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Gurol ME, Fisher M. Roundtable of Academia and Industry in Stroke Prevention. Stroke 2024; 55:203-204. [PMID: 38134257 DOI: 10.1161/strokeaha.123.043698] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 11/10/2023] [Indexed: 12/24/2023]
Affiliation(s)
- M Edip Gurol
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (M.E.G.)
| | - Marc Fisher
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA (M.F)
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2
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Sitbon S, Ou P, Nguyen C, Ehmer C, Garbarz E, Brochet E, Fuchs A, Aubry P, Abtan J. Four-Dimensional Flow Magnetic Resonance Imaging Features of a Platypnea-Orthodeoxia Syndrome Caused by a Patent Foramen Ovale. Circ Cardiovasc Imaging 2023:e014722. [PMID: 37092323 DOI: 10.1161/circimaging.122.014722] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Affiliation(s)
- Samuel Sitbon
- Département de Cardiologie, Hôpital Bichat, AP-HP (Assistance Publique - Hôpitaux de Paris), Université de Paris, France (S.S., C.N., E.G., E.B., A.F., P.A., J.A.)
| | - Phalla Ou
- Département de Radiologie, Hôpital Bichat, AP-HP (Assistance Publique - Hôpitaux de Paris), Université de Paris, France (P.O., C.E.)
| | - Caroline Nguyen
- Département de Cardiologie, Hôpital Bichat, AP-HP (Assistance Publique - Hôpitaux de Paris), Université de Paris, France (S.S., C.N., E.G., E.B., A.F., P.A., J.A.)
| | - Carsten Ehmer
- Département de Radiologie, Hôpital Bichat, AP-HP (Assistance Publique - Hôpitaux de Paris), Université de Paris, France (P.O., C.E.)
| | - Eric Garbarz
- Département de Cardiologie, Hôpital Bichat, AP-HP (Assistance Publique - Hôpitaux de Paris), Université de Paris, France (S.S., C.N., E.G., E.B., A.F., P.A., J.A.)
| | - Eric Brochet
- Département de Cardiologie, Hôpital Bichat, AP-HP (Assistance Publique - Hôpitaux de Paris), Université de Paris, France (S.S., C.N., E.G., E.B., A.F., P.A., J.A.)
| | - Adeline Fuchs
- Département de Cardiologie, Hôpital Bichat, AP-HP (Assistance Publique - Hôpitaux de Paris), Université de Paris, France (S.S., C.N., E.G., E.B., A.F., P.A., J.A.)
| | - Pierre Aubry
- Département de Cardiologie, Hôpital Bichat, AP-HP (Assistance Publique - Hôpitaux de Paris), Université de Paris, France (S.S., C.N., E.G., E.B., A.F., P.A., J.A.)
| | - Jeremie Abtan
- Département de Cardiologie, Hôpital Bichat, AP-HP (Assistance Publique - Hôpitaux de Paris), Université de Paris, France (S.S., C.N., E.G., E.B., A.F., P.A., J.A.)
- FACT (French Alliance for Cardiovascular Clinical Trials), an F-CRIN network, Paris, France (J.A.)
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3
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Alperi A, Guedeney P, Horlick E, Nombela-Franco L, Freixa X, Pascual I, Mesnier J, Houde C, Abrahamyan L, Montalescot G, Rodés-Cabau J. Transcatheter Closure of Patent Foramen Ovale in Older Patients With Cryptogenic Thromboembolic Events. Circ Cardiovasc Interv 2022; 15:e011652. [PMID: 35735021 DOI: 10.1161/circinterventions.121.011652] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [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] [Indexed: 12/24/2022]
Abstract
BACKGROUND The main randomized trials evaluating patent foramen ovale (PFO) closure after a presumed PFO-associated stroke excluded patients older than 60 years. We aimed to evaluate the early- and long-term clinical outcomes of transcatheter PFO closure in older (>60 years) patients with a cryptogenic ischemic event. METHODS This is a multicenter study including consecutive patients older than 60 years (mean age, 67±5 years) who had a PFO closure following a presumed PFO-related ischemic event. Patients ≤60 years old (mean age, 44±10 years) served as the control group. The primary end point was the occurrence of stroke, transient ischemic attack, or peripheral embolism over the follow-up period. New-onset atrial fibrillation was a secondary end point. RESULTS A total of 388 and 883 patients >60 and ≤60 years old were included, respectively. Procedural success rate was high (99.9%), and procedural-related complications low (<2%) in both groups. After a median follow-up of 3 (1-8) years, older patients exhibited an incidence of stroke/transient ischemic attack/peripheral embolism of 1.6 events per 100 patient-years (stroke: 0.6 events per 100 patient-years), lower than that expected according to the risk of paradoxical embolism score (observed-to-expected ratio, 0.31 [95% CI, 0.11-0.91]). However, the event rate in older patients was higher than that observed in their younger counterparts (incidence rate ratio, 4.7 [95% CI, 2.36-9.8]). De novo atrial fibrillation after the procedure was more frequent in older patients (2.66 per 100 patient-years versus 0.49 per 100 patient-years, P<0.001). CONCLUSIONS In patients older than 60 years with a presumed PFO-related ischemic event, PFO closure was safe and associated with a relatively low incidence of recurrent ischemic events after a median follow-up of 3 years compared with historical cohorts of patients who did not undergo PFO closure. However, a higher risk of recurrent cerebrovascular events was observed in older patients compared to their younger counterparts. Randomized trials are warranted in this population.
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Affiliation(s)
- Alberto Alperi
- Quebec Heart and Lung Institute, Laval University, Quebec City, Canada (A.A., J.M., J.R.-C.).,Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain (A.A., I.P.)
| | - Paul Guedeney
- Institut de Cardiologie, Groupe Hospitalier Pitié-Salpetrière, Paris, France (P.G., G.M.)
| | - Eric Horlick
- Department of Cardiology, Toronto General Hospital, University of Toronto, Canada (E.H., L.A.)
| | - Luis Nombela-Franco
- Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (L.N.-F.)
| | - Xavier Freixa
- Institut Clínic Cardiovascular, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain (X.F., J.R.-C.)
| | - Isaac Pascual
- Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain (A.A., I.P.)
| | - Jules Mesnier
- Quebec Heart and Lung Institute, Laval University, Quebec City, Canada (A.A., J.M., J.R.-C.)
| | - Christine Houde
- Centre Hospitalier Universitaire de Quebec, Quebec City' Canada (C.H., J.R.-C.)
| | - Lusine Abrahamyan
- Department of Cardiology, Toronto General Hospital, University of Toronto, Canada (E.H., L.A.)
| | - Gilles Montalescot
- Institut de Cardiologie, Groupe Hospitalier Pitié-Salpetrière, Paris, France (P.G., G.M.)
| | - Josep Rodés-Cabau
- Quebec Heart and Lung Institute, Laval University, Quebec City, Canada (A.A., J.M., J.R.-C.).,Institut Clínic Cardiovascular, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain (X.F., J.R.-C.).,Centre Hospitalier Universitaire de Quebec, Quebec City' Canada (C.H., J.R.-C.)
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4
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Abstract
The past decade has seen significant advances in stroke prevention. These advances include new antithrombotic agents, new options for dyslipidemia treatment, and novel techniques for surgical stroke prevention. In addition, there is greater recognition of the benefits of multifaceted interventions, including the role of physical activity and dietary modification. Despite these advances, the aging of the population and the high prevalence of key vascular risk factors pose challenges to reducing the burden of stroke. Using a cause-based framework, current approaches to prevention of cardioembolic, cryptogenic, atherosclerotic, and small vessel disease stroke are outlined in this paper. Special emphasis is given to recent trials of antithrombotic agents, including studies that have tested combination treatments and responses according to genetic factors.
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Affiliation(s)
| | | | - Charlotte Cordonnier
- Univ. Lille, Inserm, CHU Lille, U1172 - LilNCog - Lille Neuroscience & Cognition, F-59000 Lille, France
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5
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Calabrò P, Gragnano F, Niccoli G, Marcucci R, Zimarino M, Spaccarotella C, Renda G, Patti G, Andò G, Moscarella E, Mancone M, Cesaro A, Giustino G, De Caterina R, Mehran R, Capodanno D, Valgimigli M, Windecker S, Dangas GD, Indolfi C, Angiolillo DJ. Antithrombotic Therapy in Patients Undergoing Transcatheter Interventions for Structural Heart Disease. Circulation 2021; 144:1323-1343. [PMID: 34662163 DOI: 10.1161/circulationaha.121.054305] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [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] [Indexed: 12/12/2022]
Abstract
Contemporary evidence supports device-based transcatheter interventions for the management of patients with structural heart disease. These procedures, which include aortic valve implantation, mitral or tricuspid valve repair/implantation, left atrial appendage occlusion, and patent foramen ovale closure, profoundly differ with respect to clinical indications and procedural aspects. Yet, patients undergoing transcatheter cardiac interventions require antithrombotic therapy before, during, or after the procedure to prevent thromboembolic events. However, these therapies are associated with an increased risk of bleeding complications. To date, challenges and controversies exist regarding balancing the risk of thrombotic and bleeding complications in these patients such that the optimal antithrombotic regimens to adopt in each specific procedure is still unclear. In this review, we summarize current evidence on antithrombotic therapies for device-based transcatheter interventions targeting structural heart disease and emphasize the importance of a tailored approach in these patients.
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Affiliation(s)
- Paolo Calabrò
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli," Naples, Italy (P.C., F.G., E.M., A.C.).,Division of Cardiology, A.O.R.N. "Sant'Anna e San Sebastiano," Caserta, Italy (P.C., F.G., E.M., A.C.)
| | - Felice Gragnano
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli," Naples, Italy (P.C., F.G., E.M., A.C.).,Division of Cardiology, A.O.R.N. "Sant'Anna e San Sebastiano," Caserta, Italy (P.C., F.G., E.M., A.C.)
| | - Giampaolo Niccoli
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy (G.N.).,Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy (G.N.).,Department of Medicine, University of Parma, Italy (G.N.)
| | - Rossella Marcucci
- Department of Experimental and Clinical Medicine, University of Florence, Italy (R. Marcucci.)
| | - Marco Zimarino
- Institute of Cardiology, University "G. D'Annuzio" of Chieti-Pescara, Italy (M.Z., G.R)
| | - Carmen Spaccarotella
- Department of Medical and Surgical Sciences, Magna Grecia University, Catanzaro, Italy (C.S., C.I.)
| | - Giulia Renda
- Institute of Cardiology, University "G. D'Annuzio" of Chieti-Pescara, Italy (M.Z., G.R)
| | - Giuseppe Patti
- Department of Translational Medicine, "Maggiore della Carità" Hospital, University of Eastern Piedmont, Via Solaroli, Novara, Italy (G.P.)
| | - Giuseppe Andò
- Unit of Cardiology, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy (G.A.)
| | - Elisabetta Moscarella
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli," Naples, Italy (P.C., F.G., E.M., A.C.).,Division of Cardiology, A.O.R.N. "Sant'Anna e San Sebastiano," Caserta, Italy (P.C., F.G., E.M., A.C.)
| | - Massimo Mancone
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Italy (M.M.)
| | - Arturo Cesaro
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli," Naples, Italy (P.C., F.G., E.M., A.C.).,Division of Cardiology, A.O.R.N. "Sant'Anna e San Sebastiano," Caserta, Italy (P.C., F.G., E.M., A.C.)
| | - Gennaro Giustino
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (G.G., R. Mehran., G.D.D.)
| | - Raffaele De Caterina
- University Cardiology Division, University of Pisa, Pisa University Hospital, Italy; Fondazione Villa Serena per la Ricerca, Città Sant'Angelo, Italy (R.D.C.)
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (G.G., R. Mehran., G.D.D.)
| | - Davide Capodanno
- Cardio-Thoracic-Vascular Department, Centro Alte Specialità e Trapianti, Catania, Italy (D.C.).,Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Italy (D.C.)
| | - Marco Valgimigli
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano, Switzerland (M.V.).,Department of Cardiology, Bern University Hospital, University of Bern, Switzerland (M.V., S.W.)
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, University of Bern, Switzerland (M.V., S.W.)
| | - George D Dangas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (G.G., R. Mehran., G.D.D.)
| | - Ciro Indolfi
- Department of Medical and Surgical Sciences, Magna Grecia University, Catanzaro, Italy (C.S., C.I.).,Mediterranea Cardiocentro, Naples, Italy (C.I.)
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville (D.J.A.)
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6
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Thomalla G, Upneja M, Camen S, Jensen M, Schröder J, Barow E, Boskamp S, Ostermeier B, Kissling S, Leinisch E, Tiburtius C, Clausen H, Cheng B, Blankenberg S, Nedelmann M, Steinbrecher A, Andres F, Rosenkranz M, Sinning C, Schnabel RB, Gerloff C. Treatment-Relevant Findings in Transesophageal Echocardiography After Stroke: A Prospective Multicenter Cohort Study. Stroke 2021; 53:177-184. [PMID: 34496617 DOI: 10.1161/strokeaha.121.034868] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [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: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Cardiac ultrasound to identify sources of cardioembolism is part of the diagnostic workup of acute ischemic stroke. Recommendations on whether transesophageal echocardiography (TEE) should be performed in addition to transthoracic echocardiography (TTE) are controversial. We aimed to determine the incremental diagnostic yield of TEE in addition to TTE in patients with acute ischemic stroke with undetermined cause. METHODS In a prospective, observational, pragmatic multicenter cohort study, patients with acute ischemic stroke or transient ischemic attack with undetermined cause before cardiac ultrasound were studied by TTE and TEE. The primary outcome was the rate of treatment-relevant findings in TTE and TEE as defined by a panel of experts based on current evidence. Further outcomes included the rate of changes in the assessment of stroke cause after TEE. RESULTS Between July 1, 2017, and June 30, 2019, we enrolled 494 patients, of whom 492 (99.6%) received TTE and 454 (91.9%) received TEE. Mean age was 64.7 years, and 204 (41.3%) were women. TEE showed a higher rate of treatment-relevant findings than TTE (86 [18.9%] versus 64 [14.1%], P<0.001). TEE in addition to TTE resulted in 29 (6.4%) additional patients with treatment-relevant findings. Among 191 patients ≤60 years additional treatment-relevant findings by TEE were observed in 27 (14.1%) patients. Classification of stroke cause changed after TEE in 52 of 453 patients (11.5%), resulting in a significant difference in the distribution of stroke cause before and after TEE (P<0.001). CONCLUSIONS In patients with undetermined cause of stroke, TEE yielded a higher number of treatment-relevant findings than TTE. TEE appears especially useful in younger patients with stroke, with treatment-relevant findings in one out of seven patients ≤60 years. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03411642.
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Affiliation(s)
- Götz Thomalla
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Germany (G.T., M.U., M.J., J.S., E.B., B.C., C.G.)
| | - Mira Upneja
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Germany (G.T., M.U., M.J., J.S., E.B., B.C., C.G.)
| | - Stephan Camen
- Klinik für Kardiologie, Universitäres Herz- und Gefäßzentrum, Hamburg, Germany (S.C., S.B., C.S., R.B.S.).,DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Germany (S.C., M.J., S.B., C.S., R.B.S.)
| | - Märit Jensen
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Germany (G.T., M.U., M.J., J.S., E.B., B.C., C.G.).,DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Germany (S.C., M.J., S.B., C.S., R.B.S.)
| | - Julian Schröder
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Germany (G.T., M.U., M.J., J.S., E.B., B.C., C.G.)
| | - Ewgenia Barow
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Germany (G.T., M.U., M.J., J.S., E.B., B.C., C.G.)
| | - Stefan Boskamp
- Klinik für Kardiologie, Universitäres Herz- und Gefäßzentrum, Hamburg, Germany (S.C., S.B., C.S., R.B.S.).,DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Germany (S.C., M.J., S.B., C.S., R.B.S.)
| | | | - Sandra Kissling
- Klinik für Neurologie, Kreiskliniken Reutlingen, Germany. (S.K., F.A.)
| | - Elke Leinisch
- Klinik für Neurologie, Helios Klinikum Erfurt, Germany (E.L., A.S.)
| | - Claudia Tiburtius
- Klinik für Kardiologie, Albertinen Krankenhaus, Hamburg, Germany (C.T.)
| | - Henning Clausen
- Klinik für Neurologie, Regio Kliniken Pinneberg, Germany (H.C., M.N.)
| | - Bastian Cheng
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Germany (G.T., M.U., M.J., J.S., E.B., B.C., C.G.)
| | - Stefan Blankenberg
- DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Germany (S.C., M.J., S.B., C.S., R.B.S.).,Klinik für Neurologie und Neurologische Frührehabilitation, Albertinen Krankenhaus, Hamburg, Germany (S.B., M.R.)
| | - Max Nedelmann
- Klinik für Neurologie, Regio Kliniken Pinneberg, Germany (H.C., M.N.)
| | | | - Frank Andres
- Klinik für Neurologie, Kreiskliniken Reutlingen, Germany. (S.K., F.A.)
| | - Michael Rosenkranz
- DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Germany (S.C., M.J., S.B., C.S., R.B.S.).,Klinik für Neurologie und Neurologische Frührehabilitation, Albertinen Krankenhaus, Hamburg, Germany (S.B., M.R.)
| | - Christoph Sinning
- Klinik für Kardiologie, Universitäres Herz- und Gefäßzentrum, Hamburg, Germany (S.C., S.B., C.S., R.B.S.).,DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Germany (S.C., M.J., S.B., C.S., R.B.S.)
| | - Renate B Schnabel
- Klinik für Kardiologie, Universitäres Herz- und Gefäßzentrum, Hamburg, Germany (S.C., S.B., C.S., R.B.S.).,DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Germany (S.C., M.J., S.B., C.S., R.B.S.)
| | - Christian Gerloff
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Germany (G.T., M.U., M.J., J.S., E.B., B.C., C.G.)
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Ribeiro R, Fialho I, Boavida L. Platypnea-Orthodeoxia Syndrome: A Case of Persistent Hypoxemia in an Elderly Patient. Circulation 2021; 144:395-398. [PMID: 34339308 DOI: 10.1161/circulationaha.121.054424] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Renata Ribeiro
- Internal Medicine Department 4 (R.R., L.B.), Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal
| | - Inês Fialho
- Cardiology Department (I.F.), Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal
| | - Leonor Boavida
- Internal Medicine Department 4 (R.R., L.B.), Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal
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8
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Shah AH, Puri R, Krasuski RA. Transcatheter Closure of Patent Foramen Ovale: Not Always an "Open or Shut" Case. Circulation 2021; 143:1539-1541. [PMID: 33872078 DOI: 10.1161/circulationaha.120.050961] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ashish H Shah
- St Boniface Hospital, Section of Cardiology, University of Manitoba, Winnipeg, Canada (A.H.S.)
| | - Rishi Puri
- Department of Cardiovascular Medicine, Cleveland Clinic Coordinating Center for Clinical Research, Cleveland Clinic, Ohio (R.P.)
| | - Richard A Krasuski
- Division of Cardiology, Duke University Health System, Durham, NC (R.A.K.)
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9
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Strambo D, Sirimarco G, Nannoni S, Perlepe K, Ntaios G, Vemmos K, Michel P. Embolic Stroke of Undetermined Source and Patent Foramen Ovale: Risk of Paradoxical Embolism Score Validation and Atrial Fibrillation Prediction. Stroke 2021; 52:1643-1652. [PMID: 33784832 DOI: 10.1161/strokeaha.120.032453] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [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: 12/28/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Davide Strambo
- Service of Neurology, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Switzerland (D.S., G.S., S.N., P.M.)
| | - Gaia Sirimarco
- Service of Neurology, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Switzerland (D.S., G.S., S.N., P.M.)
| | - Stefania Nannoni
- Service of Neurology, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Switzerland (D.S., G.S., S.N., P.M.)
| | - Kalliopi Perlepe
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece (K.P., G.N.)
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece (K.P., G.N.)
| | - Kostantinos Vemmos
- Department of Clinical Therapeutics, Medical School of Athens, Alexandra Hospital, Greece (K.V.)
| | - Patrik Michel
- Service of Neurology, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Switzerland (D.S., G.S., S.N., P.M.)
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10
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Chen JZJ, Thijs VN. Atrial Fibrillation Following Patent Foramen Ovale Closure: Systematic Review and Meta-Analysis of Observational Studies and Clinical Trials. Stroke 2021; 52:1653-1661. [PMID: 33611943 DOI: 10.1161/strokeaha.120.030293] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [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: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Jessie Ze-Jun Chen
- Department of Neurology, Austin Health, Heidelberg, Victoria, Australia (J.Z.-J.C., V.N.T.)
| | - Vincent N Thijs
- Department of Neurology, Austin Health, Heidelberg, Victoria, Australia (J.Z.-J.C., V.N.T.).,Stroke Theme, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Victoria, Australia (V.N.T.)
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Diener HC, Chutinet A, Easton JD, Granger CB, Kleine E, Marquardt L, Meyerhoff J, Zini A, Sacco RL. Dabigatran or Aspirin After Embolic Stroke of Undetermined Source in Patients With Patent Foramen Ovale: Results From RE-SPECT ESUS. Stroke 2021; 52:1065-1068. [PMID: 33504190 DOI: 10.1161/strokeaha.120.031237] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [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: 12/23/2022]
Abstract
BACKGROUND AND PURPOSE Patent foramen ovale (PFO) may increase the risk of embolic stroke of undetermined source (ESUS). Guidelines suggest anticoagulation may be more effective than antiplatelets in preventing stroke in patients with ESUS and PFO when interventional closure is not performed. METHODS Patients with ESUS randomized to dabigatran (150/110 mg BID) or aspirin (100 mg QD) from the RE-SPECT ESUS study (Randomized, Double-Blind, Evaluation in Secondary Stroke Prevention Comparing the Efficacy and Safety of the Oral Thrombin Inhibitor Dabigatran Etexilate Versus Acetylsalicylic Acid in Patients With Embolic Stroke of Undetermined Source) were included. The rate of recurrent stroke (primary end point) and ischemic stroke was reported for patients with and without baseline PFO. A meta-analysis comparing the effects of anticoagulant and antiplatelet therapy on ischemic stroke in patients with PFO was updated to include RE-SPECT ESUS. RESULTS PFO was present in 680 of 5388 (12.6%) patients with documented PFO status. The risk of recurrent stroke with dabigatran versus aspirin was similar in patients with and without PFO (P for interaction, 0.8290). In patients with PFO, the meta-analysis found no statistically significant difference between anticoagulant and antiplatelet therapy (odds ratio, 0.70 [95% CI, 0.43-1.14]) for ischemic stroke. CONCLUSIONS There is insufficient evidence to recommend anticoagulation over antiplatelet therapy for patients with ESUS and a PFO. More data are needed to guide antithrombotic therapy in this population. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02239120.
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Affiliation(s)
- Hans-Christoph Diener
- Institute for Medical Informatics, Biometry and Epidemiology, University Duisburg-Essen, Germany (H-C.D.)
| | - Aurauma Chutinet
- Department of Medicine, Faculty of Medicine, Chulalongkorn Stroke Center, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Thai Red Cross Society, Bangkok, Thailand (A.C.)
| | - J Donald Easton
- Department of Neurology, University of California, San Francisco (J.D.E.)
| | | | - Eva Kleine
- Biostatistics and Data Sciences, Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany (E.K.)
| | - Lars Marquardt
- University Department of Neurology, Asklepios Hospital Hamburg Wandsbek, Germany (L.M.).,Faculty of Medicine, Semmelweis University Campus Hamburg, Germany (L.M.)
| | - Juliane Meyerhoff
- Cardiology Medicine, Boehringer Ingelheim International GmbH, Germany (J.M.)
| | - Andrea Zini
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Italy (A.Z.)
| | - Ralph L Sacco
- Department of Neurology, Miller School of Medicine, University of Miami, FL (R.L.S.)
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Tiller C, Reinstadler SJ, Bonaros N, Metzler B, Klug G. Massive Pulmonary Embolism With a Large Thrombus Trapped in the Patent Foramen Ovale. Circ Cardiovasc Imaging 2020; 13:e010501. [PMID: 32972236 DOI: 10.1161/circimaging.120.010501] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Christina Tiller
- University Clinic of Internal Medicine III, Cardiology and Angiology (C.T., S.J.R., B.M., G.K.), Medical University of Innsbruck, Austria
| | - Sebastian Johannes Reinstadler
- University Clinic of Internal Medicine III, Cardiology and Angiology (C.T., S.J.R., B.M., G.K.), Medical University of Innsbruck, Austria
| | - Nikolaos Bonaros
- University Clinic of Cardiac Surgery (N.B.), Medical University of Innsbruck, Austria
| | - Bernhard Metzler
- University Clinic of Internal Medicine III, Cardiology and Angiology (C.T., S.J.R., B.M., G.K.), Medical University of Innsbruck, Austria
| | - Gert Klug
- University Clinic of Internal Medicine III, Cardiology and Angiology (C.T., S.J.R., B.M., G.K.), Medical University of Innsbruck, Austria
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13
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Kent DM, Saver JL, Ruthazer R, Furlan AJ, Reisman M, Carroll JD, Smalling RW, Jüni P, Mattle HP, Meier B, Thaler DE. Risk of Paradoxical Embolism (RoPE)-Estimated Attributable Fraction Correlates With the Benefit of Patent Foramen Ovale Closure: An Analysis of 3 Trials. Stroke 2020; 51:3119-3123. [PMID: 32921262 PMCID: PMC7831886 DOI: 10.1161/strokeaha.120.029350] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [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: 12/11/2022]
Abstract
BACKGROUND AND PURPOSE In patients with cryptogenic stroke and patent foramen ovale (PFO), the Risk of Paradoxical Embolism (RoPE) Score has been proposed as a method to estimate a patient-specific "PFO-attributable fraction"-the probability that a documented PFO is causally-related to the stroke, rather than an incidental finding. The objective of this research is to examine the relationship between this RoPE-estimated PFO-attributable fraction and the effect of closure in 3 randomized trials. METHODS We pooled data from the CLOSURE-I (Evaluation of the STARFlex Septal Closure System in Patients With a Stroke and/or Transient Ischemic Attack due to Presumed Paradoxical Embolism through a Patent Foramen Ovale), RESPECT (Randomized Evaluation of Recurrent Stroke Comparing PFO Closure to Established Current Standard of Care Treatment), and PC (Clinical Trial Comparing Percutaneous Closure of Patent Foramen Ovale [PFO] Using the Amplatzer PFO Occluder With Medical Treatment in Patients With Cryptogenic Embolism) trials. We examine the treatment effect of closure in high RoPE score (≥7) versus low RoPE score (<7) patients. We also estimated the relative risk reduction associated with PFO closure across each level of the RoPE score using Cox proportional hazard analysis. We estimated a patient-specific attributable fraction using a PC trial-compatible (9-point) RoPE equation (omitting the neuroradiology variable), as well as a 2-trial analysis using the original (10-point) RoPE equation. We examined the Pearson correlation between the estimated attributable fraction and the relative risk reduction across RoPE strata. RESULTS In the low RoPE score group (<7, n=912), the rate of recurrent strokes per 100 person-years was 1.37 in the device arm versus 1.68 in the medical arm (hazard ratio, 0.82 [0.42-1.59] P=0.56) compared with 0.30 versus 1.03 (hazard ratio, 0.31 [0.11-0.85] P=0.02) in the high RoPE score group (≥7, n=1221); treatment-by-RoPE score group interaction, P=0.12. The RoPE score estimated attributable fraction anticipated the relative risk reduction across all levels of the RoPE score, in both the 3-trial (r=0.95, P<0.001) and 2-trial (r=0.92, P<0.001) analyses. CONCLUSIONS The RoPE score estimated attributable fraction is highly correlated to the relative risk reduction of device versus medical therapy. This observation suggests the RoPE score identifies patients with cryptogenic stroke who are likely to have a PFO that is pathogenic rather than incidental.
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Affiliation(s)
- David M Kent
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center/Tufts University School of Medicine, Boston, MA. (D.M.K., R.R.).,Department of Neurology, Tufts Medical Center/Tufts University School of Medicine, Boston, MA. (D.M.K., D.E.T.)
| | - Jeffrey L Saver
- Comprehensive Stroke Center and Department of Neurology, David Geffen School of Medicine/University of California Los Angeles (J.L.S.)
| | - Robin Ruthazer
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center/Tufts University School of Medicine, Boston, MA. (D.M.K., R.R.)
| | - Anthony J Furlan
- Department of Neurology, Case Western Reserve University, Cleveland, OH (A.J.F.)
| | - Mark Reisman
- Division of Cardiology, University of Washington Medical Center, Seattle (M.R.)
| | - John D Carroll
- Division of Cardiology, Department of Medicine, University of Colorado Denver, Aurora (J.D.C.)
| | - Richard W Smalling
- Division of Cardiology, Department of Medicine, University of Texas Medical School at Houston (R.W.S.)
| | - Peter Jüni
- Applied Health Research Centre (AHRC), Li Ka Shing Knowledge Institute of St. Michael's Hospital, Department of Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, ON, Canada (P.J.)
| | - Heinrich P Mattle
- Department of Neurology, Bern University Hospital, Bern, Switzerland. (H.P.M.)
| | - Bernhard Meier
- Department of Cardiology, Bern University Hospital, Bern, Switzerland. (B.M.)
| | - David E Thaler
- Department of Neurology, Tufts Medical Center/Tufts University School of Medicine, Boston, MA. (D.M.K., D.E.T.)
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Affiliation(s)
- Ling-Yun Kong
- Cardiology Department, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, China
| | - Ling-Ling Chen
- Cardiology Department, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, China
| | - Wei Xiang
- Cardiology Department, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, China
| | - Fang Liu
- Cardiology Department, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, China
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15
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Small AJ, Denton KL, Aboulhosn JA. Left Atrial Wall Trauma Causing Intracardiac Thrombus After Device Closure of Patent Foramen Ovale. Circ Cardiovasc Imaging 2019; 12:e008720. [PMID: 30813771 DOI: 10.1161/circimaging.118.008720] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Adam J Small
- Division of Cardiology, Department of Medicine, Ahmanson/UCLA Adult Congenital Heart Disease Center, David Geffen School of Medicine, Los Angeles, CA (A.J.S., J.A.A.)
| | | | - Jamil A Aboulhosn
- Division of Cardiology, Department of Medicine, Ahmanson/UCLA Adult Congenital Heart Disease Center, David Geffen School of Medicine, Los Angeles, CA (A.J.S., J.A.A.)
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Abstract
Platypnea-orthodeoxia syndrome is a rare disease defined by dyspnea and deoxygenation, induced by an upright position, and relieved by recumbency. Causes include shunting through a patent foramen ovale and pulmonary arteriovenous malformations. A 79-year-old woman experienced 2 syncopal episodes at rest and presented at another hospital. In the emergency department, she was hypoxic, needing 6 L/min of oxygen. Her chest radiograph showed nothing unusual. Transthoracic echocardiograms with saline microcavitation evaluation were mildly positive early after agitated-saline administration, suggesting intracardiac shunting. She was then transferred to our center. Right-sided heart catheterization revealed no oximetric evidence of intracardiac shunting while the patient was supine and had a low right atrial pressure. However, her oxygen saturation dropped to 78% when she sat up. Repeat transthoracic echocardiography while sitting revealed a dramatically positive early saline microcavitation-uptake into the left side of the heart. Transesophageal echocardiograms showed a patent foramen ovale, with right-to-left shunting highly dependent upon body position. The patient underwent successful percutaneous patent foramen ovale closure, and her oxygen supplementation was suspended. In patients with unexplained or transient hypoxemia in which a cardiac cause is suspected, it is important to evaluate shunting in both the recumbent and upright positions. In this syndrome, elevated right atrial pressure is not necessary for significant right-to-left shunting. Percutaneous closure, if feasible, is first-line therapy in these patients.
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Álvarez-Velasco R, Masjuan J, DeFelipe A, Corral I, Estévez-Fraga C, Crespo L, Alonso-Cánovas A. Stroke in Commercial Flights. Stroke 2016; 47:1117-9. [PMID: 26892280 DOI: 10.1161/strokeaha.115.012637] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [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: 12/31/2015] [Accepted: 01/21/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Stroke on board aircraft has been reported in retrospective case series, mainly focusing on economy class stroke syndrome. Data on the actual incidence, pathogenesis, and prognosis of stroke in commercial flights are lacking. METHODS A prospective registry was designed to include all consecutive patients referred from an international airport (40 million passengers a year) to our hospital with a diagnosis of ischemic stroke or transient ischemic attack and onset of symptoms during a flight or immediately after landing. RESULTS Forty-four patients (32 ischemic strokes and 12 transient ischemic attacks) were included over a 76-month period (January 2008 to April 2014). The estimated incidence of stroke was 1 stroke in 35 000 flights. Pathogeneses of stroke or transient ischemic attack were atherothrombotic in 16 (36%), economy class stroke syndrome in 8 (18%), cardioembolic in 7 (16%), arterial dissection in 4 (9%), lacunar stroke in 4 (9%), and undetermined in 5 (12%) patients. Carotid stenosis >70% was found in 12 (27%) of the patients. Overall prognosis was good, and thrombolysis was applied in 44% of the cases. The most common reason for not treating patients who had experienced stroke onset midflight was the delay in reaching the hospital. Only 1 patient with symptom onset during the flight prompted a flight diversion. CONCLUSIONS We found a low incidence of stroke in the setting of air travel. Economy class stroke syndrome and arterial dissection were well represented in our sample. However, the main pathogenesis was atherothrombosis with a high proportion of patients with high carotid stenosis.
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Affiliation(s)
- Rodrigo Álvarez-Velasco
- From the Neurology Department, Hospital Universitario Ramón y Cajal de Madrid, Madrid, Spain (R.A.-V., J.M., A.D.F., I.C., C.E.-F., L.C., A.A.-C.); Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain (J.M.); and Universidad de Alcalá, Madrid (J.M.).
| | - Jaime Masjuan
- From the Neurology Department, Hospital Universitario Ramón y Cajal de Madrid, Madrid, Spain (R.A.-V., J.M., A.D.F., I.C., C.E.-F., L.C., A.A.-C.); Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain (J.M.); and Universidad de Alcalá, Madrid (J.M.)
| | - Alicia DeFelipe
- From the Neurology Department, Hospital Universitario Ramón y Cajal de Madrid, Madrid, Spain (R.A.-V., J.M., A.D.F., I.C., C.E.-F., L.C., A.A.-C.); Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain (J.M.); and Universidad de Alcalá, Madrid (J.M.)
| | - Iñigo Corral
- From the Neurology Department, Hospital Universitario Ramón y Cajal de Madrid, Madrid, Spain (R.A.-V., J.M., A.D.F., I.C., C.E.-F., L.C., A.A.-C.); Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain (J.M.); and Universidad de Alcalá, Madrid (J.M.)
| | - Carlos Estévez-Fraga
- From the Neurology Department, Hospital Universitario Ramón y Cajal de Madrid, Madrid, Spain (R.A.-V., J.M., A.D.F., I.C., C.E.-F., L.C., A.A.-C.); Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain (J.M.); and Universidad de Alcalá, Madrid (J.M.)
| | - Leticia Crespo
- From the Neurology Department, Hospital Universitario Ramón y Cajal de Madrid, Madrid, Spain (R.A.-V., J.M., A.D.F., I.C., C.E.-F., L.C., A.A.-C.); Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain (J.M.); and Universidad de Alcalá, Madrid (J.M.)
| | - Araceli Alonso-Cánovas
- From the Neurology Department, Hospital Universitario Ramón y Cajal de Madrid, Madrid, Spain (R.A.-V., J.M., A.D.F., I.C., C.E.-F., L.C., A.A.-C.); Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain (J.M.); and Universidad de Alcalá, Madrid (J.M.)
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Affiliation(s)
- Doff B McElhinney
- From the Department of Cardiothoracic Surgery, Stanford University, Palo Alto, CA.
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19
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Henkin S, Negrotto S, Pollak PM, Cullen MW, O'Cochlain DF, Wright RS. Platypnea-Orthodeoxia Syndrome: Diagnostic Challenge and the Importance of Heightened Clinical Suspicion. Tex Heart Inst J 2015; 42:498-501. [PMID: 26504452 DOI: 10.14503/thij-14-4596] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Platypnea-orthodeoxia syndrome is an uncommon condition of positional dyspnea and hypoxemia; symptoms occur when the patient is upright and resolve with recumbency. Causes can be broadly categorized into 4 groups: intracardiac shunting, pulmonary shunting, ventilation-perfusion mismatch, or a combination of these. Platypnea-orthodeoxia syndrome should be suspected when normal arterial oxygen saturations are recorded while an individual is supine, followed by abrupt declines in those saturations when upright. Further investigations with use of imaging and cardiac catheterization aid in the evaluation. When platypnea-orthodeoxia syndrome is due to intracardiac shunting without pulmonary hypertension, intracardiac shunt closure can be curative. In this article, we report a case of platypnea-orthodeoxia syndrome in an 83-year-old woman who was successfully treated by means of percutaneous transcatheter closure of an atrial septal defect.
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Affiliation(s)
- Satish Misra
- From the Division of Cardiology (S.M., J.R.), Division of Cardiac Surgery (J.C.), Johns Hopkins School of Medicine, Baltimore, MD.
| | - John Conte
- From the Division of Cardiology (S.M., J.R.), Division of Cardiac Surgery (J.C.), Johns Hopkins School of Medicine, Baltimore, MD
| | - Jon Resar
- From the Division of Cardiology (S.M., J.R.), Division of Cardiac Surgery (J.C.), Johns Hopkins School of Medicine, Baltimore, MD
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Affiliation(s)
- Benjamin R Miller
- From the Neurological Institute, University Hospitals Case Medical Center, Cleveland, OH (B.R.M., S.S.); and Department of Neurology and Stroke Unit, Helsinki University Central Hospital, Helsinki, Finland (D.S.)
| | - Daniel Strbian
- From the Neurological Institute, University Hospitals Case Medical Center, Cleveland, OH (B.R.M., S.S.); and Department of Neurology and Stroke Unit, Helsinki University Central Hospital, Helsinki, Finland (D.S.)
| | - Sophia Sundararajan
- From the Neurological Institute, University Hospitals Case Medical Center, Cleveland, OH (B.R.M., S.S.); and Department of Neurology and Stroke Unit, Helsinki University Central Hospital, Helsinki, Finland (D.S.).
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Wąsek WC, Samul W, Ryczek R, Skrobowski A. Unique case of ST-segment-elevation myocardial infarction related to paradoxical embolization and simultaneous pulmonary embolization: clinical considerations on indications for patent foramen ovale closure in no-guidelines land. Circulation 2015; 131:1214-23. [PMID: 25825398 DOI: 10.1161/circulationaha.114.009846] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
| | | | - Robert Ryczek
- From the Military Institute of Medicine, Warsaw, Poland
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Wessler BS, Thaler DE, Ruthazer R, Weimar C, Di Tullio MR, Elkind MSV, Homma S, Lutz JS, Mas JL, Mattle HP, Meier B, Nedeltchev K, Papetti F, Di Angelantonio E, Reisman M, Serena J, Kent DM. Transesophageal echocardiography in cryptogenic stroke and patent foramen ovale: analysis of putative high-risk features from the risk of paradoxical embolism database. Circ Cardiovasc Imaging 2013; 7:125-31. [PMID: 24214884 DOI: 10.1161/circimaging.113.000807] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [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] [Indexed: 02/05/2023]
Abstract
BACKGROUND Patent foramen ovale (PFO) is associated with cryptogenic stroke (CS), although the pathogenicity of a discovered PFO in the setting of CS is typically unclear. Transesophageal echocardiography features such as PFO size, associated hypermobile septum, and presence of a right-to-left shunt at rest have all been proposed as markers of risk. The association of these transesophageal echocardiography features with other markers of pathogenicity has not been examined. METHODS AND RESULTS We used a recently derived score based on clinical and neuroimaging features to stratify patients with PFO and CS by the probability that their stroke is PFO-attributable. We examined whether high-risk transesophageal echocardiography features are seen more frequently in patients more likely to have had a PFO-attributable stroke (n=637) compared with those less likely to have a PFO-attributable stroke (n=657). Large physiologic shunt size was not more frequently seen among those with probable PFO-attributable strokes (odds ratio [OR], 0.92; P=0.53). The presence of neither a hypermobile septum nor a right-to-left shunt at rest was detected more often in those with a probable PFO-attributable stroke (OR, 0.80; P=0.45; OR, 1.15; P=0.11, respectively). CONCLUSIONS We found no evidence that the proposed transesophageal echocardiography risk markers of large PFO size, hypermobile septum, and presence of right-to-left shunt at rest are associated with clinical features suggesting that a CS is PFO-attributable. Additional tools to describe PFOs may be useful in helping to determine whether an observed PFO is incidental or pathogenically related to CS.
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Abstract
BACKGROUND AND PURPOSE Subclinical atrial fibrillation (AF) and patent foramen ovale (PFO) are the major causes of cryptogenic stroke, and neuroimaging may help distinguish the cause. We compared the imaging characteristics of ischemic stroke caused by PFO (PFO-stroke) and AF (AF-stroke). METHODS We recruited 117 patients with PFO-stroke and 358 patients with AF-stroke after excluding other causes. The lesion patterns were classified according to number, location, size, and pertinent vascular territory and were compared between the 2 groups. Occlusion of the corresponding artery and its recanalization rate were also investigated. RESULTS The lesion pattern of a PFO-stroke was more frequently observed as a single cortical infarction (34.2% versus 3.1%; P<0.001) or multiple small (<15 mm) scattered lesions (23.1% versus 5.9%; P<0.001) and in the vertebrobasilar artery territory (44.4% versus 22.9%; P<0.001). By contrast, AF-stroke was more frequently observed as a large cortico-subcortical infarction or confluent lesion (>15 mm) with additional lesions in multicirculatory territories. For a PFO-stroke, occlusion of the corresponding vessel on angiography was less frequent (34.2% versus 71.5%; P<0.001), and the neurological deficit evaluated by the National Institutes of Health Stroke Scale was mild (3.48±4.16 versus 9.15±7.35; P<0.001). The recanalization rate was also lower (57.1% versus 78.3%; P=0.007). CONCLUSIONS A PFO-stroke usually appears as a single cortical or multiple small ischemic lesions in the vertebrobasilar circulation without any visible vessel occlusion on angiography. The recanalization rate is significantly lower than in AF-stroke. These imaging characteristics of PFO-stroke may help to diagnose the mechanism and determine the treatment strategy.
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Affiliation(s)
- Bum Joon Kim
- From the Department of Neurology (B.J.K., H.S., D.-W.K., J.S.K., S.U.K.), and Department of Cardiology (B.J.S., J.-K.S.), Asan Medical Center, University of Ulsan, Seoul, Republic of Korea
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Basoor AS, Cotant JF, Halabi AR, DeGregorio M, Chughtai H, Patel KC. Minimally invasive retrieval of patent foramen ovale closure device after device migration to the descending aorta. Tex Heart Inst J 2012; 39:582-584. [PMID: 22949785 PMCID: PMC3423282] [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] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Percutaneous treatment of patent foramen ovale with a septal closure device has become a common procedure, but it is associated with various complications. Migration of the device is uncommon, and migration through the aortic valve into the aorta is rare. Managing the migration of a patent foramen ovale occluder can be challenging; it usually requires surgical retrieval of the foreign body. We report a rare case in which a patient experienced migration of a large patent foramen ovale closure device to the descending aorta. Rarer still was its successful percutaneous management.
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Affiliation(s)
- Abhijeet S Basoor
- Division of Cardiology, St. Joseph Mercy Oakland Hospital, Pontiac, Michigan 48341, USA.
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