Cryptogenic Events Research Articles

Would pfo closure prevent recurrent cryptogenic neurological events?

Background: The prevalence of patent foramen ovale (PFO) among patients with cryptogenic stroke or transient ischemic attack (TIA) is higher than that in the general population. Closure is often recommended in such patients, but it is not known whether this intervention really reduces the risk of recurrent neurological events (RNE). Objectives: The purpose of this study was to conduct a meta-analysis to evaluate the risk of RNE after PFO closure or medical therapy in patients with cryptogenic stroke or TIA due to presumed paradoxical thromboembolism. Search methods: Two independent reviewers searched MEDLINE and extracted data from observational and randomized controlled trials comparing PFO closure and medical therapy to prevent RNE. Intention-to treat analysis was used to extract data. Data collection and analysis: RevMan 5.2 (Nordic Cochrane Center, Copenhagen, Denmark) was used to pool the results of individual studies. The random effects model was applied. The effect size was presented using the risk ratio (RR). Statistical heterogeneity was evaluated using the I2 statistic. Results: Thirteen comparative observational and 3 randomized studies were identified in this analysis, including 2263 patients treated with PFO closure (94% using percutaneous device) and 2789 patients who received medical therapy. Overall, PFO closure reduced the number of patients with RNE by 50% (RR 0.50, 95% confidence interval [CI] 0.29–0.86, p = 0.01), with statistically significant heterogeneity among the studies (I2 = 70%, p < 0.0001). In comparative observational studies, closure was superior to medical therapy (RR 0.40, 95% CI 0.20-0.81; p = 0.01). The incidence of events for the control arm of the randomized trials trial was lower than the summary estimate from observational studies; thus, there was no significant benefit of closure over medical treatment (RR 0.86, 95% CI 0.56-1.32; p = 0.49). Conclusions: Although further randomized trial data are needed to precisely determine the effects of closure on stroke or TIA recurrence, the results of available randomized controlled trials challenge the credibility of a substantial body of observational evidence strongly favoring mechanical closure over medical therapy in secondary prevention of cryptogenic neurological events.

Transcranial Doppler Quantification of Residual Shunt after Percutaneous Patent Foramen Ovale Closure: Correlation of Device Efficacy with Intracardiac Anatomic Measures

Percutaneous, mechanical closure of defects of the atrial septum fails to completely resolve shunting in up to 20% of cases. Little is known about the factors associated with device failure. We measured the left atrial opening (X), right atrial opening (Z), tunnel length (Y), septum secundum, device-septum primum separation, and tunnel compressibility of the patent foramen ovale (PFO) in 301 patients with cryptogenic neurological events, PFO anatomy, and severe Valsalva shunting (Spencer Grade 5-5+). All patients then underwent percutaneous closure with the GORE®HELEX Septal Occluder device and were evaluated at 3 months for residual shunt by transcranial Doppler (TCD). Severe residual Valsalva shunt (TCD Grade 5-5+) was found at 3 months in 21 of 301 (7%) patients. X, Y, and Z were associated with failure with a high degree of statistical significance, whereas the width of the septum secundum, device-septum primum separation, and tunnel compressibility were not. An unanticipated finding was that 14 of 35 (40%) patients sized with a large balloon failed compared with 9 of 280 (3%) sized with a small balloon (P < 0.0001). In the multivariate logistic regression model, X (P = < 0.0001) and balloon size (P < 0.0001) were both strong predictors of failure. In an intracardiac echocardiography-defined PFO population, characterized by severe baseline Valsalva shunt and a high incidence of persistent (rest) shunting, association of six intracardiac measurements to closure device failure by multivariate logistic regression showed that the width of the left atrial opening was a strong predictor of residual shunting. An unanticipated finding was that use of a large sizing balloon was also strongly associated with failure.

Abstract 17197: Closure of Multiple Atrial Septal Defects with the Helex Device

Background: The performance of the Helex Septal Occluder (HSO) for closure of fenestrated atrial septum/multiple ASDs (mASDs) has not been evaluated. We sought to review our experience with closure of mASDs with the HSO. Methods: We identified 48 patients with mASDs who underwent percutaneous closure between 6/2001 and 5/2011. Number and size of ASDs, number of implanted HSOs, residual shunt, and complications were recorded. Results: Of 48 patients, 27 had defect closure with ≥ 1 HSO. Indication for closure was RV enlargement (RVE) in 24 (89%) and cryptogenic neurologic event in 3 (11%). Median age was 9.1 (1.9-66.2) years, median weight 30.7 (12.2-99.5) kg. Six patients (22%) weighed &lt; 20 kg. Median number of ASDs was 2 (2-≥5). Median stop-flow diameter in 25/27 patients was 12 (6-24) mm. Two patients had multiple small defects that were not sized. One HSO was implanted in 21 patients (78%), and 2 HSOs in 6 patients (22%). Procedural complications included device embolization in 2 patients, and both were retrieved percutaneously with successful deployment of another HSO. Residual shunt immediately post-closure was absent in 5/27 (19%), trivial in 15/27 (55%), small in 6/27 (22%), and moderate in 1/27 (4%). The median length of follow-up was 2 (0-9) years. Residual shunt at last follow-up was absent in 13/27 (48%), trivial in 8/27 (30%), small in 5/27 (18%), and moderate in 1/27 (4%). No complication occurred during follow-up. Of the 24 patients with RVE before closure, 2 are recent without follow-up and 1 is lost to follow-up. RV size normalized in 20/21 (95%) patients. No patient with a prior neurological event had a recurrence. The patient with moderate residual shunt and RVE had 1 HSO, and placement of a second HSO is planned. Conclusions: We conclude that closure of mASDs with 1 or more HSOs is effective with a low complication rate. The complication observed, embolization, did not significantly affect outcome in this series, as percutaneous retrieval was successful. In addition, the low profile of the HSO may facilitate safe implantation of multiple devices in smaller patients.

PFO Closure in Cryptogenic Embolic Events – Wellington Region Registry 2008–2011

PFO Closure in Cryptogenic Embolic Events – Wellington Region Registry 2008–2011

Transcranial Doppler Quantification of Residual Shunt After Percutaneous Patent Foramen Ovale Closure: Efficacy of the GORE® HELEX Septal Occluder

Ideally, percutaneous, mechanical closure of defects of the atrial septum should completely resolve shunt. To achieve this goal, more information is needed about the factors associated with device failure. Consecutive patients with cryptogenic neurological events who had severe baseline Valsalva shunt (Spencer Grade 5-5+) and intracardiac echocardiography (ICE) defined patent foramen ovale (PFO) who underwent percutaneous PFO closure with the GORE(®) HELEX Septal Occluder device were evaluated for residual 3-month shunt by transcranial Doppler (TCD). We closed 315 PFO patients with the HELEX devices: 15, 20, 25, 30 mm devices in 19, 138, 150, and 8 patients, respectively. Severe residual Valsalva shunt (TCD Grade 5-5+) at 3 months occurred in 23 of 315 (7%) of all patients and in 2 of 108 (2%), 5 of 86(6%), and 16 of 121 (13%) patients with none, Grade 4, and Grade 5-5+ baseline rest shunt, respectively (P = 0.002). At 3 months, rest shunting was essentially abolished by closure. The percent of patients with severe residual Valsalva shunt was also related to device size: 15 mm (0%), 20 mm (4%), 25 mm (10%), and 30 mm (25%) (P = 0.008) and to atrial septal aneurysm. All of these variables were independent predictors of failure by multivariate logistic regression. In an ICE-defined PFO population characterized by severe baseline Valsalva shunt and a high incidence of persistent (rest) shunting, the GORE(®) HELEX Septal Occluder device effectively reduces both provoked and persistent shunt. The causes of device failure are multifactorial. Larger devices perform less reliably suggesting the need for size-specific modifications to improve closure of more severe defects. (J Interven Cardiol 2011;24:366-372).

Transcranial Doppler Quantification of Residual Shunt after Percutaneous Patent Foramen Ovale Closure. Comparison of Two Devices

Recurrent paradoxical embolism after catheter-based closure of right-to-left shunt (RLS) can be related to residual RLS. To improve closure success, we need a better understanding of the anatomic and device-related factors associated with closure efficacy. Patients with cryptogenic neurologic events and severe RLS (Valsalva Spencer transcranial Doppler [TCD] grade 5/5+) who underwent patent foramen ovale (PFO) closure by either central pin (Amplatzer(®) PFO [A-PFO]) or central occluding (Amplatzer(®) SO [A-SO]) devices were evaluated for residual shunt by quantitative TCD evaluation at 3 months. The findings were correlated with atrial septal aneurysm (ASA), device type, and device size. We closed 628 consecutive patients with either the A-PFO (n = 327) or A-SO (n = 301) device. The frequency of large defects, small defects, and ASA was 12%, 88%, and 44% of cases, respectively. Severe residual shunt was detected in 13% of A-PFO and 7% of A-SO recipients (P = 0.005). This difference was attributable to a much higher frequency of severe residual shunt among patients with large defects closed with the A-PFO compared to the A-SO device (12 out of 29 [41%] vs. 3 out of 42 [7%], respectively; P < 0.001). There was no significant difference in device failure frequency for small defects. The presence of ASA increased the frequency of severe residual shunt compared to those without this feature (36 out of 275 [13%] vs. 28 out of 353 [8%], respectively; P = 0.046) but did not influence device-related differences. (1) Both noncentering and central occluding closure devices effectively reduce RLS after PFO closure. (2) Large PFO defects with or without ASA have lower residual shunt grades at 3 months when closed by central occluding devices.

Recurrent events following patent foramen ovale closure in patients above 55 years of age with presumed paradoxical embolism

The aim of this article is to summarize our experience of patent foramen ovale (PFO) closure in patients above the age of 55 years. PFO is associated with cryptogenic thromboembolic events (TEs) in patients younger than 55 years. Little is known about the recurrence rate of TE in patients above the age of 55 years undergoing PFO closure for presumed paradoxical embolism. PFO closure was performed in 1,055 patients, 423 of whom were above 55 years of age. Implantation of the device was guided by fluoroscopy and transesophageal or intracardiac echocardiography. A PFO occluding device was implanted successfully in all patients. Residual shunt was documented in 10% of patients above 55 years of age and in 8.4% of patients aged 55 years or younger (P = 0.325). During a median follow-up period of 18 months (range, 0-162 months) the annual incidence of recurrent TE in patients above 55 years was 1.8% while patients aged 55 or below had an annual incidence of recurrent TE of 1.3%. TE-free survival was similar in patients above 55 years of age compared with those aged 55 years and below. PFO closure in older patients is as efficient and seems comparable to those under the age of 55. Although traditional cardiovascular risk factors may be more frequent in the older age group compared with those younger than 55 years, PFO closure should not be withheld as a possible therapeutic option in this age group.

Persistent venous valves correlate with increased shunt and multiple preceding cryptogenic embolic events in patients with patent foramen ovale: An intracardiac echocardiographic study

It has been suggested that prominent Eustachian valve (EV) and Chiari's network (CN) predispose to paradoxical embolism but their presence in patients with presumed paradoxical stroke is not always easily detectable by transesophageal echocardiography (TEE). We sought to prospectively assess the frequency of EV/CN as assessed by intracardiac echocardiography (ICE) in patients submitted to patent foramen ovale (PFO) transcatheter closure in order to investigate their role in determining shunt severity and risk of multiple paradoxical embolisms. Over a 36-month period, we prospectively enrolled 98 consecutive patients (mean age 37 +/- 12.5 years, 68 females) with previous stroke referred to our center for PFO catheter-based closure. All patients underwent transcranial Doppler ultrasound (TC-D), TEE and ICE-guided transcatheter closure. After ICE study and measurements, a prominent EV or CN were diagnosed on ICE in 72 patients (73.4%), whereas in 45 (45.9%, P < 0.01) on TEE. Patients with EV/CN had more frequently a curtain pattern on TC-D, a larger right-to-left shunt, and recurrent cerebral paradoxical embolisms before closure. EV/CN and medium-large shunt on TEE were the strongest predictors of recurrent paradoxical embolisms. This study suggests that EV and CN have a deep impact on the pathophysiology of paradoxical embolism: EV and CN should be considered as adjunctive risk factors for paradoxical embolism in the decision-making process involving PFO patients.

Cryptogenic Emboli in Patients with Patent Foramen Ovale or Atrial Septal Defect Associated with the Use of Nonsteroidal Anti-Inflammatory Drugs

Background: Nonaspirin, nonsteroidal anti-inflammatory drugs (NANSAIDs) have been associated with arterial thromboembolic events in the general population. Our objective was to determine the prevalence of NANSAID use in patients diagnosed with cryptogenic emboli or paradoxical embolic events from a patent foramen ovale (PFO) or atrial septal defect (ASD) compared with a control population with an incidental PFO/ASD and no history of embolic events. Methods: We performed a retrospective case-control study of 90 age-matched patients to assess the association of NANSAIDs with cryptogenic arterial embolic events in patients with and without a history of PFO/ASD. Odds ratios (ORs) were obtained by χ² analysis. Multivariate analysis was conducted with a logistical regression method. Results: Patients with cryptogenic embolic events had a high prevalence of prescription NANSAID use regardless of the presence of a PFO/ASD and were far more likely to have a history of NANSAID use than those with an incidentally discovered PFO/ASD and no history of arterial emboli (OR 4.30, 95% confidence interval 1.14–13.07, p = 0.01). Conclusions: Many patients previously diagnosed with paradoxical emboli may be experiencing the prothrombotic effects of NANSAIDs rather than a paradoxical mechanism for their arterial embolic event.

Cerebrovascular events on awakening, patent foramen ovale and obstructive sleep apnea syndrome

Patent foramen ovale is a defect in the interatrial septum associated with cryptogenic stroke. The presumed mechanism of cryptogenic stroke due to a patent foramen ovale is the migration of thrombus from the venous side of the circulation to the left atrium with subsequent systematic embolism, called paradoxical embolization. Provacative maneuvers and pre-existing cardiopulmonary disease can cause elevation in right atrial pressure leading to right-to-left shunting through a patent foramen ovale. We report two patients with patent foramen ovale waking up with cryptogenic vascular events and found to have an obstructive sleep apnea syndrome. During nocturnal sleep, obstructive sleep apnea can cause right atrium pressure elevation resulting in right-to-left shunting through patent foramen ovale. The possibility of patent foramen ovale and an obstructive sleep apnea syndrome may be considered in patients with cryptogenic strokes-on-awakening. Further studies are needed to support our observation.

Experiência inicial com a utilização do dispositivo Cardia IntraseptTM no fechamento percutâneo do forame oval patente

SUMMARY Initial Experience with the CardiaIntrasept TM Device for PercutaneousOcclusion of Oval Patent Foramen Objective: The purpose of this study was to report theinitial experience with the Intrasept TM device (CARDIA,Inc., Burnsville, MN, USA) for percutaneous PFO closure. Methods: Patients with 1. previous cryptogenic thrombo-embolic event and/or 2. migraine with aura symptomsassociated with 3. transesophageal echocardiographic (TEE)evidence of a PFO with right-to-left shunt were included.The device’s efficacy was defined as the absence of right-to-left shunt assessed by TEE and/or transcranial Doppler(TCD) 6 months after the procedure and no evidence ofrecurrent thromboembolic events during follow-up. Thedevice was considered safe in the absence of peri or postprocedural major complications. Since March 2006 untilJune 2007, 15 patients underwent percutaneous PFO closurewith the Intrasept TM device (8 female; age 19 to 64 years,median of 33). Association with an atrial septal aneurysm(ASA) and prominent Eustachian valve was seen in 3(20%) and 2 (13%) patients, respectively.

HELEX Septal Occluder for transcatheter closure of patent foramen ovale: multicentre experience.

Patients with cryptogenic embolic events and a patent foramen ovale (PFO) are at risk of paradoxical embolism causing recurrent cerebral events; however, transcatheter PFO closure remains controversial. The aim of this multicentre trial was to demonstrate the feasibility and safety of transcatheter closure of PFO with the HELEX Septal Occluder. The study enrolled 128 patients (66 female; mean age, 50 years). Mean (+/-SD) PFO size was 10+/-3.7 mm; 38 patients also had an atrial septal aneurysm. Device implantation was successful in 127 patients. Device-related events during implantation or follow-up were device embolisation, wire-frame fracture, and retrieval cord breaks (two cases each; no sequelae). Other adverse events included atrial arrhythmia (two patients), migraine, convulsion, and transient ischaemic attack (one case each). There were no recurrent strokes, deaths, perforations, or accumulations of thrombi on the device. Within a mean follow-up period of 21+/-11 months, complete PFO closure using one device was achieved in 114 patients (90%). Five patients with a moderate to large residual shunt received a second device. The HELEX Occluder can be used for PFO closure. Device- and procedure-related complications are rare. The closure procedure appears to reduce recurrence rates of stroke and transient ischaemic attack.

Percutaneous PFO closure, further data but many unanswered questionsThe opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology.

This editorial refers to ‘Patent foramen ovale closure in patients with cryptogenic thrombo-embolic events using the Cardia PFO occluder’† by C. Spies et al ., on page 365 The pace of technological development in interventional congenital cardiology over the last two decades has been fast and relentless. Successful and reliable closure of secundum atrial septal defects in the catheter laboratory translated to interest in the use of similar devices for the occlusion of the patent foramen ovale (PFO), a common remnant of the fetal circulation. The pathological potential of the PFO in the genesis of unexplained thrombotic stroke had long been suspected,1 with Lechat et al. 2 in 1988 reporting a higher prevalence of PFO in patients with cryptogenic thrombotic stroke, an observation confirmed in a number of subsequent studies.3 With low risk and a simple technique for PFO closure as an alternative to surgery, many clinicians faced with patients affected by crypotogenic stroke have been quick to advance the cause of percutaneous therapy in this setting, despite the lack of a really robust evidence base. As a result, we have found ourselves in a scenario familiar to many involved with transcatheter intervention in congenital heart disease where technological advances and the ability to perform a procedure have to some degree outpaced our understanding … *Corresponding author. Tel: +44 113 3928184; fax: +44 113 3928375. E-mail address : john.thomson{at}lineone.net

Patent foramen ovale closure in patients with cryptogenic thrombo-embolic events using the Cardia PFO occluder

We report our experience with three generations of the Cardia patent foramen ovale (PFO) occluder in patients with cryptogenic thrombo-embolic events (TE). Between 1998 and 2004, interventional PFO closure was attempted in 403 patients. Prior to PFO closure, 605 TE occurred, translating into an annual incidence of 3.1%. PFO closure was successful in all patients. Peri-procedural complications occurred in eight patients (2.0%). At 6 months follow-up, residual shunt was present in 10.8% of patients. Transient thrombi developed on 10 devices (predominantly generation II) and asymptomatic wire fractures were detected in 14 cases (generation I and II). The annual incidence of recurrent TE was 2.0% (n=13). Atrial septal aneurysm and prior device-related thrombus formation were identified as predictors of recurrent TE. Owing to technical improvements and modified adjunctive pharmacotherapy, the rate of thrombus formation has declined and wire fractures are virtually absent in generation III devices. The overall rate of recurrent TE is reduced by transcatheter PFO closure with the Cardia PFO occluder, and seems comparable to recurrence rates reported for other devices used for this purpose.

Ischaemic Cerebrovascular Events in HIV Infection

Several case reports and series described ischaemic cerebrovascular events in HIV infection. However, the exact prevalence and the clinical features of these events are unknown. We performed a cohort study on 772 consecutive HIV infected patients and evaluated the rate of transient ischaemic attacks (TIA) and of completed stroke. A total prevalence of 1.9% for TIA (0.8%) and stroke (1.2%) was calculated resulting in an annual incidence rate of 216 per 100,000. The prevalence was highest in the later stages of the infection. Stroke patients had a poorer immunological state than the TIA and the cohort patients. Probable (n = 3) and possible (n = 2) vasculitis and cardiogenic embolism (n = 2) could be detected as aetiology, the remaining patients had a cryptogenic event. Our data suggest that ischaemic cerebrovascular events are more common in HIV infected patients than in the general population and that a part of these events might be caused by HIV associated vasculitis or vasculopathy.

Patent Foramen Ovale and Recurrent Stroke

Clinical management of patients with acute stroke and the approach used for secondary prevention depends upon clarification of pathogenesis. Although most strokes are a consequence of cerebrovascular disease, ≈15% to 20% of ischemic (nonhemorrhagic) strokes have been attributed to cardiogenic embolism.1 In practice, determination of the stroke mechanism is fraught with uncertainty, particularly when the possibility of thromboembolism emanating from atherosclerotic lesions in the aorta or cervical arteries is considered. When cardiogenic embolism is suspected, cardiac ultrasound is the principal method used to identify the potential source. The finding of left atrial enlargement has been shown to bear a significant relationship to the risk of stroke in a multivariate analysis of population-based data from the Framingham Heart Study2. The most frequent confounding variable is atrial fibrillation, occurring in >2 million patients in North America and in over half of all patients with cardiogenic embolism. Criteria for selection of patients with acute ischemic stroke for transesophageal echocardiography (TEE) to search for a potential cardiac source of embolism are controversial, particularly because cardiogenic embolism is often an uncertain diagnosis that is inferred merely on the basis of the finding of potential cardiac source. Even after extensive investigation, ≈40% of ischemic stroke patients have no clearly identifiable pathogenesis (cryptogenic stroke).3 In one study, 62% of patients younger than 60 years of age without an obvious source of cerebral infarction and 23% of those with arterial lesions had potential sources of cardiogenic embolism identified by TEE ( P =0.0007 for the difference).4 See p 2625 Among the cardiac anomalies detected by TEE that have been implicated as risk factors for stroke are patent foramen ovale (PFO) and atrial septal aneurysm (ASA).5,6⇓ The foramen ovale, a remnant of the fetal circulation, remains patent through adulthood in ≈1 in 4 …

Surgical Closure of Patent Foramen Ovale for Stroke Prevention: Vancouver General Hospital Experience

95 Background and Purpose Patent foramen ovale (PFO) is implicated as a potential cause of stroke, particularly in young patients with otherwise cryptogenic events. The natural history, risk of stroke recurrence and optimal secondary stroke prevention remains uncertain. Therapeutic options include long-term antiplatelet therapy, anti-coagulation therapy, and PFO closure by surgery or device. We report the results of 53 patients treated with surgical closure. Methods and Materials We have followed 53 consecutive surgically treated patients (23 men and 30 female). All patients were evaluated by a stroke neurologist, a cardiologist with expertise in adult congenital disease and a cardiovascular surgeon. Patients who met the following criteria were included: 1) embolic TIA or stroke, 2) PFO or PFO and atrial septal aneurysm (ASA), 3) investigations included cerebral angiography, transesophageal echocardiography, and hypercoagulable studies, 4) presumptive clinical diagnosis of paradoxical embolism with no other etiology detected. Follow up was obtained by clinic visit and standardized telephone questionnaire. Results Prior to surgery 27 patients had stroke and 26 had TIAs; 12 had multiple cerebrovascular events. The mean age at symptom onset was 41.8 ± 9.3 yrs (range 19 to 59). 22 patients had an isolated PFO and 31 had both a PFO and an ASA. Average PFO size measured at surgery was 8.8 ± 7.7 mm. 40 were treated with primary closure, 13 with suture and patch closure. Average post-surgical hospital stay was 4 days. There was no surgical mortality or major morbidity. Minor perioperative morbidity occurred in 13 patients. Average follow up postsurgery was 22.2 ± 17.4 months (range 0.7 to 90.8 months). There were no recurrent strokes and 1 recurrent TIA. Conclusions Surgical closure of PFO can be safely performed with low morbidity and mortality. In this group of carefully selected patients, there have been no recurrent strokes. Further studies are necessary to define high-risk patients for recurrent stroke who may benefit from surgical closure.

Surgical Closure of Patent Foramen Ovale for Stroke Prevention: Vancouver General Hospital Experience

95 Background and Purpose Patent foramen ovale (PFO) is implicated as a potential cause of stroke, particularly in young patients with otherwise cryptogenic events. The natural history, risk of stroke recurrence and optimal secondary stroke prevention remains uncertain. Therapeutic options include long-term antiplatelet therapy, anti-coagulation therapy, and PFO closure by surgery or device. We report the results of 53 patients treated with surgical closure. Methods and Materials We have followed 53 consecutive surgically treated patients (23 men and 30 female). All patients were evaluated by a stroke neurologist, a cardiologist with expertise in adult congenital disease and a cardiovascular surgeon. Patients who met the following criteria were included: 1) embolic TIA or stroke, 2) PFO or PFO and atrial septal aneurysm (ASA), 3) investigations included cerebral angiography, transesophageal echocardiography, and hypercoagulable studies, 4) presumptive clinical diagnosis of paradoxical embolism with no other etiology detected. Follow up was obtained by clinic visit and standardized telephone questionnaire. Results Prior to surgery 27 patients had stroke and 26 had TIAs; 12 had multiple cerebrovascular events. The mean age at symptom onset was 41.8 ± 9.3 yrs (range 19 to 59). 22 patients had an isolated PFO and 31 had both a PFO and an ASA. Average PFO size measured at surgery was 8.8 ± 7.7 mm. 40 were treated with primary closure, 13 with suture and patch closure. Average post-surgical hospital stay was 4 days. There was no surgical mortality or major morbidity. Minor perioperative morbidity occurred in 13 patients. Average follow up postsurgery was 22.2 ± 17.4 months (range 0.7 to 90.8 months). There were no recurrent strokes and 1 recurrent TIA. Conclusions Surgical closure of PFO can be safely performed with low morbidity and mortality. In this group of carefully selected patients, there have been no recurrent strokes. Further studies are necessary to define high-risk patients for recurrent stroke who may benefit from surgical closure.

Early transoesophageal echocardiography in cryptogenic and lacunar stroke and transient ischaemic attack

OBJECTIVESTo test the hypothesis that transoesophageal echocardiography (TOE) carried out within three days of a first stroke or transient ischaemic attack of cryptogenic or lacunar type may disclose more thrombi...