scholarly journals Management of Patients with Patent Foramen Ovale and Cryptogenic Stroke: An Update

Cardiology ◽  
2019 ◽  
Vol 143 (1-2) ◽  
pp. 62-72 ◽  
Author(s):  
Mohammad Abdelghani ◽  
Sahar A.O. El-Shedoudy ◽  
Martina Nassif ◽  
Berto J. Bouma ◽  
Robbert J. de Winter
Keyword(s):  
Healthy Subjects ◽  
Patent Foramen Ovale ◽  
Recurrent Stroke ◽  
Cryptogenic Stroke ◽  
Paradoxical Embolism ◽  
Atrial Septal Aneurysm ◽  
Evidence Based ◽  
Foramen Ovale ◽  
Device Closure ◽  
Interatrial Shunt

Patent foramen ovale (PFO) is a common benign finding in healthy subjects, but its prevalence is higher in patients with stroke of unclear cause (cryptogenic stroke). PFO is believed to be associated with stroke through paradoxical embolism, and certain clinical and anatomical criteria seem to increase the likelihood of a PFO to be pathological. Recent trials have shown that closure of PFO, especially if associated with an atrial septal aneurysm and/or a large interatrial shunt, may reduce the risk of recurrent stroke as compared to medical treatment. However, it remains challenging to risk stratify patients with suspected PFO-related stroke and to decide if device closure is indicated. We sought to review contemporary evidence and to conclude an evidence-based strategy to prevent recurrence of PFO-related stroke.

Abstract TMP13: Baseline DWMRI Characteristics In Patients With Cryptogenic Stroke And Patent Foramen Ovale: Results From The Closure I Trial

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Richard Jung ◽  
Benny Kim ◽  
Joseph Massaro ◽  
Anthony J Furlan
Keyword(s):  
Patent Foramen Ovale ◽  
Cox Regression ◽  
Recurrent Stroke ◽  
Cryptogenic Stroke ◽  
Patient Characteristics ◽  
Paradoxical Embolism ◽  
Foramen Ovale ◽  
Anterior Circulation ◽  
Significant Difference ◽  
Multivariate Proportional Hazard

Background: Cryptogenic stroke may have several etiologies including paradoxical embolism through a patent foramen ovale (PFO). A cardiac source of embolism may be suggested by multiple infarcts, sometimes hemorrhagic, in different vascular distributions or a cortical wedge shaped infarct. We report the baseline diffusion weighted MRI (DWMRI) characteristics in patients with cryptogenic stroke and a patent foramen ovale (PFO) from the CLOSURE I trial. Methods: CLOSURE I compared device closure versus medical therapy for secondary prevention in patients with cryptogenic TIA or stroke and a PFO. Of 909 patients randomized, 562 patients demonstrated acute infarcts on baseline DWMRI and are included in this analysis. Multivariate proportional hazard Cox regression compared imaging subgroups with remaining randomized patients Results: Single infarcts were found in 62% of patients. Of these, 61% were anterior circulation, 30% posterior, and 8.5% were of uncertain territory. Of the anterior circulation infarcts, 40% were cortical, 36% subcortical, and 24% affected both the cortical and subcortical regions. Of the posterior circulation infarcts, 45% were thalamic or cerebellar. Of 562 patients, 18.5% had a single subcortical lesion <1.5cm in diameter and met the radiological definition of an acute lacunar infarct. Multiple infarcts were found in 38%. Infarcts in a single vascular territory were found in 23%, often in the anterior circulation (66%). Infarcts in multiple vascular territories were found in 15%. Hemorrhagic infarction was present in 9%. Adjusting for patient characteristics, no significant difference in 2 year rate of TIA, stroke or death was found compared to remaining randomized patients. Discussion: The specificity of infarct patterns for embolism in patients with cryptogenic stroke and a PFO is uncertain. We found no significant relationship between lacunar or subcortical infarction and the risk of recurrent TIA or stroke. Baseline infarct patterns on DWMRI in patients with cryptogenic stroke and PFO may not be useful in predicting recurrent stroke risk or determining best prevention therapy.

scholarly journals Prevalence of patent foramen ovale in the Greek population is high and impacts on the interpretation of the risk of paradoxical embolism (RoPE) score

2020 ◽  
Vol 13 ◽  
pp. 175628642096467
Author(s):  
Ioanna Koutroulou ◽  
Georgios Tsivgoulis ◽  
Dimitris Karacostas ◽  
Ignatios Ikonomidis ◽  
Nikolaos Grigoriadis ◽  
...  
Keyword(s):  
Healthy Subjects ◽  
Patent Foramen Ovale ◽  
Valsalva Maneuver ◽  
Cryptogenic Stroke ◽  
Paradoxical Embolism ◽  
Attributable Fraction ◽  
Greek Population ◽  
Foramen Ovale ◽  
International Consensus ◽  
Very High

Background: The risk of paradoxical embolism (RoPE) score calculates the probability that patent foramen ovale (PFO) is causally related to stroke (PFO attributable fraction, PFOAF), based on PFO prevalence in patients with cryptogenic stroke (CS) compared with that in the general population. The latter has been estimated at 25%; however, PFO prevalence in nonselected populations varies widely. Methods: Since PFO prevalence in Greece remains unknown, we evaluated it and we calculated PFOAF stratified by RoPE score in a cohort of patients with CS ⩽55 years old. PFO was detected according to the international consensus transcranial Doppler (TCD) criteria in 124 healthy subjects (H), in 102 patients with CS, and in 56 patients with stroke of known cause (nonCS). Each subject underwent unilateral middle cerebral artery recording after infusion of agitated saline, at rest, and after a controlled Valsalva maneuver. We characterized PFO as large (>20 microbubbles or curtain), moderate (11–20), and small (⩽10). Results: PFO was detected in 42.7% of H, 49% of CS, and 25% of nonCS ( p = 0.013). Large PFOs were numerically higher in CS [28.4% (29/102)] compared with H [19.3% (24/124); p = 0.1] and to nonCS [7.1% (4/56), p = 0.04]. The median RoPE score in patients with CS and PFO was seven. Even patients with very high RoPE score (9–10) had moderate PFOAF (57%). For any individual stratum up to RopE score 8, PFOAF was <33%. Conclusions: PFO prevalence in the Greek population is much higher than the widely accepted 25%. PFO may be the cause of stroke in one out of nine Greek patients with CS. Among Greek CS patients who harbor a PFO, the latter is causal in one out of five. The established RoPE score cutoff of ⩾7 for having a probable PFO-associated stroke may overestimate the probability in patients deriving from populations with high PFO prevalence.

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

2007 ◽  
Vol 34 (1) ◽  
pp. 74-80 ◽  
Author(s):  
Leanne Casaubon ◽  
Peter McLaughlin ◽  
Gary Webb ◽  
Erik Yeo ◽  
Darren Merker ◽  
...  
Keyword(s):  
Patent Foramen Ovale ◽  
Recurrent Events ◽  
Recurrent Stroke ◽  
Cryptogenic Stroke ◽  
Antiplatelet Agents ◽  
Secondary Outcome ◽  
Foramen Ovale ◽  
Device Closure ◽  
Surgical Closure ◽  
Significant Difference

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.

New aspects of paradoxical embolism

VASA ◽  
2011 ◽  
Vol 40 (1) ◽  
pp. 31-40 ◽  
Author(s):  
Lehmeyer ◽  
Lindhoff-Last
Keyword(s):  
Patent Foramen Ovale ◽  
Recurrent Stroke ◽  
Cryptogenic Stroke ◽  
The United States ◽  
Paradoxical Embolism ◽  
Foramen Ovale ◽  
Recurrence Rates ◽  
Diagnostic Features ◽  
Arterial Embolism ◽  
Peripheral Arterial

Paradoxical emboli have their origin in the low-pressure venous system and can cause ischemic stroke or peripheral arterial embolism through a cardiac or pulmonary shunt. In most cases, a patent foramen ovale (PFO) is found. About 20 % of the population has a patent foramen ovale. This review gives insight into publications concerning the association between the presence of a patent foramen ovale and cryptogenic stroke; the association of PFO, coagulation disorders and stroke; and recurrence rates of stroke in patients with PFO. Diagnostic features are discussed, as are the different therapy modalities, taking existing national and international guidelines into account. Also, our own recommendations are given. In addition some new information on the potential improvement of migraine after PFO closure is discussed. It is widely accepted that the optimal therapy for the prevention of recurrent stroke in patients with PFO and cryptogenic stroke has not yet been found. Randomized, controlled clinical studies are ongoing in the United States and will give even more insight and answer open questions in the future.

scholarly journals Importance of Persistent Right-to-Left Shunt After Patent Foramen Ovale Closure in Cryptogenic Stroke Patients

2020 ◽  
Vol 47 (4) ◽  
pp. 244-249
Author(s):  
Lu He ◽  
Gesheng Cheng ◽  
Yajuan Du ◽  
Yushun Zhang
Keyword(s):  
Transient Ischemic Attack ◽  
Patent Foramen Ovale ◽  
Valsalva Maneuver ◽  
Recurrent Stroke ◽  
Cryptogenic Stroke ◽  
Atrial Septal Aneurysm ◽  
Foramen Ovale ◽  
Ischemic Attack ◽  
Pfo Closure

Percutaneous closure of patent foramen ovale (PFO) is widely performed to prevent recurrent stroke or transient ischemic attack in patients with cryptogenic stroke. However, the influence of different degrees of right-to-left shunting (RLS) has rarely been reported. We retrospectively evaluated the cases of 268 patients with cryptogenic stroke who underwent PFO closure at our hospital from April 2012 through April 2015. In accordance with RLS severity, we divided the patients into 2 groups: persistent RLS during normal breathing and the Valsalva maneuver (n=112) and RLS only during the Valsalva maneuver (n=156). Baseline characteristics, morphologic features, and procedural and follow-up data were reviewed. The primary endpoint was stroke or transient ischemic attack. More patients in the persistent group had multiple or bilateral ischemic lesions, as well as a larger median PFO diameter (2.5 mm [range, 1.8–3.9 mm]) than did patients in the Valsalva maneuver group (1.3 mm [range, 0.9–1.9 mm]) (P &lt;0.001). Atrial septal aneurysm was more frequent in the persistent group: 25 patients (22.3%) compared with 18 (11.5%) (P=0.018). Three patients in the persistent group had residual shunting. The annual risk of recurrent ischemic stroke was similar between groups: 0.298% (persistent) and 0.214% (Valsalva maneuver). Our findings suggest that patients with persistent RLS have more numerous severe ischemic lesions, larger PFOs, and a higher incidence of atrial septal aneurysm than do those without. Although our persistent group had a greater risk of residual shunting after PFO closure, recurrence of ischemic events did not differ significantly from that in the Valsalva maneuver group.

scholarly journals Safety and efficacy of endovascular patent foramen ovale closure: the first results of a Russian multicenter study

2020 ◽  
Vol 12 (6) ◽  
pp. 26-32
Author(s):  
D. V. Ognerubov ◽  
A. S. Tereshchenko ◽  
A. N. Samko ◽  
G. К. Arutyunyan ◽  
O. A. Sivakova ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Secondary Prevention ◽  
Patent Foramen Ovale ◽  
Cryptogenic Stroke ◽  
Young Patients ◽  
Paradoxical Embolism ◽  
Atrial Septal Aneurysm ◽  
Foramen Ovale ◽  
History Of ◽  
Pfo Closure

Patent foramen ovale (PFO) is detectable in more than 25% of the adult population and is generally clinically insignificant. However, it can be a cause of paradoxical embolism in some cases. Randomized trials indicate that endovascular PFO closure in patients with a history of cryptogenic stroke is an effective method for the secondary prevention of catastrophic brain damage.Objective: to study the safety and efficiency of endovascular PFO closure in young patients with a history of cryptogenic stroke.Patients and methods. Sixty-two patients, including (22 males and 40 females) women, underwent percutaneous PFO closure in May 2018 to March 2020. The patients' mean age was 37.4±7.6 years. The inclusion criteria were a prior cryptogenic ischemic stroke lasting less than 12 months and PFO with a high risk for paradoxical embolism (PFO concurrent with atrial septal aneurysm or hypermobility; PFO, ≥2 mm size; the presence of the Chiari network and/or the Eustachian valve).Results and discussion. The technical success of the operation was achieved in all cases. In 50 (80.6%) patients, the right chamber of the heart was completely isolated from the left one in the first 3 months. During the first year, the atria were also completely isolated in 10 (16.1%) patients. A left-to-right shunt persisted in 2 (3.2%) patents 12 months later. Two patients were found to have main procedural complications: one had perioperative atrial fibrillation and the other had pseudoaneurysm formation at the puncture site.Conclusion. Endovascular PFO closure is a safe and effective operation for the secondary prevention of recurrent ischemic stroke. In our study, blood shunting through the PFO was stopped in 96.6% of patients at less than 6 months after surgery, which suggests that there is a rapid and effective reduction in the risk of paradoxical embolism.

scholarly journals Importance of saline contrast transthoracic echocardiography for evaluating large right-to-left shunt in patent foramen ovale associated with cryptogenic stroke

2021 ◽  
Author(s):  
Yoichi Takaya ◽  
Rie Nakayama ◽  
Teiji Akagi ◽  
Fumi Yokohama ◽  
Takashi Miki ◽  
...  
Keyword(s):  
High Risk ◽  
Transthoracic Echocardiography ◽  
Patent Foramen Ovale ◽  
Transcatheter Closure ◽  
Recurrent Stroke ◽  
Cryptogenic Stroke ◽  
Foramen Ovale ◽  
Device Closure ◽  
Specific Patient ◽  
Higher Sensitivity

AbstractTranscatheter closure of patent foramen ovale (PFO) is an effective therapy for preventing recurrent stroke in very specific patient cohorts, such as cryptogenic stroke (CS). The identification of high-risk PFO, which is more likely to be linked to CS, is essential. This study aimed to assess the accuracy of saline contrast transthoracic echocardiography (TTE) for evaluating large right-to-left (RL) shunt. We enrolled 119 patients with or without CS who were confirmed to have PFO by transesophageal echocardiography (TEE) or catheterization. The severity of RL shunt evaluated by TTE and TEE was classified as follows: small (< 10 microbubbles), moderate (10–20 microbubbles), and large (> 20 microbubbles). With TTE, large RL shunt was observed in 94 (79%) of 119 patients, including 66 of 74 with CS and 28 of 45 without CS. With TEE, large RL shunt was observed in 33 (28 %) patients, including 26 with CS and 7 without CS. TTE showed large RL shunt more frequently than TEE (p < 0.01). Large RL shunt evaluated by TTE had a sensitivity of 89 % and an accuracy of 70 % for the association with CS, whereas large RL shunt evaluated by TEE had a sensitivity of 35% and an accuracy of 56 %. Accuracy was significantly greater in TTE than in TEE (p = 0.02). In conclusion, TTE identified large RL shunt associated with CS with higher sensitivity and accuracy compared to TEE. Our findings suggest that the decision for device closure should be made based on the severity of RL shunt by TTE.

scholarly journals Device closure for patent foramen ovale in patients with cryptogenic stroke: which patients should get it?

2020 ◽  
Vol 22 (Supplement_M) ◽  
pp. M43-M50
Author(s):  
Iris Parrini ◽  
Enrico Cecchi ◽  
Davide Forno ◽  
Alexander R Lyon ◽  
Riccardo Asteggiano
Keyword(s):  
Medical Therapy ◽  
Patent Foramen Ovale ◽  
Cryptogenic Stroke ◽  
Stroke Recurrence ◽  
Cardiac Complications ◽  
Atrial Septal Aneurysm ◽  
Foramen Ovale ◽  
Device Closure ◽  
Meta Analyses ◽  
Pfo Closure

Abstract Patent foramen ovale (PFO) and cryptogenic stroke (CS) both have a high prevalence. The optimal treatment to reduce stroke recurrence after CS remains controversial. Results from clinical trials, meta-analyses, and position papers, support percutaneous PFO device closure and medical therapy compared to medical therapy alone. However, the procedure may be associated with cardiac complications including an increased incidence of new atrial fibrillation. The benefit/risk balance should be determined on a case-by-case basis with the greatest benefit of PFO closure in patients with atrial septal aneurysm and PFO with large shunts. Future studies should address unsolved questions such as the choice of medical therapy in patients not undergoing closure, the duration of antiplatelet therapy, and the role of PFO closure in patients over 60 years old.

Patent foramen ovale

2020 ◽  
Vol 20 (3) ◽  
pp. 225-233 ◽  
Author(s):  
Vafa Alakbarzade ◽  
Tracey Keteepe-Arachi ◽  
Nazia Karsan ◽  
Robin Ray ◽  
Anthony C Pereira
Keyword(s):  
Antiplatelet Therapy ◽  
Patent Foramen Ovale ◽  
Cryptogenic Stroke ◽  
Paradoxical Embolism ◽  
Current Evidence ◽  
Atrial Septal Aneurysm ◽  
Foramen Ovale ◽  
Peripheral Ischaemia ◽  
New Evidence ◽  
Pfo Closure

Patent foramen ovale (PFO) is the most common anatomical cause of an interatrial shunt. It is usually asymptomatic but may cause paradoxical embolism, manifesting as stroke, myocardial infarction or visceral/peripheral ischaemia. PFO is a risk factor for stroke and may be associated with migraine with aura. New evidence suggests PFO closure reduces the risk of recurrent ischaemic stroke in a highly selected population of stroke survivors: those aged 60 years or younger with a cryptogenic stroke syndrome, a large right-to-left shunt, an atrial septal aneurysm and no evidence of atrial fibrillation. They benefit from percutaneous PFO closure in addition to antiplatelet therapy, rather than antiplatelet therapy alone. Current evidence does not support PFO closure in the treatment of migraine.

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