Patent Foramina Research Articles

Lower patent foramen ovale detection with transthoracic echocardiography in atrial fibrillation

Patent foramina ovale (PFO) are small defects within the atrial septum that may play a role in paradoxical embolism, stroke and migraines. The relationship between PFO and atrial fibrillation (AF) has not been formally studied. We prospectively studied patients with a history of AF, versus those without (controls), in order to compare PFO prevalence among them. Sixty-one patients with AF and forty-one controls completed the study, all undergoing transthoracic echocardiography using agitated saline microbubbles and a Valsalva maneuver. In the control group, 12/41 participants (29.2%) had PFOs compared to 5/61 (8.2%) in the AF group (P < 0.01). PFO positive patients within the entire study population demonstrated greater leftward inter-atrial septal shifting (82% vs 49%, P < 0.05). There was also reduced leftward inter-atrial septal shift observed within the AF group compared to controls (32/61 (52%) vs 31/41 (76%), P < 0.05). This study is the first to demonstrate an apparent lower rate of PFO in patients with AF, using bubble contrast echocardiography.

Transesophageal contrast echocardiography, open foramen ovale and aneurysm of the atrial septum. Experiences with D-galactose suspension

The advantages of transesophageal echocardiography using a D-galactose suspension rather than conventional ultrasonic contrast medium for the detection of a cardiac source of peripheral embolism was to be investigated. In 100 patients consecutively examined with transesophageal echocardiography applying a conventional ultrasonic contrast medium the examination was repeated adding a Valsalva test and using a solution of D-galactose (Echovist-300, Schering AG) as contrast medium. With conventional contrast media, 5 interatrial shunts only (2 ASD, 3 patent foramina ovalia, PFO) were detected. Completion of echocardiography with a systemic Valsalva test and use of Echovist-300 resulted in the diagnosis of another 40 PFO. In 17 of 26 patients having an atrial septal aneurysm, an interatrial shunt (1 ASD, 16 PFO) was demonstrated. The use of a solution of D-galactose as contrast medium appears to increase the sensitivity of echo-cardiography for demonstrating a cardiac source of peripheral embolism.

Intracardiac and intraluminal echocardiography: indications and standard approaches

In particular clinical scenarios, transthoracic and transoesophageal echocardiography (TEE) have limitations. This study sought to test if intracardiac and intraluminal echocardiography (ICLE), including 2-D, M-mode and Doppler analysis with a miniaturised, multiple-frequency transducer-tipped catheter, is suitable for assessing distinct cardiac and vascular disorders. ICLE was employed in 10 animals using 6 standard approaches. In 12 patients undergoing device closure of patent foramina ovalia (PFO) ( n = 6) or atrial septal defects (ASD) ( n = 3), or aortic stent implantation ( n = 3), interventional procedures were guided by ICLE and, for comparison, also by TEE. ICLE provided enhanced diagnostic information on the aorta, cardiac valves, main pulmonary vessels and both atria and, therefore, added to the diagnostic spectrum of TEE. Especially for guiding interventional procedures ( e.g., device closure of atrial septal defects and patent foramina ovalia), ICLE was shown to be helpful. Compared with the conventional approach, the technique reduced fluoroscopy time for device closure procedures: 6.5 min vs. 8.9 min, p < 0.0011. With the patient in a supine position, ICLE was better tolerated than TEE. Complications did not occur, either with ICLE or with TEE. In conclusion, ICLE adds to conventional echocardiography and promises to become a clinical alternative for guiding interventional procedures. (E-mail: thomas.bartel@uni-essen.de)

Role of Inverted Buttoned Device in Transcatheter Occlusion of Atrial Septal Defects or Patent Foramen Ovale With Right-to-Left Shunting Associated With Previously Operated Complex Congenital Cardiac Anomalies

Feasibility, safety, and effectiveness of transcatheter occlusion of atrial septal defect (ASD) with the buttoned device has been demonstrated. Despite its effectiveness in occluding secundum ASD with left-to-right shunt and patent foramina ovalia, presumably responsible for paradoxic embolism, it has limitations in effectively occluding ASD with evident right-to-left shunts. Therefore, the device was modified so that the square-shaped occluder component of the device is on the right atrial side, the inverted buttoned device. This study determines the feasibility, safety, and effectiveness of inverted buttoned device occlusion of atrial defects with right-to-left shunts. During a 17-month period ending August 1996, 12 patients, aged 1.6 to 39.0 years, underwent occlusion of residual ASD after repair of pulmonary atresia/stenosis with intact ventricular septum (n = 5), modified or fenestrated Fontan for tricuspid or pulmonary atresia (n = 5), and double-inlet left ventricle (n = 2). The systemic arterial oxygen saturation increased (p <0.001) from 82 ± 7% (range 72% to 90%) to 94 ± 3% (range 88% to 98%). There was no change in heart rate or cardiac index measured by Fick. Right atrial pressure increased by 1 to 4 mm in 5 of 12 patients (42%). There was trivial (n = 5) or no (n = 7) residual shunt by color Doppler study. Six- to 18-month (median 12) follow-up in all 12 patients revealed stable oxygen saturations (92 ± 3%) by pulse oximetry. Color Doppler studies revealed small (n = 1), trivial (n = 1), or no (n = 10) residual shunt at follow-up. Based on these data, it is concluded that transcatheter occlusion of ASD with right-to-left shunts with inverted buttoned device is feasible in relieving arterial hypoxemia. Further clinical trials in a larger number of patients and careful evaluation of follow-up results are indicated to examine its safety and longer term effectiveness.

Characteristics of patent foramen ovale associated with cryptogenic stroke. A biplane transesophageal echocardiographic study.

Patent foramen ovale is associated with ischemic stroke in patients without a clearly identifiable etiology for stroke (cryptogenic stroke). Paradoxical embolization is thought to be a potential mechanism. However, patent foramen ovale is also found in patients with known cause of stroke. Therefore, using contrast transesophageal echocardiography, we characterized the patent foramen ovale in cryptogenic stroke patients to assess morphological factors that may contribute to paradoxical embolization. Contrast transesophageal echocardiographic studies of 74 consecutive patients referred for ischemic stroke were reviewed. Twenty-three patients with patent foramen ovale were identified. These patients were classified as having strokes of determined origin or cryptogenic strokes according to criteria developed for the Stroke Data Bank of the National Institute of Neurological Disorders and Stroke. Separation of septum primum from secundum and the number of microbubbles appearing in left atrium were then quantitated. These parameters were compared between patients with cryptogenic stroke and those with known cause of stroke. The patent foramen ovale dimension was significantly larger in patients with cryptogenic stroke compared with patients with an identifiable cause of stroke (2.1 +/- 1.7 mm versus 0.57 +/- 0.78 mm [mean +/- SD]; P < .01). The number of microbubbles was also greater in patients with cryptogenic stroke compared with patients with an identifiable cause of stroke (13.9 +/- 10.7 versus 1.6 +/- 0.8 [mean +/- SD]; P < .0005). Patients with cryptogenic stroke have larger patent foramen ovale with more extensive right-to-left interatrial shunting than patients with stroke of determined cause. Transesophageal echocardiographically identifiable characteristics of patent foramen ovale may be important in defining the clinical significance of individual patent foramina.

Arterial Desaturation Due to Patent Foramina Ovale in Healthy Adults

Arterial Desaturation Due to Patent Foramina Ovale in Healthy Adults

Transcatheter closure of patent foramen ovale after presumed paradoxical embolism.

Many have proposed a relation between presence of a patent foramen ovale, with or without atrial septal aneurysm, and cryptogenic stroke. The effect of foramen ovale closure on the risk for subsequent strokes is unknown. Transcatheter closure of a patent foramen ovale was undertaken in 36 patients with known right-to-left atrial shunting and presumed paradoxical emboli (31 strokes, 25 transient neurological events, four systemic arterial emboli, and two brain abscesses). Individual patients had between one and four such events. None had a left heart or carotid source of embolism; 31 of 35 had no known risk factors for stroke. Events occurred in 12 patients while they were taking warfarin. At cardiac catheterization, patent foramina ovalia were significantly larger than predicted for age in 67% of the patients. Implantation of a double-umbrella device in the patent foramen ovale was achieved in all without serious procedural complications. Of 34 who have returned for follow-up, one has a residual atrial communication that may be clinically important, five had trivial leaks, and 28 have complete closure. There have been no strokes during a mean follow-up of 8.4 months. Transcatheter closure of a patent foramen ovale can be accomplished with little morbidity and may reduce the risk of recurrence. Further investigations directed toward identifying the population at risk and assessing the effect of intervention are warranted.

Patent foramina ovale in elderly stroke patients

Patent foramina ovale in elderly stroke patients

Patent foramina ovale in elderly stroke patients

Fifty elderly patients who had suffered cerebrovascular incidents from no obvious cause and 33 age-matched controls were investigated for the presence of a patent foramen ovale by contrast 2-dimensional echocardiography at rest and after the Valsalva manoeuvre. Right-to-left shunting was found in only one patient and in none of the controls. This finding is in contradistinction to young adult stroke patients in whom the prevalence of a haemodynamically significant patent foramina ovale is high. Paradoxical embolism is an uncommon cause of stroke in the elderly.

An evaluation of two newly formulated calcium hydroxide cements: A leakage study

One-hundred extracted human single-rooted teethwere biomechanically instrumented. Sixty teeth were obturated with gutta-percha and three types of root canal cements, which were Roth Root Canal Cement, Calciobiotic Root Canal Sealer, and Sealapex. None of the remaining 40 teeth (controls) were obturated; however, 20 had their apical foramina sealed and the other 20 had patent foramina. Five microliters of [3H]uridine were deposited into the prepared root canal of each tooth, and radioisotope counts were obtained at various intervals postoperatively (2 to 60 days). The results showed that there was no statistical difference in leakage between the obturated groups and the sealed control group; however, when compared with the control group with patent foramina there was a significant difference. One-hundred extracted human single-rooted teethwere biomechanically instrumented. Sixty teeth were obturated with gutta-percha and three types of root canal cements, which were Roth Root Canal Cement, Calciobiotic Root Canal Sealer, and Sealapex. None of the remaining 40 teeth (controls) were obturated; however, 20 had their apical foramina sealed and the other 20 had patent foramina. Five microliters of [3H]uridine were deposited into the prepared root canal of each tooth, and radioisotope counts were obtained at various intervals postoperatively (2 to 60 days). The results showed that there was no statistical difference in leakage between the obturated groups and the sealed control group; however, when compared with the control group with patent foramina there was a significant difference.

Effect of Valsalva maneuver on circulation time.

Arm-to-tongue circulation times in conjunction with a Valsalva maneuver at 40 mm Hg for 15 seconds were determined in 189 young men. In 112 subjects the 20% sodium dehydrocholate indicator was injected just as the Valsalva maneuver was begun. Circulation times ranged from 13 to 31 seconds. The frequency-distribution was tetramodal, means 14.6 ± 0.25 seconds, 18.8 ± 0.17 seconds, 24.2 ± 0.22 seconds and 29.5 ± 0.37 seconds; within the respective modes lay 9.8%, 42.9%, 35.7% and 11.6% of the sample. In 77 subjects the indicator was not injected until an expiratory pressure of 40 mm Hg had been attained. The range was 14–33 seconds and the frequency-distribution bimodal, means at 14.7 ± 0.18 seconds (9.1%) and 24.6 ± 0.40 seconds (90.9%). It is possible that the lowest mode in both cases may represent subjects with large patent foramina ovalia. The tetramodal nature of the first distribution is probably consequent upon differences in the manner in which the Valsalva maneuver was initiated. Submitted on November 7, 1957