Patent Foramen Ovale Diameter Research Articles

Predictive value of transesophageal echocardiography combined with contrast transthoracic echocardiography for embolic stroke of undetermined source.

In this study, we aimed to assess the predictive value of transesophageal echocardiography (TEE) combined with contrast transthoracic echocardiography (cTTE) for embolic stroke of undetermined source (ESUS). A total of 52 patients with ESUS were examined by TEE and cTTE. The detection rate of patent foramen ovale (PFO) and right-to-left shunt (RLS) grade were compared in patients with ESUS between cTTE alone and cTTE combined with TEE. The Risk of Paradoxical Embolism (RoPE) score, PFO diameter, and PFO length of patients with PFO-associated ESUS and non-PFO-associated ESUS were compared by cTTE alone and cTTE combined with TEE. The receiver operating characteristic (ROC) curve was utilized to determine the effect of RoPE score and PFO diameter on patients with PFO-associated ESUS. The positive rate of PFO detected by cTTE alone (46.15%) was lower than that detected by cTTE combined with TEE (69.23%). The proportion of patients with RLS grade I + II + III detected by cTTE combined with TEE (69.23%) was higher than that detected by cTTE alone (46.15%). Both the RoPE score and PFO diameter were significantly greater in the patients with PFO-associated ESUS than in the patients with non-PFO-associated ESUS (p < .05). The combination of RoPE score and PFO diameter had the largest area under the ROC curve (AUC = 0.875), which was larger than the AUC alone of RoPE score (AUC = 0.819) and PFO diameter (AUC = 0.783) (p < .05). The combination of cTTE and TEE is helpful to the diagnosis of ESUS patients caused by PFO and to judge the degree of RLS.

Unrecognized Patent Foramen Ovale in Patient With Sinus Venosus-Type Atrial Septal Defect With Partial Anomalous Pulmonary Venous Return.

Unrecognized Patent Foramen Ovale in Patient With Sinus Venosus-Type Atrial Septal Defect With Partial Anomalous Pulmonary Venous Return.

Safety and efficacy of left atrial appendage closure combined with patent foramen ovale closure for atrial fibrillation patients with patent foramen ovale

Objective: To analyze the safety and efficacy of combined left atrial appendage (LAA) and patent foramen ovale (PFO) closure in adult atrial fibrillation (AF) patients complicating with PFO. Methods: This study is a retrospective and cross-sectional study. Seven patients with AF complicated with PFO diagnosed by transesophageal echocardiography (TEE) in Zhoupu Hospital Affiliated to Shanghai University of Medicine & Health Sciences from June 2017 to October 2020 were selected. Basic data such as age, gender and medical history were collected. The atrial septal defect or PFO occluder and LAA occluder were selected according to the size of PFO, the ostia width and depth of LAA. Four patients underwent left atrial appendage closure(LAAC) and PFO closure at the same time. PFO closure was performed during a one-stop procedure of cryoablation combined with LAAC in 2 patients. One patient underwent PFO closure at 10 weeks after one-stop procedure because of recurrent transient ischemic attack (TIA). All patients continued to take oral anticoagulants. TEE was repeated 8-12 weeks after intervention. In case of device related thrombus(DRT), TEE shall be rechecked 6 months after adjusting anticoagulant and antiplatelet drug treatment. Patients were follow-up at 1, 3, 6, 12, 24 months by telephone call, and the occurrence of cardio-cerebrovascular events was recorded. Results: Among the 7 patients with AF, 2 were male, aged (68.0±9.4) years, and 3 had a history of recurrent cerebral infarction and TIA. Average PFO diameter was (3.5±0.8)mm. Three patients were implanted with Watchman LAA occluder (30, 30, 33 mm) and atrial septal defect occluder (8, 9, 16 mm). 2 patients were implanted with LAmbre LAA occluder (34/38, 18/32 mm) and PFO occluder (PF1825, PF2525). 2 patients were implanted with LACbes LAA occluder (24, 28 mm) and PFO occluder (PF2525, PF1825) respectively. The patients were followed up for 12 (11, 24) months after operation. TEE reexamination showed that the position of LAA occluder and atrial septal defect occluder or PFO occluder was normal in all patients. DRT was detected in 1 patient, and anticoagulant therapy was adjusted in this patient. 6 months later, TEE showed that DRT disappeared. No cardiovascular and cerebrovascular events occurred in all patients with AF during follow-up. Conclusions: In AF patients complicated with PFO, LAAC combined with PFO closure may have good safety and effectiveness.

Importance of Persistent Right-to-Left Shunt After Patent Foramen Ovale Closure in Cryptogenic Stroke Patients.

Percutaneous closure of patent foramen ovale (PFO) is widely performed to prevent recurrent stroke or transient ischemic attack in patients with cryptogenic stroke. However, the influence of different degrees of right-to-left shunting (RLS) has rarely been reported. We retrospectively evaluated the cases of 268 patients with cryptogenic stroke who underwent PFO closure at our hospital from April 2012 through April 2015. In accordance with RLS severity, we divided the patients into 2 groups: persistent RLS during normal breathing and the Valsalva maneuver (n=112) and RLS only during the Valsalva maneuver (n=156). Baseline characteristics, morphologic features, and procedural and follow-up data were reviewed. The primary endpoint was stroke or transient ischemic attack. More patients in the persistent group had multiple or bilateral ischemic lesions, as well as a larger median PFO diameter (2.5 mm [range, 1.8-3.9 mm]) than did patients in the Valsalva maneuver group (1.3 mm [range, 0.9-1.9 mm]) (P <0.001). Atrial septal aneurysm was more frequent in the persistent group: 25 patients (22.3%) compared with 18 (11.5%) (P=0.018). Three patients in the persistent group had residual shunting. The annual risk of recurrent ischemic stroke was similar between groups: 0.298% (persistent) and 0.214% (Valsalva maneuver). Our findings suggest that patients with persistent RLS have more numerous severe ischemic lesions, larger PFOs, and a higher incidence of atrial septal aneurysm than do those without. Although our persistent group had a greater risk of residual shunting after PFO closure, recurrence of ischemic events did not differ significantly from that in the Valsalva maneuver group.

Echocardiographic Markers for the Prediction of Nonclosure of the Patent Ductus Arteriosus in Premature Neonates

Four echocardiographic markers—left ventricular ejection fraction (LVEF), the ratio of the left atrial diameter to the aortic root diameter (LA/Ao), the ratio of the patent ductus arteriosus (PDA) diameter to the left pulmonary arterial diameter (PDA/LPA), and the patent foramen ovale (PFO) diameter—were explored to predict a PDA in 221 premature neonates (53% male). There were 182 cases with PDA (mean diameter = 2.49 mm); 39 control subjects were observed with a closed ductus arteriosus. Although 104 of the cases (57.1 %) were diagnosed when 0 to 3 days old (median age = 1 day), 78 (42.9%) were diagnosed when 4 to 86 days old (median age = 13 days). Birth weights of the neonates ranged from 0.5 to 4.8 kg (mean = 1.68 kg). After controlling for age and birth weight, the mean LVEF (%) was not significantly different in the cases versus controls ( P &gt; .05); the mean LA/Ao and mean PFO diameter were significantly larger ( P &lt; .001) in the cases. The mean PDA/LPA was consistently ≥ .7 in the cases. The sensitivity of the LA/Ao ratio as a positive test for PDA (cutoff = 1.5) varied with age but not birth weight. When the neonatal age was 0 to 3 days, the sensitivity was 56% with a specificity of 88%; when the neonatal age was &gt; 3 days, the sensitivity of LA/Ao was 82% with a specificity of 63%. The sensitivity of PFO (cutoff = 3.0 mm) was 61% with a specificity of 48%, irrespective of age or birth weight. These data suggest that LVEF is not a significant predictor of the presence of PDA, but a combination of the LA/Ao ratio, PDA/LPA ratio, and PFO diameter is predictive of the presence of PDA.

Differences of morphological and functional characteristics of patent foramen ovale between patients with and without cryptogenic brain ischemia

Purpose: To assess in a prospective study whether morphological and functional parameters of Patent Foramen Ovale (PFO) differ between patients with and without cryptogenic ischemic stroke or Transient Ischemic Attack (TIA). Methods: A total of 331 consecutive patients with cryptogenic brain ischemia underwent contrast multiplane transesophageal echocardiography (265 patients with ischemic stroke and 66 patients with TIA). The control group consisted of 312 consecutive patients without the history of stroke or TIA. We analysed 103 patients (64 male; mean age 52,9±12,3 years) with cryptogenic cerebrovascular event and PFO (Group I; 31,1% of all patiens with brain ischemia) and compared them to 56 control patients (19 male; mean age 50,0±12,7 years) with PFO (Group II; 18,0% of the control group). Following parameters were investigated: diameter of the PFO, length of the PFO, presence of the atrial septal aneurysm, presence of the Eustachian valve, shunt severity (graded with a 1-3 scale). Diameter and length of the channel were correlated with the shunt severity. Results: Patients with cryptogenic brain ischemia had significantly larger PFO diameter and higher prevalence of large PFO (≥ 4 mm) compared to the control group (2,5±1,6 mm vs 2,1±1,1 mm, p < 0,05; 17,5% vs 5,3%, p < 0,05). There was no significant difference between Group I and Group II in prevalence of the atrial septal aneurysm (14,6% vs 21,4%) and Eustachian valve (4,9% vs 7,1%), in the tunnel length (13,7±5,4 mm vs 12,8±5,8 mm) and in the degree of the shunt (1,8±0,7 vs 1,8±0,8). Both groups did not differ in the proportion of the shunt identified only after the Valsalva manoeuvre (41,7% vs 51,8%). There was a significant correlation between the PFO diameter and the degree of the shunt in patients with brain ischemia (r = 0,54, p < 0,0001). A weak but significant correlation was found between the tunnel length and the degree of the shunt in these patients (r = 0,21, p < 0,05). Morphological and functional parameters of PFO were not different between patients with ischemic stroke and TIA. Conclusions: The results may support the hypothesis that the decisive characteristic of the PFO distinguishing the patients with cryptogenic brain ischemia and asymptomatic patients is the diameter. Symptomatic patient have significantly larger PFO diameter and higher proportion of large PFO. The PFO diameter positively correlates with the degree of the shunt. Symptomatic and asymptomatic patients did not differ in the tunnel length, in the degree of the shunt and in the prevalence of atrial septal aneurysm or Eustachian valve.

Anatomy of the patent foramen ovale for the interventionalist

Patent foramen ovale (PFO) is an interatrial communication whose management is controversial. Several manufacturers have submitted protocols for Food and Drug Administration (FDA) approval of their PFO closure device. The purpose of this study was to define anatomy relevant to percutaneous PFO closure, validate the clinical observation that most PFOs contain little tissue rim at the aorta, comment on proposed closure guidelines, and to discuss approaches to PFO closure. From the Mayo Clinic Tissue Registry, five normal hearts with PFO were selected from each sex from the first 10 decades of life (n = 100). Measurements (mm) included PFO length, diameter, and distance from FO-superior vena cava (SVC) and FO-aortic annulus (AoAn). Patient age, weight, and height were obtained from autopsy reports, and body surface area (BSA) was calculated. PFO length and diameter increased with age (P = 0.029 and 0.001, respectively), and FO-SVC and FO-AoAn increased with BSA (P <or= 0.0001 and 0.006, respectively). PFO diameter was larger in women than men (P = 0.028). Using current sizing guidelines, 66% (CI = 56-75%) of the 100 patients would have been excluded from device closure, and only 31% could have received the smallest (18 mm) device. Our results suggest that the proposed device closure guidelines may result in inappropriate device sizing. In addition to excluding suitable candidates, strict application of the guidelines could also result in incomplete closure or device embolization. Suggestions for modification of the guidelines and options for device closure are discussed.

Maximal Potential Patent Foramen Diameter Does Not Correlate with the Type or Frequency of the Neurologic Event prior to Closure

Background: We analyzed our data on patients undergoing transcatheter patent foramen ovale (PFO) closure to determine if the maximal potential PFO diameter (MPPD) by balloon sizing correlates with important clinical characteristics in this population. Methods: We defined stroke as a focal neurologic deficit lasting >24 h, or focal deficit of shorter duration associated with permanent MRI/CT changes consistent with a focal infarction. Parameters analyzed included age, gender, anticoagulation, hypertension, smoking, MRI/CT findings and MPPD at catheterization. We specifically analyzed the type of neurologic event (stroke/transient ischemic attack, TIA), and number of recorded preceding clinical neurologic events. Results: In 216 consecutive patients, 167 suffered a stroke. MRI/CT changes consistent with one or more embolic events were seen in 156 patients; 49 had a clinical TIA. There was no significant difference in MPPD between stroke (11.0 ± 3.6 mm) and TIA groups (10.9 ± 3.9 mm; 95% confidence interval for difference: –1.33 to 1.00). MPPD did not differ between MRI/CT-positive vs. -negative strokes, and had no correlation with the number of identified pre-closure clinical neurologic events. Conclusions: Continued investigation is needed to determine whether other PFO characteristics, or other anatomic/physiologic parameters, may be useful to identify patients at high risk for cryptogenic stroke/TIA, even before they have their first neurologic event.

Is Surgical Closure of Patent Foramen Ovale the Gold Standard for Treating Interatrial Shunts? An Echocardiographic Follow-up Study

Surgical closure of patent foramen ovale (PFO) has been considered definitive and the gold standard for preventing recurrent paradoxical embolism. However, in contrast to transcatheter PFO closure, patients undergoing operation have not systematically been re-evaluated for residual shunting. This study aimed to assess the efficacy of surgical PFO closure during follow-up by transesophageal echocardiography (TEE). Eleven adult patients with diagnosis of a PFO by contrast and/or color Doppler TEE underwent PFO closure by thoracotomy and direct suturing because of paradoxical embolism (n = 4), because of impending paradoxical embolism (n = 1), or during valve operation (n = 6). TEE performed 5 days to 7 months after PFO closure revealed residual shunting in 8 of 11 patients (73%). The shunt size was unchanged in two patients. According to the color Doppler jet width across the atrial septum, the postoperative PFO diameter was smaller in 5 of the remaining 6 patients. Right-to-left shunting by contrast TEE, however, had newly developed (n = 1) or increased (n = 2) for patients with concomitant valve operation. Despite therapeutic anticoagulation a cerebrovascular event occurred in one patient 4 weeks after attempted PFO closure. The mechanism for persistent shunting was incomplete sealing of septum primum and septum secundum by the suture line (n = 6) or a new iatrogenic defect of the fossa ovalis caused by surgical manipulation (n = 2). In two patients a second TEE after 12 and 41 months revealed enlargement of the PFO diameter. Surgical PFO closure can not be regarded as the gold standard for definitive treatment of interatrial shunts. Residual shunting present in a high proportion of patients may partly explain the recurrence of embolic events.

441 Comparison of multiplane transesophageal echocardiography with balloon sizing in assessing patent foramen ovale diameter

441 Comparison of multiplane transesophageal echocardiography with balloon sizing in assessing patent foramen ovale diameter

Diagnosis of patent foramen ovale by transesophageal echocardiography and correlation with autopsy findings

Transesophageal echocardiography (TEE) is accepted as the method of choice for the diagnosis of a patent foramen ovale (PFO). However, direct anatomic confirmation regarding the presence or absence of a PFO on transesophageal imaging has been obtained in only a limited number of patients. Consequently, this study was performed to assess the diagnostic accuracy of contrast and color Doppler TEE for detection of a PFO by comparing the results of TEE with autopsy. The study population comprised 35 consecutive patients (mean age 64 ± 14 years) who underwent autopsy and prior TEE with examination of the atrial septum. For diagnosis of a PFO, the following criteria were used: (1) no defect in the continuity of the atrial septum on 2-dimensional imaging; (2) ≥1 bright microbubble appearing in the left atrium within 3 heart cycles after opacification of the right atrium during contrast TEE; and (3) turbulent color jet within the atrial septum by color Doppler TEE. For estimating the PFO size, positive contrast studies were graded semiquantitatively (from 1 to 3), and the maximal color Doppler jet width was measured within the atrial septum at the area of maximal turbulence. At autopsy, a PFO was present in 9 of 35 patients (26%). All were correctly diagnosed by color Doppler TEE. The color Doppler jet width correlated well with the PFO diameter determined at autopsy (r = 0.99, SEE = 0.51 mm, p < 0.0001). By contrast TEE, 8 of the 9 patients with autopsy-proven PFO were correctly identified. In 1 case with left heart disease and a long interatrial channel, a PFO was missed by contrast TEE but clearly demonstrated by color Doppler TEE. All patients with a PFO diameter >10 mm showed intense left atrial opacification of grade 3. With both methods, there were no falsepositive results. Sensitivity and specificity for diagnosis of a PFO were 89% and 100%, respectively, for contrast TEE, and both 100% for color Doppler TEE. Thus, contrast and color Doppler TEE are complementary and represent a highly sensitive and specific method for diagnosis of a PFO and for estimation of the PFO size.