Transcatheter closure of interatrial communications for secondary prevention of paradoxical embolism: single-center experience

Differences and similarities in interatrial shunts management

Atrial septal defects (ASD) and Patent foramen ovale (PFO) represent the most common congenital heart diseases (CHD) adulthood. These two clinical entities, having different embryological origin, as well as clinical manifestations, clinical course and treatment must be carefully distinguished. Right heart failure and pulmonary hypertension are considered the major determinants of morbidity and mortality in ASD. Conversely, new pathophysiology concepts have been raised in the management of PFO as left atrium cardiopathy. New diagnostic tools, including cardiac magnetic resonance and intracardiac echocardiography have joint transthoracic and transesophageal echocardiography in the diagnostic definition of both ASD and PFO as well as in guiding their percutaneous closure. Moreover, several innovations have been developed in the field of percutaneous ASD and PFO closure devices including new evidence supporting the safety and efficacy of device-based closure. Aim of the present review is to present review we provided and update overview on ASD and PFO, focusing on the novel concepts regarding their pathophysiological and therapeutic aspects.

Efficacy and safety of percutaneous patent foramen ovale closure in patients with a hypercoagulable disorder

BACKGROUND

Transcatheter closure of patent foramen ovale (PFO) in patients with cryptogenic stroke reduces the rate of recurrent events. Although presence of thrombophilia increases the risk for paradoxical emboli through a PFO, such patients were excluded from large randomized trials.

OBJECTIVES

We compared the safety and efficacy of percutaneous PFO closure in patients with and without a hypercoagulable state.

METHODS

Data from 800 consecutive patients undergoing percutaneous PFO closure in our medical center were analyzed. All patients were independently evaluated by specialists in neurology, cardiology, hematology, and vascular medicine. A post-procedural treatment of at least 3 months of anticoagulation was utilized in patients with thrombophilia. Follow-up events included death, recurrent neurological events, and the need for reintervention for significant residual shunt.

RESULTS

A hypercoagulable state was found in 239 patients (29.9%). At median follow-up of 41.9 months, there were no differences in the frequencies of stroke or transient ischemic attack between patients with or without thrombophilia (2.5% in non-hypercoagulable group vs. 3.4% in hypercoagulable group, log-rank test p = 0.35). There were no significant differences in baseline demographics, echocardiographic characteristics, procedural success, or complications between groups.

CONCLUSION

Percutaneous PFO closure is a safe and effective therapeutic approach for patients with cryptogenic stroke and an underlying hypercoagulable state.

Cryptogenic Stroke: To Close a Patent Foramen Ovale or Not to Close?

A patent foramen ovale (PFO) has been shown to be highly prevalent in patients diagnosed with strokes of unknown cause, which are also called cryptogenic strokes (CSs). It has been a long-running controversy as to whether a PFO should be closed or not to prevent recurrent strokes in patients diagnosed with CS. A paradoxical embolism that is produced through a PFO is hypothesized to be a leading cause of CS, especially in younger patients with low risk factors for stroke. It remains controversial as to which anticoagulation therapy, defined as antithrombin or antiplatelet therapy, is better for patients with CS and a PFO. In addition, surgical and transcutaneous closure of a PFO has been proposed for the secondary prevention of stroke in patients with CS with PFO. Several randomized controlled trials have been conducted in recent years to test whether a PFO closure gives a significant benefit in the management of CS. Three earlier randomized controlled trials failed to show a statistically significant benefit for a PFO closure; thus, many investigators believed that a PFO was an incidental bystander in patients with CS. However, meta-analyses and more recent specific trials have eliminated several confounding factors and possible biases and have also emphasized the use of a shunt closure over medical therapy in patients with CS. Therefore, these latest studies (the CLOSE and REDUCE trials) can possibly change the treatment paradigm in the near future.

Patent foramen ovale and atrial fibrillation as causes of cryptogenic stroke: is treatment with surgery superior to device closure and anticoagulation? A review of the literature

Closure of persistent foramen ovale (PFO) to avoid cryptogenic strokes is performed globally with enthusiasm but lacks prove of efficacy. We present a 79-year-old man who had had a PFO device introduced nine years previously because of cryptogenic strokes presenting as syncopes. The patient was referred from his general practitioner with two new syncopes. Transthoracic echocardiography revealed no cardiac causes of embolism. Transesophageal echocardiography (TEE) revealed a misplaced device like an umbrella in a storm, but no septum defects. Holter revealed seconds-long episodes of atrial fibrillation (AF). The patient was successfully treated with anticoagulation.

A literature review showed that: (i) the efficacy of PFO closure devices has not been proven in any trial, but was demonstrated in a meta-analysis comparing three different devices; (ii) PFO devices are rarely controlled by TEE during or after insertion; (iii) residual shunts are detected in up to 45% of cases; (iv) there is an increased rate of post-arrhythmic complications; (v) the risk of AF in congenital heart disease increases with increasing age, with a 13% risk of transient ischemic attacks and stroke; and (vi) surgical treatment of PFO was found to have a 4.1% risk of complications including stroke.

The question to be asked is whether device closure of PFO should be avoided, considering that PFO is a congenital heart defect with risks of AF and (cryptogenic) stroke? Heart surgery should be a treatment option for symptomatic PFO.

AMPLATZER versus Figulla occluder for transcatheter patent foramen ovale closure

AIMS

The aim of this observational study was to compare acute and 12-month results of percutaneous closure of patent foramen ovale (PFO) with two occluder devices.

METHODS AND RESULTS

Between June 2007 and October 2014, 406 consecutive patients (48.1±13.3 years, 243 women) underwent percutaneous PFO closure with either the AMPLATZER (n=179) or the Figulla (n=227) device after a stroke or a transient ischaemic attack ascribed to the PFO. A right-to-left shunt grade >1 was previously detected in all patients and atrial septal aneurysm was present in 111 (27.5%) patients. Patients were followed up with a contrast transthoracic echocardiogram and clinically at 24 hours, six months, and 12 months after the procedure. A high procedural success was observed in both groups. Despite a trend towards a higher incidence of acute residual shunt immediately after device deployment among Figulla occluder patients, a residual grade ≥2 right-to-left shunt was observed in 4.5% of patients, independently of the device used for PFO closure. The only difference reported after Figulla device implantation was a lower rate of supraventricular arrhythmias (9% vs. 17%, p=0.02).

CONCLUSIONS

According to this two-centre study, PFO closure appears safe and effective with the Figulla occluder as well as with the AMPLATZER device.

Recurrent Stroke/TIA in Cryptogenic Stroke Patients with Patent Foramen Ovale

Background:

Patent foramen ovale (PFO) is present in 40% of patients with cryptogenic stroke and may be associated with paradoxical emboli to the brain. Therapeutic options include antiplatelet agents, anticoagulation, percutaneous device and surgical closure. We assessed the hypothesis that there are differences in rates of recurrent TIA or stroke between patients in the four treatment groups.

Methods:

Patients presenting from January 1997 with cryptogenic stroke or TIA and PFO were followed prospectively until June 2003. Treatment choice was made on an individual case basis. The primary outcome was recurrent stroke. The secondary outcome was a composite of stroke, TIA, and vascular death.

Results:

Baseline. Our cohort consisted of 121 patients; 64 (53%) were men. Median age was 43 years. Sixty-nine percent presented with stroke and 31% with TIA. One or more vascular risk factor was present in 40%. Atrial septal aneurysm (ASA) was present in 24%. Treatment consisted of antiplatelet agents (34%), anticoagulation (17%), device (39%) and surgical closure (11%). Follow-up. Recurrent events occurred in 16 patients (9 antiplatelet, 3 anticoagulation, 4 device closure); 7 were strokes, 9 were TIA. Comparing individual treatments there was a trend toward more strokes in the antiplatelet arm (p=0.072); a significant difference was seen for the composite endpoint (p=0.012). Comparing closure versus combined medical therapy groups, a significant difference was seen for primary (p=0.014) and secondary (p=0.008) outcomes, favoring closure. Age and pre-study event predicted outcome.

Conclusion:

Patent foramen ovale closure was associated with fewer recurrent events. Complications of surgical and device closure were self-limited.

Stroke Recurrence and its Prevention in Patients with Patent Foramen Ovale

BACKGROUND

It is unclear whether medical or invasive (surgical or catheter interventional) treatment is preferable to prevent recurrence of cerebral ischemia in patients with patent foramen ovale (PFO) as the suspected cause of stroke and what the role of concomitant risk factors is in stroke recurrence.

METHODS

Over a period of ten years, 124 patients (mean age 51 +/- 15 years) with cryptogenic cerebral ischemia and PFO were included into the study and prospectively followed over a mean of 52 +/- 32 months. Of these, 83 were treated medically, 34 underwent transcatheter closure, and seven had surgical closure of the foramen. Of the medically treated patients, 11 stopped medication during follow-up. Recurrent ischemic events and risk factors for recurrence were analyzed.

RESULTS

Annual stroke recurrence rates were generally low and comparable in catheter and medically treated patients, and in patients who had stopped medication (2.9%/2.1%2.2%/year). Patients suffering from recurrence after transcatheter closure (n = 2) both had residual shunts. No stroke recurrence was observed in the few surgically treated patients. An atrial septal aneurysm was not a predictor of recurrent or multiple strokes (p > 0.05, OR = 0.31, and OR = 0.74). Large shunts and a history of previous ischemic events were considerably more frequent in patients with recurrent strokes (p < 0.05, OR = 5.0, and OR = 4.4). Pulmonary embolism and case fatality rates were significantly higher in patients with stroke recurrence (p < 0.001, and p < 0.01).

CONCLUSIONS

The absolute risk of recurrent cerebrovascular events in patients with PFO receiving medical or catheter interventional therapy is low. The small group of untreated patients had a comparably low rate of stroke recurrences. Previous ischemic events and shunt size were risk factors in this observational study. Given conflicting findings across multiple studies, enrollment into a randomized controlled trial would be the optimal choice.

Percutaneous implantation of a second device in patients with residual right-to-left shunt after patent foramen ovale closure

INTRODUCTION

The management of patients with residual right-to-left shunt (rRLS) after percutaneous patent foramen ovale (PFO) closure is debated. The aim of this study was to define the incidence of moderate-to-large rRLS and to report the feasibility, safety and long-term clinical outcome of transcatheter closure of rRLS.

METHODS AND RESULTS

From June 2000 to March 2013, 322 subjects underwent percutaneous PFO closure. In 39 patients (12.1%) with moderate-to-large rRLS on transcranial Doppler (TCD) and/or transesophageal echocardiogram a second cardiac catheterization was performed with the aim of completing the closure. A second closure device was implanted in 21 patients (53.8%). In the remaining 18 (46.2%), a second device was not delivered for the following reasons: in 13 (72.2%) no residual passage could be crossed, in 5 (27.8%) the residual shunt was deemed to be negligible. No complications occurred. After the second procedure, complete closure was proved by TCD in 16/21 (76.2%) subjects. One patient received a third device. During follow-up (41 ± 19 months), no cerebrovascular ischemic accidents occurred.

CONCLUSION

A second percutaneous PFO occlusion device can be safely implanted in patients with significant rRLS. However, a moderate-to-large rRLS on TCD and/or TEE may not necessarily represent a significant risk of further paradoxical embolization.

Residual shunting after percutaneous PFO closure: how to manage and how to close

INTRODUCTION

Initial transcatheter Percutaneous patent foramen ovale (PFO) closure attempt may be incomplete and result in persistent residual shunting. The optimal treatment strategy for these patients remains unknown.

PATIENTS AND METHODS

Twenty-seven patients were diagnosed to have a moderate-large residual shunt at least 12 months after initial PFO closure associated or not to a recurrent ischemic event and underwent a second procedure. Residual shunt characteristics were classified in two types: Type I: tunnel-like or between the disk defect (11 patients); Type II: accessory defect next to a device rim or accessory defect (16 patients).

RESULTS

Fourteen subjects had a recurrent transient ischemic attack/stroke (52%). Median time between the first and the second PFO closure procedure was 17 months (range 12-60 months). Deployment of a second device was successful in 92% (25/27) patients. A Type I defect was closed by using a coil or Amplatzer Vascular Plugs. In two patients a surgical option was chosen as a first option. A Type II defect was closed by using a double disc device. At a median follow-up of 36 months (range 12-60 months), two subjects showed significant residual shunting between the two disks of the device (Type I) at 12 months follow-up and were sent to surgery.

CONCLUSIONS

Significant residual shunts can be successfully closed by using a second device. Care is required to select an optimal device depending on anatomy and original device. In some subjects, lack of endothelial covering account for the persistence of a significant residual shunting.

Comparison of outcome after patent foramen ovale closure in older versus younger patients

AIMS

Percutaneous patent foramen ovale (PFO) closure seems to be effective for secondary prevention of cryptogenic stroke in patients younger than 55 years of age. The efficacy in older patients remains uncertain. We compared the efficacy of PFO closure between patients younger and older than 55 years.

METHODS AND RESULTS

All 335 patients (mean age 50.2 ± 12.6 years; 205 men) with cryptogenic thromboembolism who underwent PFO closure in our centres between 1998 and 2008 were included. Mean follow-up period was 4.2 ± 1.9 years in the elderly (n=120) and 3.8 ± 2.4 years in the younger patients (n=215) (p=0.15). Prevalence of hypertension, diabetes, hyperlipidaemia and coronary and peripheral artery disease was higher in the elderly (p<0.05 for all). Re-occurrence of stroke or TIA was higher in the elderly compared to the younger (annual event rate 2.4% versus 0.6%; log rank, p=0.005). Re-occurrence of stroke alone was higher in the elderly (annual event rate 1.2% versus 0.1%; log rank, p=0.01). Multivariate analysis showed that an age of >55 years was an independent predictor of recurrent stroke or TIA (HR 3.2, p=0.03).

CONCLUSIONS

Percutaneous PFO closure appears to be effective for secondary prevention of cryptogenic stroke in younger patients but seems to be related with less beneficial outcome in elderly. Randomised controlled trials are needed to confirm our findings.

Intracardiac echocardiography: clinical utility and application

Intracardiac echocardiography (ICE) broadens the spectrum of available echocardiographic techniques and provides the operator direct visualization of cardiac structures in real time. ICE has clear advantages over fluoroscopy, transthoracic echocardiography, and transesophageal echocardiography as the imaging modality of choice in the cardiac catheterization and electrophysiological laboratories. With the development of steerable phased array catheters with low frequency and Doppler qualities, there is marked improvement in visualization of left-sided structures from the right heart. Appropriate utilization of ICE is likely to maximize safety and efficacy of complex interventional procedures and may improve patient outcomes. Future advances in ICE imaging will further improve the ease of device guidance and, in combination with new imaging modalities, could dramatically improve other applications of echocardiography which may result in improved patient outcomes. This review describes the technical evolution of ICE, the use of ICE in guiding percutaneous interventional procedures and possible future applications of ICE in the ever-growing field of interventional cardiology.

Intermediate and long-term results of transcatheter closure of patent foramen ovale using the amplatzer patent foramen ovale occluder: one case of pulmonary embolism irrespective of patent foramen ovale closure

Background and Objectives

Patent foramen ovale (PFO) has been implicated in the pathogenesis of cryptogenic stroke or transient ischemic attack (TIA) due to paradoxical embolism, and in the pathogenesis of migraine. This paper reports the intermediate and long-term results of transcatheter closure of PFO associated with cerebrovascular accidents (CVAs), TIAs and migraine, using the Amplatzer PFO occluder. This paper also reports a case of pulmonary embolism which developed in one patient after PFO closure.

Subjects and Methods

From January 2003 to May 2010, 16 patients with PFO (seven males and nine females) with a history of at least one episode of cryptogenic stroke/TIA, CVA, or migraine and who underwent percutaneous transcatheter closure of PFO using the Amplatzer occluder. All the procedures were performed under general anesthesia and were assisted by transesophageal echocardiography.

Results

The device was implanted without any significant complications in all the patients, and the PFOs were effectively closed. At an average follow-up period of 54 months, the 15 patients with TIA/CVA had no recurrence of any thromboembolic event. The symptoms in one patient with migraine subsided after occlusion of the PFO. In this study, pulmonary embolism occurred five months after PFO closure in one patient, but the cause of pulmonary embolism was not identified. However, it is believed that the pulmonary embolism occurred without stroke recurrence because occlusion of the PFO was performed when the patient had a stroke event.

Conclusion

It can be concluded that according to the intermediate and long-term follow-up results, transcatheter PFO closure is an effective and safe therapeutic modality in the prevention of thromboembolic events, especially in the patients with cryptogenic stroke/TIA, and PFO closure is helpful in the treatment of migraine. However, this study involved a small number of patients and also the follow-up period was not long enough. Hence, randomized, controlled trials are necessary to determine if this approach is preferable to medical therapy for the prevention of recurrent stroke or as primary treatment for patients with migraine headache.

Risk and fate of residual interatrial shunting after transcatheter closure of patent foramen ovale: a long term follow up study

BACKGROUND

Percutaneous transcatheter closure of patent foramen ovale (PFO) in cryptogenic stroke is an alternative to medical therapy. There is still debate on different outcome for each currently available device. The impact of residual shunting after PFO-closure on recurrent arterial embolism is unknown. -

AIMS

(i) To evaluate the prevalence of residual interatrial shunting after device- closure of PFO, (ii) to identify risk factors predicting residual interatrial shunting after device implantation, and (iii) to investigate the outcome of patients after PFO-closure during long- term follow- up (FU).

METHODS AND RESULTS

Between 2000- 2005 PFO-closure was performed in 124 patients using four different devices: Amplatzer PFO-(n = 52), CardioSeal (n = 33), Helex (n = 23) and Premere (n = 16) occluder. All patients underwent serial contrast-enhanced transesophageal echocardiography (TEE) for 24 months after PFO- closure; clinical FU was at minimum 5 years up to 9.75 years (mean 6.67 ± 1.31 years). Overall-closure rate was 87% at 2 years, device-specific closure time curves differed significantly (p-logrank = 0.003). Independent risk factors for residual-shunting were implantation of a Helex occluder (hazard ratio [HR] 12.6, 95% confidence interval [CI] 2.6- 57.4, p = 0.002), PFO- canal- lengths (HR 1.2, 95%CI 1.1- 1.3, p = 0.004) and extend of atrial-septal-aneurysm (HR 1.1, 95%CI 0.9- 1.3; p = 0.05). 4 (3.2%) arterial embolic events occurred during a FU-period of 817.2 patient-years, actuarial annual thromboembolic-risk was 0.49%. All ischemic events were not related to residual PFO-shunting or device-related thrombus- formation.

CONCLUSION

Success rates of PFO- closure are mainly dependent on occluder-type, extend of concomitant atrial-septum-aneurysm and PFO-canal- length. Importantly, residual shunting after PFO-closure was not associated with recurrence of arterial embolism during long-term follow-up.

Massive pulmonary embolism and acute limb ischaemia in a patient of hereditary spherocytosis and patent foramen ovale

Paradoxical embolism accounts for 2% of patients who present with acute arterial embolism of extremities. We report a case of a 41 year-old male with hereditary spherocytosis who presented to the emergency department with acute limb ischaemia and pulmonary embolism. On further evaluation, he was found to have patent foramen ovale (PFO) and deep vein thrombosis (DVT), leading to paradoxical embolism. The purpose of this report is to emphasise that in a patient presenting with acute limb ischaemia without an obvious systemic arterial embolic source, an evaluation for a right-to-left shunting lesion, especially PFO, should be performed.

Incidence of Atrial Fibrillation after Percutaneous Closure of Patent Foramen Ovale and Small Atrial Septal Defects in Patients Presenting with Cryptogenic Stroke

Objective

The occurrence of atrial fibrillation after percutaneous closure of a patent foramen ovale for cryptogenic stroke has been reported in a variable percentage of patients. However, its precise incidence and mechanism are presently unclear and remain to be elucidated.

Design

Prospective follow-up study.

Patients

Ninety-two patients undergoing a percutaneous patent foramen ovale closure procedure (closure group) for cryptogenic stroke were compared with a similar group of 51 patients, who were medically treated.

Methods

A systematic arrhythmia follow-up protocol to assess the incidence of AF was performed including a 7-day event-loop recording at day 1, after 6 and 12 months in patients of the closure group and compared with those of the medically treated group.

Results

The incidence of AF was similar in both study groups during a follow-up of 12 months, including 7·6% (95% CI: 3·1–15·0%) in the closure and 7·8% (95% CI: 2·18–18·9%) in the medically treated group ( P = 1·0). The presence of a large patent foramen ovale was the only significant risk factor for the occurrence of AF as demonstrated by a multivariate Cox regression analysis (95% CI, 1·275–20·018; P = 0·021).

Conclusions

Our findings indicate that patients with cryptogenic stroke and patent foramen ovale have a rather high incidence of AF during a follow-up of 12 months. Atrial fibrillation occurred with a similar frequency whether the patent foramen ovale/atrial septal defect was successfully percutaneously closed or was medically managed. The presence of a large patent foramen ovale was the only significant predictor of AF occurrence during follow-up.

Patent foramen ovale, systemic embolization, and closure

Patent foramen ovale has become the subject of increasing interest in modern cardiovascular disease. This has been the result of several factors including, among others, description of paradoxical embolism, documentation of patent foramen ovale with right to left shunt, the rather ubiquitous use of echocardiography, the issue of stroke prevention, and more recently, the relationship between patent foramen ovale and migraine.

Percutaneous PFO closure with Amplatzer PFO occluder: predictors of residual shunts at 6 months follow-up

OBJECTIVE

The objective of this study was to assess predictors of residual shunts after percutaneous patent foramen ovale (PFO) closure with Amplatzer PFO occluder (AGA Medical Corporation, Golden Valley, MN, USA).

METHODS

All percutaneous PFO closures, using Amplatzer PFO occluder performed at a tertiary center between May 2002 and August 2006, were reviewed. Follow-up, including saline contrast transesophageal echocardiography, was performed in all patients 6 months after the intervention.

PATIENTS

A total of 135 procedures were performed. Mean age of the patients was 51 years. The indication for PFO closure was an ischemic cerebrovascular event in 92%, paradoxical systemic embolism in 4%, and a diving accident in 4%. Recurrent events prior to PFO closure were noted in 34%. A concomitant atrial septal aneurysm was present in 61%.

RESULTS

At 6 months follow-up, a residual shunt was detected in 26 patients (19%). Residual shunts were more common in patients with an atrial septal aneurysm (27 vs. 8%, P= .01) and in patients treated with a 35-mm compared with a 25-mm device (39 vs. 15%, P= .01). A concomitant atrial septal aneurysm remained independently associated with residual shunts when controlled for body mass index, gender, age, atrial dimensions, and presence of a Chiari network (odds ratio 4.1, 95% confidence intervals 1.1-15.0).

CONCLUSION

The presence of atrial septal aneurysms in patients undergoing percutaneous PFO closure with an Amplatzer PFO occluder significantly increases the rate of residual shunts at 6 months follow-up, even if 35-mm devices are used.

Pulmonary function changes in children after transcatheter closure of atrial septal defect

This study was performed to assess changes in pulmonary function test (PFT) and pulmonary outcome after transcatheter closure of atrial septal defect (ASD) in pediatric patients. A total 55 pediatric patients undergoing transcatheter ASD closure received PFT at baseline (day before ASD closure), and at 3 days and 6 months after procedure. Forced vital capacity (FVC), forced expired volume in 1 sec (FEV(1)), FEV(1) to FVC ratio (FEV(1)/FVC), peak expiratory flow (PEF), and mean forced expiratory flow during the middle half of FVC (FEF(25-75)) were measured. Individually, subjects were classified by spirometry as normal, obstructive or restrictive, to evaluate the effect of transcatheter closure on pulmonary outcome. These 55 children had significantly reduced mean PEF and FEF(25-75) (84 +/- 24%, P = 0.040 and 76 +/- 22%, P = 0.010, respectively) at baseline, with FEF(25-75) reduced significantly at 3 days and 6 months (78 +/- 24%, P = 0.010 and 81 +/- 24%, P = 0.040, respectively) after transcatheter closure. Six months after transcatheter closure of ASD, significant improvement was observed in mean FVC (94 +/- 19% vs. 98 +/- 15%, P = 0.034) and FEV(1) (90 +/- 20% vs. 96 +/- 19%, P = 0.008). Assessed individually, better pulmonary outcome was found in patients without pulmonary hypertension (PH) (chi(2) = 8.333, P = 0.044). PFT disturbance was observed in significant flow limitation in the peripheral airway of ASD patients. Improved PFT was found after transcatheter closure and better pulmonary outcome was observed in patients without PH. ASD children need monitoring pulmonary function and should receive transcatheter closure before PH develops.

Percutaneous closure of patent foramen ovale and atrial septal defect in adults: the impact of clinical variables and hospital procedure volume on in-hospital adverse events

BACKGROUND

Percutaneous closure of patent foramen ovale/atrial septal defect (PFO/ASD) is an increasingly common procedure perceived as having minimal risk. There are no population-based estimates of in-hospital adverse event rates of percutaneous PFO/ASD closure.

METHODS

We used nationally representative data from the 2001-2005 Nationwide Inpatient Sample to identify patients >or-=20 years old admitted to an acute care hospital with an International Classification of Diseases, Ninth Revision code designating percutaneous PFO/ASD closure on the first or second hospital day. Variables analyzed included age, sex, number of comorbidities, year, same-day use of intracardiac or other echocardiography, same-day left heart catheterization, hospital size and teaching status, PFO/ASD procedural volume, and coronary intervention volume. Outcomes of interest included length of stay, charges, and adverse events.

RESULTS

The study included 2,555 (weighted to United States population: 12,544 +/- 1,987) PFO/ASD closure procedures. Mean age was 52.0 +/- 0.4 years, and 57.3% +/- 1.0% were women. Annual hospital volume averaged 40.8 +/- 7.7 procedures (range, 1-114). Overall, 8.2 +/- 0.8% of admissions involved an adverse event. Older patients and those with comorbidities were more likely to sustain adverse events. Use of intracardiac echocardiography was associated with fewer adverse events. The risk of adverse events was inversely proportional to annual hospital volume (odds ratio [OR] 0.91, 95% confidence interval [CI] 0.86-0.96, per 10 procedures), even after limiting the analysis to hospitals performing >or=10 procedures annually (OR 0.91, 95% CI 0.85-0.98). Adverse events were more frequent at hospitals in the lowest volume quintile as compared with the highest volume quintile (13.3% vs 5.4%, OR 2.42, 95% CI 1.55-3.78).

CONCLUSIONS

The risk of adverse events of percutaneous PFO/ASD closure is inversely correlated with hospital volume. This relationship applies even to hospitals meeting the current guidelines, performing >or=10 procedures annually.

Right-to-left shunt, atrial septal aneurysm and thrombophilia in patients with cryptogenic stroke or TIA vs. those with venous thrombo-embolism

Whether intracardiac right-to-left shunt (RLS) is an independent risk factor for cerebrovascular accidents is disputed. In patients with RLS, venous thrombo-embolism (VTE) may predispose to paradoxical embolic events, among which stroke and transient ischemic attack (TIA). Whether genetic or acquired thrombophilia is associated with RLS is unclear. Thus, we compared prevalences of intra- and extracardiac intrapulmonary RLS and of atrial septal aneurysm (ASA) between 29 nondiabetic patients with cryptogenic stroke (n=17) or TIA (n=12) and 19 patients with VTE but without history of stroke/TIA, or autoimmune systemic disease or migraine. Carotid atherosclerosis was excluded in all patients. RLS and ASA were also evaluated in 30 healthy volunteers. We found that intracardiac RLS (31%) and ASA (21%) were detected in stroke/TIA patients and not in our selected VTE patients (both p<0.05); however, those prevalences were comparable to those detected in our controls (20% intracardiac RLS, 7% ASA, respectively, both p=NS). Within patients, thrombophilia was not associated with intracardiac RLS, but tended to be associated with ASA (83% in those with vs. 43% in those without ASA, p=0.08). In conclusions, intracardiac RLS may have a role in selected populations in the frame the multi-factorial pathogenesis of stroke/TIA of embolic origin. ASA appears to be an independent risk factor for stroke/TIA with possible interaction with thrombophilia.

Complications and mid-term outcome after percutaneous patent foramen ovale closure in patients with cryptogenic stroke

BACKGROUND

Percutaneous patent foramen ovale (PFO) closure seems to reduce the risk of recurrent thromboembolism. We report the safety and efficacy of percutaneous PFO closure in our centre.

METHODS

All patients, >16 years of age, who underwent a percutaneous PFO closure in our centre were included. Reoccurrence of stroke, transient ischaemic attack (TIA) and peripheral thromboembolism were assessed. Periprocedural and midterm complications are reported.

RESULTS

Eighty-three consecutive patients (mean age 49+/-13 years) were included. Indications for PFO closure were cryptogenic stroke (59.0%), TIA (33.7%), peripheral embolism (2.4%) and other (4.8%). For PFO closure, a Cardioseal/Starflex device was used in 63 patients and an Amplatzer PFO occluder device in 20 patients. Stroke recurred in 1.2%, TIA in 3.6%, peripheral embolism in 0% during a mean follow-up of 1.9+/-1.2 years. Major periprocedural complications occurred in 1.2%. The mid-term complication rate was 2.4% and only consisted of minor complications. During follow-up, a residual right-to-left shunt was present in 5.7% of the patients. No significant difference in outcome, complications or residual shunting could be documented between the two device types.

CONCLUSION

In our centre, the percutaneous closure of a PFO seems to be a safe and effective procedure to prevent recurrence of paradoxical thrombo-embolic events. (Neth Heart J 2008;16:332-6.).

Cryptogenic stroke in a patient with a PFO: a decision analysis

BACKGROUND

Octogenarian Israeli prime-minister Ariel Sharon recently sustained a mild, reversible stroke. A patent foramen ovale (PFO) was detected and anticoagulants were given pending PFO closure. A few days later, he sustained major intracerebral hemorrhage and has since remained in vegetative state. The events triggered serious criticism in the mass media, experts promoting one management option over others. Because knowledge of outcome and hindsight bias evaluation of appropriateness of care, we sought to systematically review the clinical case.

METHODS

We performed a formal decision analysis to identify the preferred management between anticoagulation, antiplatelets, PFO closure, or no treatment. Using the best evidence available, we built a decision tree.

MAIN OUTCOMES

recurrent stroke and treatment complications within 1 year.

RESULTS

Optimal decision was found to be critically sensitive to assumptions about etiology, efficacy and safety of treatments, recurrence risk, and to small changes in utilities. In multiway sensitivity analysis, when the risk of recurrent stroke was <0.12 per year, no treatment was the best management. PFO closure is dominant only when the risk of recurrent stroke is >0.12 per year closure effectiveness is assumed to be <0.28. When closure effectiveness is >0.6, it is inferior to anticoagulation and antiplatelet management.

CONCLUSIONS

Uncertainties precluded a clear-cut answer and choice was found to be a "toss-up," often associated with much controversy. Use of novel therapies, such as PFO closure, outside clinical trials will not reduce uncertainty about efficacy.

Cryptogenic stroke: time to determine aetiology

Strokes that remain without a definite cause even after extensive work-up are classified as cryptogenic. These constitute about 30-40% of all strokes. Stroke aetiology may remain undetermined for the following reasons: (i) the cause of stroke is transitory or reversible and the diagnostic work-out is not therefore performed at the appropriate time; (ii) all known causes of stroke are not fully investigated; (iii) some causes of stroke remain unknown. Recent studies have challenged the previous view that cryptogenic stroke is a relatively benign cerebrovascular event, and have shown that cryptogenic stroke is associated with a higher rate of recurrence and adverse outcome at long-term follow-up. The determination of stroke aetiology is a valuable procedure to avoid the risk of stroke recurrence, especially in young patients. In this review, we discuss new evidence on the aetiology of cryptogenic stroke, specifically focusing on patients with patent foramen ovale and atheroma of the aortic arch.