Higher Prevalence Of Patent Foramen Ovale Research Articles

A retrospective review of divers treated for inner ear decompression sickness at Fiona Stanley Hospital hyperbaric medicine unit 2014-2020.

Inner ear decompression sickness (IEDCS) is increasingly recognised in recreational diving, with the inner ear particularly vulnerable to decompression sickness in divers with a right-to-left shunt, such as is possible through a persistent (patent) foramen ovale (PFO). A review of patients treated for IEDCS at Fiona Stanley Hospital Hyperbaric Medicine Unit (FSH HMU) in Western Australia was performed to examine the epidemiology, risk factors for developing this condition, the treatment administered and the outcomes of this patient population. A retrospective review of all divers treated for IEDCS from the opening of the FSH HMU on 17 November 2014 to 31 December 2020 was performed. Patients were included if presenting with vestibular or cochlear dysfunction within 24 hours of surfacing from a dive, and excluded if demonstrating features of inner ear barotrauma. There were a total of 23 IEDCS patients and 24 cases of IEDCS included for analysis, with 88% experiencing vestibular manifestations and 38% cochlear. Median dive time was 40 minutes and median maximum depth was 24.5 metres. The median time from surfacing to hyperbaric oxygen treatment (HBOT) was 22 hours. Vestibulocochlear symptoms fully resolved in 67% and complete symptom recovery was achieved in 58%. A PFO was found in 6 of 10 patients who subsequently underwent investigation with bubble contrast echocardiography upon follow-up. IEDCS occurred predominantly after non-technical repetitive air dives and ongoing symptoms and signs were often observed after HBOT. Appropriate follow-up is required given the high prevalence of PFO in these patients.

The Relationship Between Patent Foramen Ovale and Unexplained Dizziness: A Prospective Analysis in China.

IntroductionPatent foramen ovale (PFO) is potentially associated with abnormal embolisms, and it results in mixing of arteriovenous blood when its right-to-left shunt (RLS) emerges. Present studies have found that PFO is a risk factor that can lead to many diseases. However, few studies have examined the relationship between PFO and dizziness.MethodsThis study was a large single-center, prospective, controlled study. From March 2019 to March 2021, we recruited patients with dizziness were divided into two groups: “explained” and “unexplained”. All patients were submitted to contrast-enhanced transcranial Doppler ultrasound and screened for PFO. Transesophageal heart ultrasound or right heart catheterization was used to confirm PFO. Additionally, multiple factors were collected and statistical analysis was performed between the two groups.ResultsAmong the 244 patients included, 123 were in the “explained” group and 121 were in the “unexplained” group. The prevalence of PFO in the “explained” group was 34 (27.4%) compared to 79 (64.7%) in the “unexplained” group. In the “explained” group, 7 were RLS level IV, 6 were level III, 7 were level II, and 14 were level I. For the “unexplained” group, the numbers of patients with levels IV, III, II and I were 27, 26, 12 and 14, respectively. Univariate analysis revealed that PFO (χ2= 34.77, P < 0.001) and age (t = −3.49, P < 0.001) seemed to be potential risk factor candidates for “unexplained” dizziness. In multiple regression analysis, age (OR = 0.97; 95% CI 0.95–0.99) and the prevalence of PFO (OR = 4.37; 95% CI 2.50–7.63) were statistically significant. Massively shunted PFO showed more pronounced risk factors (OR = 8.76; 95% CI 4.04–19.03).ConclusionThere was a high prevalence of PFO and a greater RLS level in unexplained dizziness. PFO and age were independent risk factors for unexplained dizziness. When treating with unexplained dizziness, especially among young people, we must pay attention to the presence of PFO.

A Narrative and Critical Review of Randomized-Controlled Clinical Trials on Patent Foramen Ovale Closure for Reducing the Risk of Stroke Recurrence.

Patent foramen ovale (PFO) is a common cardiac anatomic variant that has been increasingly found in young (<60 years) cryptogenic stroke patients. Despite initial neutral randomized-controlled clinical trials (RCTs), there have been four recent RCTs providing consistent data in favor of the efficacy and safety of PFO closure compared to medical therapy for secondary stroke prevention. However, taking into consideration the high prevalence of PFO, the low risk of stroke recurrence under medical treatment and the uncommon yet severe adverse events of the intervention, patient selection is crucial for attaining meaningful clinical benefits. Thorough workup to exclude alternative causes of stroke and identification of high-risk PFOs through clinical, neuroimaging and echocardiographic criteria are essential. Cost effectiveness of the procedure cannot be proven for the time being, since there are no robust data on clinical outcome after PFO-associated stroke but only limited anecdotal data suggesting low risk for long-term disability.

Relation of Patent Foramen Ovale to Acute Mountain Sickness

Over 50% of patients who rapidly ascend to extreme altitudes develop various symptoms known as acute mountain sickness (AMS), which rarely can be life threatening. It is unclear why some patients are more susceptible to AMS than others. Our objective was to determine whether patent foramen ovale (PFO) is a risk factor for AMS. Subjects who had hiked to altitudes above 10,000' (∼3,000 meters) on the John Muir Trail in California were recruited. Participants completed a questionnaire and 2-physician adjudication was performed in regard to AMS status. A transcranial Doppler with agitated saline contrast injection was performed to evaluate the presence or absence of PFO. The primary outcome was the development of AMS. From 2016 to 2018, 137 hikers were recruited into the study. There was a higher prevalence of PFO in hikers with AMS 15 of 24 (63%) compared with hikers without AMS 44 of 113 (39%); p = 0.034. In the multivariate model, the presence of a PFO significantly increased the risk for developing AMS: odds ratio 4.15, 95% confidence intervals 1.14 to 15.05; p = 0.030. In conclusion, hikers with a PFO had significantly higher risk of developing AMS relative to hikers without a PFO. Clinicians should consider PFO a risk factor in patients who plan to hike to high altitudes.

Frequency of Patent Foramen Ovale and Migraine in Patients With Cryptogenic Stroke.

Individuals with migraine are at higher risk for stroke, but the mechanism has not been established. On the basis of the association between migraine and intracardiac right-to-left shunt, it has been proposed that stroke in migraineurs could be caused by a paradoxical embolus passing through a patent foramen ovale (PFO) or pulmonary arteriovenous malformation. The aim of this study was to determine the prevalence of PFO with right-to-left shunt in patients who presented with cryptogenic stroke and had a history of migraine. Patients between 18 and 60 years old who presented with an ischemic stroke were characterized based on ASCOD phenotyping (atherosclerosis; small-vessel disease; cardiac pathology; other causes; dissection). A migraine diagnosis was identified by reviewing physician notes, and frequent aura was defined if present in at least 50% of attacks. A PFO with right-to-left shunt diagnosis was identified by the presence of a positive bubble contrast study with either transcranial Doppler, transthoracic, or transesophageal echocardiography. Of the 712 patients who presented with ischemic stroke, 127 (18%) were diagnosed as cryptogenic; 68 patients had adequate testing for PFO and a documented migraine history. The prevalence of PFO in patients with cryptogenic stroke without migraine was elevated (59%) compared with the general population (18%). Patients with both cryptogenic stroke and migraine had a higher prevalence of PFO (79%). In patients with cryptogenic stroke who had migraine with frequent aura, the prevalence of PFO was 93%. Only 5 patients (4%) had a history compatible with migrainous infarction. In patients with cryptogenic stroke who have migraine, there is a high prevalence (79%) of PFO with right-to-left shunt. The timing of the stroke in migraineurs is usually not related to a migraine attack. These observations are consistent with the hypothesis that the mechanism of stroke in migraineurs is most likely because of a paradoxical embolus. Future cryptogenic stroke classification schemes should consider including PFO as a separate etiologic category.

Patent Foramen Ovale and Migraine: Casual or Causal.

Dear Editor, The atrial septum primum and septum secundum are usually closed by the first year of age. Incomplete closure of the septum primum and septum secundum results in patent foramen ovale (PFO). On the other hand, migraine is a common condition characterized by unilateral headache associated with nausea, photophobia, and phonophobia. These two conditions may be related to each other. Various mechanisms have been described to explain this relation. Subclinical emboli, as well as metabolites from the venous circulation bypass the pulmonary circulation through the PFO. They enter the systemic circulation and result in irritation of the trigeminal nerve and brain vasculature. This may trigger a migraine. A small double-blind crossover study has demonstrated that aspirin, an antiplatelet drug may reduce the formation of platelet-fibrin complexes and improve a migraine. It may be possible that increased platelet activation may be a risk factor for a migraine through the action of serotonin. Transient hypoxemia resulting from shunting of blood through the PFO causes microinfarcts in the brain. It may lead to a migraine. PFO may predispose to subclinical ischemia and paradoxical embolism that may result in triggering the migraine.[1] Another study has postulated the eustachian valve, Chiari's network, and migraine with aura can be adjunctive risk factors for paradoxical embolism in the evaluation of both symptomatic and asymptomatic PFO patients.[2] It has been demonstrated that PFO is not just an example of migraine comorbidity but exerts a causal effect in the triggering of the aura by applying the criteria proposed by Bradford Hill.[3] Epidemiologic data have shown that PFO and migraine are related. Two Italian groups were the first to report, in case-control studies, a significantly higher prevalence of PFO in subjects with a migraine with aura. They have used transcranial Doppler ultrasonography (TCD) for evaluation of patients. A study of young cryptogenic stroke patients has shown increased prevalence of a migraine in patients with PFO. A retrospective study showed that migraine patients with PFO have higher right-to-left shunting compared to controls. In a meta-analysis of seven studies, it was concluded that there was only low-grade evidence supporting the association between PFO and migraine.[1] A study published on 2012 demonstrated that the intravenous injection of air bubbles results in bioelectrical disturbances in the brain of patients with a migraine with aura. They have large right-to-left cardiac shunts. On the contrary, this effect was absent in patients with equally large right-to-left cardiac shunts, but without a migraine. However, the majority of these patients did not experience a headache. It suggested that subclinical hypoxia-ischemia induced by paradoxical cerebral embolism was not a common cause of migraine attacks in a migraine with aura patients with large PFOs. But they may occasionally trigger aura and headache in susceptible patients, especially if the clearance of the embolus is delayed.[4] It is quite natural that after all these studies, there was a search for the fact about whether closure of PFO can reduce migraine or not. Migraine intervention with STARFlex technology (MIST) trial is the only completed randomized double-blind sham-controlled study. It showed reduced median total migraine headache days in the PFO closure group compared to the control group.[5] Studies have demonstrated that primary transcatheter closure of the PFO resulted in a significant reduction in migraine.[6] In Percutaneous Closure of PFO in Migraine with Aura (PRIMA) trial, out of 107 participants, 53 patients were put on Amplatzer device for PFO closure. A total number of 54 patients were placed on medical therapy. There was no significant difference in migraine days per month in these two groups. But patients with PFO closure showed significant (P < 0.01) reduction in migraine with aura attacks.[7] There were some studies started on the relationship between PFO and migraine as well as on the effect of PFO closure on migraine.[8] But more data are required for the conclusion. It is still unclear if there is a causal relationship or simply a coexistence of these two conditions. We hope that future research works will enlighten our knowledge about this topic. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Patent Foramen Ovale in Adult Patients with Sickle Cell Disease and Stroke

Introduction: Stroke is a leading cause of death in adults with sickle cell disease (SCD), although little is known about the underlying pathophysiology or associated risk factors. A patent foramen ovale (PFO) or other intracardiac shunts are associated with ischemic stroke in children with SCD and young adults without SCD. PFOs are relatively common, with a prevalence of about 24% in the general population. Importantly, PFOs can be closed using a minimally invasive procedure, which could potentially prevent embolic strokes in individuals with SCD at risk for stroke. We therefore designed an epidemiological study to determine the prevalence of PFOs in adults with SCD and stroke.Methods: To identify SCD patients with stroke who had evidence for a PFO by echocardiagraph, we retrospectively reviewed charts from the Johns Hopkins Hospital. All adult patients (>18 years old) with the diagnosis of stroke followed in our Sickle Cell Program were included. PFO was diagnosed by conventional echocardiogram, color Doppler studies, and contrast studies with agitated saline (10 mls) through a peripheral IV or central venous catheter with and without a Valsalva maneuver (2 times each) to increase the sensitivity of detecting intracardiac shunting. The presence of bubbles in the left atrium, either spontaneously or after Valsalva, within five cardiac cycles was noted. PFOs or other intracardiac shunts were graded by the appearance of bubbles in the left atrium, including: Grade 1 (mild shunt with 1-10 bubbles), Grade 2 (moderate shunt with 10-25 bubbles and a distinct portion filling the left atrium), and Grade 3 (substantial shunt with >25 bubbles and complete filling of the left atrium). Brain MRI/MRAs were classified by stroke subtype and severity of cerebral vasculopathy. Age at the time of the study and stroke, gender, hemoglobinopathy, presence of a peripheral deep venous thrombosis (DVT), and evidence for other stroke risk factors (moyamoya or cerebral aneurysms) were ascertained by chart review. The study was approved by the IRB at our institution.Results: From this group of 65 adult patients with a sickling hemoglobinopathy (hemoglobin SS, SC, or S beta thalassemia) and stroke, we identified 15 patients who underwent an evaluation for a PFO or other intracardiac shunt (Table 1). The prevalence of PFO or other intracardiac shunt in these adults with SCD and a history of stroke was 40% (6/15). Of these 6 patients with SCD, PFO and stroke, 1 had hemoglobin SC and 5 had hemoglobin SS. Three of the PFOs were Grade 1 and 3 were Grade 3. Three patients with PFO and stroke also had a DVT at the time of the stroke; 3 patients with PFO and stroke also had Moyamoya.Conclusions: The high prevalence of PFOs in adults with SCD and stroke compared to the prevalence of PFOs in the general population suggest that PFOs could be a risk factor for stroke in this population. These findings also underscore the urgent need for further research to establish the role of PFOs in stroke in adults with SCD because PFOs can be closed with a minimally invasive procedure. DisclosuresNaik:NHLBI: Research Funding.

Patent Foramen Ovale Is Not Associated with Hypoxemia in Severe Chronic Obstructive Pulmonary Disease and Does Not Impair Exercise Performance

Patent foramen ovale (PFO) may be disadvantageous in chronic obstructive pulmonary disease (COPD). It is unknown whether right-to-left shunting through PFO increases during exercise impairing exercise performance. To determine whether (1) PFO prevalence is greater in hypoxemic versus less hypoxemic patients with COPD, (2) PFO is associated with clinically relevant impairment, and (3) right-to-left shunting increases during exercise and impairs exercise performance. Patients with COPD and age-matched control subjects underwent contrast transthoracic echocardiography and transcranial Doppler to identify PFO. Patients with COPD with no shunt and patients with large PFO underwent cardiopulmonary exercise tests with contrast transcranial Doppler, esophageal, and gastric balloon catheters. PFO prevalence was similar in 50 patients with COPD and 50 healthy control subjects (46% vs. 30%; P = 0.15). Large shunts were more common in patients with COPD (26% vs. 6%; P = 0.01). In an expanded COPD cohort, PFO prevalence was similar in 31 hypoxemic (Pao2 ≤ 7.3 kPa) and 63 less hypoxemic (Pao2 > 8.0 kPa) patients with COPD (39% vs. 52%; P = 0.27). Patients with intrapulmonary shunting had lower Pao2 than both patients with PFO and those with no right-to-left shunt (7.7 vs. 8.6 vs. 9.3 kPa, respectively; P = 0.002). Shunting significantly increased during exercise in patients with COPD with PFO. Endurance time at 60% Vo2max was 574 (178) seconds for patients with PFO and 534 (279) seconds for those without (P = ns). Hypoxemic patients with COPD do not have a higher prevalence of PFO. Patients with COPD with PFO do not perform less well either on a 6-minute walk or submaximal exercise testing despite increased right-to-left shunting during exercise.

Migraine Headache and the Patent Foramen Ovale

What are the indications for closure of a patent foramen ovale (PFO) in an adult? Very few questions in the field of cardiology are as controversial. Disagreement exists about definitive indications for PFO closure under various circumstances. Approximately 25% of all adults have patency of the foramen ovale. This translates to 60 million people in the United States who have this finding. It is estimated that there are 280 000 cryptogenic strokes per year.1,2 Patients with cryptogenic stroke have a higher prevalence of PFO than age- and sex-matched controls.3,4 Nevertheless, without pathological evidence, definitive proof of the linkage is hard to come by. Statistical associations can be suggestive or even rather convincing, but for the vast majority of patients, absolute evidence is lacking. Catheter interventions for such patients are usually performed at low risk, but are even small risks justified when cause and effect remains unproven? There is extensive literature that attempts to answer this question, but controversy remains. Article see p 1406 Patients who have had a cryptogenic stroke and a PFO are often treated with chronic anticoagulation therapy, and the risk of recurrent events appears to be reduced.5 Currently, the labeled indication for PFO device closure is recurrent stroke in patients who had an event despite treatment, or are not candidates for anticoagulation. Nevertheless, a considerable number of interventional and general cardiologists are convinced that device closure in the cardiac catheterization laboratory is …

Reversible Neurological Deficit after Foam Sclerotherapy

A 37-year-old male was treated with 9 ml of 3% polidocanol foam, and he immediately reported photopsiae lasting a few minutes, though without migraine. Two hours after sclerotherapy, the patient developed speech disturbance for a few minutes. A pathological examination revealed nothing except a patent foramen ovale (PFO). Given the contrast between the high prevalence of PFO in general population and the extremely low incidence of neurological deficits after foam sclerotherapy, these deficits may only arise due to as-yet-unknown aetiology.

Relevancia clínica del foramen oval permeable con cortocircuito derecha-izquierda

A frequent finding in healthy individuals, patent foramen ovale (PFO) with right-to-left shunt (RLSh), is an embrionary residue that has been linked with cryptogenic stroke and peripheral ischemia. Pulmonary hypertension and entities like decompression illness, migraine with aura or plathypnea-orthodeoxia have been found to have a higher prevalence of PFO with RLSh. Some dementias and unexplained syncopes could also have some relationship. Paradoxical embolism, thrombosis of the foramen channel or the atrial structures with subsequent embolism, transient arrhythmias, prothrombotic states and vasoactive substances passage have been proposed as physiopathologic mechanisms involved. Contrast-enhanced transesophageal echocardiography is the standard reference diagnostic procedure but contrast-enhanced transcranial Doppler is a good non-invasive alternative diagnostic tool that is highly sensitive and specific.

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

High prevalence of patent foramen ovale in migraine with aura

In this study we evaluated the presence of patent foramen ovale (PFO) in a cohort of 25 consecutive patients suffering from migraine with aura (MA) during an attack presenting to the emergency ward of an Italian hospital. Patients underwent brain magnetic resonance imaging (MRI) with contrast medium, routine coagulation tests, contrast transcranial echocolour–coded sonography (c–TCCS) and transoesophageal echocardiography (TEE). Of the enrolled patients, 88.7% showed a PFO according to the c–TCCS test, whereas only in 72% TEE confirmed the presence of PFO. This discordance could be due to the fact that c–TCCS is more sensitive even with shunts with minimal capacity also located in the pulmonary vasculature. After surgical treatment of the PFO, MA disappeared within two months. Also, the treatment with warfarin as well as with acetylsalicylic acid and flunarizine was able to dramatically reduce the frequency of migraine attacks. These data indicate a higher prevalence of PFO in MA vs. normal population (OR=2.92) and could suggest that the presence of arteriovenous (AV) shunts could represent a trigger for MA attacks as well as for stroke, but more studies are needed to confirm this preliminary hypothesis.

Increased Prevalence of Patent Foramen Ovale in Patients with Severe Chronic Obstructive Pulmonary Disease

This study was designed to assess the prevalence of patent foramen ovale (PFO) in patients with severe chronic obstructive pulmonary disease (COPD) and the magnitude of any effects of right-to-left interatrial PFO shunting on systemic arterial oxygen desaturation after the Valsalva maneuver. The prevalence of PFO was compared between a group of 20 patients with severe chronic obstructive pulmonary disease (FEV 1 % <50%; FEV 1 /FVC <50%) and 20 control subjects (FEV 1 % >70%; FEV 1 /FVC >70%) by contrast transesophageal echocardiography during the Valsalva maneuver with simultaneous measurement of systemic arterial oxygen saturation (SaO 2 ) by pulse oximetry. Patients with severe COPD (FEV 1 = 27.2% ± 8.4%; FEV 1 /FVC = 44.3% ± 11.0%) had a significantly higher pulmonary artery systolic pressure (38.3 ± 7.3 vs 21.0 ± 2.4 mm Hg; P < .005), higher prevalence of PFO (14/20 = 70% vs 7/20 = 35%; P < .05), and greater systemic arterial desaturation after Valsalva (Sa o 2 change: –2.6% ± 1.4% vs –1.1% ± 0.9%; P < .005) than control subjects. In the severe COPD group, the degree of systemic arterial desaturation after Valsalva in patients with PFO was significantly greater than in patients without PFO (Sa o 2 change: –3.1% ± 1.4% vs –1.5% ± 0.5%; P < .05). Significant systemic arterial oxygen desaturation was observed after Valsalva in 45% of patients with interatrial PFO shunting and severe COPD. This significantly correlated with the degree of pulmonary hypertension ( r = 0.6; P < .05). We conclude (1) that patients with severe COPD have an increased prevalence of PFO and (2) that approximately one half of subjects with severe COPD and PFO demonstrate statistically significant systemic arterial oxygen desaturation after the Valsalva maneuver. (J Am Soc Echocardiogr 1999;12:99-105.)