Patent Foramen Ovale In Patients Research Articles

Thrombus Inside the Channel of Patent Foramen Ovale Revealed by Optical Coherence Tomography Imaging in a Patient with Myocardial Infarction—Case Report

Abstract Background Myocardial infarction (MI) caused by patent foramen ovale (PFO)-based paradoxical embolism is rare, and there are few case reports in the literature. Case Summary Here, we report a case of MI in which optical coherence tomography revealed in situ thrombi in the PFO channel. Discussion In addition to paradoxical embolism, in situ thrombus may also be one of the pathogenic mechanisms of PFO in patients with MI.

Device Closure or Antithrombotic Therapy After Cryptogenic Stroke in Elderly Patients With a High-Risk Patent Foramen Ovale.

In young patients (aged 18-60 years) with patent foramen ovale (PFO)-associated stroke, percutaneous closure has been found to be useful for preventing recurrent ischemic stroke or transient ischemic attack (TIA). However, it remains unknown whether PFO closure is also beneficial in older patients. Patients aged ≥60 years who had a cryptogenic stroke and PFO from ten hospitals in South Korea were included. The effect of PFO closure plus medical therapy over medical therapy alone was assessed by a propensity-score matching method in the overall cohort and in those with a high-risk PFO, characterized by the presence of an atrial septal aneurysm or a large shunt. Out of the 437 patients (mean age, 68.1), 303 (69%) had a high-risk PFO and 161 (37%) patients underwent PFO closure. Over a median follow-up of 3.9 years, recurrent ischemic stroke or TIA developed in 64 (14.6%) patients. In the propensity score-matched cohort of the overall patients (130 pairs), PFO closure was associated with a significantly lower risk of a composite of ischemic stroke or TIA (hazard ratio [HR]: 0.45; 95% confidence interval [CI]: 0.24-0.84; P=0.012), but not for ischemic stroke. In a subgroup analysis of confined to the high-risk PFO patients (116 pairs), PFO closure was associated with significantly lower risks of both the composite of ischemic stroke or TIA (HR: 0.40; 95% CI: 0.21-0.77; P=0.006) and ischemic stroke (HR: 0.47; 95% CI: 0.23-0.95; P=0.035). Elderly patients with cryptogenic stroke and PFO have a high recurrence rate of ischemic stroke or TIA, which may be significantly reduced by device closure.

Long-term impact of transcatheter closure interatrial shunts on disabling migraine

Backgrounds Effectiveness of patent foramen ovale (PFO) closure on relief of migraine, is still unclear. We sought to analyse the long-term (>10 years) effects of interatrial septal shunt repair on disabling migraine performing a retrospective non-randomised study. Methods Clinical records of patients with disabling, medication-refractory migraine and PFO or significant ASD referred to our centre for closure from 2006 to 2018, were analysed. Results Forty -six patients (38 female, mean age 40.0 ± 3.7 years) with PFO and 32 patients with significant ASD (28 female, mean age 38.0 ± 4.1 years) submitted to transcatheter closure had a pre-existing disabling migraine with mean Migraine Disability Assessment Score (MIDAS) of 35.8 ± 4.7. After a mean follow-up of 118.2 ± 19.1 months (range 96 to 144), 72 out of 78 patients were still followed-up: in all subjects, aura was abolished, and migraine improved also in patients without aura. The mean MIDAS significantly decreased from baseline value (p < 0.01). Complete migraine resolution was associated in PFO patients with a shorter history of migraine, a more severe thrombophilic profile, a more severe Right-to-Left Shunt (RLS) and larger left atrial diameter and volume, and in ASD patients with bidirectional shunt. Conclusions Device-based repair of PFO/ASD in patients with migraine was associated with abolition of aura and symptoms reduction in the long-term period.

Clinical significance of a patent foramen ovale in patients with pulmonary embolism

The phenomenon of a patent foramen ovale in patients with pulmonary embolism increases the risk of ischemic stroke. The clinical significance of this phenomenon should be taken into account to determine the diagnostic algorithm, management tactics and choice of secondary prevention. The prognosis of a patient with pulmonary embolism depends not only on the likelihood of recurrent pulmonary embolism, the formation of chronic pulmonary hypertension, but is also associated with an increased risk of ischemic stroke through the mechanism of paradoxical embolism due to the presence of a patent foramen ovale. A venous thrombus migrates through the patent foramen ovale as a result of the operation of an intracardiac right-left shunt. The purpose of the scientific review is to raise awareness of the problem of ischemic stroke in patients with pulmonary embolism. The results of studies and registries are presented, which reflect that the presence of patent foramen ovale increases the risk of developing ischemic stroke in patients with pulmonary embolism. Ischemic stroke can occur within 2–22 days after the onset of a pulmonary embolism clinic, and the risk of ischemic stroke remains within a year. Non-invasive transcranial dopplerography is recommended for diagnosis at the first stage of identification of the right-to-left shunt and is highly sensitive method (95–98%). Transesophageal echocardiography should be considered for the second stage of diagnosis. Thrombolytic therapy or surgical thrombectomy improves the prognosis for this category of patients. Тhrombolytic therapy may be given for up to 14 days in patients with pulmonary embolism. The use of thrombolytic therapy in the development of ischemic stroke becomes a possible option to improve the prognosis patients. The choice strategy for secondary prevention is important because patients have an increased risk of relapse.

A whole-exome sequencing study of patent foramen ovale: investigating genetic variants and their association with cardiovascular disorders.

Patent foramen ovale (PFO) has a genetic predisposition and is closely associated with cryptogenic stroke (CS), migraine, decompression sickness, and hypoxemia. Identifying PFO-related mutant genes through whole-exome sequencing (WES) can help in the early recognition of cardiovascular genetic risk factors, guide timely clinical intervention, and reduce the occurrence of cardiovascular events. We analyzed mutant genes from ClinVar and OMIM databases. WES was performed on 25 PFO patients from Zhejiang Provincial Hospital of Chinese Medicine. Pathogenicity of variants was evaluated using American College of Medical Genetics and Genomics (ACMG) and Association for Molecular Pathology. (AMP) guidelines. In ClinVar (4 Feb 2023), 113 coding gene mutations were found, including 83 associated with PFO. From OMIM (18 Apr 2023), 184 gene mutations were analyzed, with 110 mutant coding genes. WES identified pathogenic mutations in two of 25 PFO patients (8%). LDLR, SDHC, and NKX2-5 genes were linked to PFO and primarily involved in myocardial tissue function. NKX2-5 may play a crucial role in PFO development, interacting with NOTCH1, GATA4, MYH6, SCN5A signaling pathways regulating cardiomyocyte characteristics. We identified pathogenic mutations in LDLR, SDHC, and NKX2-5 genes, implying their role in PFO development. Functional enrichment analysis revealed NKX2-5's interaction with signaling pathways regulating cardiomyocyte function. These findings enhance our understanding of PFO's genetic basis, suggesting potential therapeutic targets for future research.

Atrial Septal Abnormalities and Cryptogenic Stroke: A Cross-Sectional Study.

Cryptogenic stroke, whose underlying pathology is unknown, accounts for 30-40% of all ischemic strokes. Studies have mentioned the association between atrial septal abnormalities and cryptogenic stroke, but there are still disparities in the results among different studies. We aimed to clarify the prevalence of atrial septal abnormalities in patients with cryptogenic stroke. We conducted a cross-sectional study on 91 patients with cryptogenic stroke/transient ischemic attack from March 2021 to March 2022. We evaluated the demographic data of the patients and also the existence of neurologic attacks. Furthermore, echocardiography was performed to determine the type of atrial septal abnormality. Out of 91 patients with cryptogenic stroke/transient ischemic attack, 16 patients (17.5%) had patent foramen ovale, 1 man (1.1%) had atrial septal aneurysm, and 1 woman (1.1%) had an atrial septal defect. Patients with patent foramen ovale were significantly younger than those without. The size of patent foramen ovale in patients with cryptogenic stroke was larger than those with transient ischemic attack, but this difference was not significant. Also, the size of the patent foramen ovale (length and width) was not significantly related to any of the demographic variables (p-value = 0.544, 0.604). Based on our results, the prevalence of atrial septal abnormalities was relatively high. Considering these issues and the importance of preventing neurological accidents in patients, especially young people, it is recommended to always consider atrial septal disorders and, if diagnosed, to carry out the necessary treatment in this field.

Construction and validation of a nomogram for predicting remission of migraine patients with patent foramen ovale after closure

ObjectiveThis study aimed to construct and validate a nomogram model that predicts the remission of migraine attacks by screening factors that affect the prognosis of migraine patients with patent foramen ovale (PFO) after closure. MethodRetrospective analysis was conducted in migraine patients with PFO who underwent PFO closure in the Department of Cardiology of Jiangsu Province Hospital from September 2020 to April 2023. Based on the Migraine Disability Assessment (MIDAS) scores from the 1-year follow-up after PFO closure, all patients who met the inclusion criteria were categorized into a remission group and a non-remission group. The primary efficacy endpoint was remission of migraine headache. After collecting clinical data, transcranial doppler sonography (TCD) results and MIDAS scores, LASSO (least absolute shrinkage and selection operator) regression and multivariable logistic regression analysis were used to filter variables predictive to migraine remission and construct the nomogram model. The Nomogram's accuracy and consistency were respectively assessed through Receiver Operating Characteristic (ROC) curves and calibration curves. Additionally, an analysis of decision curves (DCA) was conducted to evaluate the clinical utility of this newly developed model. ResultA total of 241 consecutive patients were included in the study. The remission group included 21 males and 93 females, with a median age of 39 (30.25,50) years. The non-remission group included 26 males and 101 females, with a median age of 35 (25.5,47.5) years. All Patients were randomly divided into a training cohort and a validation cohort. Multivariable logistic regression analysis showed that 5 independent predictors, including MIDAS before closure (p = 0.0002), mitigating factors (p = 0.0057), number of attacks/month (p = 0.0058), TCD (p = 0.0093) and Platelet Crit (PCT) (p = 0.0351), played a significant role in the prediction of remission of migraine patients with PFO after closure. Based on these independent predictors, the predictive nomogram model of migraine remission in PFO patients was constructed. The application of the nomogram in the training cohort exhibited good discrimination (area under the ROC curve was 0.7763[95% CI 0.7108–0.8418]), which was confirmed in the validation cohort (AUC was 0.704[95% CI 0.5533–0.8547]). The calibration curve showed that the nomogram model demonstrated good calibration performance. Additionally, the decision curve analysis indicated the clinical utility of the nomogram model. ConclusionThe construction of the nomogram model had a considerable predictive accuracy for migraine remission in patients after PFO closure, which may provide constructive guidance for clinical decision making.

Atrial septum anatomy as a predictor of ischemic neurological episodes in patients with a patent foramen ovale.

The correlation between atrial septum anatomy and the risk of ischemic neurological events remains underexplored. This study aimed to examine both the functional and anatomical attributes of the atrial septum and identify predictors of stroke and/or transient ischemic attack (TIA) in patients diagnosed with patent foramen ovale (PFO). A total of 155 patients diagnosed with PFO, with a cardiological cause of neurological events, were enrolled. Transesophageal echocardiography was utilized to assess the anatomy of the PFO canal, size of the right-to-left shunt, thickness of the primary and secondary atrial septum, presence of atrial septum aneurysm, and anatomical structures of the right atrium. Regression analysis showed that factors such as female sex, hypercholesterolemia, PFO canal width, and a large right-to-left shunt were significantly associated with stroke and/or TIA. Receiver operating characteristic analysis indicated that the width of the PFO canal holds a relatively weak, although significant predictive, value for ischemic neurological episodes (area under the curve = 0.7; P = 0.002). A PFO canal width of 4 mm was associated with 70% sensitivity and 55% specificity for predicting stroke and/or TIA. The atrial septum's anatomy, especially the dimensions of the PFO canal and the magnitude of the right-to-left shunt, combined with specific demographic and clinical factors, are linked to ischemic neurological incidents in PFO patients.

Headache patterns in patent foramen ovale patients: beyond migraine with aura.

Patent foramen ovale (PFO) is a common cardiac anomaly linked with cryptogenic strokes and migraine, particularly migraine with aura. This study aims to explore the spectrum of headache disorders in PFO patients, focusing on identifying patterns beyond the well-established migraine-PFO connection. A retrospective observational study was conducted on patients diagnosed with PFO. Headache types were classified using the International Classification of Headache Disorders, 3rd edition. The study analyzed headache prevalence and patterns in PFO patients, comparing those with and without a history of stroke. Of 177 participants, 63 (35.59%) reported headaches. Tension-type headache was the most common (15.25%), followed by migraine without aura (11.30%) and migraine with aura (8.47%). Notably, migraine without aura was more prevalent than migraine with aura, contrasting previous assumptions. No significant differences were found in headache types based on stroke history. The study reveals a diverse spectrum of headache types in PFO patients, with migraine without aura being more common than migraine with aura. These findings suggest a need for broader diagnostic perspective and individualized treatment approaches in PFO patients with headaches.

Assessment of the Characteristics of Patent Foramen Ovale Associated with Cryptogenic Stroke.

This study aims to comprehensively assess the characteristics of patent foramen ovale (PFO) in relation to Cryptogenic Strok (CS) by utilizing transesophageal echocardiography (TEE) and contrast transthoracic echocardiography (c-TTE) and to identify high-risk factors associated with PFO-related CS. Transcatheter PFO closure has demonstrated its effectiveness in preventing PFO-related CS. Therefore, understanding the specific structural attributes of PFO associated with CS is imperative. Enrollment comprised 113 test patients who experienced CS in conjunction with PFO and 117 control patients diagnosed with migraine with PFO but without a history of stroke. The characteristics of the PFO were observed by TEE and c-TTE. A comparative analysis was undertaken to assess the variations in PFO characteristics between the test patients and controls, and to uncover the independent factors relevant to CS. The patients in the test group were older than the controls. Both the height and length of the PFO during Valsalva exhibited greater dimensions in the test group when contrasted with controls. Notably, the test group presented higher incidence rates of low-angle PFO (defined as an angle between the inferior vena cava (IVC) and PFO ≤ 10°) and atrial septal aneurysm (ASA) as contrasted with the control group. Right-to-left shunt (RLS) III during Valsalva demonstrated a significantly elevated occurrence within the test group as opposed to the controls. Conversely, RLS II during Valsalva exhibited a significantly higher frequency in the controls in contrast to the tests. No significant disparities were observed between the two groups with respect to RLS I during Valsalva and all grades of RLS at rest. Multivariate analysis revealed that the length of the PFO during Valsalva, the presence of ASA, RLS III during Valsalva and low-angle PFO were independent relevant factors associated with CS. The length of the PFO tunnel, low-angle PFO, RLS III during Valsalva and the presence of ASA were independent risk factors for CS. The combined utilization of TEE and c-TTE may prove valuable in identifying PFO patients at a heightened risk of CS and in facilitating the screening process for transcatheter PFO closure.</p>.

Abstract TP225: Prevalence of Patent Foramen Ovale in Patients With Cancer-Related Stroke

Background and Purpose: Cancer increases the risk for acute ischemic stroke (AIS) and deep venous thrombosis. The role of paradoxical embolization as a stroke etiology in patients with cancer is uncertain. Our study investigated the relationship between cancer-related stroke and the presence of a patent foramen ovale (PFO). Methods: We included AIS patients hospitalized at our comprehensive stroke center between January 2015 and December 2020 with available PFO status as detected on transesophageal echocardiography. Active cancer, including cancer known at the time of stroke as well as occult cancer newly diagnosed within one year after stroke, were retrospectively identified. The association between PFO status and active cancer was assessed with multivariable logistic regression and reported using adjusted odds ratios (aOR) and their 95% confidence intervals (CI). Results: Among 2236 AIS patients (median age 68.3 years, female sex 36.4%), 103 (4.6%) had active cancer, of whom 24 (23%) were diagnosed with PFO. This included 32 patients (1.4%) with occult cancer, of whom 19% were diagnosed with PFO. Conversely, among 2133 AIS patients without active cancer, 774 were diagnosed with PFO (36%). In multivariable analysis (Fig 1), the absence of PFO was associated with active cancer (aOR 2.62, 95% CI 1.28-5.38). This association appeared stronger when patients older than 80 years of age were excluded (aOR 3.06, 95% CI 1.42 - 6.58) and persisted among patients with occult cancer at the time of AIS (aOR 5.39, 95% CI 1.18-24.74). Conclusions: In patients with AIS, PFO was diagnosed more commonly among patients without cancer than those with cancer. This might be due to cancer-related stroke being related to arterial coagulopathy rather than paradoxical emboli resulting from venous thrombi. Further studies are needed to confirm these findings and to assess the diagnostic role of PFO in patients with cancer and AIS.

Abstract TMP39: Paucity of Evidence-Based Patent Foramen Ovale Severity Ratings in Transesophageal Echocardiogram Clinical Reports

Introduction: The presence of a large physiologic shunt, defined as &gt;20 left atrial microbubbles within 3 cardiac cycles on transesophageal echocardiography (TEE), is a key, randomized controlled trial-validated, indication for patent foramen ovale (PFO) with a closure device in patients with otherwise cryptogenic ischemic stroke. The frequency with which this information is available to treating physicians from clinical TEE reports has not been well delineated. Methods: Among consecutive ischemic stroke patients admitted to an academic medical center undergoing TEE between January-June 2023, TEE reports were reviewed to determine frequency with which formal, clinical-trial definition-adherent characterization of PFO shunt size was provided, frequency of informal PFO shunt size descriptions, and correlations with transcranial Doppler (TCD) formal shunt grades (Spencer Grades 1-5). Results: Among the 50 patients, median age was 64 (IQR 58-74.5), and 20 (40%) were female. On TEE, shunt presence was assessed by bubble study in 38 (76%), direct Doppler alone in 6 (12%), and neither in 6 (12%). Among patients with bubble study, a right-to-left shunt (RLS) potentially due to PFO was present 15 (39%). RLS severity was quantified in 27% (4/15) of PFO patients, all with formally small (&lt;20) shunts. For the remaining 11, reports informally characterized shunt severity with various descriptive terms, including “mild” (7 cases), “mild/trace” (1), “moderate” (2), and “large” (1). TCD bubble studies were performed in 67% (10/15) of the TEE RLS PFO patients. Shunt severity correlation between TEE and TCD was 100% (3/3) for the formally quantified TEE shunts, but poor for the 7 informally assessed TEE shunts, with 60% (3/5) of shunts deemed “mild” on TEE quantified as intermediate-large on TCD, 1/1 deemed “moderate” on TEE quantified as intermediate on TCD, and 1/1 deemed “large” on TEE quantified as miniscule on TCD. Conclusions: Quantified, evidence-based ratings of PFO shunt severity were present in less than 3 of every 10 TEE reports, and unquantified, informal size estimates correlated poorly with TCD quantification of shunt severity. Patient management would be aided by inclusion of formal PFO shunt size quantification in all clinical stroke patient TEE reports.

Clinical Implications and Procedural Complications in Patients with Patent Foramen Ovale Concomitant with Atrial Septal Aneurysm

Atrial septal aneurysm (ASA) is defined as excursion of the atrial septum exceeding 10 mm beyond the atrial septum into the right or left atrium, or a combined total excursion of 15 mm on the right and left sides during the cardiac cycle. According to previous studies, 20–40% of patent foramen ovale (PFO) cases are accompanied by ASAs. ASA is associated with the presence of PFO, left atrial dysfunction, cryptogenic stroke, migraine, and arterial embolism, thus making closure of PFO in patients with concomitant ASA necessary but challenging. The anatomy of ASAs associated with PFO has crucial effects on complications after the closure procedure; therefore, several factors must be considered. Herein, we review the clinical implications of concomitant PFO and ASA; discuss the complications occurring after the closure procedure; and provide practical guidance for the closure of concomitant PFO and ASA.

Study design and rationale of COMPETE: Comparison of the effect of medication therapy in alleviating migraine with patent foramen ovale

Previous studies have examined the impact of antithrombotic agents on Patent Foramen Ovale (PFO) in relation to migraine. However, differences in effectiveness of different antithrombotic agents and traditional migraine medications are not known. This study is an investigator-initiated, randomized, multicenter, single-masked (outcomes assessor), and active-controlled parallel-group trial (ClinicalTrials.gov Identifier: NCT05546320), with the objective of evaluating the prevention efficacy of antithrombotic agents compared to first-line migraine medication in PFO patients. The trial involves 1,000 migraine patients with a right-to-left shunt at the atrial level, randomized in a 1:1:1:1 fashion to receive either aspirin 300 mg QD, clopidogrel 75 mg QD, rivaroxaban 20 mg QD, or the active-control metoprolol 25 mg BID. The primary efficacy end point is the response rate, defined as a 50% or greater reduction in the average migraine attack days per month or in the average number of migraine attacks per month at 12-week visit compared to baseline. The COMPETE trial aims to provide valuable insights into the comparative effectiveness of antithrombotic agents and standard migraine therapies in patients with PFO. This study holds the promise of advancing treatment approaches for individuals having migraines associated with PFO, thus addressing an important gap in current migraine management strategies.

Abstract 17959: Cardiovascular Outcomes and Readmissions of Atrial Fibrillation Among Patent Foramen Ovale Occluder Device Recipients : A Propensity Matched National Readmission Study

Introduction: Patent foramen ovale (PFO) occluder devices are increasingly utilized minimally invasive procedures used to treat cryptogenic stroke. Data on the impact of Atrial Fibrillation (AF) among PFO occluder device recipients are limited. Methods: The Nationwide Readmissions Database was queried between 2016 to 2019 to identify PFO patients with and without AF. The two groups were compared using propensity score matching (PSM) and multivariate regression models. The outcomes included in-hospital mortality, acute kidney injury (AKI), Mechanical circulatory support use (MCS), Cardiogenic shock (CS) acute ischemic stroke, bleeding and other cardiovascular outcomes. Statistical analysis was performed using STATA v. 17. Results: Out of 6,508 Weighted hospitalizations for PFO occluder device procedure over the study period, 877 (13.4%) had AF compared to 5,631 (86.6%) who did not. On adjusted analysis, PFO with AF group had higher rates of MCS (PSM, 4.5% vs. 2.2 %, p value=0.011) and SCA (PSM, 7.6% vs. 4.6 %, p value=0.015) compared to PFO with no AF. There was no statistically significant difference in the rate of in hospital mortality (PSM, 5.4% vs. 6.4 %, p value=0.39), CS (PSM, 8.3% vs. 5.9 %, p value=0.075), AKI (PSM, 32.4% vs. 32.3 %, p value=0.96), bleeding (PSM, 2.08% vs. 1.3 %, p value=0.235) or the readmission rates among both cohorts. Additionally, AF was associated with higher hospital length of stay (9.5 +/-13.2 vs. 8.2 +/-24.3 days, p value =0.012 ) and total cost ($66,513+/-$80,922 vs. $52,013+/-$125,136, 0.025, p value = 0.025) compared to PFO without AF. Conclusions: The presence of AF among PFO occluder device recipients is associated with increased adverse outcomes including MCS use and SCA with no difference in mortality and the readmission rates among both cohorts. Long term follow up needs further studies.

Incidence of atrial fibrillation in cryptogenic stroke with patent foramen ovale closure: protocol for the prospective, observational PFO-AF study

IntroductionAfter closure of patent foramen ovale (PFO) due to stroke, atrial fibrillation (AF) occurs in up to one in five patients. However, data are sparse regarding the possible pre-existence of...

Patent foramen ovale in carcinoid heart disease: The potential role for and risks of percutaneous closure prior to cardiothoracic surgery.

Neuroendocrine tumours (NETs) are rare but once metastasised, can lead to the release of vasoactive substances into the systemic circulation, and the classical features of carcinoid syndrome (CS) such as flushing and diarrhoea. A consequence of CS is carcinoid heart disease (CHD) which primarily affects the right-sided heart valves and can eventually lead to right heart failure. In this cohort, tricuspid and/or pulmonary valve replacement provides symptomatic relief. A patent foramen ovale (PFO) in patients with CHD can lead to the shunting of oxygen deficient blood to the systemic circulation causing hypoxaemia and reduced exercise tolerance. Additionally, the haemodynamic changes caused by regurgitant right-sided heart valves can increase the patency of a PFO allowing the passage of vasoactive substances to the systemic circulation thereby affecting the left-sided heart valves. We present data on the incidence of PFO in patients referred for surgery at our centre, in which the standard approach is to close the defect at time of cardiothoracic surgery. In addition, we present a series of four cases that highlight how the option of percutaneous PFO closure prior to open valve surgery may reduce haemodynamic instability and open a window of opportunity to enhance preoperative status. Percutaneous PFO closure then acts as a bridge to definitive cardiothoracic surgery, although there are risks in such an approach.

Risk of recurrent ischemic stroke in patients with patent foramen ovale: The role of D-dimer

BackgroundParadoxical embolism under elevated thromboembolic conditions is known to be the primary mechanism of patent foramen ovale (PFO)-related stroke. We hypothesized that higher levels of D-dimer, a marker of thromboembolism, could increase the risk of stroke recurrence in patients with PFO. MethodsWe conducted a retrospective analysis of data from 1226 consecutive patients with acute ischemic cryptogenic stroke (CS) who underwent transesophageal echocardiography (TEE). D-dimer was assessed during admission. We used a multivariate Cox proportional hazards model to evaluate the association of long-term outcomes between the presence of PFO and levels of D-dimer. ResultsOf the 1226 patients, the study included 461 who underwent TEE. Among them, 242 (52.5%) had PFOs. Among PFO patients, those with a D-dimer level >1.0 mg/L had a significantly higher risk of stroke recurrence compared to those with <0.5mg/L (adjusted hazard ratio (aHR) 4.04, 95% confidence interval [CI] 1.63–10.02). A pattern of increased risk of event with increasing D-dimer levels was observed (Ptrend=0.008). However, there was no significant difference in the risk of stroke recurrence at any D-dimer level compared to D-dimer level <0.5 mg/L among patients without PFO. In these patients, there was little evidence of increased risk with increasing D-dimer levels (Ptrend=0.570). ConclusionsThis study demonstrated that the elevated D-dimer level increased the recurrence of stroke in CS patients with PFO, particularly showing a dose-dependent relationship between D-dimer levels and recurrence. However, no such effect was observed in patients without PFO. These findings provide valuable insights into the potential benefits of anticoagulation for strokes related to PFO.

Identification of potential influencing factors associated with elimination of migraine headache in patients with PFO after percutaneous closure

Objective: To recognize the potential factors that contribute to the eradication of migraine headache in patients with patent foramen ovale (PFO) at one year after percutaneous closure. Methods: A prospective cohort study was conducted, which enrolled patients diagnosed with migraines and PFO at the Department of Structural Heart Disease, First Affiliated Hospital of Xi'an Jiaotong University between May 2016 and May 2018. The patients were segregated into two groups based on their response to treatment, and one group showed elimination of migraines while another did not. Elimination of migraines was defined as a Migraine Disability Assessment Score (MIDAS) score of 0 at one year postoperatively. Least Absolute Shrinkage and Selection Operator (LASSO) regression model was utilized to identify the predictive variables for migraine elimination post-PFO closure. Multiple logistic regression analysis was employed to determine the independent predictive factors. Results: The study enrolled a total of 247 patients, with an average age of (37.5±13.6) years, comprising 81 male individuals (32.8%). One year after closure, 148 patients (59.9%) reported eradication of their migraines. Multivariate logistic regression analysis revealed that migraine with or without aura (OR=0.003 9, 95%CI 0.000 2-0.058 7, P=0.000 18), a history of antiplatelet medication use (OR=0.088 2, 95%CI 0.013 7-0.319 3, P=0.001 48) and resting right-to-left shunt (RLS) (OR=6.883 6, 95%CI 3.769 2-13.548 0, P<0.001) were identified as independent predictive factors for elimination of migraine. Conclusion: Migraine with or without aura, a history of antiplatelet medication use, and resting RLS are the independent prognostic factors associated with elimination of migraine. These results provide important clues for clinicians to choose the optimal treatment plan for PFO patients. However, further studies are needed to confirm these findings.

Detection of patent foramen ovale in patients with ischemic stroke on prospective ECG-gated cardiac CT compared to transthoracic echocardiography

BackgroundCardiac CT acquired during the acute stroke imaging protocol is an emerging alternative to transthoracic echocardiography (TTE) to screen for sources of cardioembolism. Currently, its diagnostic accuracy to detect patent foramen ovale (PFO) is unclear.MethodsThis was a substudy of Mind the Heart, a prospective cohort in which consecutive adult patients with acute ischemic stroke underwent prospective ECG-gated cardiac CT during the initial stroke imaging protocol. Patients also underwent TTE. We included patients < 60 years who underwent TTE with agitated saline contrast (cTTE) and assessed sensitivity, specificity, negative and positive predictive value of cardiac CT for the detection of PFO using cTTE as the reference standard.ResultsOf 452 patients in Mind the Heart, 92 were younger than 60 years. Of these, 59 (64%) patients underwent both cardiac CT and cTTE and were included. Median age was 54 (IQR 49–57) years and 41/59 (70%) were male. Cardiac CT detected a PFO in 5/59 (8%) patients, 3 of which were confirmed on cTTE. cTTE detected a PFO in 12/59 (20%) patients. Sensitivity and specificity of cardiac CT were 25% (95% CI 5–57%) and 96% (95% CI 85–99%), respectively. Positive and negative predictive values were 59% (95% CI 14–95) and 84% (95% CI 71–92).ConclusionProspective ECG-gated cardiac CT acquired during the acute stroke imaging protocol does not appear to be a suitable screening method for PFO due to its low sensitivity. Our data suggest that if cardiac CT is used as a first-line screening method for cardioembolism, additional echocardiography remains indicated in young patients with cryptogenic stroke, in whom PFO detection would have therapeutic consequences. These results need to be confirmed in larger cohorts.