Foramen Ovale Closure Research Articles

Treatment strategies for thromboembolism-in-transit with pulmonary embolism.

A 46-year-old obese woman undergoing treatment for bipolar disorder presented with acute shortness of breath, chest pain and palpitations. She was tachypnoea and tachycardia, but blood pressure was stable. Computed tomography angiogram revealed bilateral pulmonary embolism. Echocardiogram revealed thrombus-in-transit. She underwent surgical embolectomy only for thrombus-in-transit and closure of the patent foramen ovale. However, pulmonary hypertension worsened, haemodynamical instability prolonged and hepatic congestion progressed. After veno-arterial extracorporeal membrane oxygenation insertion, we performed thrombectomy by catheter and anticoagulation therapy. One month later, the patient was transferred to another hospital for rehabilitation.

Coronary Sinus Defect, Premature Restriction of Foramen Ovale and Cysto-Colic Peritoneal Band

Background: Unroofed coronary sinus is a congenital cardiac anomaly usually associated with persistent left superior vena cava. Premature restriction or closure of foramen ovale is described in association with hypoplastic left heart syndrome. Abdominal peritoneal bands when present manifest clinically. Case report: A 27 years, gravida 2, presented with intrauterine fetal death at 24 weeks gestation due to fetal congestive cardiac failure, cardiomegaly and hydrops. Perinatal autopsy showed absent coronary sinus with cardiac veins draining directly into the heart. There was no persistent left superior vena cava. The foramen ovale was restricted prematurely. The ductus arteriosus was present and non-restrictive. Abdomen showed a cysto-colic peritoneal band. Conclusion: This is the first report showing a triad of (1) complete absence of coronary sinus without left superior vena cava (type-II); (2) premature restriction of foramen ovale without hypoplastic left heart; and (3) a cysto-colic peritoneal band between the gall bladder and colon.

P123 PERCUTANEOUS CLOSURE OF PATENT FORAME OVALE IN PATIENT WITH FORME FRUSTE COR TRIATRIATUM DEXTER: A CASE REPORT

Abstract Cortriatriatum Dexter (CTD) is an uncommon congenital cardiac anomaly defined by the presence of abnormal septation within the right atrium due to incomplete reabsorption of the right venous valve. While Cor triatriatum with obstructive membranous is often found in early infancy, the non–obstructive forme (“forme fruste”, ff–CTD) usually remain asymptomatic until late adulthood. Non–obstructive forms, in fact, generally have a modest clinical impact, but in some clinical situations, they may represent a significant obstacle. CTD and ff–CTD are commonly associated with other congenital heart anomalies, e.g. atrial septal defects (ASDs), and a few cases of extreme difficulties in percutaneous procedures like ASD or patent foramen ovale (PFO) closure have been described. We present a case of a 51–year–old male patient with a recent diagnosis of paradoxical cardioembolic stoke that during the procedure of percutaneous PFO closure, ff–CTD was detected. Multifenestrated Amplatzer septal occluder 18 mm device was successfully deployed under TEE monitoring, confirming optimal positioning and no distortion of the device, particularly of the right disk. Conclusion cc–CTD is generally a benign condition but may represent a challenge and should be searched prior to percutaneous heart procedures.

Patent foramen ovale as a cause of cryptogenic ischemic stroke

A patent foramen ovale from an anatomical and physiological point of view is a normal communication between the atria, which is present in utero and allows oxygenated placental blood to reach the fetal arterial circulation. With incomplete postpartum fusion of the primary and secondary septa, a patent foramen ovale is formed. In the last two decades, clinical interest in the problem of the patent foramen ovale is dictated by the fact that its role in the development of such clinical syndromes as ischemic stroke, myocardial infarction, pulmonary embolism, migraine and decompression sickness of divers has been established, as well as the introduction of endovascular techniques for endovascular transcatheter closure of the atrial septal defect. It was found that the frequency of patent foramen ovale detection in patients with cryptogenic stroke is on average 2 times higher than in patients with an established cause of ischemic stroke and ranges from 40% to 50%.Aim of study. Raising awareness of neurologists about the causes, pathogenetic mechanisms of development, methods of diagnosis and treatment of ischemic stroke in patients with patent foramen ovale.Material and methods. To achieve this goal, the results of scientific research devoted to patent foramen ovale as a risk factor for cryptogenic stroke were analyzed. The literature search was carried out in electronic search engines Scopus, eLibrary, PubMed using the keywords: «ischemic stroke», «cryptogenic stroke», «patent foramen ovale», «pathogenesis of ischemic stroke». Scientific articles published between 1878 and 2021 were selected for analysis. 31% of the analyzed works are not older than 5 years.Conclusion. The patent foramen ovale is etiologically associated with cryptogenic stroke. Possible mechanisms of ischemic stroke in patent foramen ovale patients include in situ thrombosis, paradoxical embolism, and atrial arrhythmias. Transcatheter endovascular closure of patent foramen ovale with anatomical signs of a high risk of cerebrovascular events in combination with antiplatelet therapy are indicated for patients with cryptogenic stroke aged 18 to 60 years as an optimal means of secondary prevention of ischemic stroke.

Short-term results of percutaneous closure of a patent foramen ovale guided by transoesophageal echocardiography in patients with cryptogenic stroke: a retrospective study

BackgroundA patent foramen ovale (PFO) is a risk factor for cryptogenic stroke (CS), and interventional therapy for PFO can reduce the recurrence rate of CS. However, interventional therapies are primarily guided by X-ray imaging, and data on regular post-surgical follow-up with the transthoracic ultrasound foaming test (UFT) are rare. Thus, this study aimed to assess the short-term (12 months) results of PFO occlusion guided by transoesophageal echocardiography (TEE) and the results of regular UFTs.MethodsClinical records, echocardiographic data, and UFT results of 75 patients who underwent interventional therapy for PFO and CS were retrospectively analysed. The patients were grouped according to their preoperative UFT results: group A (n = 21), small volume of right-to-left shunts; group B (n = 22), moderate volume of right-to-left shunts; and group C (n = 32), large volume of right-to-left shunts. All patients were treated with an Amplatzer occluder under TEE guidance. UFT follow-up was conducted regularly until 12 months after surgery.ResultsNo significant differences in preoperative data, length of hospital stay, or operative time were noted between the groups (p > 0.05). The length of the PFO and diameter of the occluder differed between the groups as follows: group A = group B < group C (p < 0.001). Notably, 1 patient in group C developed recurrent stroke 11 months postoperatively, and 2 patients in group C developed atrial arrhythmia, which improved after 3 months of antiarrhythmic treatment. However, 19 patients still had positive UFT results 12 months postoperatively. Furthermore, the positive UFT rate 12 months postoperatively differed between the groups as follows: group A = group B < group C (p < 0.05). A preoperative large-volume shunt was negatively associated with a negative UFT rate 12 months postoperatively (OR = 0.255, 95% CI: 0.104–0.625).ConclusionsIn patients with PFO and CS, interventional therapy guided by TEE could lead to satisfactory short-term (12 months) outcomes. Although the positive UFT rate gradually decreased, some patients still had positive UFT results 12 months postoperatively. Preoperatively, a large volume of right-to-left shunts and a longer PFO were the two risk factors for positive UFT results postoperatively. Further studies are required to clarify the relationship between postoperative positive UFT results and stroke recurrence.

Percutaneous Closure of Patent Foramen Ovale after Anterior Spinal Cord Infarction

In patients with a patent foramen ovale (PFO) who have had a cryptogenic ischemic stroke, percutaneous closure reduces its recurrence risk. However, its role in spinal cord infarction (SCI) is less well-established. A few case reports describe the putative causative role of PFO in SCI. We present a case of a teenager with cryptogenic anterior SCI in the setting of a deep vein thrombosis and a high risk-PFO who underwent successful percutaneous closure.

Abstract TMP106: Pooled Analysis Of Five Randomized Trials Comparing Device Closure Of Patent Foramen Ovale After Stroke To Medical Treatment: Impact Of Residual Shunt On Stroke Outcomes

Introduction: Patent foramen ovale (PFO) closure is effective for secondary stroke prevention in well selected patients. After device implantation some patients have residual shunting. There was no impact of incomplete closure on recurrent stroke risk in any of the trials but outcome rates are low with little power to detect an effect. Hypothesis: Patients with residual shunts after PFO closure have more recurrent strokes than those with complete elimination of shunting. Methods: We pooled individual patient data from 5 of 6 randomized clinical trials comparing medical therapy to PFO closure + medical therapy. Residual shunt data were not available for 1 trial. This analysis only includes PFO closure subjects. Hazard ratios (HR) and 95% confidence intervals (CI) were estimated with Cox proportional hazards regression, adjusted for age, sex, coronary disease, diabetes, hypertension, hyperlipidemia, prior stroke/TIA, smoking, index event (stroke vs TIA), hypermobile septum, shunt size (large vs small) and infarct location (superficial vs deep). Multiple imputation of missing values for adjusted variables was used. Results: Among 1475 patients treated with PFO closure and with non-missing residual shunt data, 149 (10%) had incomplete closure. The median time from procedure to shunt measurement was 204 days (25 th -75 th percentile, 181-722). In the complete closure group the primary endpoint of recurrent ischemic stroke occurred in 30 patients (2.3%; 95% CI 1.5-3.2%) compared to 4 (2.7%; 95% CI 0.7-6.7%) with incomplete closure. Unadjusted and adjusted HRs comparing incomplete vs complete closure were 1.37 (0.48, 3.92) and 1.69 (0.37, 4.95) respectively. The secondary endpoint of recurrent ischemic stroke, TIA, or vascular death occurred in 66 (5.0%; 95% CI 3.9-6.3%) patients with complete closure compared to 9 (6.0%; 95% CI 2.8-11.2%) without. Unadjusted and adjusted HRs were 1.26 (0.63, 2.54) and 1.39 (0.68, 2.83) respectively. Conclusions: Our pooled analysis of individual subjects after PFO closure from 5 of 6 relevant randomized clinical trials, showed no association between residual shunt and recurrent stroke events. This analysis was limited by low rates of residual shunt and recurrent events even in this large, combined dataset.

Abstract TP98: Diagnostic Utility Of Transcranial Color Flow Imaging Identifying High Risk Patent Foramen Ovale

Background and Purpose: Recent several studies demonstrated that percutaneous patent foramen ovale (PFO) closure reduced the risk of stroke recurrence for patients with cryptogenic stroke and PFO. Our aim of this retrospective study is to evaluate the usefulness of transcranial color flow imaging (TC-CFI) in the diagnosis of anatomically high risk PFO, in which percutaneous PFO closure is expected to be more effective in preventing embolism. Methods: Subjects were ischemic stroke patients who were investigated the presence of right-to-left shunt (RLS) using TC-CFI and transesophageal echocardiography (TEE). Anatomically high risk PFO evaluated by TEE were defined as satisfying one or more of the following findings: 1) large shunt (more than 20 microbubbles (MB) identified in the left ventricular system), 2) atrial septal aneurism, and 3) the presence of shunt without Valsalva maneuver (VM). TC-CFI was performed in the middle cerebral artery and/or intracranial vertebral artery once without VM and three times with VM, respectively. The number of microembolic signals from MB was determined using international Consensus Criteria (ICC). The accuracy of TC-CFI for high risk PFO diagnosed by TEE was calculated, and then the positive rate of TC-CFI in detecting high risk PFO was also analyzed by TC-CFI’s findings (A: ICC grade II or higher, B: positive without VM, and C: positive on multiple times or in multiple vessels). Results: We analyzed 176 patients (41 females, mean age 64 years) admitted to our facility from July 2019 to July 2021. Of them, 44 patients (25%) had PFO, and 29 patients (16%) were high risk. The diagnostic power of TC-CFI was sufficient, with sensitivity of 93%, specificity of 80%, and accuracy of 89%. The positive rate of each finding was significantly higher in C than in A and B (A: 23%, B: 39%, and C: 55%. P=0.04). Conclusions: To perform the TC-CFI procedure frequently in multiple vessels is useful for screening of high risk PFO.

Cardioembolic stroke: classification of causes and prevention strategies

This literature review covers the diversity of cardioembolic stroke (CES), the heterogeneity of the embolism sources and the morphological characteristics of the embolic substrate. It is emphasized that the determination of the individual tactics of secondary prevention is based on the verification of specific cardiac causes of stroke, for convenience, stratified as pathology of chambers, heart valves and variants of paradoxical embolism (PE). It has been shown that the leading pathology of the heart chambers associated with CES is nonvalvular atrial fibrillation and left ventricular thrombosis, and the main basis for the prevention of stroke in this pathology is oral anticoagulant therapy with direct oral anticoagulants or vitamin K antagonists (warfarin). The main types of heart valve pathology are prosthetic valves and rheumatic mitral stenosis. In this case, oral anticoagulant therapy also serves as the basis for secondary prevention. In the absence of the need to prescribe anticoagulants (mainly in the pathology of natural heart valves) acetylsalicylic acid is the drug of choice. In infective endocarditis (IE), the basic prevention strategies are antibiotic therapy and surgery. Surgical tactics also remain the main one for the prevention of CES in tumors of the left heart. Transcatheter closure of the patent foramen ovale and occlusion of the left atrial appendage are being introduced into the daily practice of interventional medicine in order to prevent ischemic stroke. A balanced individual approach to the patient, a targeted cardiological examination, a comprehensive analysis of clinical and instrumental data and the reasonable use of funds that have proven their effectiveness and safety in the main strategies for stroke prevention, are essential in effective prevention of CES.

The Genetic Landscape of Patent Foramen Ovale: A Systematic Review.

Patent Foramen Ovale (PFO) is a common postnatal defect of cardiac atrial septation. A certain degree of familial aggregation has been reported. Animal studies suggest the involvement of the Notch pathway and other cardiac transcription factors (GATA4, TBX20, NKX2-5) in Foramen Ovale closure. This review evaluates the contribution of genetic alterations in PFO development. We systematically reviewed studies that assessed rare and common variants in subjects with PFO. The protocol was registered with PROSPERO and followed MOOSE guidelines. We systematically searched English studies reporting rates of variants in PFO subjects until the 30th of June 2021. Among 1231 studies, we included four studies: two of them assessed the NKX2-5 gene, the remaining reported variants of chromosome 4q25 and the GATA4 S377G variant, respectively. We did not find any variant associated with PFO, except for the rs2200733 variant of chromosome 4q25 in atrial fibrillation patients. Despite the scarceness of evidence so far, animal studies and other studies that did not fulfil the criteria to be included in the review indicate a robust genetic background in PFO. More research is needed on the genetic determinants of PFO.

Abstract 11058: Pooled Analysis of Six Randomized Trials Comparing Device Closure of Patent Foramen Ovale After Stroke to Medical Treatment: Overall Effects and Patient Selection Using a Causal Classification System

Introduction: Patent foramen ovale (PFO)-associated strokes account for ~10% of ischemic strokes in adults aged 18-60. Despite overall beneficial effects of device closure on stroke recurrence risk, the best treatment option for any individual patient is often unclear. Methods: We pooled individual participant-level data from all 6 RCTs comparing PFO closure with percutaneous devices plus medical therapy vs medical therapy alone. The primary outcome was recurrent ischemic stroke. We used Cox proportional hazards models to estimate adjusted HRs, with study-specific baseline hazards and a fixed treatment effect. Pre-specified primary subgroup analyses used the Risk of Paradoxical Embolism (RoPE) Score (a 10 point score with higher scores reflecting younger age and absence of vascular risk factors) and the PFO-Associated Stroke Causal Likelihood (PASCAL) algorithm, a classification system that combines the RoPE Score with presence/absence of high risk PFO features (either atrial septal aneurysm or large-sized shunt) to group patients into 3 causal relatedness categories: Unlikely (RoPE&lt; 7 and no high risk PFO feature); Possible (either RoPE &gt; 7 or any high risk PFO feature); or Probable (both RoPE &gt; 7 and any high risk PFO feature). The protocol was registered at PROSPERO. Results: A total of 121 recurrent strokes occurred in 3740 patients over median follow up of 57 months (IQR 24-64). The annualized incidence of stroke was lower with device vs medical therapy: 0.47% (0.34-0.65) vs 1.09% (0.87-1.36); adjusted HR 0.41 (0.27-0.60), p &lt; 0.001. The main results were robust to alternative analytic approaches. The primary subgroup analyses (Figure) showed statistically significant and clinically important interaction effects. Discussion: PFO closure reduces recurrent ischemic stroke in a robust manner. However, patients with neither a RoPE Score &gt; 7 or a high risk PFO feature (i.e. PASCAL Unlikely) do not appear to benefit, even in the well-selected trial population.

Safety and Cost Implications of Same-Day Discharge Following Elective Percutaneous Closure of Patent Foramen Ovale and Atrial Septal Defects in Australia

Background: Percutaneous closure of patent foramen ovale (PFO) and atrial septal defects (ASD) is being more commonly performed due to changes in international guidelines supporting its use. This study was performed to determine the clinical outcomes, safety and cost implications of same-day discharge (SDD) following such procedures and place this in an Australian context. Methods: This was a retrospective, observational study of patients undergoing elective percutaneous PFO or ASD closure at St. George Hospital, Australia between January 2011 and January 2020. Primary outcomes included 30-day major adverse cardiovascular endpoints (MACE) and readmission to hospital within 30 days. Results: Twenty-four patients were included in the primary analysis. Ten (41.7%) patients underwent elective ASD closure while 14 (58.3%) underwent PFO closure. Among the 24 patients who underwent elective percutaneous closure of structural heart disease, 23 patients (95.8%) were managed with SDD. There were no MACE outcomes at 30 days. No patients were re-admitted to hospital at 30 days following these procedures. When compared to overnight admission to hospital post-elective percutaneous structural heart condition closure, SDD yielded a cost saving of AUD 5999 per case. Conclusion: SDD following elective percutaneous closure of ASD and PFO was demonstrated to be a safe and effective strategy for managing patients. With more widespread use, it can lead to significant cost savings for hospitals without compromising patient care.

How Old is Too Old? Closure of Patent Foramen Ovale in Older Patients

Percutaneous closure of a patent foramen ovale (PFO) reduces the risk of recurrent cryptogenic stroke specifically in younger patients. The three randomized controlled trials that led to the widespread adoption of PFO closure excluded patients over the age of 60 years. Older patients frequently have other cardiac and vascular conditions that are common risk factors for stroke, whereas paradoxical embolism through a PFO is relatively rare. Younger patients theoretically benefit the most from closure due to longer lifetime exposure risk and absence of other traditional risk factors. PFO in older patients with cryptogenic strokes is often encountered in clinical practice, making up an increasing number of cardiology referrals, yet cardiologists lack guidelines and evaluation tools for these patients. This review explores the history of PFO closure – emphasizing data in older adults – and discusses the evaluation and treatment of older people with cryptogenic stroke and PFO while further trials in this important population are awaited.

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

Transcatheter 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.

Debate: Closure of patent foramen ovale. The interventional cardiologist perspective

Debate: Closure of patent foramen ovale. The interventional cardiologist perspective

Debate: Closure of patent foramen ovale. A neurologist�s perspective

Debate: Closure of patent foramen ovale. A neurologist�s perspective

Patent foramen ovale—When to close and how?

Closure of apatent foramen ovale (PFO) in patients after cryptogenic/cardioembolic stroke is recommended by current guidelines for patients who are 16-60years of age with ahigh-risk PFO (class of recommendationA, level of evidenceI). The use of double-disk occlusion devices followed by antiplatelet therapy is recommended. The procedure of interventional PFO closure compared with other interventions in cardiology is rather easy to learn. However, it should be performed carefully to avoid postinterventional complications. The number needed to treat (NNT) to avoid one stroke in 5years in the RESPECT trial was 42, in the CLOSE trial even lower with 20. In the REDUCE trial, the NNT was 28 at 2years. This can be reduced by longer follow-up, e.g., at 10years the NNT is 18. While other conditions such as migraine are currently under investigation with respect to the impact of PFO closure, sufficiently powered trials are lacking so that closure in diseases other than stroke should always be individualized.

Impact on daily clinical practice of the latest evidence on percutaneous closure of patent foramen ovale after cryptogenic stroke: a single-center experience.

At the end of 2017, three clinical trials demonstrated that, in selected patients, percutaneous closure of patent foramen ovale (PFO) after cryptogenic stroke (CS) reduces the risk of recurrence. Our aim was to determine the impact of these findings on routine clinical practice in a tertiary hospital. Patients with CS and percutaneous closure of PFO during 2001-2020 were included. The clinical characteristics of the patient and the anatomical characteristics of the foramen were analyzed. Based on both, the closure indications were classified into three groups according to the latest European recommendations and were analyzed in two periods, before and after the publication date of the clinical trials. A total of 293 patients were included. The mean age was 49 ± 11years, and 15% were older than 60years. The median RoPE score was 6 [p25-75, 5-7] and 75% had complex anatomy (CA). After the publication of the studies, the frequency of CA and the mean age of the patients were significantly higher (89% vs. 69% p < 0.0005 and 51 ± 11 vs. 48 ± 11years, p = 0.02, respectively), and the RoPE score, significantly lower (5 [5-7] versus 6 [5-7], p = 0.02). Inadequate closure indications were significantly reduced (8% vs. 18%, p = 0.02). After the publication of clinical trials that have shown benefit of PFO closure after CS, the number of inappropriate indications for closure has decreased significantly in our institution, with a higher percentage of CA, despite a clinical profile suggestive of lower causal probability of PFO.

Impact of Echocardiographic Parameters on Recurrent Stroke in the Randomized REDUCE PFO Cryptogenic Stroke Trial

ABSTRACT Background Transcatheter closure of patent foramen ovale (PFO) in cryptogenic stroke reduces the risk for recurrent stroke, but whether anatomic parameters can predict this remains unclear. We examined the associations between quantitated transesophageal echocardiogram (TEE) parameters and recurrent stroke in a large randomized study of PFO closure with adjudicated endpoints. Methods Baseline TEEs from the REDUCE trial comparing medically treated patients with transcatheter closure were analyzed by a trained sonographer blinded to patient characteristics. Associations between echocardiographic parameters with recurrent stroke and treatment groups were determined with a log-rank test and Cox multivariable regression. Results All TEEs were analyzed (180 medically treated, 358 PFO closure; mean age 45 years). Parameters were similar, including large shunt (22%), hypermobile septum (27%), eustachian valve (26%), and Chiari network (7%). Atrial septum aneurysm (ASA) was observed more frequently in the medically treated group (12% vs 6%, p = 0.018). Among patients in the medically treated group, there was a signal toward higher incidence of recurrent stroke to 5 years with than without ASA (19% vs 6%, p = 0.097), for large shunt (15% vs 5%, p = 0.116), and was significantly higher for ASA or hypermobile septum with large shunt (67% vs 5%, p ≤ 0.001 and 29% vs 6%, p = 0.036, respectively). Closure was associated with a lower risk of stroke in all subgroups. Conclusions In this TEE analysis of cryptogenic stroke patients, recurrent stroke was higher in medically treated patients with ASA or hypermobile septum and a large shunt. The relative reduction of stroke with transcatheter PFO closure was similar regardless of anatomy, suggesting that treatment should not be limited to these patients. Abbreviations ASA, atrial septum aneurysm; CI, confidence interval; EV, eustachian valve; IQR, interquartile range; KM, Kaplan–Meier; LA, left atrium; PFO, patent foramen ovale; RA, right atrium; SD, standard deviation; TEE, transesophageal echocardiogram.

Relation between the size of patent foramen ovale and the volume of acute cerebral ischemic lesion in young patients with cryptogenic ischemic stroke

BackgroundPatent foramen ovale (PFO) closure is superior to medical therapy alone to prevent stroke recurrence in selected patients. Small cortical infarcts and large right to left shunts seem to identify patients who will benefit most from closure. We aimed to study the correlation between the size of the PFO and the volume of cerebral ischemic lesions in young patients with cryptogenic ischemic stroke.MethodsPFO dimensions and acute ischemic lesion volume of 20 patients, aged<55 years, were analyzed with transesophageal echocardiography and brain magnetic resonance imaging, respectively. The association between the volume of ischemic lesions with the length of PFO, maximum separation between septum primum and septum secundum, and the combination of the twos was explored.ResultsA direct statistically significant correlation was found between cerebral lesion volume and maximum separation of septum primum and septum secundum (p=0.047). Length of PFO showed a non-significant trend towards an inverse correlation with lesion volume (p=0.603). Multiple linear regression analysis showed that cerebral lesion volume was dependent directly on maximum separation and inversely on length of PFO (regression coeff. −0,837; p= 0.057; 2,536, p=0.006, respectively).ConclusionsThese data suggest that even small PFO might be pathogenetic in case of small cerebral infarcts and that large cerebral infarcts might be PFO related if the shunt is large. If confirmed, the combination of detailed characteristics of PFO with the volume of cerebral infarct could be integrated in a new score to select patients who would take real advantage from a percutaneous closure.