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    Echocardiographic evaluation of partial anomalous pulmonary venous drainage. Wong M L,McCrindle B W,Mota C,Smallhorn J F Journal of the American College of Cardiology OBJECTIVES:This study was undertaken to determine the accuracy of routine echocardiography in the detection of partial anomalous pulmonary venous drainage. BACKGROUND:Although there are occasional case reports of the echocardiographic appearance of partial anomalous pulmonary venous drainage, no large series have addressed the accuracy of this technique in a large cohort of patients. METHODS:Between January 1983 and December 1993, 50 patients with partial anomalous pulmonary venous drainage (with or without an associated atrial septal defect as the only other significant intracardiac defect) were identified from the data base at the Hospital For Sick Children, Toronto. Routine echocardiographic reports were reviewed, and the results were compared with surgical or catheterization findings. Risk factors related to diagnostic errors were sought using a Fisher exact test, chi-square analysis, t test and Kruskal-Wallis analysis of variance. RESULTS:Confirmation of the diagnosis was available in 45 patients whose data were subsequently used for risk factor analysis. The median age at echocardiography was 4.1 years (range 1 month to 18 years). Right-sided drainage was present in 43 patients (86%), with left-sided drainage in 7 (14%). Thirteen patients had an intact atrial septum, 7 a patent foramen ovale and 30 a secundum atrial septal defect. Right ventricular dilation was observed in 46 patients. Two had normal dimensions (two not assessed). The diagnosis was missed by echocardiography in 15 (33%) of the 45 patients with a confirmed diagnosis. Year of study and use of color flow mapping were the only significant variables related to detection rate (7% missed diagnosis with vs. 62% without the use of color flow, p < 0.0005). The median year of missed diagnosis was 1985 versus 1990 (p < 0.002). Transesophageal echocardiography accurately defined the site of drainage in all three patients in whom it was utilized. CONCLUSIONS:Two-dimensional echocardiography in conjunction with color flow mapping is a valuable tool for the diagnosis of partial anomalous pulmonary venous drainage. 10.1016/0735-1097(95)80029-g
    Carcinoid heart disease. Clinical and echocardiographic spectrum in 74 patients. Pellikka P A,Tajik A J,Khandheria B K,Seward J B,Callahan J A,Pitot H C,Kvols L K Circulation BACKGROUND:The carcinoid syndrome is a rare cause of acquired valvular heart disease. Although the typical echocardiographic features of carcinoid heart disease are well recognized, this large series provides new information about unusual manifestations of the disease as well as the role of Doppler echocardiography. METHODS AND RESULTS:Between 1980 and 1989, 132 patients with carcinoid syndrome underwent echocardiographic study. The echocardiographic, Doppler, and clinical features of the 74 patients (56%) with echocardiographic evidence of carcinoid heart disease are described. Among these patients, 97% had shortened, thickened tricuspid leaflets. Tricuspid regurgitation was present in all 69 patients with carcinoid heart disease who underwent Doppler examination, and it was of moderate or severe degree in 62 patients (90%). Severe tricuspid regurgitation was characterized by a dagger-shaped Doppler spectral profile with an early peak pressure and rapid decline. The pressure half-time was prolonged (mean, 116 msec), which is consistent with associated tricuspid stenosis. The pulmonary valve appeared thickened, retracted, and immobile in 36 patients (49%) and was diminutive to the extent of not being visualized in an additional 29 patients (39%). Among the 47 patients who underwent Doppler evaluation of the pulmonary valve, regurgitation was present in 81%, and stenosis was present in 53%. Left-sided valvular involvement was present in five patients (7%), four of whom had patent foramen ovale or carcinoid tumor involving the lung. Previously undescribed myocardial metastases were present in three patients (4%) and were confirmed by biopsy in each case. Small pericardial effusions were present in 10 patients (14%). Patients with and without echocardiographic evidence of carcinoid heart disease did not differ with regard to sex, age, location of the primary tumor, duration of diagnosis, or duration of symptoms of carcinoid syndrome. However, the mean pretreatment level of urinary 5-hydroxyindoleacetic acid was higher in patients with carcinoid heart disease than in patients without carcinoid heart disease (270 versus 131 mg/24 hrs, p < 0.001). The symptom of dyspnea was more prevalent among patients with carcinoid heart disease than in patients without the disease (54% versus 27%, p = 0.003); as expected, heart murmurs were also noted more frequently in patients with disease (92% versus 43%, p < 0.0001). Treatment regimens and response to therapy were similar in the two groups. Survival of patients with echocardiographic evidence of carcinoid heart disease was reduced compared with those without cardiac involvement (p = 0.0003). ECG and chest roentgenographic findings in patients with carcinoid heart disease were nonspecific. CONCLUSIONS:The broad spectrum of carcinoid heart disease is detailed in this large series. This includes not only right-sided valvular lesions but also left-sided involvement, pericardial effusion, and myocardial metastases. 10.1161/01.cir.87.4.1188
    Frequency of atrial septal aneurysms in patients with cerebral ischemic events. Agmon Y,Khandheria B K,Meissner I,Gentile F,Whisnant J P,Sicks J D,O'Fallon W M,Covalt J L,Wiebers D O,Seward J B Circulation BACKGROUND:Atrial septal aneurysm (ASA) is a putative risk factor for cardioembolism. However, the frequency of ASA in the general population has not been adequately determined. Therefore, the frequency in patients with cerebral ischemic events, compared with the frequency in the general population, is poorly defined. We sought to determine the frequency of ASA in the general population and to compare the frequency of ASA in patients with cerebral ischemic events with the frequency in the general population. METHODS AND RESULTS:The frequency of ASA in the population was determined in 363 subjects, a sample of the participants in the Stroke Prevention: Assessment of Risk in a Community study (control subjects), and was compared with the frequency in 355 age- and sex-matched patients undergoing transesophageal echocardiography in search of a cardiac source of embolism after a focal cerebral ischemic event. The proportion with ASA was 7.9% in patients versus 2.2% in control subjects (P=0.002; odds ratio of ASA, 3.65; 95% CI, 1.64 to 8.13, in patients versus control subjects). Patent foramen ovale (PFO) was detected with contrast injections in 56% of subjects with ASA. The presence of ASA predicted the presence of PFO (odds ratio of PFO, 4.57; 95% CI, 2.18 to 9.57, in subjects with versus those without ASA). In 86% of subjects with ASA and cerebral ischemia, transesophageal echocardiography did not detect an alternative source of cardioembolism other than an associated PFO. CONCLUSIONS:The prevalence of ASA based on this population-based study is 2.2%. The frequency of ASA is relatively higher in patients evaluated with transesophageal echocardiography after a cerebral ischemic event. ASA is frequently associated with PFO, suggesting paradoxical embolism as a mechanism of cardioembolism. In patients with cerebral ischemia and ASA, ASA (with or without PFO) commonly is the only potential cardioembolic source detected with transesophageal echocardiography. 10.1161/01.cir.99.15.1942
    Partial anomalous pulmonary venous connection: diagnosis by transesophageal echocardiography. Ammash N M,Seward J B,Warnes C A,Connolly H M,O'Leary P W,Danielson G K Journal of the American College of Cardiology OBJECTIVE:This study sought to demonstrate that with proper technique, identification of the normal and abnormal pulmonary venous connection can be made with confidence using transesophageal echocardiography (TEE). BACKGROUND:Partial anomalous pulmonary venous connection (PAPVC) is an uncommon congenital anomaly whose diagnosis has classically been made using angiography. METHODS:We performed a retrospective review of all patients of all ages with PAPVC diagnosed at the Mayo Clinic who had undergone TEE because of either right ventricular volume overload or suspected intracardiac shunting by transthoracic echocardiography or intraoperatively. RESULTS:A total of 66 PAPVCs were detected in 43 patients (1.5/patient); in 2 additional patients, TEE suggested, but did not diagnose, PAPVCs. Shortness of breath was the most common presenting symptom (42.2%), followed by heart murmur and supraventricular tachycardia. Right-sided anomalous veins were identified in 35 patients (81.4%), left-sided in 7 (16.3%) and bilateral in 1 (2.3%). There was a single anomalous connecting vein in 23 patients (53.5%), two in 18 (41.9%), three in 1 (2.3%) and four in 1 (2.3%). The connecting site was the superior vena cava (SVC) in 39 veins (59.1%), right atrial-SVC junction in 6 (9.1%), right atrium in 8 (12.1%), inferior vena cava in 1 (1.5%) and the coronary sinus in 2 (3.0%). Ten anomalous left pulmonary veins were connected by a vertical vein to the innominate vein (15.1%). Sinus venosus atrial septal defect (ASD) was the most common associated anomaly in 22 patients (49%), followed by ostium secundum ASD in 6 and patent foramen ovale in 4. Fifteen patients had an intact atrial septum. Thirty-one patients (68.8%) underwent surgical repair. PAPVC was confirmed in all patients, including the two whose TEE results were suggestive of PAPVC. All 49 PAPVCs detected by TEE preoperatively were confirmed at the time of operation. CONCLUSIONS:TEE is highly diagnostic for PAPVC and can obviate angiography. Accurate anatomic diagnosis may influence the need for medical and surgical management. TEE should be performed in patients with right ventricular volume overload when the precordial examination is inconclusive. 10.1016/s0735-1097(97)82758-1
    Atrial septal aneurysm in adult patients. A multicenter study using transthoracic and transesophageal echocardiography. Mügge A,Daniel W G,Angermann C,Spes C,Khandheria B K,Kronzon I,Freedberg R S,Keren A,Denning K,Engberding R Circulation BACKGROUND:An atrial septal aneurysm (ASA) is a well-recognized abnormality of uncertain clinical relevance. We reevaluated the clinical significance of ASA in a large series of patients. The aims of the study were to define morphological characteristics of ASA by transesophageal echocardiography (TEE), to define the incidence of ASA-associated abnormalities, and to investigate whether certain morphological characteristics of ASA are different in patients with and without previous events compatible with cardiogenic embolism. METHODS AND RESULTS:Patients with ASA were enrolled from 11 centers between May 1989 and October 1993. All patients had to undergo transthoracic and transesophageal echocardiography within 24 hours of each other; ASA was defined as a protrusion of the aneurysm > 10 mm beyond the plane of the atrial septum as measured by TEE. Patients with mitral stenosis or prosthesis or after cardiothoracic surgery involving the atrial septum were excluded. Based on these criteria, 195 patients 54.6 +/- 16.0 years old (mean +/- SD) were included in this study. Whereas TEE could visualize the region of the atrial septum and therefore diagnose ASA in all patients, ASA defined by TEE was missed by transthoracic echocardiography in 92 patients (47%). As judged from TEE, ASA involved the entire septum in 100 patients (51%) and was limited to the fossa ovalis in 95 (49%). ASA was an isolated structural defect in 62 patients (32%). In 106 patients (54%), ASA was associated with interatrial shunting (atrial septal defect, n = 38; patent foramen ovale, n = 65; sinus venosus defect, n = 3). In only 2 patients (1%), thrombi attached to the region of the ASA were noted. Prior clinical events compatible with cardiogenic embolism were associated with 87 patients (44%) with ASA; in 21 patients (24%) with prior presumed cardiogenic embolism, no other potential cardiac sources of embolism were present. Length of ASA, extent of bulging, and incidence of spontaneous oscillations were similar in patients with and without previous cardiogenic embolism; however, associated abnormalities such as atrial shunts were significantly more frequent in patients with possible embolism. CONCLUSIONS:As shown previously, TEE is superior to the transthoracic approach in the diagnosis of ASA. The most common abnormalities associated with ASA are interatrial shunts, in particular patent foramen ovale. In this retrospective study, patients with ASA (especially with shunts) showed a high frequency of previous clinical events compatible with cardiogenic embolism; in a significant subgroup of patients, ASA appears to be the only source of embolism, as judged by TEE. Our data are consistent with the view that ASA is a risk factor for cardiogenic embolism, but thrombi attached to ASA as detected by TEE are apparently rare. 10.1161/01.cir.91.11.2785
    Chiari's network: normal anatomic variant or risk factor for arterial embolic events? Schneider B,Hofmann T,Justen M H,Meinertz T Journal of the American College of Cardiology OBJECTIVES:This study was performed to assess the prevalence of Chiari's network in patients undergoing transesophageal echocardiography and to determine whether this anomaly is associated with other cardiac lesions or is characterized by typical clinical findings. BACKGROUND:Chiari's network is a congenital remnant of the right valve of the sinus venosus. It has been found in 1.3% to 4% of autopsy studies and is believed to be of little clinical consequence. METHODS:Video recordings of 1,436 consecutive adult patients evaluated by transesophageal echocardiography over a 30-month period were reviewed for the presence of Chiari's network. Echocardiographic contrast studies had been performed in all patients with Chiari's network and were compared with those of 160 consecutive patients without a Chiari net, serving as a control group. RESULTS:Chiari's network was present in 29 of 1,436 patients (prevalence 2%). A frequently associated finding was a patent foramen ovale in 24 (83%) of the 29 patients with Chiari's network versus 44 (28%) of 160 control patients (p < 0.001). Intense right-to-left shunting occurred significantly more often in patients with Chiari's network than in control patients (16 [55%] of 29 patients vs. 19 [12%] of 160 control patients, p < 0.001). Another frequent association was an atrial septal aneurysm in 7 (24%) of 29 patients. The indication for transesophageal echocardiography was a suspected cardiac source of arterial embolism in 24 (83%) of 29 patients with a Chiari net, 13 of whom (54%) had recurrent embolic events. Chiari's network was significantly more common in patients with unexplained arterial embolism than in patients evaluated for other indications (24 [4.6%] of 522 patients vs. 5 [0.5%] of 914 patients, p < 0.001). Potential causes for arterial embolism were present in 9 of the 24 patients with a Chiari net and embolic events (atrial septal aneurysm in 7, cerebrovascular lesion in 2). In 15 (62%) of 24 patients only a patent foramen ovale could be identified. Three patients had deep venous thrombosis and pulmonary embolism at the time of arterial embolism; none had a thrombus detected within the network. CONCLUSIONS:In patients undergoing transesophageal echocardiography, the prevalence of Chiari's network was 2%, which is consistent with autopsy studies. By maintaining an embryonic right atrial flow pattern into adult life and directing the blood from the inferior vena cava preferentially toward the interatrial septum, Chiari's network may favor persistence of a patent foramen ovale and formation of an atrial septal aneurysm and facilitate paradoxic embolism. 10.1016/0735-1097(95)00144-o
    Transoesophageal echocardiographic evaluation of atrial morphology in children with congenital heart disease. Tuccillo B,Stümper O,Hess J,van Suijlen R J,Bos E,Roelandt J R,Sutherland G R European heart journal In a prospective study, atrial morphology was evaluated by both transoesophageal and precordial echocardiography in 86 unoperated children with congenital heart disease (age range = 0.2 to 14.8 years, mean = 3.8 years) to determine what advantages, if any, might be inherent in the transoesophageal approach. The information derived from both ultrasound approaches was correlated and compared to information obtained during subsequent cardiac catheterization (78 patients) and, or, surgical inspection (53 patients). Atrial appendage morphology and hence atrial situs was determined by transoesophageal echocardiography in every case (82 solitus, two right atrial isomerism, two left atrial isomerism). In addition, the transoesophageal approach indicated left juxtaposition in four patients, compared to only one by precordial examination. Probe patency of the foramen ovale was correctly predicted in 21 patients by transoesophageal imaging, but in only 10 by precordial imaging. In two children significant secundum defects, undetected by the precordial route, were identified. Multiple atrial septal defects were correctly defined in four patients by transoesophageal study but in only one by precordial study. Sinus venosus defects were documented in four by the transoesophageal approach, but in only one by the precordial. Primum defects were equally well documented (nine patients) by either technique, but the associated valve leaflet morphology was better documented by transoesophageal study in 5/9. A subtotal cor triatriatum was diagnosed in one child only by transoesophageal investigation. Transoesophageal echocardiography allows a much more detailed evaluation of atrial morphology than precordial imaging even in infants. It provides direct diagnosis of atrial situs, detection of juxtaposed atrial appendages and improved demonstration or definitive exclusion of atrial septal defects. 10.1093/oxfordjournals.eurheartj.a060151
    Transcatheter closure of atrial septal defects without fluoroscopy: feasibility of a new method. Ewert P,Berger F,Daehnert I,van Wees J,Gittermann M,Abdul-Khaliq H,Lange P E Circulation BACKGROUND:In an effort to reduce x-ray exposure, we developed a technique for transcatheter closure of atrial septal defects under echocardiographic guidance without fluoroscopy. To assess the efficiency of this procedure for routine use, we compared our initial results with those for the conventional procedure. METHODS AND RESULTS:Twenty-two randomly selected patients (median age 18 years; range 2 to 66 years) with atrial septal defects (n=13) or patent foramen ovale (n=9) underwent cardiac catheterization for possible interventional defect closure with echocardiography as the only imaging tool. Median stretched diameter was 9 mm (range 6 to 26 mm); median left-to-right shunt over the atrial septal defects was Qp/Qs=1.8 (range 1.5 to 2.6). An Amplatzer septal occluder was successfully implanted in 19 defects without fluoroscopy and in 3 with the help of radiography. After 1 month, complete defect closure was documented in all patients. Compared with the conventional procedure of a control group of 131 patients, procedure times were not significantly different (88 versus 100 minutes; P=0.09). However, the study group received significantly higher doses of propofol for sedation (9.9 versus 5.6 mg/kg body weight; P=0.002) owing to extended transesophageal echocardiography. CONCLUSIONS:In the majority of patients in whom transcatheter closure of interatrial communications with the Amplatzer septal occluder is possible, the procedure can be safely performed under echocardiographic guidance without fluoroscopy. 10.1161/01.cir.101.8.847
    Contrast echocardiographic visualization of cough-induced right to left shunt through a patent foramen ovale. Dubourg O,Bourdarias J P,Farcot J C,Gueret P,Terdjman M,Ferrier A,Rigaud M,Bardet J C Journal of the American College of Cardiology In a series of 24 consecutive patients referred to the echocardiography laboratory because of suspected patent foramen ovale, contrast two-dimensional and M-mode echocardiographic studies were performed during normal breathing and during two provocative tests: the Valsalva maneuver and cough. A right to left shunt was visualized in 8 patients during normal breathing, in 11 patients during the Valsalva maneuver and in 17 patients during the cough test. Cardiac catheterization performed in all 24 patients and postmortem examination available in 3 patients confirmed the patency of the foramen ovale in only 15 patients. In these 15 patients, echo contrast appeared in the left heart cavities in early systole and almost simultaneously with complete right heart opacification. In contrast, for the two false positive results during the cough test, ultrasound contrast appeared at any time of the cardiac cycle when the right heart cavities had been partially cleared of contrast material. Right and left atrial pressures were simultaneously measured in four patients, and the normal interatrial pressure gradient was reversed during the Valsalva maneuver and the cough test. Echocardiography during both provocative tests showed that the interatrial septum flattened or became convex toward the left atrium. The cough test appears to be more reliable and easier to perform in critically ill patients than the Valsalva maneuver for the detection of right to left shunting through a patent foramen ovale. 10.1016/s0735-1097(84)80106-0
    Transmitral Doppler: a new transthoracic contrast method for patent foramen ovale detection and quantification. Kerr A J,Buck T,Chia K,Chow C M,Fox E,Levine R A,Picard M H Journal of the American College of Cardiology OBJECTIVES:This study compared a new transthoracic echocardiographic (TTE) method for detection of right to left bubble passage, transmitral Doppler (TMD), against two-dimensional (2D) TTE contrast study and the gold standard, of transesophageal echocardiography (TEE), and assessed its utility in quantitative assessment of patent foramen ovales (PFO). BACKGROUND:Current TTE methods are relatively insensitive in PFO detection and do not allow quantitative assessment of right to left shunt. METHODS:In 44 patients (59 years, range 34 to 76 years) saline contrast and color Doppler studies were performed in three conditions--TTE TMD, TTE 2D and TEE. Bubble transit on the TMD was measured semiquantitatively by a visual bubble score and objectively by integrating the acoustic power within the mitral velocity envelope. RESULTS:By TEE it was determined that 17 patients (39%) had PFOs; 16 had right to left contrast passage, and only 1 had left to right flow by color Doppler. Against TEE contrast study, the sensitivity of TMD and 2D contrast studies were 100% and 75%, respectively, with specificity of 96% and 100%. Greater than 10 bubbles on a single beat of the resting contrast TMD identified patients with a maximum resting TEE PFO opening diameter >2 mm with 78% sensitivity and 100% specificity. There was a strong correlation (r2 = 0.72, p<0.01) between the TMD acoustic power and PFO opening diameter. CONCLUSIONS:Transmitral Doppler is a sensitive and specific method for TTE PFO detection that allows quantification of right to left bubble passage and may obviate the need for TEE in many patients after stroke. 10.1016/s0735-1097(00)00951-7
    Significance of left-sided heart disease for the detection of patent foramen ovale by transesophageal contrast echocardiography. Siostrzonek P,Lang W,Zangeneh M,Gössinger H,Stümpflen A,Rosenmayr G,Heinz G,Schwarz M,Zeiler K,Mösslacher H Journal of the American College of Cardiology Detection of patent foramen ovale by contrast echocardiography is based on transient inversion (right atrial pressure higher than left atrial pressure) of the interatrial pressure gradient. Therefore, the presence of left-sided heart disease with potential elevation of left atrial pressure might obscure the diagnosis of patent foramen ovale. Accordingly, 150 patients (88 men, 62 women; mean age 51.7 +/- 15.2 years) were evaluated for a patent foramen ovale by transesophageal contrast echocardiography. Additionally, atrial septal motion during normal respiration and during the Valsalva maneuver was analyzed. Patency of the foramen ovale was observed in 20 (27%) of 74 patients without left-sided heart disease and with previous arterial embolism, in none (0%) of 25 patients with left-sided heart disease and embolism, in 7 (39%) of 18 patients without left-sided heart disease and without embolism and in 3 (9%) of 33 patients with left-sided heart disease and without embolism. The detection rate of patent foramen ovale was lower in patients with than without left-sided heart disease (5% vs. 29%, p = 0.0007) but was similar in patients with and without embolism (20% vs. 19.5%, p = NS). Abnormal atrial septal motion was more frequently observed in patients with left-sided heart disease (p = 0.0003) and was inversely correlated to detection of patent foramen ovale (p = 0.0003). Multivariate analysis revealed an independent association between the absence of left-sided heart disease and the detection of patent foramen ovale (p = 0.0003). These data suggest that in patients with left-sided heart disease, patency of the foramen ovale may be missed even by transesophageal contrast echocardiography. 10.1016/0735-1097(92)90323-f
    Transesophageal echocardiographic diagnosis of right to left shunting across the foramen ovale in adults without prior stroke. Louie E K,Konstadt S N,Rao T L,Scanlon P J Journal of the American College of Cardiology OBJECTIVES:The purpose of this study was to estimate the prevalence of potential right to left interatrial shunting and to quantify the morphologic characteristics of the fossa ovalis in adults without a prior history of stroke or systemic embolism. BACKGROUND:Paradoxic embolization through a patent foramen ovale is an important cardiac mechanism for embolic stroke. Although anatomic and physiologic data obtained by transesophageal echocardiography increase the frequency of demonstration of potential cardiac sources of systemic embolism and occasionally can conclusively demonstrate the mechanism for embolic stroke, the prevalence and prognostic implications of these findings in neurologically healthy persons are still being actively investigated. METHODS:Intraoperative transesophageal saline contrast echocardiography was performed on 50 adult patients without prior history of stroke or systemic embolism who were undergoing elective cardiovascular surgery. RESULTS:No patient had a manifest atrial septal defect by right heart oximetric measurements or transesophageal Doppler echocardiographic examination. Eleven of the 50 patients demonstrated right to left atrial passage of saline contrast medium during apnea or after release of 20-cm H2O positive airway pressure, signifying patency of the foramen ovale. These 11 patients with a patent foramen ovale had increased total excursion of the flap valve (septum primum) of the fossa ovalis (1.3 +/- 0.7 cm) compared with findings in the 39 patients without a patent foramen ovale (0.3 +/- 0.5 cm, p < 0.001). All patients with a patent foramen ovale exhibited some mobility of the septum primum and 73% of these patients had > or = 1 cm total excursion of the septum primum. In contrast, 56% of patients without a patent foramen ovale exhibited no motion of the septum primum out of the plane of the atrial septum. The maximal diameter of the fossa ovalis was greater in patients with (1.4 +/- 0.4 cm) than in patients without (1.0 +/- 0.3 cm, p < 0.003) a patent foramen ovale. CONCLUSIONS:Hypermobility of the septum primum and enlargement of the fossa ovalis are morphologic findings that occur in the presence of a patent foramen ovale. 10.1016/0735-1097(93)90251-u
    Patent foramen ovale: a review of associated conditions and the impact of physiological size. Kerut E K,Norfleet W T,Plotnick G D,Giles T D Journal of the American College of Cardiology Patent foramen ovale (PFO) is implicated in platypnea-orthodeoxia, stroke and decompression sickness (DCS) in divers and astronauts. However, PFO size in relation to clinical illness is largely unknown since few studies evaluate PFO, either functionally or anatomically. The autopsy incidence of PFO is approximately 27% and 6% for a large defect (0.6 cm to 1.0 cm). A PFO is often associated with atrial septal aneurysm and Chiari network, although these anatomic variations are uncommon. Methodologies for diagnosis and anatomic and functional sizing of a PFO include transthoracic echocardiography (TTE), transesophageal echocardiography (TEE) and transcranial Doppler (TCD), with saline contrast. Saline injection via the right femoral vein appears to have a higher diagnostic yield for PFO than via the right antecubital vein. Saline contrast with TTE using native tissue harmonics or transmitral pulsed wave Doppler have quantitated PFO functional size, while TEE is presently the reference standard. The platypnea-orthodeoxia syndrome is associated with a large resting PFO shunt. Transthoracic echocardiography, TEE and TCD have been used in an attempt to quantitate PFO in patients with cryptogenic stroke. The larger PFOs (approximately > or =4 mm size) or those with significant resting shunts appear to be clinically significant. Approximately two-thirds of divers with unexplained DCS have a PFO that may be responsible and may be related to PFO size. Limited data are available on the incidence of PFO in high altitude aviators with DCS, but there appears to be a relationship. A large decompression stress is associated with extra vehicular activity (EVA) from spacecraft. After four cases of serious DCS in EVA simulations, a resting PFO was detected by contrast TTE in three cases. Patent foramen ovales vary in both anatomical and functional size, and the clinical impact of a particular PFO in various situations (platypnea-orthodeoxia, thromboembolism, DCS in underwater divers, DCS in high-altitude aviators and astronauts) may be different. 10.1016/s0735-1097(01)01427-9
    Recurrent cerebrovascular events associated with patent foramen ovale, atrial septal aneurysm, or both. Mas J L,Arquizan C,Lamy C,Zuber M,Cabanes L,Derumeaux G,Coste J, The New England journal of medicine BACKGROUND:Patent foramen ovale and atrial septal aneurysm have been identified as potential risk factors for stroke, but information about their effect on the risk of recurrent stroke is limited. We studied the risks of recurrent cerebrovascular events associated with these cardiac abnormalities. METHODS:A total of 581 patients (age, 18 to 55 years) who had had an ischemic stroke of unknown origin within the preceding three months were consecutively enrolled at 30 neurology departments. All patients received aspirin (300 mg per day) for secondary prevention. RESULTS:After four years, the risk of recurrent stroke was 2.3 percent (95 percent confidence interval, 0.3 to 4.3 percent) among the patients with patent foramen ovale alone, 15.2 percent (95 percent confidence interval, 1.8 to 28.6 percent) among the patients with both patent foramen ovale and atrial septal aneurysm, and 4.2 percent (95 percent confidence interval, 1.8 to 6.6 percent) among the patients with neither of these cardiac abnormalities. There were no recurrences among the patients with an atrial septal aneurysm alone. The presence of both cardiac abnormalities was a significant predictor of an increased risk of recurrent stroke (hazard ratio for the comparison with the absence of these abnormalities, 4.17; 95 percent confidence interval, 1.47 to 11.84), whereas isolated patent foramen ovale, whether small or large, was not. CONCLUSIONS:Patients with both patent foramen ovale and atrial septal aneurysm who have had a stroke constitute a subgroup at substantial risk for recurrent stroke, and preventive strategies other than aspirin should be considered. 10.1056/NEJMoa011503
    Transcatheter treatment of atrial septal aneurysm associated with patent foramen ovale for prevention of recurrent paradoxical embolism in high-risk patients. Wahl Andreas,Krumsdorf Ulrike,Meier Bernhard,Sievert Horst,Ostermayer Stephan,Billinger Kai,Schwerzmann Markus,Becker Ulf,Seiler Christian,Arnold Marcel,Mattle Heinrich P,Windecker Stephan Journal of the American College of Cardiology OBJECTIVES:This study sought to investigate the safety and efficacy of transcatheter treatment of atrial septal aneurysm (ASA) associated with patent foramen ovale (PFO). BACKGROUND:Patients with both ASA and PFO are at high risk for recurrent paradoxical embolism. METHODS:The procedural, echocardiographic, and clinical outcomes of 141 patients with ASA + PFO and > or =1 paradoxical embolic event undergoing transcatheter treatment were compared with 220 patients with PFO alone. RESULTS:Device success (ASA + PFO, 99.3%; PFO alone, 99.5%; p = 0.75) and procedural complications (ASA + PFO, 0.7%; PFO alone, 3.2%; p = 0.12) were similar in both groups. Maximal atrial septal excursion in patients with ASA + PFO decreased from 16 +/- 4 mm before to 4 +/- 3 mm after the intervention (p < 0.0001). At 6 months follow-up, right-to-left shunt was abolished in 120 (86%) patients with ASA + PFO, compared to 187 (85%) patients with PFO alone (p = 0.80). Freedom from recurrent transient ischemic attack, stroke, and peripheral embolism at 4 years was 95% (ASA + PFO) and 94% (PFO alone, p = 0.70), respectively. A residual right-to-left shunt after the intervention was the only predictor for recurrence (hazard ratio [HR] 6.9; 95% confidence interval [CI] 1.3 to 36.9, p < 0.03) in patients with ASA + PFO. CONCLUSIONS:Transcatheter treatment of ASA + PFO is safe and effective in patients with paradoxical embolism. The procedure effectively abolishes right-to-left shunt and decreases atrial septal mobility. Long-term prevention of recurrent events appears favorable when compared to patients with PFO alone. 10.1016/j.jacc.2004.10.043
    Cardiac magnetic resonance imaging and transesophageal echocardiography in patients with transcatheter closure of patent foramen ovale. Nusser Thorsten,Höher Martin,Merkle Nico,Grebe Olaf C,Spiess Jochen,Kestler Hans A,Rasche Volker,Kochs Matthias,Hombach Vinzenz,Wöhrle Jochen Journal of the American College of Cardiology OBJECTIVES:We studied the value of cardiac magnetic resonance imaging (CMRI) before and after closure of patent foramen ovale (PFO) in patients with cryptogenic ischemic events. BACKGROUND:Cardiac magnetic resonance imaging is a powerful noninvasive tool for detailed assessment of cardiac anatomy and function. The relevance of CMRI compared with transesophageal echocardiography (TEE) in patients undergoing transcatheter PFO closure has not been evaluated so far. METHODS:Contrast-enhanced CMRI and TEE were performed in 75 patients before and after PFO closure. Twelve months after PFO closure, both imaging techniques were repeated in 61 patients with contrast application. To determine provokable atrial right-to-left shunting in CMRI, we applied a contrast-enhanced perfusion imaging technique. Detection of atrial septal aneurysm (ASA) was achieved by means of a high-resolution cine imaging technique. RESULTS:Before PFO closure, ASA was seen with CMRI in 28 of 75 cases (37.3%), compared with 47 of 75 (62.7%) cases using TEE. There were a total of 211 CMRI studies with a corresponding TEE performed in 75 patients. No shunt was present in 107 of 211 studies with both techniques. Contrast-enhanced right-to-left shunting was detected by CMRI in 48 of 72 (66.6%) cases with moderate or severe shunts seen with TEE, but only in 6 of 32 (18.8%) studies with mild shunts with TEE. Anomalous venous returns were excluded in all patients. In two patients, coronary anomalies were seen. CONCLUSIONS:The present CMRI technique is inferior to TEE in detection of contrast-enhanced right-to-left shunting and identification of ASA. 10.1016/j.jacc.2006.03.036
    Prevalence and repair of intraoperatively diagnosed patent foramen ovale and association with perioperative outcomes and long-term survival. Krasuski Richard A,Hart Stephen A,Allen Drew,Qureshi Athar,Pettersson Gosta,Houghtaling Penny L,Batizy Lillian H,Blackstone Eugene JAMA CONTEXT:A recent survey suggested that cardiothoracic surgeons may alter planned procedures to repair incidentally discovered patent foramen ovale (PFO). How frequently this occurs and the impact on outcomes remain unknown. OBJECTIVE:To measure the frequency of incidentally discovered PFO closure during cardiothoracic surgery and determine its perioperative and long-term impact. DESIGN, SETTING, AND PATIENTS:We reviewed the intraoperative transesophageal echocardiograms of 13,092 patients without prior diagnosis of PFO or atrial septal defect undergoing surgery at the Cleveland Clinic, Cleveland, Ohio, from 1995 through 2006. Postoperative outcomes were prospectively collected until discharge. MAIN OUTCOME MEASURES:All-cause hospital mortality and stroke were predetermined primary outcomes; length of hospital stay, length of intensive care unit stay, and time on cardiopulmonary bypass were secondary outcomes. RESULTS:Intraoperative PFO was diagnosed in 2277 patients in the study population (17%), and risk factors for stroke were similar in patients with and without PFO. After propensity matching was performed with the comparator groups, patients with PFO demonstrated similar rates of in-hospital death (3.4% vs 2.6%, P = .11) and postoperative stroke (2.3% vs 2.3%, P = .84). Surgical closure was performed in 639 PFO patients (28%), and surgeons were more likely to close defects in patients who were younger (mean [SD] age, 61.1 [14] vs 64.4 [13] years; P < .001), were undergoing mitral or tricuspid valve surgery (51% vs 32%, P < .001), or had history of transient ischemic attack or stroke (16% vs 10%, P < .001). Patients with repaired PFO demonstrated a 2.47-times greater odds (95% confidence interval, 1.02-6.00) of having a postoperative stroke compared with those with unrepaired PFO (2.8% vs 1.2%, P = .04). Long-term analysis demonstrated that PFO repair was associated with no survival difference (P = .12). CONCLUSIONS:Incidental PFO is common in patients undergoing cardiothoracic surgery but is not associated with increased perioperative morbidity or mortality. Surgical closure appears unrelated to long-term survival and may increase postoperative stroke risk. 10.1001/jama.2009.1012
    Permanent right-to-left shunt is the key factor in managing patent foramen ovale. Rigatelli Gianluca,Dell'Avvocata Fabio,Cardaioli Paolo,Giordan Massimo,Braggion Gabriele,Aggio Silvio,Chinaglia Mauro,Mandapaka Sangeeta,Kuruvilla John,Chen Jack P,Nanjundappa Aravinda Journal of the American College of Cardiology OBJECTIVES:We sought to prospectively evaluate risk of stroke and impact of transcatheter patent foramen ovale (PFO) closure in patients with permanent right-to left shunt compared with those with Valsalva maneuver-induced right-to-left shunt. BACKGROUND:Pathophysiology and properly management of PFO still remain far from being fully clarified: in particular, the contribution of permanent right-to-left shunt remains unknown. METHODS:Between March 2006 and October 2010, we enrolled 180 (mean age 44 ± 10.9 years, 98 women) of 320 consecutive patients referred to our center for transcatheter PFO closure, who had spontaneous permanent right-to-left shunt on transcranial Doppler and transthoracic/transesophageal echocardiography. All patients fulfilled the standard current indications for transcatheter closure and underwent preoperative transesophageal echocardiography and brain magnetic resonance imaging, with subsequent intracardiac echocardiographic-guided transcatheter PFO closure. We compared the clinical echocardiographic characteristics of these patients (Permanent Group) with the rest of 140 patients with right-to-left shunt only during Valsalva maneuver (Valsalva Group). RESULTS:Compared with the Valsalva Group patients, patients of the Permanent Group had increased frequency of multiple ischemic brain lesions on magnetic resonance imaging, previous recurrent stroke, previous peripheral arteries embolism, migraine with aura, and-more frequently-atrial septal aneurysm and prominent Eustachian valve. The presence of permanent shunt confers the highest risk of recurrent stroke (odds ratio: 5.9, 95% confidence interval: 2.0 to 12, p < 0.001). No differences were recorded between the 2 groups with regard to recurrence of ischemic events after the closure procedure. CONCLUSIONS:Despite its small-sample nature, our study suggests that patients with permanent right-to-left shunt have potentially a higher risk of paradoxical embolism compared with those without. 10.1016/j.jacc.2011.06.064
    End-inspiratory occlusion maneuver during transesophageal echocardiography for patent foramen ovale detection in intensive care unit patients. Koroneos Apostolos,Politis Panagiotis,Malachias Sotiris,Manolis Antonis S,Vassilakopoulos Theodoros Intensive care medicine OBJECTIVE:Mechanically ventilated patients in the intensive care unit cannot cooperate to perform the Valsalva maneuver during echocardiography for detection of patent foramen ovale. We evaluated the effectiveness of the end-inspiratory occlusion maneuver to enhance detection of patent foramen ovale in this patient population. DESIGN:Prospective interventional study. SETTING:The 40-bed intensive care unit of a university hospital. PATIENTS AND PARTICIPANTS:Twenty five sedated and mechanically ventilated intensive care unit patients referred by their attending physician for bedside transesophageal echocardiography and agitated saline contrast study for detection of patent foramen ovale. INTERVENTION:Agitated saline contrast study with end-inspiratory occlusion maneuver. MEASUREMENTS AND RESULTS:All patients underwent a complete transesophageal echocardiographic study without any complications. Reduction in right atrial cross-sectional area (from 15.80 +/- 6.08 cm2 to 12.40 +/- 4.63 cm2; p < 0.001) and interatrial septum deviation during the maneuver were recorded in all patients. Microbubbles imaged in the left atrium within three cardiac cycles after injection of agitated saline diagnosed patent foramen ovale in three patients. When end-inspiratory occlusion maneuver was added, patent foramen ovale was diagnosed in seven patients (McNemar chi2 = 9.33, p = 0.0023). CONCLUSIONS:The end-inspiratory occlusion maneuver enhances the sensitivity of transesophageal echocardiography with agitated saline contrast study for diagnosing intermittent patent foramen ovale in critically ill mechanically ventilated patients. 10.1007/s00134-007-0639-6
    Inter-atrial shunt inversion by the sitting position in a patient with a patent foramen ovale and acute pulmonary embolism. Valbusa Filippo,Bonapace Stefano,Lanzoni Laura,Tubaro Alessandro,Delaini Carlo,Barbieri Enrico,Targher Giovanni,Arcaro Guido European heart journal 10.1093/eurheartj/ehu018
    European position paper on the management of patients with patent foramen ovale. Part II - Decompression sickness, migraine, arterial deoxygenation syndromes and select high-risk clinical conditions. Pristipino Christian,Germonpré Peter,Toni Danilo,Sievert Horst,Meier Bernhard,D'Ascenzo Fabrizio,Berti Sergio,Onorato Eustaquio Maria,Bedogni Francesco,Mas Jean-Louis,Scacciatella Paolo,Hildick-Smith David,Gaita Fiorenzo,Kyrle Paul A,Thomson John,Derumeaux Genevieve,Sibbing Dirk,Chessa Massimo,Hornung Marius,Zamorano Jose,Dudek Dariusz, ,D'Ascenzo Fabrizio,Omedè Pierluigi,Ballocca Flavia,Barbero Umberto,Giordana Francesca,Gili Sebastiano,Iannaccone Mario, ,Akagi Teiji,Anzola Gianpaolo,Carroll John,Dalvi Bharat,Angelis Claudio De,Junbo Ge,Kasner Scott E,Michel-Behnke Ina,Musumeci Giuseppe,Søndergaard Lars,Tarantini Giuseppe,Biondi-Zoccai Giuseppe G L, , ,Capodanno Davide,Valgimigli Marco,Byrne Robert,Kunadian Vijay European heart journal Patent foramen ovale (PFO) is implicated in the pathogenesis of a number of medical conditions but to date only one official position paper related to left circulation thromboembolism has been published. This interdisciplinary paper, prepared with the involvement of eight European scientific societies, reviews the available evidence and proposes a rationale for decision making for other PFO-related clinical conditions. In order to guarantee a strict evidence-based process, we used a modified grading of recommendations, assessment, development, and evaluation (GRADE) methodology. A critical qualitative and quantitative evaluation of diagnostic and therapeutic procedures was performed, including assessment of the risk/benefit ratio. The level of evidence and the strength of the position statements were weighed and graded according to predefined scales. Despite being based on limited and observational or low-certainty randomised data, a number of position statements were made to frame PFO management in different clinical settings, along with suggestions for new research avenues. This interdisciplinary position paper, recognising the low or very low certainty of existing evidence, provides the first approach to several PFO-related clinical scenarios beyond left circulation thromboembolism and strongly stresses the need for fresh high-quality evidence on these topics. 10.1093/eurheartj/ehaa1070
    Patent foramen ovale. Homma Shunichi,Messé Steven R,Rundek Tatjana,Sun Yee-Ping,Franke Jennifer,Davidson Karina,Sievert Horst,Sacco Ralph L,Di Tullio Marco R Nature reviews. Disease primers Patent foramen ovale (PFO) is the most common congenital heart abnormality of fetal origin and is present in approximately ∼25% of the worldwide adult population. PFO is the consequence of failed closure of the foramen ovale, a normal structure that exists in the fetus to direct blood flow directly from the right to the left atrium, bypassing the pulmonary circulation. PFO has historically been associated with an increased risk of stroke, the mechanism of which has been attributed to the paradoxical embolism of venous thrombi that shunt through the PFO directly to the left atrium. However, several studies have failed to show an increased risk of stroke in asymptomatic patients with a PFO, and the risk of stroke recurrence is low in patients who have had a stroke that may be attributed to a PFO. With the advent of transoesophageal and transthoracic echocardiography, as well as transcranial Doppler, a PFO can be routinely detected in clinical practice. Medical treatment with either antiplatelet or anticoagulation therapy is recommended. At the current time, closure of the PFO by percutaneous interventional techniques does not appear to reduce the risk of stroke compared to conventional medical treatment, as shown by three large clinical trials. Considerable controversy remains regarding the optimal treatment strategy for patients with both cryptogenic stroke and PFO. This Primer discusses the epidemiology, mechanisms, pathophysiology, diagnosis, screening, management and effects on quality of life of PFO. 10.1038/nrdp.2015.86
    Association of Preoperatively Diagnosed Patent Foramen Ovale With Perioperative Ischemic Stroke. Ng Pauline Y,Ng Andrew K-Y,Subramaniam Balachundhar,Burns Sara M,Herisson Fanny,Timm Fanny P,Med Cand,Rudolph Maira I,Med Cand,Scheffenbichler Flora,Med Cand,Friedrich Sabine,Med Cand,Houle Timothy T,Bhatt Deepak L,Eikermann Matthias JAMA Importance:Perioperative stroke is a major complication for patients undergoing surgery. Patent foramen ovale (PFO) represents a possible anatomical link between venous thrombosis and stroke. Objective:To determine whether a preoperatively diagnosed PFO is associated with increased risk of perioperative ischemic stroke. Design, Setting, and Participants:Retrospective cohort study from Massachusetts General Hospital and 2 affiliated community hospitals between January 1, 2007, and December 31, 2015. Participants were 182 393 consecutive adults undergoing noncardiac surgery with general anesthesia. Exposures:Preoperatively diagnosed PFO. Main Outcomes and Measures:Perioperative ischemic stroke occurring within 30 days of surgery; stroke subtype by Oxfordshire Community Stroke Project classification and stroke severity by National Institute of Health Stroke Scale (NIHSS). Results:Among the 150 198 patient cases analyzed (median [SD] age, 55 [16] years), 1540 (1.0%) had a diagnosis of PFO before surgery. A total of 850 (0.6%) ischemic strokes occurred within 30 days of surgery (49 [3.2%] among patients with PFO and 801 [0.5%] among patients without PFO). In adjusted analyses, patients with PFO had an increased risk of ischemic stroke compared with patients without PFO (odds ratio, 2.66 [95% CI, 1.96-3.63]; P < .001). The estimated risks of stroke were 5.9 for every 1000 patients with PFO and 2.2 for every 1000 patients without PFO (adjusted absolute risk difference, 0.4% [95% CI, 0.2%-0.6%). Patients with PFO also had an increased risk of large vessel territory stroke (relative risk ratio, 3.14 [95% CI, 2.21-4.48]; P < .001) and a more severe stroke-related neurologic deficit measured by NIHSS (median, 4 [interquartile range {IQR}, 2-10] vs median, 3 [IQR, 1-6] for those without PFO; P = .02). Conclusions and Relevance:Among adult patients undergoing noncardiac surgery at 3 hospitals, having a preoperatively diagnosed PFO was significantly associated with increased risk of perioperative ischemic stroke within 30 days after surgery. Further research is needed to confirm these findings and to determine whether interventions would decrease this risk. 10.1001/jama.2017.21899
    Prevalence of patent foramen ovale in cryptogenic transient ischaemic attack and non-disabling stroke at older ages: a population-based study, systematic review, and meta-analysis. Mazzucco Sara,Li Linxin,Binney Lucy,Rothwell Peter M, The Lancet. Neurology BACKGROUND:Percutaneous closure of patent foramen ovale (PFO) has been shown to be superior to medical treatment alone for prevention of recurrent stroke after cryptogenic transient ischaemic attack or non-disabling stroke in patients aged 60 years or younger. The justification for trials in older patients with transient ischaemic attack or stroke depends on whether PFO is shown to be associated with cryptogenic events at older ages, for which existing evidence is conflicting, and on the population burden of PFO-associated events. Therefore, we did a population-based screening study using contrast-enhanced transcranial Doppler (bubble-TCD) to detect probable PFO as indicated by a right-to-left shunt (RLS); we also did a systematic review and meta-analysis to compare our results with previous studies. METHODS:In this population-based study, nested in the Oxford Vascular Study (OXVASC), we established the prevalence of any RLS, and of large RLS (>20 microbubbles), in consecutive patients attending a rapid-access transient ischaemic attack and stroke clinic, or at 1-month follow-up after stroke unit admission, with transient ischaemic attack or non-disabling ischaemic stroke, comparing cryptogenic events with those of known cause (according to Trial of Org 10172 in Acute Stroke Treatment [TOAST] criteria). We stratified participants by age, and extrapolated data to the UK population. We also did a systematic review of published studies of PFO prevalence (using transthoracic or transoesophageal echocardiography or bubble-TCD) according to stroke subtype, which included older patients and reported age-specific results, and determined by meta-analysis (including the OXVASC data) the pooled odds ratio (95% CI) of finding PFO of any size in cryptogenic events compared with events of known cause, stratified by screening modality (transthoracic or transoesophageal echocardiography or bubble-TCD). The study protocol is registered with PROSPERO, number CRD42018087074. FINDINGS:Among 572 consecutive patients with transient ischaemic attack or non-disabling stroke between Sept 1, 2014, and Oct 9, 2017 (439 [77%] patients aged >60 years, mean age 70·0 years [SD 13·7]), bubble-TCD was feasible in 523 patients (91%) of whom 397 were aged older than 60 years. Compared with those with transient ischaemic attack or stroke of known cause, patients with cryptogenic events had a higher prevalence of RLS overall (odds ratio [OR] 1·93, 95% CI 1·32-2·82; p=0·001), and in those aged older than 60 years (2·06, 1·32-3·23; p=0·001). When we pooled the OXVASC data with that from two previous smaller studies of bubble-TCD in patients aged 50 years or older, we found an association between RLS and cryptogenic events (OR 2·35, 95% CI 1·42-3·90; p=0·0009; p=0·15), which was consistent with the equivalent estimate from transoesophageal echocardiography studies (2·20, 1·15-4·22; p=0·02; p=0·02). No data on large RLS in patients with TOAST-defined cryptogenic events compared with other events were available from previous studies, but we found no evidence that the association was diminished in such cases. Of 41 patients with large RLS and cryptogenic transient ischaemic attack or non-disabling stroke in our study, 25 (61%) were aged older than 60 years, which extrapolates to 5951 patients per year in the UK (data from mid-2016). INTERPRETATION:Bubble-TCD was feasible in most older patients with transient ischaemic attack or non-disabling stroke, the association of RLS with cryptogenic events remained at older ages, and the population burden of PFO-associated events is substantial. Randomised trials of PFO closure at older ages are required and should be feasible. FUNDING:National Institute for Health Research, Oxford Biomedical Research Centre, Wellcome Trust, and Wolfson Foundation. 10.1016/S1474-4422(18)30167-4
    Comparison of residual shunt rate and complications across 6 different closure devices for patent foramen ovale. Gevorgyan Fleming Rubine,Kumar Preetham,West Brian,Noureddin Nabil,Rusheen Joshua,Aboulhosn Jamil,Tobis Jonathan M Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions OBJECTIVES:To compare residual shunt rate and complications associated with six different devices used for PFO closure. BACKGROUND:Transcutaneous PFO closure is an effective treatment for preventing recurrent stroke in patients with a history of cryptogenic stroke. The rate of residual shunt is one metric by which the technical success of PFO closure can be measured. METHODS:Patients who underwent PFO closure at a single center between February 2001 and July 2019 were retrospectively enrolled in the study. Right-to-left shunt at baseline and during follow-up was assessed using transcranial Doppler (TCD) or transthoracic echocardiography (TTE). Periprocedural and device-related complications, including atrial fibrillation, were also assessed. RESULTS:Of 467 PFO closures performed during this period, 320 patients received quantitative assessment of right-to-left shunting both before and after percutaneous closure. The highest effective closure was achieved with the Cardioform device (100%, n = 104), followed by the Amplatzer Cribriform (93%, n = 14), Helex (90%, n = 137), Amplatzer ASO (88%, n = 17), CardioSEAL (86%, n = 14), and Amplatzer PFO (85%, n = 33) devices. The most common significant adverse event was atrial fibrillation, which was more common with the Cardioform device (13%) than the Helex (4%) or the Amplatzer PFO (4%) devices. CONCLUSIONS:The Gore Cardioform Septal Occluder provides more robust closure of a PFO when compared to other devices but its effectiveness is offset by the higher prevalence of transient atrial fibrillation. 10.1002/ccd.28527
    Atrial Septal Aneurysm, Shunt Size, and Recurrent Stroke Risk in Patients With Patent Foramen Ovale. Turc Guillaume,Lee Jong-Young,Brochet Eric,Kim Jong S,Song Jae-Kwan,Mas Jean-Louis, Journal of the American College of Cardiology BACKGROUND:In patients with patent foramen ovale (PFO)-associated stroke, the presence of large shunt or atrial septal aneurysm (ASA) has been suggested to convey a high risk of stroke recurrence. OBJECTIVES:The purpose of this study was to assess the respective influence of PFO size and ASA status on stroke recurrence under medical therapy in patients with recent PFO-associated stroke without alternative cause. METHODS:The authors pooled individual patient data from 2 prospective observational studies and the medical arms of 2 randomized trials, in which shunt size and ASA status was assessed by independent reading of echocardiographic images. Associations between PFO anatomical features and recurrent ischemic stroke were assessed by mixed effects Cox models. RESULTS:Of 898 patients (mean age 45.3 years), 178 (19.8%) had ASA with large PFO, 71 (7.9%) ASA with nonlarge PFO, 397 (44.2%) large PFO without ASA, and 252 (28.1%) nonlarge PFO without ASA. Over a median follow-up of 3.8 years (interquartile range: 2.6 to 5.5 years), 47 (5.2%) patients experienced a recurrent stroke. There was a heterogeneity across studies for the association between PFO size and stroke recurrence (p = 0.01). In a model accounting for age, hypertension, antithrombotic therapy, and PFO anatomy, ASA was independently associated with recurrent stroke (adjusted hazard ratio: 3.27; 95% confidence interval: 1.82 to 5.86; p < 0.0001), whereas large PFO was not (average adjusted hazard ratio across studies: 1.43; 95% confidence interval: 0.50 to 4.03; p = 0.50). CONCLUSIONS:In patients with PFO-associated stroke, ASA is a more important predictor of recurrent stroke than shunt size. These results can help to better identify those patients with a high risk of stroke recurrence under medical therapy who may derive the most benefit from PFO closure. (Patent Foramen Ovale Closure or Anticoagulants Versus Antiplatelet Therapy to Prevent Stroke Recurrence [CLOSE]; NCT00562289) (Device Closure versus Medical Therapy in Patients with Cryptogenic Stroke and High-Risk Patent Foramen Ovale [DEFENSE-PFO]; NCT01550588). 10.1016/j.jacc.2020.02.068