Patent foramen ovale: high-risk echocardiographic features related to secondary stroke prevention

Abstract

Abstract Introduction Patent foramen ovale (PFO) closure has long been a matter of debate concerning the impact of such procedure on preventing ischemic events recurrence. Recent reports support this strategy raising the issue of optimal patient selection based on anatomical high-risk characteristics evaluated by transoesophageal echocardiography (TEE) that may be associated with an increased risk of recurrence. Purpose Characterize PFO-related echocardiographic findings and clinical features of a cohort of Embolic Stroke of Undetermined Source (ESUS) patients (pts). Methods Unicentric, retrospective analysis of pts with ESUS diagnosis who underwent TEE between 1/2014 and 11/2019. Excluded pts aged older than 70 years. Clinical stroke characteristics and echocardiographic PFO features were analysed. Results A total of 124 pts were included in the analysis, presenting a mean age of 50±1.6 [20;68] years and female gender predominance (58.9%). 48.4% of ESUS pts had PFO (53% female). Regarding PFO pts, 38 (62.3%) had significant right-to-left shunt on TEE, which was statistically associated with cortical infarcts (78.9 vs 56.5%,p=0.037). 35pts (58.3%) had shunt occurring at rest and during the Valsalva manoeuvre; when associated to significant shunt there was a correlation with cortical located infarcts (82.1 vs 60.0%, p<0.001). 33 PFOs (54.1%) had tunnel-like morphology. Tunnel-like PFOs were associated with significant right-to-left shunt (78.8 vs 42.9%, p<0.001), atrial septum aneurysm (ASA) presence (68.8 vs 50.0%, p<0.001) and with haemorrhagic transformation of ischemic stroke (15.2 vs 3.6%, p=0.031). 34 PFO pts (60.7%) had ASA. Mean PFO length was 6.42±5.0mm and mean height was 3.2±2.0mm. Conclusion In this cohort, there was a similar number of pts with and without PFO. Regarding ESUS pts with PFO, the majority had significant right-to-left shunt that occurred at rest and during Valsalva manoeuvre and were associated with cortical located infarcts. Tunnel-like morphology and ASA were also frequent. Tunnel-like morphology were associated with haemorrhagic transformation of ischemic strokes. These findings support the proposal that PFO characterization should have an additional role in stratifying pts with ESUS and selecting them for device closure.