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Lin TY, Fu YC, Jan SL, Lin MC. Detecting Patent Foramen Ovale after Cryptogenic Stroke - A Single Center Experience in Taiwan. Acta Cardiol Sin 2022; 38:373-380. [PMID: 35673343 PMCID: PMC9121751 DOI: 10.6515/acs.202205_38(3).20211228a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 12/28/2021] [Indexed: 01/24/2023]
Abstract
BACKGROUND Cryptogenic strokes related to a patent foramen ovale (PFO) in young patients have been reported. Percutaneous transcatheter occlusion is considered a safe and effective method for achieving PFO closure. Here, we present our experience of PFO closure in a series of young patients diagnosed with cryptogenic stroke. METHODS This was a retrospective study of 62 patients who were younger than 60 years of age and previously diagnosed with cryptogenic stroke. They underwent cardiac catheterization for the diagnosis of PFO and/or device closure. Bubble and echocardiography studies, the patients' characteristics, complications, and recurrence of stroke were recorded. The Risk of Paradoxical Embolism (RoPE) score index was also calculated. RESULTS Patients with a bubble study grade greater than grade I were likely to have PFO (odds ratio: 22.2 [95% confidence interval: 1.2-412.3]). The mean RoPE score in the PFO closure group was 7.18. Two patients (3.9%) developed atrial fibrillation during the procedure. Ischemic stroke recurred in two patients (3.3%). CONCLUSIONS Combining a bubble study with transcranial Doppler ultrasound or transthoracic echocardiography may increase the validity of PFO diagnosis. Because of the low recurrence rate of stroke and low complication rate, it is important to identify PFO patients with a bubble study grade greater than grade I. Closure of PFO may be a good strategy for preventing recurrent stroke among such patients.
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Affiliation(s)
- Ting-Yu Lin
- Children’s Medical Center, Taichung Veterans General Hospital
| | - Yun-Ching Fu
- Children’s Medical Center, Taichung Veterans General Hospital
| | - Sheng-Ling Jan
- Children’s Medical Center, Taichung Veterans General Hospital;
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Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University
| | - Ming-Chih Lin
- Children’s Medical Center, Taichung Veterans General Hospital;
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Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University;
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Department of Food and Nutrition, Providence University;
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School of Medicine, Chung Shan Medical University, Taichung, Taiwan
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2
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Cho K, Kempton H, Roy D. Cardiac Platypnoea-Orthodeoxia Syndrome - Supine and Upright Transoesophageal Echocardiography. Heart Lung Circ 2021; 30:e88-e90. [PMID: 33642172 DOI: 10.1016/j.hlc.2021.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 10/12/2020] [Accepted: 01/22/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Kenneth Cho
- Department of Cardiology, St Vincent's Hospital, Sydney, NSW, Australia; University of New South Wales, Sydney, NSW, Australia; Western Sydney University, Sydney, NSW, Australia
| | - Hannah Kempton
- Department of Cardiology, St Vincent's Hospital, Sydney, NSW, Australia; University of New South Wales, Sydney, NSW, Australia
| | - David Roy
- Department of Cardiology, St Vincent's Hospital, Sydney, NSW, Australia; University of New South Wales, Sydney, NSW, Australia; University of Notre Dame, Sydney, NSW, Australia.
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3
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Leitman M, Blondheim DS, Sabetay S, Tyomkin V. Diagnosis of patent foramen ovale using maximum intensity T-projection imaging. Int J Cardiovasc Imaging 2021; 37:1343-1348. [PMID: 33394216 DOI: 10.1007/s10554-020-02123-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 11/24/2020] [Indexed: 11/29/2022]
Abstract
Accurate diagnosis of patent foramen ovale (PFO) and grading of right-to-left shunt severity by the standard method of transthoracic or transesophageal echocardiography (TEE) with bubble injection is often challenging. We proposed the novel Maximum Intensity T-Projection (MIP) Imaging method as a complementary or alternative approach for simplified diagnosis and grading of PFO. MIP Imaging represents the superimposition of all frames of an echocardiographic video onto one image. Thus, all bubbles passing from right to left atrium are represented in this single image. Diagnosis and quantification of PFO by MIP Images were compared to those obtained by standard echocardiographic methods, using the same echocardiography video loops. We applied the MIP Imaging approach to 122 echo examinations (75% of them TEE studies), performed to rule out PFOs. The average time needed to manually analyze video loops taken during bubble injection was 102 ± 52 s vs. less than 1 s using the MIP Imaging method. There was good concordance between the conventional echo method and MIP Imaging in the diagnosis and quantification of PFOs. MIP Imaging for diagnosis and quantification of PFOs was much less time consuming than the classical method and at least as accurate as the classical method. Thus MIP Imaging may be used initially as an adjunct method for PFO diagnosis and quantification and may eventually replace the classical method.
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Affiliation(s)
- Marina Leitman
- Department of Cardiology, Shamir Medical Center, Zerifin, and Sackler School of Medicine Tel-Aviv University, Tel-Aviv, Israel.
| | - David S Blondheim
- Department of Cardiology, Hillel Yaffe Medical Center, Hadera, affiliated with the Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Sergiu Sabetay
- Department of Neurology, Hillel Yaffe Medical Center, Hadera, affiliated with the Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Vladimir Tyomkin
- Department of Cardiology, Shamir Medical Center, Zerifin, Israel
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Bernard S, Churchill TW, Namasivayam M, Bertrand PB. Agitated Saline Contrast Echocardiography in the Identification of Intra- and Extracardiac Shunts: Connecting the Dots. J Am Soc Echocardiogr 2020; 34:S0894-7317(20)30615-5. [PMID: 34756394 DOI: 10.1016/j.echo.2020.09.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 09/01/2020] [Accepted: 09/05/2020] [Indexed: 02/08/2023]
Abstract
Agitated saline contrast studies are an essential component of contemporary echocardiography. Agitated saline contrast plays a critical role in the elucidation of intracardiac versus intrapulmonary shunting and can have major therapeutic implications, particularly in light of the evolution of percutaneous treatment options for atrial septal defects or a patent foramen ovale. Despite their perceived simplicity, however, there are numerous pitfalls of these investigations that can occur during their performance and interpretation. As such, the authors review the "bubble study" in identifying intracardiac and extracardiac shunts, including the history of its development, the physics and physiology of contrast enhancement, how to optimally perform and interpret an agitated saline contrast study, and its safety in unique populations.
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Affiliation(s)
- Samuel Bernard
- Cardiac Ultrasound Laboratory, Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
| | - Timothy W Churchill
- Cardiac Ultrasound Laboratory, Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Mayooran Namasivayam
- Cardiac Ultrasound Laboratory, Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Philippe B Bertrand
- Cardiac Ultrasound Laboratory, Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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Maggiore P, Bellinge J, Chieng D, White D, Lan NSR, Jaltotage B, Ali U, Gordon M, Chung K, Stobie P, Ng J, Hankey GJ, McQuillan B. Ischaemic Stroke and the Echocardiographic " Bubble Study": Are We Screening the Right Patients? Heart Lung Circ 2018; 28:1183-1189. [PMID: 30131285 DOI: 10.1016/j.hlc.2018.07.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 05/08/2018] [Accepted: 07/18/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Patent foramen ovale (PFO) is a potential mechanism for paradoxical embolism in cryptogenic ischaemic stroke or transient ischaemic attack (TIA). PFO is typically demonstrated with agitated saline ("bubble study", BS) during echocardiography. We hypothesised that the BS is frequently requested in patients that have a readily identifiable cause of stroke, that any PFO detected is likely incidental, and its detection often does not alter management. METHODS This was a retrospective observational study of patients with recent ischaemic stroke/TIA referred for a BS. Patient demographics, stroke risk factors, vascular/cerebral imaging results and transoesophageal echocardiogram (TOE) reports were recorded. A "modified" Risk of Paradoxical Embolism (RoPE) score was calculated. Change in management was defined as antiplatelet/anticoagulant therapy alteration or referral for PFO closure. Bubble Study complications were recorded. RESULTS Among 715 patients with ischaemic stroke/TIA referred for a BS, 8.7% had atrial fibrillation and 9.2% had carotid stenosis ≥70%. At least three stroke risk factors were present in 39.3% and only 47.1% of patients screened had a "modified" RoPE score of >5. A PFO was detected in 248 patients of whom only 31% (77/248) had a subsequent change in management. Of BS performed, 1/924 patients (0.1%) suffered a TIA as a complication. CONCLUSIONS The echocardiographic BS is frequently performed in patients that have a readily identifiable cause of stroke and whose PFO unlikely relates to the stroke/TIA. Bubble Study findings resulted in a change in management in the minority. The procedure is safe but the complication rate warrants informed consent.
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Affiliation(s)
- Paul Maggiore
- Department of Cardiology, Sir Charles Gairdner Hospital, Perth, WA, Australia.
| | - Jamie Bellinge
- Department of Cardiology, Royal Perth Hospital, Perth, WA, Australia
| | - David Chieng
- Department of Cardiology, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - David White
- Department of Cardiology, Royal Perth Hospital, Perth, WA, Australia
| | - Nick S R Lan
- Department of Cardiology, Fiona Stanley Hospital, Perth, WA, Australia
| | - Biyanka Jaltotage
- Department of Cardiology, Fiona Stanley Hospital, Perth, WA, Australia
| | - Umar Ali
- Department of Cardiology, Fiona Stanley Hospital, Perth, WA, Australia
| | - Madeleine Gordon
- Department of Cardiology, Fiona Stanley Hospital, Perth, WA, Australia
| | - Kevin Chung
- Department of Cardiology, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Paul Stobie
- Department of Cardiology, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Justin Ng
- Department of Cardiology, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Graeme J Hankey
- Department of Neurology, Sir Charles Gairdner Hospital, Perth, WA, Australia; University of Western Australia School of Medicine, WA, Australia
| | - Brendan McQuillan
- Department of Cardiology, Sir Charles Gairdner Hospital, Perth, WA, Australia; University of Western Australia School of Medicine, WA, Australia
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Mohammad Nijres B, Kenny D, Kazmouz S, Hijazi ZM. Transcatheter closure of unroofed coronary sinus using covered stents in an adult with drainage of the coronary sinus to the right ventricle after supra-annular tricuspid valve replacement. Catheter Cardiovasc Interv 2017; 90:1154-1157. [PMID: 28296217 DOI: 10.1002/ccd.26996] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 01/25/2017] [Accepted: 01/28/2017] [Indexed: 11/08/2022]
Abstract
We present a rare case of unroofed coronary sinus in a patient who underwent supra-annular tricuspid valve replacement with consequent drainage of the coronary sinus to the right ventricle. It is unclear whether the coronary sinus was unroofed congenitally or iatrogenically. This rare setup resulted in significant cyanosis. The abnormal drainage was successfully closed via trans-catheter delivery of covered stents with resolution of the cyanosis. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- Bassel Mohammad Nijres
- Rush Center for Congenital and Structural Heart Disease, Rush University Children's Hospital, Chicago, Illinois
| | - Damien Kenny
- Department of Cardiology and Cardiac Surgery, Our Lady's Children's Hospital, Dublin, Ireland
| | - Suhaib Kazmouz
- Department of Pediatric cardiology, Rockford Memorial Hospital, Rockford, Illinois
| | - Ziyad M Hijazi
- Weill Cornell Medicine & Sidra Medical and Research Center, Doha, Qatar
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Mahmoud AN, Elgendy IY, Agarwal N, Tobis JM, Mojadidi MK. Identification and Quantification of Patent Foramen Ovale-Mediated Shunts: Echocardiography and Transcranial Doppler. Interv Cardiol Clin 2017; 6:495-504. [PMID: 28886841 DOI: 10.1016/j.iccl.2017.05.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Once deemed benign, patent foramen ovale (PFO)-mediated right-to-left shunting has now been linked to stroke, migraine, and hypoxemia. Contrast transesophageal echocardiography is considered the standard technique for identifying a PFO, allowing visualization of the atrial septal anatomy and differentiation from non-PFO right-to-left shunts. Transthoracic echocardiography is the most common method for PFO imaging, being cost-effective, but has the lowest sensitivity. Transcranial Doppler is highly sensitive but is unable to differentiate cardiac from pulmonary shunts; it is the best method to quantitate shunt severity, being more sensitive than transthoracic or transesophageal echocardiography so is our preferred screening method for PFO.
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Affiliation(s)
- Ahmed N Mahmoud
- Division of Cardiology, Department of Medicine, University of Florida, 1600 Southwest Archer Road, Gainesville, FL 32608, USA
| | - Islam Y Elgendy
- Division of Cardiology, Department of Medicine, University of Florida, 1600 Southwest Archer Road, Gainesville, FL 32608, USA
| | - Nayan Agarwal
- Division of Cardiology, Department of Medicine, University of Florida, 1600 Southwest Archer Road, Gainesville, FL 32608, USA
| | - Jonathan M Tobis
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, Factor Building CHS, Room B-976, Los Angeles, CA 90095, USA
| | - Mohammad Khalid Mojadidi
- Division of Cardiology, Department of Medicine, University of Florida, 1600 Southwest Archer Road, Gainesville, FL 32608, USA.
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