cerebrovasculares (RICORS), Spain
| | - A Luna Rodríguez
- Biocruces Bizkaia Health Research Institute, Hospital Universitario Cruces, Enfermedades Cerebrovasculares (RICORS), Spain
| | - M de Lera-Alfonso
- Unidad de Ictus, Servicio de Neurología, Hospital Clínico Universitario de Valladolid, Spain
| | - J F Arenillas Lara
- Unidad de Ictus, Servicio de Neurología, Hospital Clínico Universitario de Valladolid, Spain
| | - C Pérez Lázaro
- Servicio de Neurología, Hospital Clínico Universitario Lozano Blesa, Spain
| | - M P Navarro Pérez
- Servicio de Neurología, Hospital Clínico Universitario Lozano Blesa, Spain
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16
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Baik M, Shim CY, Gwak SY, Kim YD, Nam HS, Lee HS, Nam CM, Heo JH. Patent foramen ovale and risks of recurrence in stroke of determined etiology. Ann Neurol 2022; 92:596-606. [PMID: 35753038 DOI: 10.1002/ana.26449] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 06/20/2022] [Accepted: 06/23/2022] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Patent foramen ovale (PFO) is often found in stroke patients with determined etiologies. PFO may be the actual cause of stroke in some of them. We determined whether the risk of recurrent ischemic stroke differs with PFO status in stroke patients with determined etiologies. METHODS This study included consecutive patients with stroke of determined etiology who underwent transesophageal echocardiography. We compared the rates of recurrent cerebral infarction in patients with versus without PFO, and according to PFO-Associated Stroke Causal Likelihood (PASCAL) classification. RESULTS Of 2314 included patients, 827 (35.7%) had PFO. During a median follow-up of 4.4 years, cerebral infarction recurred in 202 (8.7%). In multivariate modified Cox regression analyses, recurrence of infarction did not significantly differ between patients with PFO and those without PFO (hazard ratio [HR], 0.86; 95% confidence interval [CI], 0.64-1.17; P = 0.339). Interaction analysis showed a significant effect of PFO in patients < 65 years (adjusted P for interaction = 0.090). PFO was independently associated with a decreased risk of recurrent infarction in patients younger than 65 years (HR, 0.41; 95% CI, 0.20-0.85; adjusted P = 0.016). Patients with probable PFO-associated stroke on the PASCAL classification had a significantly lower risk of recurrent infarction than those without PFO (HR 0.31; 95% CI 0.10-0.97; P=0.044). INTERPRETATION Considering the generally low risk of recurrence in PFO-associated stroke, PFO may be the actual cause of stroke in some patients with determined etiologies, especially younger patients or those with PFO features of probable PFO-associated stroke. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Minyoul Baik
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea.,Department of Neurology, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin-si, Gyeonggi-do, South Korea
| | - Chi Young Shim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Seo-Yeon Gwak
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Young Dae Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea.,Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Seoul, South Korea
| | - Hyo Suk Nam
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea.,Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Seoul, South Korea
| | - Hye Sun Lee
- Biostatistics Collaboration Unit, Department of Research Affairs, Yonsei University College of Medicine, Seoul, South Korea
| | - Chung Mo Nam
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Ji Hoe Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea.,Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Seoul, South Korea
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17
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Lüscher TF, Davies A, Beer JH, Valgimigli M, Nienaber CA, Camm JA, Baumgartner I, Diener HC, Konstantinides SV. Towards personalized antithrombotic management with drugs and devices across the cardiovascular spectrum. Eur Heart J 2022; 43:940-958. [PMID: 34624084 DOI: 10.1093/eurheartj/ehab642] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 05/06/2021] [Accepted: 09/01/2021] [Indexed: 01/10/2023] Open
Abstract
Intravascular thrombus formation and embolization are among the most frequent events leading to a number of cardiovascular conditions with high morbidity and mortality. The underlying causes are stasis of the circulating blood, genetic and acquired coagulation disorders, and reduced antithrombotic or prothrombotic properties of the vascular wall (Virchow's triad). In the venous system, intravascular thrombi can cause venous thrombosis and pulmonary and even peripheral embolism including ischaemic stroke [through a patent foramen ovale (PFO)]. Thrombi in the left atrium and its appendage or ventricle form in the context of atrial fibrillation and infarction, respectively. Furthermore, thrombi can form on native or prosthetic aortic valves, within the aorta (in particular at sites of ulcers, aortic dissection, and abdominal aneurysms), and in cerebral and peripheral arteries causing stroke and critical limb ischaemia, respectively. Finally, thrombotic occlusion may occur in arteries supplying vital organs such the heart, brain, kidney, and extremities. Thrombus formation and embolization can be managed with anticoagulants and devices depending on where they form and embolize and on patient characteristics. Vitamin K antagonists are preferred in patients with mechanical valves, while novel oral anticoagulants are first choice in most other cardiovascular conditions, in particular venous thromboembolism and atrial fibrillation. As anticoagulants are associated with a risk of bleeding, devices such as occluders of a PFO or the left atrial appendage are preferred in patients with an increased bleeding risk. Platelet inhibitors such as aspirin and/or P2Y12 antagonists are preferred in the secondary prevention of coronary artery disease, stroke, and peripheral artery disease either alone or in combination depending on the clinical condition. A differential and personalized use of anticoagulants, platelet inhibitors, and devices is recommended and reviewed in this article.
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Affiliation(s)
- Thomas F Lüscher
- Royal Brompton & Harefield Hospitals, Heart Division, Guy Scadding Building, Dovehouse Street, Imperial College, London SW3 6LY, UK.,Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Allan Davies
- Royal Brompton & Harefield Hospitals, Heart Division, Guy Scadding Building, Dovehouse Street, Imperial College, London SW3 6LY, UK
| | - Juerg H Beer
- Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Marco Valgimigli
- CardioCentro, Lugano, Switzerland.,University of Bern, Bern, Switzerland
| | - Christoph A Nienaber
- Royal Brompton & Harefield Hospitals, Heart Division, Guy Scadding Building, Dovehouse Street, Imperial College, London SW3 6LY, UK
| | - John A Camm
- St. Georges University and Imperial College, London, UK
| | | | - Hans-Christoph Diener
- Institute for Medical Informatics, Biometry and Epidemiology, Medical Faculty of the University Duisburg-Essen, Duisburg-Essen, Germany
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18
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Hariharan NN, Patel K, Sikder O, Perera KS, Diener HC, Hart RG, Eikelboom JW. Oral anticoagulation versus antiplatelet therapy for secondary stroke prevention in patients with embolic stroke of undetermined source: A systematic review and meta-analysis. Eur Stroke J 2022; 7:92-98. [PMID: 35647310 PMCID: PMC9134773 DOI: 10.1177/23969873221076971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 01/12/2022] [Indexed: 01/10/2023] Open
Abstract
Purpose We performed a systematic review and meta-analysis of randomized
controlled trials (RCTs) to evaluate the efficacy and safety of
direct oral anticoagulation (DOAC) compared with antiplatelet
therapy for secondary stroke prevention in adult patients with
embolic stroke of undetermined source (ESUS). Method We searched major databases (Embase, MEDLINE, CINAHL, CENTRAL, and
Web of Science) for RCTs published until March 2021. The primary
outcome was recurrent stroke, and the main safety outcomes were
major bleeding and clinically relevant non-major bleeding
(CRNB). We assessed risk of bias using the Cochrane Risk of Bias
tool. We used a random-effects model to determine pooled risk
ratios and 95% confidence intervals in the datasets and key
subgroups. Findings Our search identified two RCTs, involving a total of 12,603
patients with ESUS. Anticoagulation with dabigatran or
rivaroxaban compared with aspirin did not reduce the risk of
recurrent stroke (RR, 0.96 [0.76–1.20]) or increase major
bleeding (RR, 1.77 [0.80–3.89]) but significantly increased the
composite of major or clinically relevant non-major bleeding
(RR, 1.57 [1.26–1.97]). Prespecified subgroup analysis
demonstrated consistent results according to age and sex.
Additional post-hoc subgroup analyses demonstrated consistent
results according to prior stroke and presence of a patent
foramen ovale but suggested that DOACs reduced recurrent stroke
in patients with an estimated glomerular filtration rate (eGFR)
<50 and 50-80 ml/min but not in those with eGFR >80 ml/min
(interaction P = 0.0234). Discussion/conclusion Direct oral anticoagulations are not more effective than aspirin in
preventing stroke recurrence in patients with ESUS and increase
bleeding. Registration PROSPERO ID: CRD42019138593
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Affiliation(s)
| | - Kashyap Patel
- School of Medicine, University of Ottawa, Ottawa, ON, Canada
| | | | - Kanjana S Perera
- Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
| | | | - Robert G Hart
- McMaster University, Hamilton, ON, Canada
- Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
| | - John W Eikelboom
- McMaster University, Hamilton, ON, Canada
- Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
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19
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Different patterns of white matter lesions among patent foramen ovale, atherosclerotic cerebral small vessel disease and cerebral venous thrombosis. J Thromb Thrombolysis 2022; 53:911-925. [PMID: 34985685 DOI: 10.1007/s11239-021-02624-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/19/2021] [Indexed: 01/10/2023]
Abstract
None of studies are available on the predictive ability of white matter lesions (WMLs) among patent foramen ovale (PFO), atherosclerotic cerebral small vessel disease (aCSVD) and cerebral venous thrombosis (CVT). Herein, we aimed to uncover the difference of the WML patterns among the three disease entities in a real-world setting to provide clinical references for predicting probable WML etiologies. We retrospectively reviewed data from consecutive patients with imaging-confirmed PFO, aCSVD, or CVT enrolled from 2014 through 2020. WMLs presented on fluid-attenuated inversion recovery (FLAIR) maps were compared among the three groups based on visual evaluation, Fazekas and modified Scheltens scales. Propensity score matching (PSM) was implemented to correct age and hypertension differences among groups. A total of 401 patients were entered into final analysis, including PFO (n = 112, 46.5 ± 12.8 years), aCSVD (n = 177, 61.6 ± 11.8 years) and CVT (n = 112, 37.4 ± 11.4 years) groups. In this study, WMLs occurred in all of the involved patients in the three groups (100%), which were independent to age, symptom onset and disease durations. On visual evaluation, PFO-WMLs were multiple spots distributed asymmetrically around bilateral subcortex and peri-ventricles. aCSVD-WMLs were dots or sheets distributed symmetrically in subcortex and peri-ventricles, and often coexisted with lacunar infarctions. CVT-WMLs were cloud-like around bilateral peri-ventricles, and enabled to attenuate after recanalization. Fazekas and modified Scheltens scores of PFO-WML vs. aCSVD-WML were significantly different even after being matched by 1:2 PSM (all p < 0.05), meaning that the WML burden in aCSVD was considerably heavier than that in PFO. WML patterns induced by PFO, aCSVD and CVT were obviously different, and were therefore of great clinical significance to preliminarily predict and differentiate the three diseases entities.
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20
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Tsivgoulis G, Safouris A, Alexandrov AV. Ultrasonography. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00046-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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21
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Kent DM, Saver JL, Kasner SE, Nelson J, Carroll JD, Chatellier G, Derumeaux G, Furlan AJ, Herrmann HC, Jüni P, Kim JS, Koethe B, Lee PH, Lefebvre B, Mattle HP, Meier B, Reisman M, Smalling RW, Soendergaard L, Song JK, Mas JL, Thaler DE. Heterogeneity of Treatment Effects in an Analysis of Pooled Individual Patient Data From Randomized Trials of Device Closure of Patent Foramen Ovale After Stroke. JAMA 2021; 326:2277-2286. [PMID: 34905030 PMCID: PMC8672231 DOI: 10.1001/jama.2021.20956] [Citation(s) in RCA: 93] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 11/03/2021] [Indexed: 01/10/2023]
Abstract
Importance Patent foramen ovale (PFO)-associated strokes comprise approximately 10% of ischemic strokes in adults aged 18 to 60 years. While device closure decreases stroke recurrence risk overall, the best treatment for any individual is often unclear. Objective To evaluate heterogeneity of treatment effect of PFO closure on stroke recurrence based on previously developed scoring systems. Design, Setting, and Participants Investigators for the Systematic, Collaborative, PFO Closure Evaluation (SCOPE) Consortium pooled individual patient data from all 6 randomized clinical trials that compared PFO closure plus medical therapy vs medical therapy alone in patients with PFO-associated stroke, and included a total of 3740 participants. The trials were conducted worldwide from 2000 to 2017. Exposures PFO closure plus medical therapy vs medical therapy alone. Subgroup analyses used the Risk of Paradoxical Embolism (RoPE) Score (a 10-point scoring system in which higher scores reflect younger age and the absence of vascular risk factors) and the PFO-Associated Stroke Causal Likelihood (PASCAL) Classification System, which combines the RoPE Score with high-risk PFO features (either an atrial septal aneurysm or a large-sized shunt) to classify patients into 3 categories of causal relatedness: unlikely, possible, and probable. Main Outcomes and Measures Ischemic stroke. Results Over a median follow-up of 57 months (IQR, 24-64), 121 outcomes occurred in 3740 patients. The annualized incidence of stroke with medical therapy was 1.09% (95% CI, 0.88%-1.36%) and with device closure was 0.47% (95% CI, 0.35%-0.65%) (adjusted hazard ratio [HR], 0.41 [95% CI, 0.28-0.60]). The subgroup analyses showed statistically significant interaction effects. Patients with low vs high RoPE Score had HRs of 0.61 (95% CI, 0.37-1.00) and 0.21 (95% CI, 0.11-0.42), respectively (P for interaction = .02). Patients classified as unlikely, possible, and probable using the PASCAL Classification System had HRs of 1.14 (95% CI, 0.53-2.46), 0.38 (95% CI, 0.22-0.65), and 0.10 (95% CI, 0.03-0.35), respectively (P for interaction = .003). The 2-year absolute risk reduction was -0.7% (95% CI, -4.0% to 2.6%), 2.1% (95% CI, 0.6%-3.6%), and 2.1% (95% CI, 0.9%-3.4%) in the unlikely, possible, and probable PASCAL categories, respectively. Device-associated adverse events were generally higher among patients classified as unlikely; the absolute risk increases in atrial fibrillation beyond day 45 after randomization with a device were 4.41% (95% CI, 1.02% to 7.80%), 1.53% (95% CI, 0.33% to 2.72%), and 0.65% (95% CI, -0.41% to 1.71%) in the unlikely, possible, and probable PASCAL categories, respectively. Conclusions and Relevance Among patients aged 18 to 60 years with PFO-associated stroke, risk reduction for recurrent stroke with device closure varied across groups classified by their probabilities that the stroke was causally related to the PFO. Application of this classification system has the potential to guide individualized decision-making.
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Affiliation(s)
- David M. Kent
- Predictive Analytics and Comparative Effectiveness Center, Tufts Medical Center/Tufts University School of Medicine, Boston, Massachusetts
| | - Jeffrey L. Saver
- Comprehensive Stroke Center and Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles
| | - Scott E. Kasner
- Comprehensive Stroke Center, Department of Neurology, University of Pennsylvania Medical Center, Philadelphia
| | - Jason Nelson
- Predictive Analytics and Comparative Effectiveness Center, Tufts Medical Center/Tufts University School of Medicine, Boston, Massachusetts
| | - John D. Carroll
- Division of Cardiology, Department of Medicine, University of Colorado Denver, Aurora
| | - Gilles Chatellier
- Centre d’Investigations Cliniques, Unité de Recherche Clinique, Hôpital Européen Georges–Pompidou, Assistance Publique–Hôpitaux de Paris, Paris, France
| | - Geneviève Derumeaux
- Département de Physiologie, Hôpital Henri Mondo, Assistance Publique–Hôpitaux de Paris, Créteil, France
| | - Anthony J. Furlan
- Department of Neurology, Case Western Reserve University, Cleveland, Ohio
| | - Howard C. Herrmann
- Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Peter Jüni
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael’s Hospital, University of Toronto, Ontario, Canada
| | - Jong S. Kim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Benjamin Koethe
- Predictive Analytics and Comparative Effectiveness Center, Tufts Medical Center/Tufts University School of Medicine, Boston, Massachusetts
| | - Pil Hyung Lee
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Benedicte Lefebvre
- Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | | | - Bernhard Meier
- Department of Cardiology, Bern University Hospital, Bern, Switzerland
| | - Mark Reisman
- Division of Cardiology, University of Washington Medical Center, Seattle
| | - Richard W. Smalling
- Division of Cardiology, Department of Medicine, UTHealth/McGovern Medical School, Houston, Texas
| | - Lars Soendergaard
- Department of Cardiology, University of Copenhagen Hospital Rigshospitalet, Copenhagen, Denmark
| | - Jae-Kwan Song
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jean-Louis Mas
- GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne, Département of Neurology, Institut de Psychiatrie et Neurosciences de Paris, Université de Paris, Paris, France
| | - David E. Thaler
- Department of Neurology, Tufts Medical Center/Tufts University School of Medicine, Boston, Massachusetts
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22
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Wu X, Ya J, Zhou D, Ding Y, Ji X, Meng R. Pathogeneses and Imaging Features of Cerebral White Matter Lesions of Vascular Origins. Aging Dis 2021; 12:2031-2051. [PMID: 34881084 PMCID: PMC8612616 DOI: 10.14336/ad.2021.0414] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 04/14/2021] [Indexed: 01/10/2023] Open
Abstract
White matter lesion (WML), also known as white matter hyperintensities or leukoaraiosis, was first termed in 1986 to describe the hyperintense signals on T2-weighted imaging (T2WI) and fluid-attenuated inversion recovery (FLAIR) maps. Over the past decades, a growing body of pathophysiological findings regarding WMLs have been discovered and discussed. Currently, the generally accepted WML pathogeneses mainly include hypoxia-ischemia, endothelial dysfunction, blood-brain barrier disruption, and infiltration of inflammatory mediators or cytokines. However, none of them can explain the whole dynamics of WML formation. Herein, we primarily focus on the pathogeneses and neuroimaging features of vascular WMLs. To achieve this goal, we searched papers with any type published in PubMed from 1950 to 2020 and cross-referenced the keywords including “leukoencephalopathy”, “leukoaraiosis”, “white matter hyperintensity”, “white matter lesion”, “pathogenesis”, “pathology”, “pathophysiology”, and “neuroimaging”. Moreover, references of the selected articles were browsed and searched for additional pertinent articles. We believe this work will supply the robust references for clinicians to further understand the different WML patterns of varying vascular etiologies and thus make customized treatment.
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Affiliation(s)
- Xiaoqin Wu
- 1Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,2Advanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,3Department of China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jingyuan Ya
- 1Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,2Advanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,3Department of China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China.,4Division of Clinical Neuroscience, Queen's Medical Center School of Medicine, the University of Nottingham, Nottingham NG7 2UH, UK
| | - Da Zhou
- 1Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,2Advanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,3Department of China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yuchuan Ding
- 3Department of China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China.,5Department of Neurosurgery, Wayne State University School of Medicine, Detroit, Michigan 48201, USA
| | - Xunming Ji
- 1Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,2Advanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,3Department of China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Ran Meng
- 1Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,2Advanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,3Department of China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
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23
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Patent foramen ovale closure and decompression sickness among divers. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 40:160-162. [PMID: 34810112 DOI: 10.1016/j.carrev.2021.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 11/15/2021] [Accepted: 11/15/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND Decompression sickness is a diving-related disease that results in various clinical manifestations, ranging from joint pain to severe pulmonary and CNS affection. Complications of this disease may sometimes persist even after treatment with hyperbaric oxygen therapy. In addition, it may hamper the quality of life by forcing divers to restrict their recreational practice. The presence of a patent foramen ovale (PFO) increases the risk of decompression sickness by facilitating air embolization. Therefore, PFO closure may play a role in reducing such complications. However, PFO closure remains associated with its own set of risks and complications. We sought to assess the benefit and harm of PFO closure for the prevention of decompression sickness in divers. METHODS We conducted a comprehensive search of MEDLINE, Embase, CENTRAL, and Web of Science. Two-armed studies comparing the incidence of decompression sickness with or without PFO closure were included. We used a random-effects model to compute risk ratios comparing groups undergoing PFO closure to those not undergoing PFO closure. RESULTS Four observational studies with a total of 309 divers (PFO closure: 141 and no closure: 168) met inclusion criteria. PFO closure was associated with a significantly lower incidence of decompression sickness (PFO-closure: 2.84%; no closure: 11.3%; RR: 0.29; 95% CI: 0.10 to 0.89; NNTB = 11), with low heterogeneity (I2 = 0%). The mean follow-up was 6.12 years (Standard deviation 0.70). Adverse events occurred in 7.63% of PFO closures, including tachyarrhythmias and bleeding. CONCLUSION PFO closure may potentially reduce the risk of decompression sickness among divers; however, it is not free of potential downsides, with nearly one in thirteen patients in our analysis experiencing an adverse event.
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24
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Thaler A, Kvernland A, Kelly S, Song C, Aparicio HJ, Mac Grory B, Yaghi S. Stroke Prevention in Patients with Patent Foramen Ovale. Curr Cardiol Rep 2021; 23:183. [PMID: 34718891 DOI: 10.1007/s11886-021-01605-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/31/2021] [Indexed: 01/10/2023]
Abstract
PURPOSE OF REVIEW Patent foramen ovale (PFO) is widely prevalent and studies have suggested an association with ischemic stroke. In this review, we aim to highlight current management of patients with ischemic stroke in the setting of PFO and discuss some areas of controversy. RECENT FINDINGS Upon reviewing the literature, we have found that the evidence regarding the management of patients with cryptogenic stroke and PFO has come a long way in the past several years, and many uncertainties remain in clinical practice. The Risk of Paradoxical Embolism (RoPE) score helps to predict the probability of a pathogenic PFO, and recent trial data confirms the benefit of closure in carefully selected patients. The benefit of closure in older patients and in patients with alternate, competing mechanisms is still uncertain, and the long-term risks of closure are not known. Finally, the efficacy of direct oral anticoagulants (DOACs) in this patient population as compared to other medical therapy or mechanical closure has not yet been investigated. Randomized data is needed to help answer these questions. PFO closure is a safe and effective strategy in reducing stroke risk in carefully selected patients with cryptogenic stroke in the setting of a PFO. More studies are needed to test optimal medical treatment strategies and the safety and efficacy of PFO closure in patient subgroups not included in prior PFO closure trials.
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Affiliation(s)
- Alison Thaler
- Department of Neurology, New York University Grossman School of Medicine, New York, NY, USA
| | - Alexandra Kvernland
- Department of Neurology, New York University Grossman School of Medicine, New York, NY, USA
| | - Sean Kelly
- Department of Neurology, New York University Grossman School of Medicine, New York, NY, USA
| | - Christopher Song
- Department of Internal Medicine, Brown University, Providence, RI, USA
| | - Hugo J Aparicio
- Department of Neurology, Boston University, Boston, MA, USA
- Department of Neurology, Boston Medical Center, Boston, MA, USA
| | | | - Shadi Yaghi
- Department of Neurology, Brown University, 593 Eddy Street APC 5, Providence, RI, 02903, USA.
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25
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Scavasine VC, Chamma JF, Bazan R, Braga GP, Lange MC, Zétola VDHF. Comparison of right-to-left shunt characteristics in cryptogenic embolic ischemic stroke and non-cardioembolic ischemic stroke. ARQUIVOS DE NEURO-PSIQUIATRIA 2021; 79:859-863. [PMID: 34706014 DOI: 10.1590/0004-282x-anp-2020-0430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 12/07/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND Patent foramen ovale (PFO) has been considered a potential mechanism of embolic stroke of undetermined origin. OBJECTIVE The aim of the present study was to identify the features of the right-to-left shunt (RLS) in patients with undetermined embolic ischemic stroke and compare them with those of patients with non-cardioembolic ischemic stroke. METHODS A retrospective study was conducted with 168 patients with stroke and RLS separated into the following two groups: the undetermined embolic stroke group (UES group) and non-cardioembolic stroke group (NCES group). All patients were assessed by transcranial Doppler to evaluate the presence and quantification of microembolic signals (MES) at rest and under Valsalva maneuver. RESULTS Of all patients evaluated in the current study, 96 were included in the UES group and 72 in the NCES group. In the UES group, 65 patients had RLS with ≥10 MES (67.7%), which was higher than that observed in the NCES group (51.4%, p=0.038). According to the moment of the cardiac cycle, 75 patients (78.1%) in the UES group had a positive test at rest compared to 42 (58.3%) in the NCES group (p=0.007). CONCLUSIONS The current study demonstrated that almost 70% of patients with undetermined embolic stroke and PFO presented a large RLS and more than 75% had RLS at rest. These findings suggest that the size of the shunt should be taken into account when evaluating whether PFO could be a possible mechanism underlying cryptogenic stroke.
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Affiliation(s)
| | - Jamileh Ferreira Chamma
- Universidade Federal do Paraná, Hospital de Clínicas, Departamento de Neurologia, Curitiba PR, Brazil
| | - Rodrigo Bazan
- Universidade Estadual Paulista "Júlio de Mesquita Filho", Departamento de Neurologia, Botucatu SP, Brazil
| | - Gabriel Pereira Braga
- Universidade Federal de Mato Grosso do Sul, Departamento de Neurologia, Campo Grande MS, Brazil
| | - Marcos Christiano Lange
- Universidade Federal do Paraná, Hospital de Clínicas, Departamento de Neurologia, Curitiba PR, Brazil
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26
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Barrios-López JM, Rego-García I, Fernández Pérez MD. Reply. Neurologia 2021; 36:563-564. [PMID: 34332953 PMCID: PMC8316972 DOI: 10.1016/j.nrleng.2021.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 04/06/2021] [Indexed: 01/10/2023] Open
Affiliation(s)
- J M Barrios-López
- Servicio de Neurología, Hospital Universitario Virgen de las Nieves, Granada, Spain.
| | - I Rego-García
- Servicio de Neurología, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - M D Fernández Pérez
- Servicio de Neurología, Hospital Universitario Virgen de las Nieves, Granada, Spain
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27
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Hołda MK, Krawczyk-Ożóg A, Koziej M, Kołodziejczyk J, Sorysz D, Szczepanek E, Jędras J, Dudek D. Patent Foramen Ovale Channel Morphometric Characteristics Associated with Cryptogenic Stroke: The MorPFO Score. J Am Soc Echocardiogr 2021; 34:1285-1293.e3. [PMID: 34389468 DOI: 10.1016/j.echo.2021.07.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 07/22/2021] [Accepted: 07/29/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND It is still disputable whether the specific morphologic properties of patent foramen ovale (PFO) may contribute to the occurrence of stroke. The aim of this study was to evaluate the differences in the morphometric and functional features of the PFO channel in patients with cryptogenic stroke and those without stroke. METHODS PFO channel morphology in 106 consecutive patients with cryptogenic stroke and 93 control patients without stroke with diagnosed PFO (by transesophageal echocardiography) was analyzed using transesophageal echocardiography. A validation cohort was established that consisted of 31 patients with cryptogenic stroke and 30 without stroke. RESULTS Multivariable regression logistic analyses indicated PFO channel length change (odds ratio [OR], 2.50; 95% confidence interval [CI], 1.75-3.55; P < .001), PFO length/height ratio during the Valsalva maneuver (OR, 0.75; 95% CI, 0.60-0.95; P = .015), septum primum thickness (OR, 0.34; 95% CI, 0.14-0.80; P = .013), septum secundum height (OR, 0.91; 95% CI, 0.84-0.98; P = .013), the presence of an atrial septal aneurysm (OR, 3.38; 95% CI, 1.27-8.97; P = .014), and large shunt (OR, 2.49; 95% CI, 1.13-5.46; P = .022) as PFO-related stroke factors. The Morphologic Stroke Factors of PFO (MorPFO) score was developed, in which six factors were included: PFO channel length reduction (≥21%; 7 points), short septum secundum (<8.6 mm; 5 points), thin septum primum (<1.6 mm; 3 points), large right-to-left shunt (3 points), low PFO channel length/height ratio during the Valsalva maneuver (≤2.1; 2 points), and atrial septal aneurysm presence (1 point). Patients with scores of 0 to 7 points have low-risk PFO channels, those with scores of 8 to 11 points have intermediate-risk PFO channels, and those with scores of 12 to 21 points have high-risk PFO channels. External validation showed good MorPFO score performance (C index = 0.90). CONCLUSIONS Transesophageal echocardiography can be used to differentiate pathogenic from incidental PFO channels on the basis of their morphologic characteristics. The MorPFO score may help identify high-stroke-risk PFO channels.
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Affiliation(s)
- Mateusz K Hołda
- Heart Embryology and Anatomy Research Team, Department of Anatomy, Jagiellonian University Medical College, Cracow, Poland; Division of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom.
| | - Agata Krawczyk-Ożóg
- Heart Embryology and Anatomy Research Team, Department of Anatomy, Jagiellonian University Medical College, Cracow, Poland; Department of Interventional Cardiology, University Hospital, Jagiellonian University Medical College, Cracow, Poland
| | - Mateusz Koziej
- Heart Embryology and Anatomy Research Team, Department of Anatomy, Jagiellonian University Medical College, Cracow, Poland
| | - Joanna Kołodziejczyk
- Department of Computer Science and Information Technology, West Pomeranian University of Technology, Szczecin, Poland
| | - Danuta Sorysz
- Department of Interventional Cardiology, University Hospital, Jagiellonian University Medical College, Cracow, Poland
| | - Elżbieta Szczepanek
- Heart Embryology and Anatomy Research Team, Department of Anatomy, Jagiellonian University Medical College, Cracow, Poland
| | - Justyna Jędras
- Heart Embryology and Anatomy Research Team, Department of Anatomy, Jagiellonian University Medical College, Cracow, Poland
| | - Dariusz Dudek
- Department of Interventional Cardiology, University Hospital, Jagiellonian University Medical College, Cracow, Poland
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Onorato EM. Large eustachian valve fostering paradoxical thromboembolism: passive bystander or serial partner in crime? World J Cardiol 2021; 13:204-210. [PMID: 34367504 PMCID: PMC8326156 DOI: 10.4330/wjc.v13.i7.204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 01/06/2021] [Accepted: 03/26/2021] [Indexed: 02/06/2023] Open
Abstract
Catheter-based closure of patent foramen ovale (PFO) is more effective than medical therapy in the prevention of recurrent stroke[1]. It is likely that a proportion of patients evaluated for potential transcatheter PFO closure has actually different anatomical variants particularly common in the right atrium such as eustachian valve, Chiari network, Thebesian valve and Crista Terminalis. Notably, the eustachian valve may represent an increased risk factor for left circulation thromboembolism beyond that associated with PFO size and shunting. Such patients may benefit the most from percutaneous closure procedure.
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Affiliation(s)
- Eustaquio Maria Onorato
- Invasive Cardiology, Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan 20138, Italy
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Vizzari G, Pizzino F, Zwicke D, Tajik AJ, Carerj S, Di Bella G, Micari A, Khandheria BK, Zito C. Patent foramen ovale: anatomical complexity and long-tunnel morphology related issues. AMERICAN JOURNAL OF CARDIOVASCULAR DISEASE 2021; 11:316-329. [PMID: 34322302 PMCID: PMC8303044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 05/05/2021] [Indexed: 06/13/2023]
Abstract
Patent foramen ovale (PFO) is present in about one-quarter of the population and should be considered an anatomical variant rather than a malformation. The association of PFO with cryptogenic stroke, migraine, peripheral embolism and other pathologies is still controversial. The evaluation of anatomical complexity, and particularly the long-tunnel morphology, is crucial for the assessment of the risk profile and for a targeted therapeutic management. Long-tunnel PFOs seem to be more prone to clot formation and complications related to percutaneous closure procedures. Echocardiography is the most useful method to investigate anatomical complexity, confirm and reinforce the indication to treatment, select the appropriate device and guide the PFO closure towards a successful procedure.
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Affiliation(s)
- Giampiero Vizzari
- Department of Clinical and Experimental Medicine, University of Messina, A.O.U. Policlinic “G. Martino”Messina 98165, Italy
| | - Fausto Pizzino
- Cardiology Unit, Conegliano Hospital, AULSS2 Marca TrevigianaConegliano (TV) 31015, Italy
| | - Dianne Zwicke
- Aurora Cardiovascular Services, Aurora Sinai/Aurora St. Luke’s Medical Centers, University of Wisconsin School of Medicine and Public Health2801 W. Kinnickinnic River Parkway, #840, Milwaukee, WI 53215, USA
| | - A Jamil Tajik
- Aurora Cardiovascular Services, Aurora Sinai/Aurora St. Luke’s Medical Centers, University of Wisconsin School of Medicine and Public Health2801 W. Kinnickinnic River Parkway, #840, Milwaukee, WI 53215, USA
| | - Scipione Carerj
- Department of Clinical and Experimental Medicine, University of Messina, A.O.U. Policlinic “G. Martino”Messina 98165, Italy
| | - Gianluca Di Bella
- Department of Clinical and Experimental Medicine, University of Messina, A.O.U. Policlinic “G. Martino”Messina 98165, Italy
| | - Antonio Micari
- Department of Biomedical and Dental Sciences and Morphological and Functional Imaging, University of Messina, A.O.U. Policlinic “G. Martino”Messina 98165, Italy
| | - Bijoy K Khandheria
- Aurora Cardiovascular Services, Aurora Sinai/Aurora St. Luke’s Medical Centers, University of Wisconsin School of Medicine and Public Health2801 W. Kinnickinnic River Parkway, #840, Milwaukee, WI 53215, USA
| | - Concetta Zito
- Department of Clinical and Experimental Medicine, University of Messina, A.O.U. Policlinic “G. Martino”Messina 98165, Italy
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Characteristics and prognosis of patients with cryptogenic stroke and suggestive of patent foramen ovale. Cardiovasc Ultrasound 2021; 19:20. [PMID: 34090472 PMCID: PMC8180014 DOI: 10.1186/s12947-021-00255-0] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 05/25/2021] [Indexed: 01/16/2023] Open
Abstract
AIMS The purpose of this study were to identify the usefulness of screening for PFO using agitated saline echocardiography (ASE) and characteristics and prognosis of patients with suggestive of patent foramen ovale (PFO). METHODS Three hundred three patients (mean age, 53 ± 9 years; 199 [66%] men) admitted with acute stroke or suspicion of stroke were included. Patients were classified into those with and without right-to-left shunt (RLS) according to the ASE results (positive ASE [n = 92] vs. negative ASE [n = 211]). Fifty-one out of ninety-two patients with positive ASE and twenty-one out of two hundred eleven patients with negative ASE underwent TEE with ASE to confirm PFO. RESULTS Ninety-two were positive for ASE and thirty-six of the fifty-one patients who underwent TEE were confirmed as having PFO. Of the patients with RLS grade 1, 50% were diagnosed with PFO and all patients with RLS grade ≥ 2 were diagnosed with PFO. All patients with negative ASE had no PFO (sensitivity of 100% and specificity of 58%). Patients with positive ASE were younger, had a lower body mass, and a lower prevalence of hypertension. The positive ASE patients had a higher mean S' velocity and better diastolic function. Four of ninety-one patients with positive ASE and thirteen of one hundred seventy-seven showed recurrence of stroke and suspicion of stroke. CONCLUSION Transthoracic ASE is a good method to screen for PFO. Patients with suggestive of PFO had lower risk factors, less atherosclerosis, and better cardiac performance.
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Olindo S, Chausson N, Signate A, Mecharles S, Hennequin JL, Saint-Vil M, Edimonana-Kaptue M, Jeannin S, Landais A, Cabre P, Sibon I, Smadja D, Joux J. Stroke Recurrence in First-Ever Symptomatic Carotid Web: A Cohort Study. J Stroke 2021; 23:253-262. [PMID: 34102760 PMCID: PMC8189848 DOI: 10.5853/jos.2020.05225] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 04/05/2021] [Indexed: 01/10/2023] Open
Abstract
Background and Purpose Carotid web (CaW) is an intimal variant of fibromuscular dysplasia responsible for ipsilateral cerebral ischemic events (CIE). Symptomatic CaW likely has a high risk of recurrent CIE, but no salient prospective data are available. We aimed to assess recurrence rate and its predictors after a first-ever CIE.
Methods Consecutive Afro-Caribbean patients who had cryptogenic first-ever CIEs (ischemic stroke [IS] or transient ischemic attack [TIA]) associated with ipsilateral CaW were included in this multicenter observational cohort study. The follow-up (January 2008 to March 2019) focused on CIE recurrences. Kaplan-Meier method assessed rates of recurrences and Cox proportional hazards regression analyzed risk factors.
Results Ninety-two patients (79 first-ever ISs and 13 TIAs; mean age±standard deviation, 49.8±9.9 years; 52 [56.5%] women) were included. During a mean follow-up of 50.5±29.6 months, 19 (20.7%) patients experienced recurrent ipsilateral CIEs (16 ISs and three TIAs). Of 23 patients receiving surgery/stenting treatment, no recurrence occurred after the intervention (median follow-up, 39.8 months [interquartile range, 27.6 to 72.4]). Under medical treatment alone, the annual recurrent CIE rate was 6.9%, and the cumulative rate was 4.4% at 30-day, 10.8% at 1-year, 19.8% at 2-year, 23.2% at 3-year, and 27.3% at 5-year. Presence of silent cerebral infarctions was the only independent risk factor of CIE recurrences (hazard ratio, 6.99; 95% confidence interval, 2.4 to 20.4; P=0.004).
Conclusions Under medical treatment alone, symptomatic CaW was associated with a high rate of recurrence that reached 27.3% at 5-year. Surgery/stenting seems to be efficient, and randomized control trials are required to confirm the benefit of these interventions.
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Affiliation(s)
| | - Nicolas Chausson
- Neurology Department, Sud-Francilien Hospital, Corbeil-Essonnes, France
| | - Aissatou Signate
- Neurology Department, Martinique University Hospital, Martinique
| | - Sylvie Mecharles
- Neurology Department, Guadeloupe University Hospital, Guadeloupe
| | | | | | | | - Severine Jeannin
- Neurology Department, Martinique University Hospital, Martinique
| | - Anne Landais
- Neurology Department, Guadeloupe University Hospital, Guadeloupe
| | - Philippe Cabre
- Neurology Department, Martinique University Hospital, Martinique
| | - Igor Sibon
- Stroke Unit, Bordeaux University Hospital, Bordeaux, France
| | - Didier Smadja
- Neurology Department, Sud-Francilien Hospital, Corbeil-Essonnes, France
| | - Julien Joux
- Neurology Department, Martinique University Hospital, Martinique
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Barrios-López JM, Rego-García I, Fernández Pérez MD. [Reply]. Neurologia 2021; 36:563-564. [PMID: 34024656 PMCID: PMC8040538 DOI: 10.1016/j.nrl.2021.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Affiliation(s)
- J M Barrios-López
- Servicio de Neurología, Hospital Universitario Virgen de las Nieves, Granada, España
| | - I Rego-García
- Servicio de Neurología, Hospital Universitario Virgen de las Nieves, Granada, España
| | - M D Fernández Pérez
- Servicio de Neurología, Hospital Universitario Virgen de las Nieves, Granada, España
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Deng W, McMullin D, Inglessis-Azuaje I, Locascio JJ, Palacios IF, Buonanno FS, Lo EH, Ning M. Effect of Patent Foramen Ovale Closure After Stroke on Circulatory Biomarkers. Neurology 2021; 97:e203-e214. [PMID: 33986139 DOI: 10.1212/wnl.0000000000012188] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 04/13/2021] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE To determine the influence of patent foramen ovale (PFO) closure on circulatory biomarkers. METHODS Consecutive patients with PFO-related stroke were prospectively enrolled and followed with serial sampling of cardiac atrial and venous blood pre- and post-PFO closure over time. Candidate biomarkers were identified by mass spectrometry in a discovery cohort first, and lead candidates were validated in an independent cohort. RESULTS Patients with PFO-related stroke (n = 254) were recruited and followed up to 4 years (median 2.01; interquartile range 0.77-2.54). Metabolite profiling in the discovery cohort (n = 12) identified homocysteine as the most significantly decreased factor in intracardiac plasma after PFO closure (false discovery rate 0.001). This was confirmed in a validation cohort (n = 181), where intracardiac total homocysteine (tHcy) was immediately reduced in patients with complete closure, but not in those with residual shunting, suggesting association of PFO shunting with tHcy elevation (β 0.115; 95% confidence interval [CI] 0.047-0.183; p = 0.001). tHcy reduction was more dramatic in left atrium than right (p < 0.001), suggesting clearance through pulmonary circulation. Long-term effect of PFO closure was also monitored and compared to medical treatment alone (n = 61). Complete PFO closure resulted in long-term tHcy reduction in peripheral blood, whereas medical therapy alone showed no effect (β -0.208; 95% CI -0.375∼-0.058; p = 0.007). Residual shunting was again independently associated with persistently elevated tHcy (β 0.184; 95% CI 0.051-0.316; p = 0.007). CONCLUSIONS PFO shunting may contribute to circulatory tHcy elevation, which is renormalized by PFO closure. PFO is not just a door for clots, but may itself enhance clot formation and injure neurovasculature by clot-independent mechanisms. Biomarkers such as tHcy can potentially serve as cost-effective measures of residual shunting and neurovascular risk for PFO stroke.
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Affiliation(s)
- Wenjun Deng
- From the Clinical Proteomics Research Center (W.D., D.M., F.S.B., E.H.L., M.M.N.), Cardio-Neurology Division (W.D., I.I.-A., J.J.L., I.F.P., F.S.B., E.H.L., M.M.N.), and Neuroprotection Research Laboratory (E.H.L., M.M.N.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - David McMullin
- From the Clinical Proteomics Research Center (W.D., D.M., F.S.B., E.H.L., M.M.N.), Cardio-Neurology Division (W.D., I.I.-A., J.J.L., I.F.P., F.S.B., E.H.L., M.M.N.), and Neuroprotection Research Laboratory (E.H.L., M.M.N.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Ignacio Inglessis-Azuaje
- From the Clinical Proteomics Research Center (W.D., D.M., F.S.B., E.H.L., M.M.N.), Cardio-Neurology Division (W.D., I.I.-A., J.J.L., I.F.P., F.S.B., E.H.L., M.M.N.), and Neuroprotection Research Laboratory (E.H.L., M.M.N.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Joseph J Locascio
- From the Clinical Proteomics Research Center (W.D., D.M., F.S.B., E.H.L., M.M.N.), Cardio-Neurology Division (W.D., I.I.-A., J.J.L., I.F.P., F.S.B., E.H.L., M.M.N.), and Neuroprotection Research Laboratory (E.H.L., M.M.N.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Igor F Palacios
- From the Clinical Proteomics Research Center (W.D., D.M., F.S.B., E.H.L., M.M.N.), Cardio-Neurology Division (W.D., I.I.-A., J.J.L., I.F.P., F.S.B., E.H.L., M.M.N.), and Neuroprotection Research Laboratory (E.H.L., M.M.N.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Ferdinando S Buonanno
- From the Clinical Proteomics Research Center (W.D., D.M., F.S.B., E.H.L., M.M.N.), Cardio-Neurology Division (W.D., I.I.-A., J.J.L., I.F.P., F.S.B., E.H.L., M.M.N.), and Neuroprotection Research Laboratory (E.H.L., M.M.N.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Eng H Lo
- From the Clinical Proteomics Research Center (W.D., D.M., F.S.B., E.H.L., M.M.N.), Cardio-Neurology Division (W.D., I.I.-A., J.J.L., I.F.P., F.S.B., E.H.L., M.M.N.), and Neuroprotection Research Laboratory (E.H.L., M.M.N.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - MingMing Ning
- From the Clinical Proteomics Research Center (W.D., D.M., F.S.B., E.H.L., M.M.N.), Cardio-Neurology Division (W.D., I.I.-A., J.J.L., I.F.P., F.S.B., E.H.L., M.M.N.), and Neuroprotection Research Laboratory (E.H.L., M.M.N.), Massachusetts General Hospital, Harvard Medical School, Boston.
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Zhu Y, Zhang J, Huang B, Liu Y, Deng Y, Weng Y, Sun R. Impact of Patent Foramen Ovale Anatomic Features on Right-to-Left Shunt in Patients with Cryptogenic Stroke. ULTRASOUND IN MEDICINE & BIOLOGY 2021; 47:1289-1298. [PMID: 33541750 DOI: 10.1016/j.ultrasmedbio.2021.01.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 12/24/2020] [Accepted: 01/07/2021] [Indexed: 06/12/2023]
Abstract
The purpose of this study was to investigate the impact of the morphologic characteristics of patent foramen ovale (PFO) on right-to-left shunt (RLS) in patients with PFO and cryptogenic stroke using transesophageal echocardiography and saline contrast transthoracic echocardiography (c-TTE). Of the 165 patients with PFO stroke, both the height and the length of PFO in the provoked RLS group were smaller than those in the constant RLS group. PFO height, interatrial septum mobility and proportion of atrial septal aneurysms were greater in the severe RLS group than in the mild and moderate RLS groups. Multivariate analysis revealed that PFO height and interatrial septum mobility were independent predictors of severe RLS. Multiple territorial ischemic lesions were more common in the severe RLS or constant RLS group. Our findings indicated that the severity of RLS was related to the anatomic features in PFO, inducing different cerebral ischemia lesion patterns in cryptogenic stroke patients with PFO.
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Affiliation(s)
- Ying Zhu
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jun Zhang
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bo Huang
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yani Liu
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Youbin Deng
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yahui Weng
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ruiying Sun
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Chiarini G, Cho SM, Whitman G, Rasulo F, Lorusso R. Brain Injury in Extracorporeal Membrane Oxygenation: A Multidisciplinary Approach. Semin Neurol 2021; 41:422-436. [PMID: 33851392 DOI: 10.1055/s-0041-1726284] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) represents an established technique to provide temporary cardiac and/or pulmonary support. ECMO, in veno-venous, veno-arterial or in extracorporeal carbon dioxide removal modality, is associated with a high rate of brain injuries. These complications have been reported in 7 to 15% of adults and 20% of neonates, and are associated with poor survival. Thromboembolic events, loss of cerebral autoregulation, alteration of the blood-brain barrier, and hemorrhage related to anticoagulation represent the main causes of severe brain injury during ECMO. The most frequent forms of acute neurological injuries in ECMO patients are intracranial hemorrhage (2-21%), ischemic stroke (2-10%), seizures (2-6%), and hypoxic-ischemic brain injury; brain death may also occur in this population. Other frequent complications are infarction (1-8%) and cerebral edema (2-10%), as well as neuropsychological and psychiatric sequelae, including posttraumatic stress disorder.
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Affiliation(s)
- Giovanni Chiarini
- Department of Cardiothoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands.,Division of Anesthesiology, Intensive Care and Emergency Medicine, Spedali Civili University, Affiliated Hospital of Brescia, Brescia, Italy
| | - Sung-Min Cho
- Departments of Neurology, Anesthesiology, and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Glenn Whitman
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Frank Rasulo
- Division of Anesthesiology, Intensive Care and Emergency Medicine, Spedali Civili University, Affiliated Hospital of Brescia, Brescia, Italy
| | - Roberto Lorusso
- Department of Cardiothoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
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Yan L, Huangfu C, Yang N, Li R, Yang X, Feng Y, Xuan L, Wang Q, Meng Y, Hou X, Li X. Sex- related differences in the factors associated with outcomes among patients with strokes of undetermined source: a hospital-based follow-up study. Postgrad Med 2021; 133:428-435. [PMID: 33554703 DOI: 10.1080/00325481.2021.1886770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Objective: Sex-related differences are well established among stroke patients, including the incidence and prevalence of stroke being higher among men than among women. However, the sex-related factors for differences in the outcomes of strokes of undetermined source (SUSs) have not been well described, especially in the Chinese population. We assessed the sex-related differences in the factors associated with outcomes among patients with SUSs in China.Method: Between January 2011 and December 2018, we recruited 205 patients diagnosed with SUSs from Kailuan General Hospital (China). The clinical features, risk factors, and outcome data were collected for the patients at 3 and 12 months after their strokes.Results: There were higher frequencies of hyperlipidemia (27.8% vs. 26.4%), smoking (41.4% vs. 5.6%), and alcohol consumption (21.8% vs. 0%) for male patients than for female patients. However, women were more likely than men to have hypertension (63.9% vs. 46.6%), diabetes (27.8% vs. 20.3%), and atrial fibrillation (9.7% vs. 5.3%); they were also more likely to be obese (16.7% vs. 12.0%). There were no significant differences in outcome between the sexes. Among men, severe strokes were associated with higher case fatality and disability risks at 12 months after stroke onset; hyperlipidemia was a risk factor for recurrence within 3 months of the initial stroke. Among women, severe strokes also increased the risk of disability; in women, high total cholesterol (TC) and age were associated with poor outcomes.Conclusion: The factors associated with outcomes in SUS differed by sex. For male patients, more severe stroke and hyperlipidemia were associated with poor outcomes in SUS. Risk factors for poor outcomes in female patients were stroke severity, age, and TC level. These findings suggest that taking measures to manage blood lipid levels and severe stroke among patients with SUS is important for both male and female patients and is crucial for reducing the burden of stroke in China.
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Affiliation(s)
- Lili Yan
- Department of Neurology, Kailuan General Hospital. Tangshan, Hebei Province, China
| | - Chunmei Huangfu
- Department of Neurology, Kailuan General Hospital. Tangshan, Hebei Province, China
| | - Na Yang
- Department of Neurology, Kailuan General Hospital. Tangshan, Hebei Province, China
| | - Renzi Li
- Department of Neurology, Kailuan General Hospital. Tangshan, Hebei Province, China
| | - Xiuping Yang
- Department of Neurology, Kailuan General Hospital. Tangshan, Hebei Province, China
| | - Yujing Feng
- Department of Neurology, Kailuan General Hospital. Tangshan, Hebei Province, China
| | - Lihui Xuan
- Department of Neurology, Kailuan General Hospital. Tangshan, Hebei Province, China
| | - Qian Wang
- Department of Neurology, Kailuan General Hospital. Tangshan, Hebei Province, China
| | - Yanhong Meng
- Department of Neurology, Kailuan General Hospital. Tangshan, Hebei Province, China
| | - Xiaoqiang Hou
- Department of Neurology, Kailuan General Hospital. Tangshan, Hebei Province, China
| | - Xuemei Li
- Department of Neurology, Kailuan General Hospital. Tangshan, Hebei Province, China
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Thet MS, Sepehripour A, Atieh AEFA, Di Salvo C. Migration of PFO closure device and entrapment within tricuspid valve leading to tricuspid regurgitation: surgical correction of an extremely rare complication after transcutaneous PFO closure. BMJ Case Rep 2021; 14:14/1/e239398. [PMID: 33500310 PMCID: PMC7843329 DOI: 10.1136/bcr-2020-239398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
A 41-year-old woman was referred to tertiary cardiothoracic surgery centre following embolisation of the Amplatzer patent foramen ovale (PFO) closure device to septal leaflet of tricuspid valve with reopening of PFO. Two years earlier, she presented with thalamic stroke, and she was found to have a PFO following investigations. The following year she underwent transcatheter closure. Six months after the percutaneous closure, she presented again with significant periods of shortness of breath. Imaging studies revealed the migration and embolisation of PFO closure device to the septal leaflet of tricuspid valve with reopening of the foramen and significant tricuspid valve regurgitation. She underwent open heart surgery using cardiopulmonary bypass for retrieval of the device, closure of the foramen and repair of the tricuspid valve. The patient recovered well without any significant issues following surgery.
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Affiliation(s)
- Myat Soe Thet
- Cardiothoracic Surgery, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Amir Sepehripour
- Cardiothoracic Surgery, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | | | - Carmelo Di Salvo
- Cardiothoracic Surgery, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
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Liu K, Song B, Palacios IF, Inglessis-Azuaje I, Deng W, McMullin D, Wang X, Lo EH, Xu Y, Buonanno FS, Ning M. Patent Foramen Ovale Attributable Cryptogenic Embolism With Thrombophilia Has Higher Risk for Recurrence and Responds to Closure. JACC Cardiovasc Interv 2020; 13:2745-2752. [PMID: 33303111 PMCID: PMC9612803 DOI: 10.1016/j.jcin.2020.09.059] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 07/22/2020] [Accepted: 09/15/2020] [Indexed: 01/22/2023]
Abstract
OBJECTIVES The aim of this study was to investigate the effect of management on the risk for recurrent events among patients with cryptogenic ischemic stroke or transient ischemic attack. BACKGROUND The combination of patent foramen ovale (PFO) and hypercoagulability may greatly increase the risk for paradoxical embolism. However, previous randomized controlled trials evaluating the efficacy of PFO closure excluded these potential high-risk patients. METHODS Patients diagnosed with PFO attributable cryptogenic embolism were prospectively, without randomization, recruited from January 2005 to March 2018. The relationship between thrombophilia and recurrent events was evaluated in overall patients. Multivariate Cox regression was conducted to assess the relative risk for recurrence in PFO closure and medical therapy groups. RESULTS A total of 591 patients with cryptogenic embolism with PFO were identified. The median duration of follow-up was 53 months, and thrombophilia significantly increased the risk for recurrent events (hazard ratio [HR]: 1.85; 95% confidence interval [CI]: 1.09 to 3.16; p = 0.024). PFO closure was superior to medical therapy in overall patients (HR: 0.16; 95% CI: 0.09 to 0.30; p < 0.001). Of the 134 patients (22.7%) with thrombophilia, there was a difference in the risk for recurrence events between the PFO closure (6 of 89) and medical therapy (15 of 45) groups (HR: 0.25; 95% CI: 0.08 to 0.74; p = 0.012). There was no potential heterogeneity in the further subgroup analysis. CONCLUSIONS Patients with cryptogenic stroke with PFO and hypercoagulable state had increased risk for recurrent stroke or transient ischemic attack. PFO closure provided a lower risk for recurrent events compared with medical therapy alone.
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Affiliation(s)
- Kai Liu
- Cardio-Neurology Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Bo Song
- Cardio-Neurology Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Igor F Palacios
- Cardio-Neurology Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ignacio Inglessis-Azuaje
- Cardio-Neurology Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - WenJun Deng
- Cardio-Neurology Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - David McMullin
- Cardio-Neurology Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - XiaoYing Wang
- Department of Neurosurgery, Clinical Neuroscience Research Center, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Eng H Lo
- Cardio-Neurology Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Neuroprotection Research Laboratory, Massachusetts General Hospital, Harvard Medical School, Massachusetts, USA
| | - YuMing Xu
- Department of Neurology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China.
| | - Ferdinando S Buonanno
- Cardio-Neurology Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
| | - MingMing Ning
- Cardio-Neurology Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Neuroprotection Research Laboratory, Massachusetts General Hospital, Harvard Medical School, Massachusetts, USA.
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Trabattoni D, Gili S, Teruzzi G, Tamborini G. A severe right-to-left intracardiac shunt after NobleStitch failure: when a device is needed. Eur Heart J Case Rep 2020; 4:1-4. [PMID: 33204941 PMCID: PMC7649439 DOI: 10.1093/ehjcr/ytaa162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Revised: 02/24/2020] [Accepted: 05/19/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND Transcatheter closure of patent foramen ovale (PFO) has been demonstrated to be superior to medical therapy in stroke prevention in selected patients. Beyond traditional permanent metallic devices, NobleStitch EL, a suture-based system, has been developed as a potential alternative. CASE SUMMARY A 50-year-old man underwent transcatheter closure of PFO with mild interatrial septal bulging and tunnel-like morphology with a NobleStitch device. A transthoracic echocardiography performed immediately after PFO closure showed residual shunt (RS), which persisted unchanged at staged controls, due to the inability of the delivery system to capture both the septum primum and the septum secundum. A second procedure was performed with the implantation of a Figulla Flex II 27/30 mm device, with no RS detectable at control echocardiography. DISCUSSION The NobleStitch device is interesting in its concept, but several pitfalls may be encountered during its deployment. Opposite to permanent metallic devices, RSs after the procedure are not expected to decrease over time and should be managed with a different approach.
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Affiliation(s)
| | - Sebastiano Gili
- Centro Cardiologico Monzino, IRCCS, Via Carlo Parea 4, Milan, Italy
| | - Giovanni Teruzzi
- Centro Cardiologico Monzino, IRCCS, Via Carlo Parea 4, Milan, Italy
| | - Gloria Tamborini
- Centro Cardiologico Monzino, IRCCS, Via Carlo Parea 4, Milan, Italy
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40
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Pietzsch JB, Geisler BP, Daniels MJ, Busca RM, Tarantini G, Søndergaard L, Kasner SE. An assessment of annual procedure volumes and therapy adoption of transcatheter closure of patent foramen ovale in four European countries. Eur Stroke J 2020; 6:72-80. [PMID: 33817337 DOI: 10.1177/2396987320939804] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 06/12/2020] [Indexed: 01/10/2023] Open
Abstract
Introduction Patent foramen ovale closure reduces recurrence of cryptogenic ischaemic stroke compared to anti-platelet therapy. Our goal was to determine procedure volumes and closure utilisation as a proportion of candidates in four large European countries. Patients and methods National statistics were obtained for Germany, England, France, and Italy for the last available five years (2014-2018). Eligibility was aligned to the enrolment criteria of pivotal trials and current consensus documents. Stroke and transient ischaemic attack incidences were obtained from epidemiological registries and claims data. The eligible candidate pool for analysis included current year candidates plus untreated patients from the prior two years. Absolute strokes avoided assumed the hazard ratio for ischaemic stroke recurrence from a recent meta-analysis. Results In 2018, closure incidence rates were 5.64, 0.53, 2.94 and 5.26 per 100,000 in Germany, England, France and Italy, respectively. This reflects five-year increases of 128% in Germany, 462% in France and 36% in Italy (p < 0.05 for all), and a decline of 37% in England. The proportions of treated patients versus candidates for the combined stroke and transient ischaemic attack pool were 55%, 30%, 80%, and 6%, respectively. Discussion Patent foramen ovale closure volumes increased after the 2017 announcement of positive trial results but still differ substantially across large European countries. If all closure candidates in 2018 with prior ischaemic stroke were treated, the resulting absolute reduction of recurrent ischaemic strokes, compared to anti-platelet therapy alone, would be between 782 and 2295 across the four countries over five years. Conclusion Many eligible patients at risk for a recurrent cryptogenic event might remain untreated due to regional practice variations.
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Affiliation(s)
| | - Benjamin P Geisler
- Wing Tech Inc., Menlo Park, CA, USA.,Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Matthew J Daniels
- Division of Cardiovascular Sciences, University of Manchester, Manchester, UK
| | | | - Giuseppe Tarantini
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | | | - Scott E Kasner
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
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41
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Ahmad Y, Howard JP, Arnold AD, Cook CM, Prasad M, Ali ZA, Parikh MA, Kosmidou I, Francis DP, Moses JW, Leon MB, Kirtane AJ, Stone GW, Karmpaliotis D. Mortality after drug-eluting stents vs. coronary artery bypass grafting for left main coronary artery disease: a meta-analysis of randomized controlled trials. Eur Heart J 2020; 41:3228-3235. [PMID: 32118272 PMCID: PMC7557472 DOI: 10.1093/eurheartj/ehaa135] [Citation(s) in RCA: 99] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 02/10/2020] [Accepted: 02/13/2020] [Indexed: 01/10/2023] Open
Abstract
AIMS The optimal method of revascularization for patients with left main coronary artery disease (LMCAD) is controversial. Coronary artery bypass graft surgery (CABG) has traditionally been considered the gold standard therapy, and recent randomized trials comparing CABG with percutaneous coronary intervention (PCI) with drug-eluting stents (DES) have reported conflicting outcomes. We, therefore, performed a systematic review and updated meta-analysis comparing CABG to PCI with DES for the treatment of LMCAD. METHODS AND RESULTS We systematically identified all randomized trials comparing PCI with DES vs. CABG in patients with LMCAD. The primary efficacy endpoint was all-cause mortality. Secondary endpoints included cardiac death, myocardial infarction (MI), stroke, and unplanned revascularization. All analyses were by intention-to-treat. There were five eligible trials in which 4612 patients were randomized. The weighted mean follow-up duration was 67.1 months. There were no significant differences between PCI and CABG for the risk of all-cause mortality [relative risk (RR) 1.03, 95% confidence interval (CI) 0.81-1.32; P = 0.779] or cardiac death (RR 1.03, 95% CI 0.79-1.34; P = 0.817). There were also no significant differences in the risk of stroke (RR 0.74, 95% CI 0.35-1.50; P = 0.400) or MI (RR 1.22, 95% CI 0.96-1.56; P = 0.110). Percutaneous coronary intervention was associated with an increased risk of unplanned revascularization (RR 1.73, 95% CI 1.49-2.02; P < 0.001). CONCLUSION The totality of randomized clinical trial evidence demonstrated similar long-term mortality after PCI with DES compared with CABG in patients with LMCAD. Nor were there significant differences in cardiac death, stroke, or MI between PCI and CABG. Unplanned revascularization procedures were less common after CABG compared with PCI. These findings may inform clinical decision-making between cardiologists, surgeons, and patients with LMCAD.
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Affiliation(s)
- Yousif Ahmad
- Center for Interventional Vascular Therapy, Columbia University Medical Center, NewYork–Presbyterian Hospital, 161 Fort Washington Avenue, New York, NY 10032, USA
- National Heart and Lung Institute, Imperial College London, Du Cane Road, London W12 0HS, UK
| | - James P Howard
- National Heart and Lung Institute, Imperial College London, Du Cane Road, London W12 0HS, UK
| | - Ahran D Arnold
- National Heart and Lung Institute, Imperial College London, Du Cane Road, London W12 0HS, UK
| | - Christopher M Cook
- National Heart and Lung Institute, Imperial College London, Du Cane Road, London W12 0HS, UK
| | - Megha Prasad
- Center for Interventional Vascular Therapy, Columbia University Medical Center, NewYork–Presbyterian Hospital, 161 Fort Washington Avenue, New York, NY 10032, USA
| | - Ziad A Ali
- Center for Interventional Vascular Therapy, Columbia University Medical Center, NewYork–Presbyterian Hospital, 161 Fort Washington Avenue, New York, NY 10032, USA
- The Cardiovascular Research Foundation, 1700 Broadway, New York, NY 10019, USA
| | - Manish A Parikh
- Center for Interventional Vascular Therapy, Columbia University Medical Center, NewYork–Presbyterian Hospital, 161 Fort Washington Avenue, New York, NY 10032, USA
| | - Ioanna Kosmidou
- Center for Interventional Vascular Therapy, Columbia University Medical Center, NewYork–Presbyterian Hospital, 161 Fort Washington Avenue, New York, NY 10032, USA
- The Cardiovascular Research Foundation, 1700 Broadway, New York, NY 10019, USA
| | - Darrel P Francis
- National Heart and Lung Institute, Imperial College London, Du Cane Road, London W12 0HS, UK
| | - Jeffrey W Moses
- Center for Interventional Vascular Therapy, Columbia University Medical Center, NewYork–Presbyterian Hospital, 161 Fort Washington Avenue, New York, NY 10032, USA
- The Cardiovascular Research Foundation, 1700 Broadway, New York, NY 10019, USA
| | - Martin B Leon
- Center for Interventional Vascular Therapy, Columbia University Medical Center, NewYork–Presbyterian Hospital, 161 Fort Washington Avenue, New York, NY 10032, USA
- The Cardiovascular Research Foundation, 1700 Broadway, New York, NY 10019, USA
| | - Ajay J Kirtane
- Center for Interventional Vascular Therapy, Columbia University Medical Center, NewYork–Presbyterian Hospital, 161 Fort Washington Avenue, New York, NY 10032, USA
- The Cardiovascular Research Foundation, 1700 Broadway, New York, NY 10019, USA
| | - Gregg W Stone
- The Cardiovascular Research Foundation, 1700 Broadway, New York, NY 10019, USA
- Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, 1190 Fifth Avenue, New York, NY 10029, USA
| | - Dimitri Karmpaliotis
- Center for Interventional Vascular Therapy, Columbia University Medical Center, NewYork–Presbyterian Hospital, 161 Fort Washington Avenue, New York, NY 10032, USA
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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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Kahles T, Michel P, Hapfelmeier A, Eberli FR, Zedde M, Thijs V, Kraemer M, Engelter ST, Serena J, Weimar C, Mallmann A, Luft A, Hemelsoet D, Thaler DE, Müller-Eichelberg A, De Pauw A, Sztajzel R, Armon C, Kent DM, Meier B, Mattle HP, Fischer U, Arnold M, Mono ML, Nedeltchev K. Prior Stroke in PFO Patients Is Associated With Both PFO-Related and -Unrelated Factors. Front Neurol 2020; 11:503. [PMID: 32582015 PMCID: PMC7289181 DOI: 10.3389/fneur.2020.00503] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 05/07/2020] [Indexed: 01/10/2023] Open
Abstract
Background and Purpose: To identify factors associated with prior stroke at presentation in patients with cryptogenic stroke (CS) and patent foramen ovale (PFO). Methods: We studied cross-sectional data from the International PFO Consortium Study (NCT00859885). Patients with first-ever stroke and those with prior stroke at baseline were analyzed for an association with PFO-related (right-to-left shunt at rest, atrial septal aneurysm, deep venous thrombosis, pulmonary embolism, and Valsalva maneuver) and PFO-unrelated factors (age, gender, BMI, hypertension, diabetes mellitus, hypercholesterolemia, smoking, migraine, coronary artery disease, aortic plaque). A multivariable analysis was used to adjust effect estimation for confounding, e.g., owing to the age-dependent definition of study groups in this cross-sectional study design. Results: We identified 635 patients with first-ever and 53 patients with prior stroke. Age, BMI, hypertension, diabetes mellitus, hypercholesterolemia, coronary artery disease, and right-to-left shunt (RLS) at rest were significantly associated with prior stroke. Using a pre-specified multivariable logistic regression model, age (Odds Ratio 1.06), BMI (OR 1.06), hypercholesterolemia (OR 1.90) and RLS at rest (OR 1.88) were strongly associated with prior stroke.Based on these factors, we developed a nomogram to illustrate the strength of the relation of individual factors to prior stroke. Conclusion: In patients with CS and PFO, the likelihood of prior stroke is associated with both, PFO-related and PFO-unrelated factors.
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Affiliation(s)
- Timo Kahles
- Department of Neurology, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Patrik Michel
- Department of Neurology, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Alexander Hapfelmeier
- Institute of Medical Informatics, Statistics and Epidemiology, School of Medicine, Technical University Munich, München, Germany
| | - Franz R Eberli
- Department of Cardiology, Municipal Hospital Triemli, Zurich, Switzerland
| | - Marialuisa Zedde
- Department of Neurology, Azienda Unità Sanitaria Locale-IRCCS, Reggio Emilia, Italy
| | - Vincent Thijs
- Department of Neurology, University Hospitals of Leuven, Leuven, Belgium.,Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, VIC, Australia
| | - Markus Kraemer
- Department of Neurology, Alfried-Krupp Krankenhaus, Essen, Germany.,Department of Neurology, Heinrich Heine University Duesseldorf, Duesseldorf, Germany
| | - Stefan T Engelter
- Department of Neurology, University Hospital of Basel, Basel, Switzerland.,Felix-Platter Hospital, Basel, Switzerland
| | - Joaquin Serena
- Department of Neurology, University Hospital of Girona, Girona, Spain
| | - Christian Weimar
- Department of Neurology, University Hospital of Essen, Essen, Germany
| | | | - Andreas Luft
- Department of Neurology, University Hospital of Zurich, Zurich, Switzerland
| | - Dimitri Hemelsoet
- Department of Neurology, University Hospital of Ghent, Ghent, Belgium
| | - David E Thaler
- Department of Neurology, Tufts Medical Center, Boston, MA, United States
| | | | - Adinda De Pauw
- Department of Neurology, AZ Sint Blasius, Dendermonde, Belgium
| | - Roman Sztajzel
- Department of Neurology, University Hospital of Geneva, Geneva, Switzerland
| | - Carmel Armon
- Department of Neurology, Baystate Health Center, Springfield, MA, United States.,Sackler School of Medicine and Department of Neurology, Yitzchak Shamir Medical Center, Tel Aviv University, Tel Aviv-Yafo, Israel
| | - David M Kent
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, United States
| | - Bernhard Meier
- Department of Cardiology, University Hospital of Bern, Bern, Switzerland
| | - Heinrich P Mattle
- Department of Neurology, University Hospital of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, University Hospital of Bern, Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, University Hospital of Bern, Bern, Switzerland
| | - Marie-Luise Mono
- Department of Neurology, University Hospital of Bern, Bern, Switzerland
| | - Krassen Nedeltchev
- Department of Neurology, Cantonal Hospital Aarau, Aarau, Switzerland.,Department of Neurology, University Hospital of Bern, Bern, Switzerland
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Mathew A, Taylor D. Fluoroscopy-Only Guided Patent Foramen Ovale Device Closure: Will It Cut Ice With the Interventionalist Community? Can J Cardiol 2020; 36:1569-1571. [PMID: 32574604 DOI: 10.1016/j.cjca.2020.03.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 03/24/2020] [Accepted: 03/24/2020] [Indexed: 01/10/2023] Open
Affiliation(s)
- Anoop Mathew
- Division of Cardiology, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Dylan Taylor
- Division of Cardiology, University of Alberta Hospital, Edmonton, Alberta, Canada.
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Kamel H, Merkler AE, Iadecola C, Gupta A, Navi BB. Tailoring the Approach to Embolic Stroke of Undetermined Source: A Review. JAMA Neurol 2020; 76:855-861. [PMID: 30958521 DOI: 10.1001/jamaneurol.2019.0591] [Citation(s) in RCA: 78] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Importance One-third of ischemic strokes have no identifiable cause after standard evaluation. In 2014, researchers termed these embolic strokes of undetermined source (ESUS) and argued that this entity would respond to anticoagulation. Two recent randomized clinical trials have not upheld this hypothesis, leading to questions about the ESUS concept. Observations This article proposes that ESUS remains a useful concept, the clinical effect of which can be enhanced by considering 2 subsets defined by their likelihood of responding to anticoagulation. Recent studies indicate that some ESUS cases result from subclinical atrial fibrillation, atrial cardiopathy, unrecognized myocardial infarction, patent foramen ovale, or cancer, while other cases result from nonstenosing large-artery atherosclerosis, aortic atherosclerosis, or nonatherosclerotic vasculopathies. Evidence suggests that anticoagulation will prove superior to antiplatelet therapy for cases in the first group of causative mechanisms but not those in the second group, suggesting the need for personalized therapy. Conclusions and Relevance Although the ESUS concept as currently constructed cannot guide treatment, efforts to better understand ESUS and develop therapies tailored to specific mechanisms are likely to help reduce the burden of stroke.
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Affiliation(s)
- Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, New York.,Associate Editor
| | - Alexander E Merkler
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, New York
| | - Costantino Iadecola
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, New York
| | - Ajay Gupta
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, New York.,Department of Radiology, Weill Cornell Medicine, New York, New York
| | - Babak B Navi
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, New York
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46
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Ahmad Y, Howard JP, Arnold A, Prasad M, Seligman H, Cook CM, Warisawa T, Shun‐Shun M, Ali Z, Parikh MA, Al‐Lamee R, Sen S, Francis D, Moses JW, Leon MB, Stone GW, Karmpaliotis D. Complete Revascularization by Percutaneous Coronary Intervention for Patients With ST-Segment-Elevation Myocardial Infarction and Multivessel Coronary Artery Disease: An Updated Meta-Analysis of Randomized Trials. J Am Heart Assoc 2020; 9:e015263. [PMID: 32476540 PMCID: PMC7429036 DOI: 10.1161/jaha.119.015263] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 05/04/2020] [Indexed: 01/10/2023]
Abstract
Background For patients with ST-segment-elevation myocardial infarction (STEMI) and multivessel coronary artery disease, the optimal treatment of the non-infarct-related artery has been controversial. This up-to-date meta-analysis focusing on individual clinical end points was performed to further evaluate the benefit of complete revascularization with percutaneous coronary intervention for patients with STEMI and multivessel coronary artery disease. Methods and Results We systematically identified all randomized trials comparing complete revascularization with percutaneous coronary intervention to culprit-only revascularization for multivessel disease in STEMI and performed a random-effects meta-analysis. The primary efficacy end point was cardiovascular death analyzed on an intention-to-treat basis. Secondary end points included all-cause mortality, myocardial infarction, and unplanned revascularization. Ten studies (7542 patients) were included: 3664 patients were randomized to complete revascularization and 3878 to culprit-only revascularization. Across all patients, complete revascularization was superior to culprit-only revascularization for reduction in the risk of cardiovascular death (relative risk [RR], 0.68; 95% CI, 0.47-0.98; P=0.037; I2=21.8%) and reduction in the risk of myocardial infarction (RR, 0.65; 95% CI, 0.54-0.79; P<0.0001; I2=0.0%). Complete revascularization also significantly reduced the risk of unplanned revascularization (RR, 0.37; 95% CI, 0.28-0.51; P<0.0001; I2=64.7%). The difference in all-cause mortality with percutaneous coronary intervention was not statistically significant (RR, 0.85; 95% CI, 0.69-1.04; P=0.108; I2=0.0%). Conclusions For patients with STEMI and multivessel disease, complete revascularization with percutaneous coronary intervention significantly improves hard clinical outcomes including cardiovascular death and myocardial infarction. These data have implications for clinical practice guidelines regarding recommendations for complete revascularization following STEMI.
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Affiliation(s)
- Yousif Ahmad
- Columbia University Medical Center/New York‐Presbyterian HospitalNew YorkNY
- National Heart and Lung InstituteImperial College LondonLondonUnited Kingdom
| | - James P. Howard
- National Heart and Lung InstituteImperial College LondonLondonUnited Kingdom
| | - Ahran Arnold
- National Heart and Lung InstituteImperial College LondonLondonUnited Kingdom
| | - Megha Prasad
- Columbia University Medical Center/New York‐Presbyterian HospitalNew YorkNY
| | - Henry Seligman
- National Heart and Lung InstituteImperial College LondonLondonUnited Kingdom
| | - Christopher M. Cook
- National Heart and Lung InstituteImperial College LondonLondonUnited Kingdom
| | - Takayuki Warisawa
- National Heart and Lung InstituteImperial College LondonLondonUnited Kingdom
| | - Matthew Shun‐Shun
- National Heart and Lung InstituteImperial College LondonLondonUnited Kingdom
| | - Ziad Ali
- Columbia University Medical Center/New York‐Presbyterian HospitalNew YorkNY
| | - Manish A. Parikh
- Columbia University Medical Center/New York‐Presbyterian HospitalNew YorkNY
| | - Rasha Al‐Lamee
- National Heart and Lung InstituteImperial College LondonLondonUnited Kingdom
| | - Sayan Sen
- National Heart and Lung InstituteImperial College LondonLondonUnited Kingdom
| | - Darrel Francis
- National Heart and Lung InstituteImperial College LondonLondonUnited Kingdom
| | - Jeffrey W. Moses
- Columbia University Medical Center/New York‐Presbyterian HospitalNew YorkNY
| | - Martin B. Leon
- Columbia University Medical Center/New York‐Presbyterian HospitalNew YorkNY
| | - Gregg W. Stone
- Cardiovascular Research FoundationNew YorkNY
- The Zena and Michael A. Wiener Cardiovascular InstituteIcahn School of Medicine at Mount SinaiNew YorkNY
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Tsai LK, Lee IH, Chen YL, Chao TF, Chen YW, Po HL, Lien LM, Chu PH, Huang WC, Lin TH, Lin MT, Jeng JS, Hwang JJ. Diagnosis and Treatment for embolic stroke of undetermined source: Consensus statement from the Taiwan stroke society and Taiwan society of cardiology. J Formos Med Assoc 2020; 120:93-106. [PMID: 32534996 DOI: 10.1016/j.jfma.2020.05.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 04/22/2020] [Accepted: 05/18/2020] [Indexed: 01/10/2023] Open
Abstract
Cryptogenic stroke comprises about one-quarter of ischemic strokes with high recurrence rate; however, studies specifically investigating the features and treatment of this stroke subtype are rare. The concept of 'embolic stroke of undetermined source' (ESUS) may facilitate the development of a standardized approach to diagnose cryptogenic stroke and improve clinical trials. Since recent large randomized control trials failed to demonstrate a reduction in stroke recurrence with anticoagulants, anti-platelet agents remain the first-line treatment for ESUS patients. Nevertheless, patients with high risk of stroke recurrence (e.g., those with repeated embolic infarcts despite aspirin treatment) require a more extensive survey of stroke etiology, including cardiac imaging and prolonged cardiac rhythm monitoring. Anticoagulant treatments may still benefit some subgroups of high-risk ESUS patients, such as those with multiple infarcts at different arterial territories without aortic atheroma, the elderly, or patients with high CHA2D2-VASc or HOVAC scores, atrial cardiopathy or patent foramen ovale. Several important ESUS clinical trials are ongoing, and the results are anticipated. With rapid progress in our understanding of ESUS pathophysiology, new subcategorizations of ESUS and assignment of optimal treatments for each ESUS subgroup are expected in the near future.
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Affiliation(s)
- Li-Kai Tsai
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - I-Hui Lee
- Department of Neurology, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan
| | - Yung-Lung Chen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yu-Wei Chen
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan; Department of Neurology, Landseed International Hospital, Taoyuan, Taiwan
| | - Helen L Po
- Stroke Center and Department of Neurology, MacKay Memorial Hospital, Taipei, Taiwan
| | - Li-Ming Lien
- Department of Neurology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan; Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Pao-Hsien Chu
- Department of Cardiology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Wei-Chun Huang
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Tsung-Hsien Lin
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Ming-Tai Lin
- Division of Pediatric Cardiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Jiann-Shing Jeng
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan.
| | - Juey-Jen Hwang
- Cardiovascular Center and Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
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Wang W, Tang X, Liu W, Jia K, Zhao X, Yu F. Clinical Features of Embolic Stroke of Undetermined Source. Front Neurol 2020; 11:58. [PMID: 32117020 PMCID: PMC7013046 DOI: 10.3389/fneur.2020.00058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 01/15/2020] [Indexed: 01/10/2023] Open
Abstract
Background and Objective: One-third of ischemic strokes have no identifiable cause following standard evaluation. In 2014, researchers have proposed the concept of Embolic Stroke of Undetermined Source (ESUS). The purpose of this study was to report the clinical characteristics of ESUS and its difference from cardiogenic embolism (CE), large-artery atherosclerosis (LA), and small-artery occlusion lacunar (SA). Methods: Acute ischemic stroke (AIS) patients admitted to the department of Beijing Haidian Hospital from January 2017 to December 2017 were prospectively and consecutively enrolled. Base-line characteristics were collected. Stroke etiologies were presented and compared. We compared the clinical features and infarct sites of patients with acute cerebral infarction of different etiologies. Results: A total of 119 AIS patients were analyzed in the study. There were 33 (27.73%) cases in ESUS group, 11 (9.24%) cases in CE group, 45 (37.82%) cases in LAA group and 30 (25.21%) cases in SA group. There were significant differences between the ESUS group and the CE group in the NIHSS score [3 (1.5–5) vs. 6 (2–20), p = 0.007], Modified Rankin Score [19, (57.58) vs. 9, (81.82), p = 0.008], hemorrhagic transformation [0, (0) vs. 5, (45.45), p < 0.001], and left atrial diameter [37.09 ± 3.16 vs. 41.73 ± 5.00, p = 0.001]. ESUS group and LA group have different mRS scores [19, (57.58) vs. 42, (93.33), p < 0.001]. ESUS group and SA group have different mRS scores [19, (57.58) vs. 28, (93.33), p = 0.001]. During 1 year follow-up, there were 5 cases (15.15%) in ESUS group, 3 cases (27.27%) in CE group, 3 cases (6.67%) in LA group, and 1 case (3.33%) in SA group with ischemic stroke (cerebral infarction or transient ischemic attack). Conclusion: ESUS is more similar to atherosclerotic cerebral infarction in clinical features, but the distribution of lesions is more similar to cardiogenic embolism, suggesting that the pathogenesis of ESUS needs to be further explored.
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Affiliation(s)
- Weijing Wang
- Department of Neurology, Beijing Haidian Hospital, Beijing Haidian Section of Peking University Third Hospital, Beijing, China.,Department of Neurology, Haidian Section of Peking University Third Hospital, Beijing, China.,Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Xiaomei Tang
- Department of Neurology, Beijing Haidian Hospital, Beijing Haidian Section of Peking University Third Hospital, Beijing, China.,Department of Neurology, Haidian Section of Peking University Third Hospital, Beijing, China
| | - Wei Liu
- Department of Neurology, Beijing Haidian Hospital, Beijing Haidian Section of Peking University Third Hospital, Beijing, China.,Department of Neurology, Haidian Section of Peking University Third Hospital, Beijing, China
| | - Ke Jia
- Department of Neurology, Beijing Haidian Hospital, Beijing Haidian Section of Peking University Third Hospital, Beijing, China.,Department of Neurology, Haidian Section of Peking University Third Hospital, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Fengchun Yu
- Department of Neurology, Beijing Haidian Hospital, Beijing Haidian Section of Peking University Third Hospital, Beijing, China.,Department of Neurology, Haidian Section of Peking University Third Hospital, Beijing, China
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Han Y, Zhang X, Zhang F. Patent foramen ovale closure by using transesophageal echocardiography for cryptogenic stroke: single center experience in 132 consecutive patients. J Cardiothorac Surg 2020; 15:11. [PMID: 31918738 PMCID: PMC6953465 DOI: 10.1186/s13019-020-1042-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 01/02/2020] [Indexed: 01/23/2023] Open
Abstract
Background Percutaneous closure of patent foramen ovale (PFO) is routinely performed using plain fluoroscopy in the catheter room. This method results in inevitable radiation damage, adverse effects of contrast agents on kidneys, and high cost. We performed PFO closure with a simplified and economical transesophageal echocardiography (TEE)-only guided approach in the operating room. This study aimed to investigate the feasibility, safety, and effectiveness of the percutaneous closure of PFO by only using TEE. Methods We reviewed the medical records of patients who underwent percutaneous PFO closure at our center from December 2013 to December 2017. A total of 132 patients with PFO and cryptogenic strokes underwent PFO closure by using cardi-O-fix PFO device under TEE guidance. The participants comprised 64 and 68 male and female patients, respectively. The mean age and body weight of the patients were 39.40 ± 13.22 years old (12–68 years old) and 65.42 ± 9.70 kg (40–95 kg), respectively. All patients only received aspirin (3–5 mg/kg body weight, oral administration) for 6 months. Contrast-enhanced transthoracic echocardiography (c-TTE) with Valsalva maneuver was performed during follow-up, and questionnaire surveys were obtained at 3, 6, and 12 months after the procedure. Results All (100%) patients were successfully closed. Follow-ups were conducted for 13 months to 48 months, with an average of 27 months. No severe complications were found during the follow-up period. Paroxysmal atrial fibrillation occurred in 4 patients within 3 months after the procedure. No recurrent stroke or death occurred in all patients during the follow-up period. Transient ischemic attack occurred in one patient 6 months after the procedure. Ten (7.6%) patients had a right-to-left shunt, as demonstrated by c-TTE at 12 months of follow-up. Among the 57 patients suffering from migraine, significant relief or resolution was reported by 42 (73.7%) patients. Conclusion TEE-only guided PFO closure was a safe, feasible, and effective method that did not require the use of X-rays and contrast agents.
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Affiliation(s)
- Yangyang Han
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, West Wenhua Road No.107, Lixia District, Jinan, 250012, Shandong Province, China.,Department of Cardiovascular Surgery, Linyi People's Hospital Affiliated to Shandong University, Jiefang Street No. 27, Linyi, 276000, Shandong Province, China
| | - Xiquan Zhang
- Department of Cardiovascular Surgery, Linyi People's Hospital Affiliated to Shandong University, Jiefang Street No. 27, Linyi, 276000, Shandong Province, China.
| | - Fengwei Zhang
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, West Wenhua Road No.107, Lixia District, Jinan, 250012, Shandong Province, China
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