Presence Of Patent Foramen Ovale Research Articles

Anticoagulation vs Antiplatelets Across Subgroups of Embolic Stroke of Undetermined Source: A Meta-Analysis of Randomized Controlled Trials.

The term "embolic stroke of undetermined source" (ESUS) encompasses a substantial but heterogeneous population of patients with ischemic stroke, underscoring the importance of identifying personalized treatment strategies. In subgroups of patients randomized in ESUS trials, we evaluated the effectiveness of anticoagulation compared with antiplatelet therapy in secondary ischemic stroke prevention. A study-level meta-analysis was conducted on randomized controlled trials of patients with ESUS, comparing anticoagulation with antiplatelet therapy. The primary efficacy outcome was recurrent ischemic stroke, and safety outcomes were major bleeding and death. Subgroups assessed were age, sex, presence of patent foramen ovale (PFO), left atrial enlargement (LAE), and atrial cardiopathy. Pooled risk ratios (RRs) were meta-analyzed. Cochrane Risk of Bias Tool 2.0 was used for risk-of-bias assessment. A total of 7 randomized controlled trials involving 14,804 patients were analyzed, with 7,406 patients treated with anticoagulation and 7,398 treated with antiplatelet therapy. Compared with antiplatelet therapy, anticoagulation was associated with a similar rate of recurrent ischemic stroke (RR 0.91, 95% CI 0.80-1.05; I2 = 0%). In ESUS with PFO, anticoagulation was associated with significantly lower risk of ischemic stroke (RR 0.59, 95% CI 0.35-0.98; I2 = 0%). Heterogeneity was present in those with LAE: antiplatelet therapy was superior in trials allowing cardiac monitoring after randomization (RR 6.65, 95% CI 1.26-35.08; I2 = 0%), but anticoagulation was superior in trials prohibiting cardiac monitoring after randomization (RR 0.25 95% CI 0.07-0.89). Subgroups based on age, sex, or presence of atrial cardiopathy did not benefit from anticoagulation over antiplatelet therapy. In this meta-analysis, an empiric anticoagulation approach is not beneficial for patients with ESUS. This finding highlights the importance of an individualized treatment strategy. Such a strategy should include prolonged cardiac monitoring for atrial fibrillation, particularly in patients with moderate-to-severe LAE. Anticoagulation treatment showed promise in patients with medically treated PFO. Other subgroups did not benefit from anticoagulation therapy. Large prospective studies within ESUS subgroups are needed to validate our findings.

Presence of Patent Foramen Ovale Does Not Increase Cerebrovascular Event Rates in Patients with Atrial Fibrillation Following Left Atrial Appendage Closure

ObjectiveBoth atrial fibrillation (AF) and patent foramen ovale (PFO) has been associated with occurrences of ischemic stroke. The aim of this study was to investigate whether patients with concomitant AF and PFO were at an increased risk of stroke, and whether PFO closure was necessary for the prevention of stroke in AF patients who underwent left atrial appendage closure (LAAC). MethodWe retrospectively analyzed 614 patients who underwent LAAC at Wuhan Asia Heart Hospital from May 2014 to April 2021. We compared the baseline clinical characteristics and ischemic stroke rates before LAAC, major adverse cardiovascular events (MACEs) and other long-term outcomes between AF patients with and without PFO after LAAC. The predictor for ischemic stroke or TIA after LAAC was analyzed with univariate and multivariable Cox regression, and the long-term cumulative survival rates of AF patients with PFO compared to those without PFO after LAAC were analyzed with the Kaplan–Meier graph. ResultsA total of 614 patients who underwent LAAC and had completed follow-up data were included in our study. Among them, 74 patients were diagnosed with AF with PFO, and 540 with AF without PFO. There was no significant difference between their baseline clinical data, including ischemic stroke rates (p = 0.961). Patients with and without PFO had similar device implantation success rates (98.6% vs 99.4%, P=0.403) and procedure-related complications. During follow-up (medium follow-up period 36.9 months), no significant difference was observed in the incidence of MACEs (8.1% in PFO group vs 5.7% in non-PFO group, P=0.432) or the cumulative ischemic stroke/TIA rates (5.4% in PFO group vs 4.3% in non-PFO group, P = 0.554). The Cox multivariable regression analysis indicated that the presence of PFO in patients with AF had no correlation with ischemic stroke or TIA after LAAC implantation (HR 1.685, 95% CI 0.570-4.978, P = 0.345). The only predictor for ischemic stroke/TIA events after LAAC was major leakage (>5mm) seen on transesophageal echocardiography (TEE) or left atrial CTA at the 45-day follow-up (HR 10.352, 95% CI 1.221-87.736, P = 0.032). ConclusionAF patients with PFO are not at increased risk for ischemic stroke or TIA before LAAC. The presence of PFO in AF patients did not affect the success rate and safety of LAAC. The presence of mild PFO is not a viable predictor of stroke events in AF patients who underwent LAAC during long-term follow-up. Major leakage (>5 mm) is associated with a higher ischemic stroke/TIA rate in AF patients who underwent LAAC.

Patent foramen ovale and stroke: a possible association with deep vein thrombosis

Patent foramen ovale (PFO) is a congenital heart abnormality consisting of the persistence of a tunnel between the right and left atrium; it is associated with a higher prevalence of strokes. A 52-year-old man was admitted to the emergency room for confusion and deep vein thrombosis with signs of pulmonary embolism; he started treatment with fondaparinux. After admission, there was an ischemic stroke. Blood tests, thrombogenic screening, and infectious diseases showed no alterations. Holter-electrocardiogram, echocardiography, and positron emission tomography-computed tomography were negative except for the presence of PFO. Apixaban and cardioaspirin were started. The surgical treatment was planned, but despite the therapy, there was a new ischemic stroke, so the treatment with mechanical thrombectomy was attempted but failed. The patient was continuing therapy until a new cerebral ischemic episode caused his death; the etiopathogenesis of brain events appears to be associated with the presence of PFO; association with deep venous thrombosis is described in the literature.

Transcranial doppler to detect high-risk PFO and predict decompression illness in divers

Abstract Background It has not yet been clearly demonstrated whether it is feasible to diagnose patent foramen ovale (PFO) using transcranial doppler (TCD) and to use it in strategies to prevent decompression illness (DCI) in self-contained breathing apparatus (SCUBA) divers. Purpose DIVER-PFO study confirmed that high-risk PFO is associated with an increased risk of DCI in SCUBA divers. In this prespecified post-hoc analysis, we aimed to prospectively evaluate the accuracy of TCD to diagnose high-risk PFO and to predict the occurrence of DCI. Methods Eighty-two consecutive divers (mean age; 41 years, male 80.5%) underwent transesophageal echocardiogram (TEE) and TCD with a saline bubble test to determine the presence of PFO and were subsequently divided into high-risk and low-risk groups by TEE findings. Divers in the high-risk PFO group included those with the following conditions: PFO with atrial septal aneurysm, hypermobility, PFO size ≥2 mm, or right to left shunt at resting state. The enrolled divers were then followed-up using a self-reported questionnaire through e-mail or telephone interview for 3 years, while they were blinded to their PFO status. The primary endpoint of the study was PFO-related DCI, comprising cases of cutaneous or neurologic DCI, DCI symptoms requiring hyperbaric chamber therapy, DCI symptoms within 30 minutes after surfacing, or unexplained death occurring within 2 weeks after diving. Results PFO was detected in 47 (57.3%) and 59 (72.0%) divers by TCD and TEE, respectively. Diagnostic accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of TCD were 68.3%, 67.8%, 69.6% 85.1%, and 45.7% for the diagnosis of PFO, and 65.9%, 82.8%, 56.6%, 51.1% and 85.7% for the diagnosis of high-risk PFO, respectively. PFO-related DCI occurred in 9 divers in the PFO group (PFO vs non-PFO: 6.4 vs 0.7 incidences per 10,000 person dives; p=0.03) during a mean follow-up of 25.6 months. Integrated time-dependent Area Under the Curves for TCD and TEE to predict DCI occurrence using Cox’s proportional hazards regression model were 0.714 and 0.675, respectively. Conclusions TCD was moderately accurate to diagnose high-risk PFO in divers. However, it predicted DCI as much as TEE.Study flowIncidence of DCI in the PFO vs No PFO

Association of Hypertension With Early-Onset Cryptogenic Ischemic Stroke by the Presence of Patent Foramen Ovale: A Case-Control Study.

Association of Hypertension With Early-Onset Cryptogenic Ischemic Stroke by the Presence of Patent Foramen Ovale: A Case-Control Study.

Risk of early clinical deterioration and 30-day mortality in pulmonary embolism intermediate-high-risk patients with patent foramen ovale.

We assess the prognostic role of patent foramen ovale (PFO) for the estimation of 30-day mortality and risk of 48-h clinical deterioration since admission, in intermediate-high-risk pulmonary embolism (PE) patients. A post-hoc analysis of intermediate-high-risk PE patients enrolled in the Italian Pulmonary Embolism Registry (IPER) (Trial registry: ClinicalTrials.gov; No.: NCT01604538) was performed. The entire cohort was divided according to the presence or absence of PFO after transthoracic echocardiography (TTE) evaluation. Among 450 intermediate-high-risk PE patients (mean age 71.4 ± 13.8years, 298 males), PFO was diagnosed in 68 (15.1%) cases. A higher mortality rate (29.4% vs. 3.1%, p < 0.001) as well as occurrence of clinical deterioration within 48h from admission (38.2% vs. 3.6%, p < 0.001) were observed in intermediate-high-risk PE patients with PFO compared to those without multivariate Cox regression analysis showed that the presence of a PFO predicts 30-day mortality (HR: 3.21, 95% CI 3.16-3.27, p < 0.001) and was also associated with a significantly higher risk of 48-h clinical deterioration [HR: 2.24 (95% CI 2.20-2.29), p < 0.0001] in intermediate-high-risk PE patients. The presence of a PFO in intermediate-high-risk PE patients is associated with a higher risk of clinical deterioration within 48h from admission and 30-day mortality.

Transjugular intrahepatic portosystemic shunt in patients with splanchnic vein thrombosis: Prevalence and management of patent foramen ovale.

Transjugular intrahepatic portosystemic shunt (TIPS) is an established procedure for the treatment of several complications of portal hypertension (PH), including non-neoplastic portal vein thrombosis (PVT). Selection criteria for TIPS in PVT are not yet well established. Despite anecdotal, cases of thromboembolic events from paradoxical embolism due to the presence of patent foramen ovale (PFO) after TIPS placement have been reported in the literature. Therefore, we aimed at describing our experience in patients with non-neoplastic splanchnic vein thrombosis (SVT) who underwent TIPS following PFO screening. We conducted a single-centre retrospective study, including consecutive patients who underwent TIPS for the complications of cirrhotic and non-cirrhotic portal hypertension (NCPH) and having SVT. Of 100 TIPS placed in patients with SVT, 85 patients were screened for PFO by bubble-contrast transthoracic echocardiography (TTE) with PFO being detected in 22 (26%) cases. PFO was more frequently detected in patients with non-cirrhotic portal hypertension (NCPH) (23% in the PFO group vs. 6% in those without PFO, p = .04) and cavernomatosis (46% in the PFO group vs. 19% in those without PFO, p = .008). Percutaneous closure was effectively performed in 11 (50%) after multidisciplinary evaluation of anatomical and clinical features. No major complications were observed following closure. PFO screening and treatment may be considered feasible for patients with SVT who undergo TIPS placement.

Deep vein thrombosis in patients with stroke or transient ischemic attack presenting with patent foramen ovale: a retrospective observational study

ObjectiveDeep vein thrombosis (DVT) is discussed as a source of embolism for cerebral ischemia in the presence of patent foramen ovale (PFO). However, previous studies reported varying rates of DVT in stroke patients, and recommendations for screening are lacking. This study aimed to characterize patients with stroke or transient ischemic attack (TIA) and concomitant PFO and explore the rate of DVT and associated parameters.MethodsMedical records were screened for patients with stroke or TIA and echocardiographic evidence of PFO. Concomitant DVT was identified according to compression ultrasonography of the lower limbs. A variety of demographic, clinical, and laboratory parameters, the RoPE and Wells scores were compared between patients with and without DVT.ResultsThree-hundred-thirty-nine patients (mean age 61.2 ± 15.4 years, 61.1% male) with stroke or TIA and PFO, treated between 01/2015 and 12/2020, were identified. Stroke and TIA patients did not differ for demographic and vascular risk factors. DVT was found in 17 cases out of 217 (7.8%) with compression ultrasonography. DVT was associated with a history of DVT, cancer, previous immobilization, calf compression pain, calf circumference difference, and a few laboratory abnormalities, e.g., increased D-dimer. A multivariate regression model with stepwise backward selection identified the Wells score (odds ratio 35.46, 95%-confidence interval 4.71–519.92) as a significant predictor for DVT.ConclusionDVT is present in a relevant proportion of patients with cerebral ischemia and PFO, which needs to be considered for the individual diagnostic workup. The Wells score seems suitable for guiding additional examinations, i.e., compression ultrasonography.

Characteristics of patients diagnosed for cardiac cause of ischemic neurological events and prescreened with a transcranial Doppler examination.

Screening for patent foramen ovale (PFO) in patients with ischemic neurological events is becoming more common. This study aimed to evaluate clinical characteristics and atrial septum anatomy in relation to age and presence of PFO, as well as factors associated with a history of stroke in patients assessed for cardiac causes of ischemic neurological events. A total of 817 patients with a history of neurological episodes (stroke, transient ischemic attack [TIA], or migraine) were prescreened using transcranial Doppler ultrasound. Transesophageal contrast echocardiography (TEE) was employed to confirm PFO and assess the anatomy of the atrial septum and right atrium. Among the patients, 28% had ischemic stroke, 31% had TIA, and 49% had migraines. PFO was confirmed in 79% of the patients. Regardless of the analyzed age group, PFO was associated with higher prevalence of TIA, migraine and syncope history, atrial septal aneurysm (ASA), and Chiari network. There were fewer women in the PFO group, but only in the population aged 45 years or under. Patient age, male sex, typical cardiovascular risk factors, and the presence of ASA were associated with a history of stroke. In patients with ischemic neurological events who were prescreened for PFO, confirmation of PFO on TEE was associated with a higher prevalence of TIA, migraine, syncope, Chiari network, and ASA. Advanced age, typical cardiovascular risk factors, and ASA were associated with stroke history in the study population.

Age-dependent association between aneurysmal and isolated redundant inter-atrial septum with patent foramen ovale.

Interatrial septum (IAS) could be redundant by abnormal movement with or without aneurysmal bulging. We aimed to determine the prevalence of isolated redundant and aneurysmal IAS motion and their probable relationship with age and presence of patent foramen ovale (PFO) in a large-scale referral center. A total of 15,288 patients who underwent transthoracic echocardiography (TTE) at Tehran Heart Center were included From March 2019 to March 2021. Contrast echocardiography was conducted on patients with suspected PFO. Data were retrospectively analyzed from our previously established database. The prevalence of aneurysmal and redundant IAS and their relationship with age and PFO presence was evaluated. Aneurysmal and isolated redundant IAS were present in 4% and 12.4% of the participants, respectively. The aneurysmal group was older, more frequently female and had higher frequency of PFO. The frequency of PFO among patients with aneurysmal IAS was about 14.4% and 5.3% in isolated redundant IAS patients. In both groups, the prevalence of abnormal IAS motion increased across age groups from the youngest to the oldest, while the prevalence of PFO decreased. In conclusion, the frequency of PFO among patients with aneurysmal IAS was about 2.5 times more than that among patients with isolated redundant IAS and 24 times more than the normal population. The increasing trend observed across the aging group proposes a potential role for age in the pathophysiology of abnormal IAS. Furthermore, the decreasing prevalence of PFO among patients underlies its clinical significance as an important risk factor.

Impact of patent foramen ovale with left-to-right shunt on atrial fibrillation ablation in young patients

ObjectiveThe CABANA study shows that atrial fibrillation (AF) paitents younger than 65 years benefit more from the AF radiofrequency catheter ablation (RFCA) procedure. The aim of this study is to investigate the impact of inherent patent foramen ovale (PFO) with a Left-to-Right Shunt on the RFCA procedure in young AF patients. MethodsBased on the presence or absence of inherent PFO, the AF patients were divided into the PFO groups and the non-PFO group. Clinical follow-up was also investigated. ResultsA total of 285 AF patients were enrolled. PFO was detected by TEE in 42 patients. The age of patients at initial AF onset was younger in the PFO group than in the non-PFO group (58.3 ± 8.9 vs. 62.3 ± 9.6 years, P = 0.012). There were more AF patients aged <55 years in the PFO group than in the non-PFO group. For the 9 AF patients with PFO who experienced AF recurrence and the left-to-right shunts decreased in size in 5 of the patients aged <65 years. The LAD decreased in those patients. In the PeAF patients, 53/64 patients aged <65 years and 23/40 patients aged older than 65 years were free of AF (82.8 % vs. 57.5 %, respectively; P = 0.005). ConclusionSuccess is not affected when AF is combined PFO compared with AF without PFO. Young patients have better PeAF RFCA outcomes. AF in young patients with left atria enlargement and a serious AF burden, may lead to reduced EF and render PFO easy to detect.

Diagnostic value of contrast-enhanced ultrasonography for patent foramen ovale detection.

Patent foramen ovale (PFO) has been associated with migraine, cryptogenic stroke (CS), and hypoxemia. However, which examination method is most reliable remains controversial. This study sought to investigate the diagnostic value of contrast-enhanced ultrasonography (cU), including contrast-enhanced transcranial Doppler (cTCD), contrast transthoracic echocardiography (cTTE), and contrast transesophageal echocardiography (cTEE), for PFO; and to determine the best diagnostic strategy. This retrospective observational study included a total of 147 consecutive patients suspected PFO at The First Hospital of Shanxi Medical University between October 2019 and January 2022. The patients also underwent cTCD, cTTE, and cTEE examinations. The standard for the diagnosis of PFO was confirmation of the presence of PFO by color Doppler flow signals or contrast microbubbles (MBs) passing through the foramen ovale. A total of 123 patients were diagnosed with PFO and 24 patients without PFO during the study period. The detectable rates of cTCD, cTTE, and cTEE were 120 (97.56%), 110 (89.43%), and 121 (98.37%), respectively. The sensitivity between cTCD and cTEE for PFO were comparable [97.56%, 95% confidence interval (CI): 92.5% to 99.4% vs. 98.37%, 95% CI: 93.7% to 99.7%; P>0.99], and the sensitivity of both were higher than that of cTTE (89.43%, 95% CI: 82.3% to 94.0%; P=0.02 and P=0.001, respectively). In addition, the specificity of cTEE for PFO was significantly higher than that of cTCD (100%, 95% CI: 82.3% to 100.0% vs. 75.00%, 95% CI: 53.0% to 89.4%; P<0.001) and cTTE (100%, 95% CI: 82.3% to 100.0% vs. 75.00%, 95% CI: 53.0% to 89.4%; P<0.001). Further, the semi-quantitative classification ability of cTCD for PFO with right-to-left shunt (RLS) was significantly higher than that of cTTE and cTEE (P=0.02 and P<0.001, respectively), and that of cTTE was significantly higher than that of cTEE (P=0.01). The Spearman analysis showed that the degree of RLS was positively correlated with the inner diameter of the PFO (r=0.695, P<0.001). The combination of cTCD and cTEE may provide a favorable strategy for the diagnosis of PFO.

Management of patent foramen ovale in non-cardiac surgery

Patent foramen ovale (PFO) is a remnant of normal fetal anatomy which may persist into adulthood, mostly asymptomatic. In some adults, PFO may result in a potential for shunting venous thromboembolism to the arterial circulation; less frequently it can cause interatrial, right-to-left shunting of deoxygenated blood. The pathogenesis of several medical conditions is related to the presence of PFO. Some randomized clinical trials have shown evidence of benefit for device closure as compared with medical therapy in patients with cryptogenic stroke. The literature reported several cases of carbon dioxide embolism during general laparoscopic surgery and sometimes stroke after laparoscopic or neurosurgery but there are neither prospective studies addressing these issues, nor randomized clinical trials assessing the effectiveness of pharmacotherapy or interventional procedures at decreasing risk. The European position paper suggests routine monitoring in non-cardiac surgery of patients with a PFO and no actual indications for closure. This article aims to further stratify the risk of periprocedural stroke and paradoxical embolism in this category of patients.

Embolic stroke of undetermined source: Focusing on atrial cardiopathy and patent foramen ovale

BackgroundAtrial cardiopathy(AC) and patent foramen ovale (PFO) are two etiologies of embolic strokes of undetermined source (ESUS). We aimed to explore the relationship between them in ESUS. MethodsA total of 1146 participants were included from January 2019 to June 2022, which included the ESUS group and non-embolic stroke which includes LAA(large arterial atherosclerosis) + SAO(small artery occlusion) group. AC was defined as the presence of at least one of the following: PTFV1(P-wave terminal force in lead V1) > 4000 μV*ms in the electrocardiograms, NT-proBNP(N-terminal probrain natriuretic peptide) > 250 pg/mL in laboratory tests or LAD(left atrial diameter) > 3.8 cm for women and > 4.0 cm for men in cardiac ultrasound. The presence of PFO was assessed by transthoracic echocardiography, transcranial Doppler ultrasound, transesophageal echocardiography or cardiac MRI. PFO was considered pathogenic if the RoPE score was 7 to 10. ResultsThe prevalence of AC and PFO was higher in the ESUS group than the LAA + SAO group. The prevalence of AC was lower in ESUS patients with pathogenic PFO (37.9%) than those without PFO (68.4%) and with incidental PFO (64.0%) (p = 0.006). The prevalence of pathogenic PFO was lower in ESUS patients with AC than those without AC (6.0% vs. 17.8%, p = 0.006). The AUC(area under the curve) of PTFV1 for predicting ESUS was 0.724 [95%CI (0.686–0.762), p < 0.05)], indicating that PTFV1 the most valuable AC biomarker. ConclusionsThe prevalence of AC is inversely related to the prevalence of pathogenic PFO in ESUS patients. PTFV1 was the most valuable index to predict ESUS among the AC biomarkers.

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.

Chronic ischemic lesions and presence of patent foramen ovale in young adults with embolic stroke of undetermined source: Results of the young ESUS patient registry.

Chronic ischemic lesions (CILs) are frequent findings in patients with acute ischemic stroke, but their phenotypes and relevance in young adults with embolic stroke of undetermined source (Y-ESUS) remains uncertain. We aimed to compare Y-ESUS patients with CIL to those without CIL and assessed the association of CIL and its phenotypes with the presence of patent foramen ovale (PFO). This prospective longitudinal, multicenter cohort study enrolled consecutive patients 50 years and younger with ESUS from October 2017 to October 2019 in 41 stroke research centers in 13 countries. Local investigators adjudicated presence and phenotypes of CIL on routine brain imaging (either magnetic resonance imaging (MRI) or computed tomography (CT)). Overall, 535 patients were enrolled (mean age = 40.4 (standard deviation (SD) = 7.3) years, 238 (44%) female). CILs were present in 76/534 (14.2%) patients with a median count CIL count of 1.0 (interquartile range (IQR) = 1-2), 42/76 (55%) had at least one cortical phenotype and 38/76 (50%) at least one non-cortical phenotype. Y-ESUS with CIL were less often female (32% vs 47% in non-CIL Y-ESUS), were older (mean 43 vs 40 years), had more often hypertension (42% vs 19%), diabetes (17% vs 7%), and hyperlipidemia (34% vs 18%). CIL Y-ESUS were independently associated with lower stroke recurrence (relative risk (RR) = 0.17 (0.05-0.61)). In Y-ESUS with PFO, CILs were less frequent in probable pathogenic PFO than with probable non-pathogenic PFO (6.1% vs 30% p< 0.001). One in seven Y-ESUS patients has additional CIL. CILs were associated with several vascular risk factors, lower probability of a pathogenic PFO, and lower stroke recurrence.

Presence of patent foramen ovale increases risk of filamentous thrombi on interatrial septum in atrial fibrillation/flutter patients

Abstract Introduction The presence of interatrial septum (IAS) strands in atrial fibrillation or flutter (Afi/Afl) patients is frequently overlooked despite being a common occurrence. Purpose The study aims to understand the prevalence and possible pathological nature of these strands. Methods The study included 454 consecutive Afi/Afl patients who underwent transesophageal echocardiography from June 2019 to January 2020. Patients were divided into two groups based on the presence of strands on the IAS (strand and non-strand group). The echocardiograms and clinical characteristics of the patients were reviewed. The difference between the two groups was compared using independent t or chi-square test. Univariate and multivariate logistic regression analyses were performed to identify factors associated with the IAS strands. The study also examined surgical samples of the IAS strands of a patient pathologically. Results The study found that 127 (28%) of the enrolled patients had strands on the right atrial side of the IAS. The strand group had a significantly higher incidence of patent foramen ovale (PFO) (p&amp;lt;0.0001) than the non-strand group. Patients in the strand group were also more likely to be over 60 years of age(p=0.085), obese(p=0.073), and have abnormal renal function(p=0.086). Multivariate analysis revealed that PFO was independently associated with the presence of IAS strands (OR=64.51, 95% CI: 31.35-132.76, p&amp;lt;0.0001). The pathological examination of the IAS strands in a patient revealed filamentous thrombi. Conclusions The study highlights the high prevalence of IAS strands in Afi/Afl patients. The presence of PFO significantly increases the risk of IAS filamentous thrombi. This study is the first report on the pathological nature of IAS filaments in Afi/Afl patients, offering important insights into the causes of Afi/Afl-induced cardiogenic embolism other than left atrial appendage thrombi.

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.

Transesophageal echocardiography-guided percutaneous closure of the patent foramen ovale only uses the sheath.

Percutaneous closure of the patent foramen ovale (PFO) is primarily guided by fluoroscopy in the catheter room, during which procedure both the guidewire and sheath need to pass through the PFO. We performed PFO closure using a transesophageal echocardiography (TEE)-guided approach and only the sheath was passed through the PFO during the procedure. This study aimed to evaluate the feasibility and safety of PFO closure using this technique. A retrospective observational study was performed. A total of 117 consecutive adult patients underwent percutaneous PFO closure without fluoroscopy, under the sole guidance of TEE in our hospital between December 2018 and December 2021. The data of each patient consisted of preoperative, operative, and postoperative variables collected. The primary outcome is that the occluder was successfully released. The secondary outcomes included perioperative and follow-up transthoracic echocardiography (TTE), Headache impact test-6 (HIT-6) score and clinical symptoms. Transvenous PFO closure under TEE guidance was successful in all cases. The sample consisted of 93 females and 24 males with an average age of 42.3±7.8 years. There were 28 patients with preoperative cerebral infarction [Risk of Paradoxical Embolism (RoPE) score >6 points] and 89 patients with migraine. All patients underwent a preoperative TEE to confirm the presence of PFO, and contrast-enhanced transcranial Doppler (c-TCD) acoustic contrast suggested grades 3 to 4. The average time of surgery for patients (puncture to removal of the sheath) was 32 minutes. Three cases of vagus nerve reflex manifestations during surgery and two cases of transient ventricular arrhythmia all improved after symptomatic treatment. There were no instances of metal allergy, hemolysis, or other acute vascular procedural complications. For all 89 patients with migraine, significant relief or resolution was achieved during the first six-month follow-up (P<0.001). As a monotherapy, percutaneous closure of PFO guided by TEE where only the sheath passes through the PFO during the operation is an effective procedure with a high success rate and a low complication rate.

The role of transoesophageal echocardiography in diagnosis and management of patients with embolic stroke of undetermined source

Abstract Funding Acknowledgements Type of funding sources: None. Introduction About 25–30% of the cases of ischemic stroke have no established etiology after standard diagnostic evaluation and are classified as embolic strokes of undetermined source (ESUS). Transoesophageal echocardiography (TOE) may provide additional information in the evaluation of patients with ESUS and change the secondary prevention management. Purpose In this retrospective study we examined the role of TOE in diagnosis and further management of patients with ESUS. Methods Patients with ESUS (18 to 60 years old) with no comorbidities were examined at the echocardiography laboratory of our hospital, from April 2018 until August 2022. All patients were thoroughly assessed with transthoracic echocardiography and had no abnormal findings. Atrial fibrillation was excluded by ambulatory electrocardiography. All patients were examined for presence of patent foramen ovale (PFO), aortic atheromatosis and left atrial appendage thrombus. The size of PFO shunt was classified based on the number of microbubbles seen in the left atrium during the first three cardiac cycles after the infusion of agitated saline. The presence of 1–5 microbubbles was classified as small shunt, 6–25 as moderate and &amp;gt;25 as large. Patients with large shunts and RoPE score &amp;gt;6 were referred to occlusion. Τ - test was used to compare the means of the variables and a p value 0.05 was considered statistically significant. Results In this study, 200 patients with ESUS (134 males), of mean age 52.6 (SD=9.8 ears), were enrolled. In 52 of them TOE determined the etiology of stroke. The presence of PFO was found in 70 (35.0%) patients. Of those, 17 (24.3%) had a small shunt, 20(28.6%) a moderate and 32 (45.7%) had a large shunt and were referred to occlusion. Patients with PFO were younger (mean age 47.2 years, SD 11.2, p&amp;lt;0.001) than those without PFO (mean age 54.8 years, SD 8.6) (Diagram 1). Furthermore, 20 (10.0%) patients were diagnosed with atheromatosis of ascending aorta and aortic arch ≥grade 2. Patients with aortic atheromatosis were older (mean age 58.1 years SD 7.6) than those without atheromatosis (mean age 51.9 years, SD 9.8, p = 0.008) (Diagram 2). Finally, TOE did not reveal left atrial appendage thrombus in any of the examined patients. Conclusion TOE revealed the etiology of stroke in about 25% of our patients, which consequently changed their secondary prevention management.