Prevalence Of Patent Foramen Ovale Research Articles

P916 RoPE score in causal association between patent foramen ovale and cryptogenic stoke, is it enough?

Abstract Introduction The prevalence of patent foramen ovale (PFO) in the general population is high (25%). In patients with cryptogenic stroke (CS) and PFO, determining whether it is causally related to stroke or is an incidental finding is a controversial issue. The RoPE score was described in 2013 to predict the likelihood that the stroke was related to the PFO. The higher the score, the greater the risk of attributable causality, considering 6 as the cut-off point. This scale includes clinical variables, but does not consider the echocardiographic characteristics of PFO that were used as inclusion criteria in studies that have shown benefit with percutaneous closure, such as the complex anatomy of PFO (extensive passage of microbubbles across the PFO at rest and/or interatrial septum aneurysm). Purpose Our aim was to investigate the association of the RoPE score with recurrence of stroke in a series of patients with CS and percutaneously closed PFO in a period of time prior to the current recommendations, as well as to describe the presence of complex anatomy of PFO and its relationship with the value of that score. Methods A series of 172 consecutive patients with CS and percutaneous closure of PFO, included from January 2001 to November 2014 in a single center was analyzed, and the RoPE score was calculated retrospectively in each patient. The presence of complex anatomy of the PFO was estimated by echocardiography, and the rate of recurrence of stroke and the relationship of both variables with the value of the RoPE score was investigated. Results Of the 172 patients in the series, it was possible to calculate the RoPE score in 150 (87%) of them, which constitute the study sample. The mean age was 46 years (range 17-78), 60% were male, 21% were hypertense, 6% diabetic and 27% smokers. A history of previous stroke was present in 3% of patients and 11% had an imaging study with cortical infarction. RoPE score was ≥6 in 69% of the sample, and 66% of the patients presented complex anatomy of PFO, without significant differences between those with RoPE score ≥6 and <6 (65% versus 70%, p = 0.62). Acute complications (mortality, cardiac tamponade, stroke, device embolism) related to closure of the PFO were not observed. After 17.5 years of maximum follow-up (mean 9.6 ± 3.7 years, no patients lost, with a total of 1441 patients-years of observation), 6 patients presented a stroke. The recurrence rate of stroke was very low in both groups of patients, either with RoPE score ≥6 or <6 (0.4 versus 0.5 per 100 patients/year, p = 0.87). Conclusions In our center, before the current recommendations of PFO closure associated with CS, most of the patients had a RoPE score≥6. The majority of patients presented a complex anatomy of the PFO and the incidence of stroke recurrence was very low, independently of the value of the RoPE score.

Patent foramen ovale prevalence in atrial fibrillation patients and its clinical significance; A single center experience

BackgroundPatent foramen ovale (PFO) has been reported in 25–30% of the general population. The most commonly used test for detecting PFO is a contrast enhanced transesophageal echocardiography (TEE). PFO presence can be confirmed during pulmonary vein isolation (PVI) procedure by passing the transseptal catheter assembly through the foramen ovale, crossing the septum from the right to the left atrium without using a trans-septal needle for puncture. MethodsWe retrospectively reviewed data from a cohort of 178 patients with AF who underwent PVI at Saint Louis University. Pre-PVI procedure, scheduled TEE reports were reviewed to assess for the presence of PFO and the PVI procedure reports were reviewed for confirmation. ResultsRecords of 178 patients (55.6% male, mean population age 60.4 ± 11.8) were reviewed. 102 of 178 patients had a PFO detected during the PVI procedure. This translates into a 57.3% prevalence of PFO in AF patients. Out of the 178 patients, 75 patients had a pre-PVI procedure TEE for whom PFO presence was reported in 18.7%. The sensitivity and specificity of TEE in detection of PFO were 36.8% and 100%, respectively. There was no statistically significant association between stroke and PFO diagnosed during PVI (RR 1.07; 95% CI, 0.53–2.19; P = 0.805). ConclusionsOur study reports a PFO prevalence of 18.7% using a pre-procedure TEE and 56.6% during the PVI procedure in AF patients. Given that TEE is the gold standard for detection of PFO, our study suggests that the prevalence of PFO may be underestimated in our AF population.

Closing the gap on patent foramen ovale and cryptogenic stroke

ABSTRACTIntroduction: The treatment options for prevention of recurrent of cryptogenic stroke in patients with patent foramen ovale (PFO) have been intensely debated in the recent decades. The suggested options were percutaneous closure of PFO versus medical therapy. However, up to these date there is a controversy regarding the indication of percutaneous closure. Multiple meta-analysis and recent randomized control trials showed the benefit of PFO closure when compared with medical therapy alone.Areas covered: The article reviews the prevalence, physiology, diagnosis and treatment options of PFO after cryptogenic stroke. Furthermore, it will discuss the results of randomized control trials that compared the PFO closure to medical therapy.Expert opinion: The association between PFO and unexplained cryptogenic stroke has been well established in the multiple studies. The diagnosis and management of PFO might be challenging in some cases. Although multiple studies showed that PFO closure is associated with lower rates of recurrent stroke in patients presenting with cryptogenic stroke, the indication and patient selection for this intervention are not well established yet in the guidelines.

Relation of Patent Foramen Ovale to Acute Mountain Sickness

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

Abstract TMP88: Prevalence of Right-to-left Cardiac Shunt in the Greek Population is High and Impacts on the Interpretation of the Risk of Paradoxical Embolism (RoPE) Score

Introduction: The RoPE score calculates the probability that patent foramen ovale (PFO) is causally related to stroke (PFO attributable fraction, PFO-af), based on PFO prevalence in patients with cryptogenic stroke compared with that in control subjects. The latter has been estimated at 25%; however, PFO prevalence in nonselected populations varies widely. Since PFO prevalence in Greeks remains unknown, we aimed to define it and to calculate PFO-af stratified by RoPE score in a cohort of patients with embolic stroke of undetermined source (ESUS). Methods: Right-to-left cardiac shunt (RLS) was detected according to the international consensus criteria in healthy subjects (H, n=115, women=65) and patients with ESUS (n=84, women=42) ≤55 years old. Each subject underwent unilateral middle cerebral artery transcranial Doppler (TCD) recording (Sonaratek, Natus) with a 2-MHz probe after infusion of agitated saline, at rest and after a controlled Valsalva maneuver. We characterized RLS as large (>20 microbubbles or curtain), moderate (10<x≤20) and minimal (≤10). Statistical comparisons were performed using the Fisher’s exact test. We dichotomized patients with ESUS and PFO into high (>median) and low (≤median) RoPE score groups and calculated the corresponding PFO-af. Results: RLS was detected in 43.5% (50/115) of H and 50% (42/84) of ESUS. Large RLS tended to occur more often in ESUS compared to H [29.8% (25/84)] vs 18.3% (21/115); p=0.06]. The RoPE score median in patients with ESUS and RLS was 8 (interquartile range: 7,9). Patients with high RoPE score (9-10) had PFO-af of 64.4 whereas patients with low score (0-8) had PFO-af of 4.4. For any individual stratum up to RopE score 6, the PFO-af was null. Conclusions: The prevalence of RLS in Greeks is quite higher than the average used by the RoPE study. Despite a 50% chance of having RLS of any size, patients with ESUS have large RLS at least 60% more often than the general population. We suggest that optimal calculation of the PFO-af corresponding to RoPE score strata relies on the accurate estimation of PFO prevalence in national/ethnic populations. The proposed RoPE score cutoff of >6 for having a probable PFO-related stroke may overestimate the probability in patients deriving from populations with high RLS prevalence.

Abstract WP262: The Migraine-PFO-Stroke Triangle: Observations From the National Inpatient Sample

Introduction: Patients with migraine are known to have a higher risk of stroke. Migrainous-infarction, and more recently, paradoxical embolism via a patent foramen ovale (PFO) are proposed to be the causative pathophysiology. The prevalence of PFO in migraineurs with cryptogenic stroke has been shown to be as high as 80%. Objective: To determine from the Nationwide Inpatient Sample (NIS), the prevelance of acute ischemic stroke (AIS) in migraineurs with PFO who have had a PFO-closure procedure and compare them to those without a PFO-closure. Methods: Using the NIS from 2005-2014, patients carrying a diagnosis of migraine with aura (ICD 9: 346.0, 346.3, 346.5, and 346.6), migraine without aura (ICD9: 346.1, 346.2, 346.4, 346.7, 346.8, and 346.9) and PFO (ICD 9: 745.61, 745.5) were identified. From them, those who had a PFO closure (ICD 9: 35.52, 35.51, 35.71, 35.61) were identified. SAS 9.4 was used for data analysis with categorical and continuous variables tested using the Chi-Square test of proportions and Student’s t-test, respectively. Cox proportional hazard regression was used to adjust for confounders. Results: A total of 45,00,000 patients with migraine were identified, among which 3% (n=132,349) had migraine with aura. PFO detection rates in migraineurs with and without aura were 2% (n=2620) and 0.5% (n=23,225) respectively. In migraineurs with aura, PFO closure was performed in 10.5% (n=274) among which 12% (n=33) had an AIS as compared to 27.5% (n=647) AIS within the non-closure group (p<0.095, OR 0.48). However in migraineurs without aura, PFO closure was performed in 17% (n=3845) among which 7% (n=266) had an AIS as compared to 26.2% (n=5046) AIS within the non-closure group (p<0.0001, OR 0.29). Conclusion: In a nationally representative sample, PFO closure was associated with a lower prevalence of AIS in migraineurs without aura. A trend was observed favoring PFO-closure in migraineurs with aura, but lacked statistical significance which maybe secondary to the low PFO-detection rate observed in our sample. These findings may support the hypothesis of a paradoxical embolic phenomenon as being the predominant underlining pathophysiology for acute ischemic stroke in patients with migraine.

Prevalence of patent foramen ovale in cryptogenic transient ischaemic attack and non-disabling stroke at older ages: a population-based study, systematic review, and meta-analysis

SummaryBackgroundPercutaneous closure of patent foramen ovale (PFO) has been shown to be superior to medical treatment alone for prevention of recurrent stroke after cryptogenic transient ischaemic attack or non-disabling stroke in patients aged 60 years or younger. The justification for trials in older patients with transient ischaemic attack or stroke depends on whether PFO is shown to be associated with cryptogenic events at older ages, for which existing evidence is conflicting, and on the population burden of PFO-associated events. Therefore, we did a population-based screening study using contrast-enhanced transcranial Doppler (bubble-TCD) to detect probable PFO as indicated by a right-to-left shunt (RLS); we also did a systematic review and meta-analysis to compare our results with previous studies.MethodsIn this population-based study, nested in the Oxford Vascular Study (OXVASC), we established the prevalence of any RLS, and of large RLS (>20 microbubbles), in consecutive patients attending a rapid-access transient ischaemic attack and stroke clinic, or at 1-month follow-up after stroke unit admission, with transient ischaemic attack or non-disabling ischaemic stroke, comparing cryptogenic events with those of known cause (according to Trial of Org 10172 in Acute Stroke Treatment [TOAST] criteria). We stratified participants by age, and extrapolated data to the UK population. We also did a systematic review of published studies of PFO prevalence (using transthoracic or transoesophageal echocardiography or bubble-TCD) according to stroke subtype, which included older patients and reported age-specific results, and determined by meta-analysis (including the OXVASC data) the pooled odds ratio (95% CI) of finding PFO of any size in cryptogenic events compared with events of known cause, stratified by screening modality (transthoracic or transoesophageal echocardiography or bubble-TCD). The study protocol is registered with PROSPERO, number CRD42018087074.FindingsAmong 572 consecutive patients with transient ischaemic attack or non-disabling stroke between Sept 1, 2014, and Oct 9, 2017 (439 [77%] patients aged >60 years, mean age 70·0 years [SD 13·7]), bubble-TCD was feasible in 523 patients (91%) of whom 397 were aged older than 60 years. Compared with those with transient ischaemic attack or stroke of known cause, patients with cryptogenic events had a higher prevalence of RLS overall (odds ratio [OR] 1·93, 95% CI 1·32–2·82; p=0·001), and in those aged older than 60 years (2·06, 1·32–3·23; p=0·001). When we pooled the OXVASC data with that from two previous smaller studies of bubble-TCD in patients aged 50 years or older, we found an association between RLS and cryptogenic events (OR 2·35, 95% CI 1·42–3·90; p=0·0009; pheterogeneity=0·15), which was consistent with the equivalent estimate from transoesophageal echocardiography studies (2·20, 1·15–4·22; p=0·02; pheterogeneity=0·02). No data on large RLS in patients with TOAST-defined cryptogenic events compared with other events were available from previous studies, but we found no evidence that the association was diminished in such cases. Of 41 patients with large RLS and cryptogenic transient ischaemic attack or non-disabling stroke in our study, 25 (61%) were aged older than 60 years, which extrapolates to 5951 patients per year in the UK (data from mid-2016).InterpretationBubble-TCD was feasible in most older patients with transient ischaemic attack or non-disabling stroke, the association of RLS with cryptogenic events remained at older ages, and the population burden of PFO-associated events is substantial. Randomised trials of PFO closure at older ages are required and should be feasible.FundingNational Institute for Health Research, Oxford Biomedical Research Centre, Wellcome Trust, and Wolfson Foundation.

A priori, a posteriori, and back again

Cryptogenic stroke (CS) is common, as is patent foramen ovale (PFO). By chance, they overlap frequently. However, if the relationship was just chance, then PFO prevalence in patients with CS would match the general population (approximately 25%). But PFOs are overrepresented in the CS population (approximately 50%). Paradoxical embolism explains this association—the paradox being a venous source thrombus appearing in an artery (via right-to-left shunt). Because of the high background prevalence, a discovered PFO only has a 50:50 chance of actually causing the stroke in an individual patient.1 The physician asks, “Is the PFO relevant? If I can't know, then why should I look?” Ergo, diagnostic nihilism.

Clinical analysis of young and middle-aged stroke patients with patent foramen ovale

Objective: To investigate the pathogenesis of young and middle-aged stroke patients with patent foramen ovale (PFO) by analyzing clinical characteristics. Methods: Data of 298 consecutive young and middle-aged patients diagnosed as stroke were retrospectively collected from Department of Neurology, Beijing Anzhen Hospital from January 2010 to January 2017.Patients were divided into cryptogenic stroke (CS) group and not-CS group.Risk factors, characteristics of PFO and infarct of imaging were analyzed between two groups. Results: PFO was confirmed in 88 patients among 298 young and middle-aged stroke patients.The prevalence of PFO was 29.6%. Forty-six patients were assigned into CS group and 42 patients were assigned into not-CS group.The ratio of atrial fibrillation and internal carotid artery stenosis in CS group was lower than that in not-CS group (0 vs 12, 4 vs 22, P<0.05). The concentration of homocysteine was lower in CS group than that in not-CS group [(10.4±1.1) mmol/L vs(14.6±2.4) mmol/L, P<0.05]. The difference of migraine and scores of scale of Risk of Paradoxical Embolism (RoPE) in CS group were significantly higher than those in not-CS group [18 vs 4, (6.8±2.5)vs (5.5±1.4), P<0.05]. The prevalence of big PFO, constant right-to-left shunt and atrial septal aneurysm (ASA) in CS group was higher than that in not-CS group (26 vs 6, 36 vs 18, 5 vs 0, P<0.05). Post-circulation location, single cortex infarction and multiple infarctions in multiple vascular areas are indicative of PFO (25 vs 18, 15 vs 7, 20 vs 8, P<0.05). Conclusion: Migraine, high scores of RoPE, big PFO, constant RLS and ASA are indicative of important role of PFO in cryptogenic stroke in young and middle-aged patients.The imaging characteristics of CS with PFO should be emphasized.

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

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

TCT-268 Patent Foramen Ovale Closure to treat Obstructive Sleep Apnea – the PCOSA pilot study

Studies have shown a higher prevalence of patent foramen ovale (PFO) in patients with obstructive sleep apnoea (OSA). Right to left shunting via a PFO may be encouraged by OSA respiratory physiology, contributing to OSA pathophysiology. We assessed whether PFO closure would improve respiratory

Clinical Relevance of Patent Foramen Ovale and Atrial Septum Aneurysm in Stroke: Findings of a Single-Center Cross-Sectional Study

Background: A significant proportion of ischemic strokes are cryptogenic. In this context, the clinical pertinence of patent foramen ovale (PFO) with and without atrial septum aneurysm (ASA) remains controversial. The aim of this study was to identify how PFO +/–ASA and cryptogenic stroke are associated in a representative sample of stroke patients. Methods: We enrolled all patients (n = 909) with ischemic stroke or transient ischemic attack admitted to the certified stroke unit or neurological intensive care unit of our university medical center who underwent transesophageal echocardiography (TEE) between 2012 and 2014. The baseline characteristics, cardio-/neurovascular risk factors, clinical parameters and TEE findings were analyzed. Results: PFO was present in 26.2%, and PFO was combined with an ASA in 9.9%. In cryptogenic stroke, the prevalence of PFO was higher compared to other etiologies (30.9 vs. 21.9%; p < 0.002). Patients with PFO had lower National Institute of Health Stroke Score (NIHSS) values at admission than those without (2 [0–5] vs. 3 [1–7]; p = 0.001; 95% CI [0.62–0.88]). No difference was found in NIHSS values of PFO patients with or without ASA (2 [0–5] vs. 2 [0–5]; p = 0.683; 95% CI 0.94 [0.68–1.28]). Conclusions: Our study indicates that a detected PFO +/–ASA could exhibit a stroke-relevant finding, if classical risk factors for the stroke were lacking.

Effects of Patent Foramen Ovale Closure on Obstructive Sleep Apnea Syndrome: PCOSA Study

BackgroundPrevious studies have shown a higher prevalence of patent foramen ovale (PFO) in patients with obstructive sleep apnea syndrome (OSAS). Right to left shunting through a PFO may be encouraged by the respiratory physiology of OSAS, contributing to the disease pathophysiology. We assessed whether PFO closure would improve respiratory polygraphy parameters compared with baseline measurements in patients with OSAS. MethodsTwenty-six patients with newly diagnosed OSAS and a moderate-large PFO (prevalence, 18% of 143 patients screened) were referred for PFO closure. The oxygen desaturation index (ODI), apnea-hypopnea index (AHI), Epworth Sleepiness Scale (ESS), 6-minute walk test (6MWT), and Sleep Apnea Quality of Life Index (SAQLI) results were compared in these patients at baseline (before continuous positive pressure ventilation [CPAP]) and at 6-month follow-up (after interrupting CPAP for 1 week). ResultsAll PFOs were safely sealed at 6 months, as confirmed by repeated transthoracic echocardiography. The ODI (44.8 [interquartile range (IQR), 31.2-63.5) vs 42.3 [IQR, 34.0-60.8]; P = 0.89) and AHI (47.9 [IQR, 31.5-65.2] vs 42.3 [IQR, 32.1-63]; P = 0.99) did not change after PFO closure nor did the 6MWT, although the ESS (13.0 [IQR, 12.0-16.8] vs 6.0 [IQR, 4.0-8.8]; P < 0.001) and the SAQLI (3.4 [IQR, 2.8-4.3] vs 4.4 [IQR, 3.9-5.3]; P < 0.001) did improve. ConclusionsThe prevalence of PFO in OSAS appears to be no higher than that in the general population. Although PFO closure is safe and effective, it did not improve respiratory polygraphy measures of OSAS severity. The improvement in the ESS and SAQLI likely reflect residual benefits from CPAP.

Patent Foramen Ovale (PFO), Personality Traits, and Iterative Decompression Sickness. Retrospective Analysis of 209 Cases.

Introduction: There is a need to evaluate the influence of risk factors such as patency of foramen ovale (PFO) or “daredevil” psychological profile on contra-indication policy after a decompression sickness (DCS).Methods: By crossing information obtained from Belgian Hyperbaric Centers, DAN Emergency Hotline, the press, and Internet diving forums, it was possible to be accountable for the majority if not all DCS, which have occurred in Belgium from January 1993 to June 2013. From the available 594 records we excluded all cases with tentative diagnosis, medullary DCS or unreliability of reported dive profile, leaving 209 divers records with cerebral DCS for analysis. Demographics, dive parameters, and PFO grading were recorded. Twenty-three injured divers were tested using the Zuckerman's Sensation Seeking Scale V and compared to a matched group not involved in risky activities.Results: 41.2% of all injured came for iterative DCS. The average depth significantly increases with previous occurrences of DCS (1st DCS: 31.8 ± 7.9 mfw; 2nd DCS: 35.5 ± 9.8 mfw; 3rd DCS: 43.4 ± 6.1 mfw). There is also an increase of PFO prevalence among multiple injured divers (1st DCS: 66.4% 2nd & 3rd DCS: 100%) with a significant increase in PFO grade. Multiple-times injured significantly scored higher than control group on thrill and adventure seeking (TAS), experience seeking, boredom susceptibility and total score.Conclusion: There is an inability of injured diver to adopt conservative dive profile after a DCS. Further work is needed to ascertain whether selected personality characteristics or PFO should be taken into account in the clearance decision to resume diving.

1254 Resolution of persistent nocturnal hypoxia in a patient with treated obstructive sleep apnea after closure of a patent foramen ovale

A higher prevalence of patent foramen ovale (PFO) is documented in individuals with obstructive sleep apnea (OSA). Concurrent OSA and PFO can lead to more severe nocturnal desaturation although the effect of closure of PFO on nocturnal hypoxia is unclear. A 38 year old male with hypertension, tobacco use and obesity presented to the WLA-VA sleep center with a prior diagnosis of OSA. A polysomnogram (PSG) performed 7 years prior demonstrated an AHI of 99.0/hr with 4.7% of TST spent at an O2 saturation of <89% and he was successfully titrated to a CPAP of 10 cm H20. The patient was non-compliant with CPAP and was restarted on his prior settings of 10 cm H20 through the VA. Polycythemia (hgb 18) was noted and a workup was initiated. PFTs and CXR were normal and a blood gas showed a daytime room air PaO2 at 67mmHg. A 3-night oximetry showed long periods of time < 88% SaO2 while on CPAP (residual AHI < 5/hr). Supplemental oxygen with CPAP was initiated although nocturnal hypoxia persisted at 3L/min with CPAP. Echocardiogram with bubble study did not demonstrate a shunt but transcranial doppler revealed a high grade right-to-left shunt at rest, increasing with Valsalva maneuver. Cardiac catheterization showed xygenation step up from RA (74%) to RV (82%) indicating significant left to right shunt and TEE showed a PFO. Patient underwent successful percutaneous PFO closure. Repeat PSG on CPAP and room air showed resolution of nocturnal hypoxia and hgb remained normal after cessation of supplemental nocturnal oxygen. Comorbid OSA and PFO may lead to difficult to treat nocturnal hypoxia. A randomized trial is needed to assess if closure of PFO improves nocturnal hypoxia in these cases.

Ischemic Stroke in Patients with Percutaneous Patent Foramen Ovale Closure

Background: The prevalence of patent foramen ovale is approximately 50% in patients who have suffered a cryptogenic stroke. The recurrence of ischemic stroke after percutaneous patent foramen ovale closure is approximately 1% per year. Objective: The aim of this study was to evaluate the prevalence of recurrent ischemic stroke in our population undergoing percutaneous patent foramen ovale closure. Methods: All patients with diagnosis of cryptogenic ischemic stroke who underwent percutaneous patent foramen ovale closure between January 2007 and September 2015 were retrospectively included. Follow-up detected patients who had either a recurrent stroke and/or a transient ischemic attack after percutaneous patent foramen ovale closure. Results: Twenty eight patients with average age of 47 years (20-71 years) at the time of the procedure were included in the study. Fifty percent of patients were females, 79% had previous history of stroke and 21% of transient ischemic attack. The RoPE score was 7.07 points (3-10 points) and percutaneous closure was successful in all cases. During follow-up (median 989 days, interquartile range 670-1766 days), two patients (7%) had a new stroke. In both patients, transesophageal echocardiography revealed closed patent foramen ovale without residual leak. Conclusions: The incidence of a recurrent stroke is low after percutaneous patent foramen ovale closure and it is possible that a significant number of recurrent cases will not be preventable with its closure.

Abstract 170: Role of Patent Foramen Ovale in First and Recurrent Childhood Cryptogenic Arterial Ischemic Stroke

Background: Numerous studies in adults have reported a robust association between patent foramen ovale (PFO) and cryptogenic arterial ischemic stroke (AIS), particularly in younger adults. The association between PFO and stroke in children has not been well characterized and the clinical significance of identifying a PFO in a child with first or recurrent cryptogenic stroke is currently unknown. Methods: We performed a retrospective case control analysis of a 10-year prospectively enrolled cohort of children with acute AIS who underwent transthoracic echocardiogram (TTE) as part of their diagnostic evaluation. We compared PFO prevalence in children with cryptogenic stroke to those with known stroke etiologies and to non-stroke controls. We also assessed stroke recurrence risk in children with vs without PFO and assessed PFO features that may confer higher stroke risk. Results: Of 119 children with first-ever AIS, 59 had TTE available for central review, of which 17 were cryptogenic and 42 had a known cause. PFO prevalence was higher in the cryptogenic stroke group (X, 24%) compared to both the known stroke etiology group (Y, 6%, p = 0.05) and non-stroke controls (Z, 8%, p = 0.05). However, 2 year recurrence free survival rates in stroke patients with PFO did not differ from those without PFO (HR 1.58, 95% CI 0.18-13.62, p = 0.68). PFOs in children with AIS vs controls had numerically more right-to-left shunt at rest (7 vs 0) and atrial septal aneurysm (4 vs 0) but the study was underpowered to look at these factors. Conclusions: In our prospectively enrolled cohort of children with AIS, we found the prevalence of PFO to be higher in children with cryptogenic stroke compared to healthy controls and non-cryptogenic stroke patients. The implication of PFO for risk of recurrence and optimal secondary preventative treatment remains uncertain and require further study.

Prevalence of Right to Left Shunts in Japanese Patients with Migraine: A Single-center Study.

Objective Several studies have shown an increased prevalence of right-to-left shunt (RLs) in migraine patients, particularly those with aura. However, the prevalence of RLs and its relation to Japanese patients with migraine are unknown. We investigated the prevalence of RLs in Japanese patients with migraine. Methods In total, 112 consecutive patients with migraine were recruited from our headache outpatient clinic. Migraine with aura (MA) and migraine without aura (MWOA) were diagnosed according to the International Classification of Headache Disorders, 3rd edition (beta-version). Contrast transcranial Doppler ultrasound was used to detect RLs, including patent foramen ovale (PFO). Then, the associations between RLs and patients' backgrounds and presence of aura were assessed. Results The overall prevalence of RLs and PFO in migraine patients was 54.5% and 43.8%, respectively. The prevalence of RLs and PFO in the MA group were significantly higher than in the MWOA group (RLs, 62.9% vs. 44.0%, p=0.046; PFO, 54.8% vs. 30.0%, p=0.008). There were no marked differences in the prevalence of large, middle and small shunts between MA and MWOA patients. Compared with the MWOA patients, the MA patients were younger (p=0.013) and had early onset age (p=0.013) and increased prevalence of photophobia (p=0.008). Conclusion RLs were found in over half of the Japanese patients with migraine. Our study suggests a possible link between RLs and MA.

Entrapped Cardiac Thrombus and Fatal Right Heart Failure due to Massive Pulmonary Emboli

The prevalence of patent foramen ovale (PFO) in the general population is 25-30%however, paradoxical embolism is rarely seen. Entrapped cardiac thrombus (impendingparadoxical embolism) is defined as embolus that project through the patent foramen ovale(PFO) thus biatrial embolism and paradoxical embolism are rarely seen in alives. Completeremoval of the thrombus by surgery reduces the risk of embolization. Emergency surgery isindicated for biatrial thrombus, entrappedcardiacthrombusandmassivePEwithhemodynamiccompromise. We present the management of a 41 year old male with entrappedcardiac thrombus and fatal right heart failure due to massive pulmonary emboli

A Cautionary Perspective on the Utility of the RoPE Score and Reported High Risk Echocardiographic Features in Managing Cryptogenic Stroke Patients with a Patent Foramen Ovale

Background: The management of cryptogenic stroke (CS) patients with a patent foramen ovale (PFO) is topical following the release of ten-year data supporting PFO closure. The Risk of Paradoxical Embolism (RoPE) score is a 1 to 10 scale derived from patient age and vascular risk factors in which younger patients without risk factors will score higher. Echographic features such as the degree of interatrial septum mobility (IASM), PFO size and the presence of a right-to-left shunt are proposed markers of risk. However, the accuracy and reliability of these tools remain unclear in guiding the selection of CS patients for PFO closure. Method: We reviewed consecutive CS patients who presented for transthoracic echocardiographic (TTE) bubble study between January 2014 and November 2016. The RoPE score was calculated and TTE images were assessed for the aforementioned features of risk. Results: 126 patients aged 26 to 69 years were included. Fifty-six had a confirmed PFO on TTE. Assuming a PFO prevalence of 25% in the general population, the PFO-attributable fraction for RoPE score ≤6 was 67% compared to 70% for RoPE of ≥7 (p = 0.76). A low RoPE score thus did not exclude a PFO-attributable stroke. In outcomes analysis for TTE imaging, the degree of IASM demonstrated a trend towards clinical significance in influencing the PFO closure decision (p = 0.05). Conclusion: There is often uncertainty in attributing stroke to a PFO. Our data shows that great care should be taken when using risk scores and putative echocardiographic risk markers in isolation for clinical decision making on PFO closure.