Is Moderate/Large Residual Shunt After PFO Closure Justifiable for a Patient with a Prior History of Cryptogenic Stroke and Transient Ischemic Attack?

A 36-year-old woman suffered from an embolic stroke of an undetermined source documented by magnetic resonance imaging with residual right arm weakness. She underwent percutaneous patent foramen ovale (PFO) closure with an 18/25 mm device in another center. One year later, the patient suffered from a transient ischemic attack with dysarthria. She asked for a second opinion at our institution and a contrast-transthoracic (cTTE) /transesophageal echocardiography showed a large residual right-to-left shunt (RLS) through a still patent tunnel after PFO closure. Written informed consent for a redo procedure was obtained from the patient. A catheter-based closure of the residual shunt was therefore planned under local anesthesia and rotational intracardiac echo monitoring. A second equally sized disc (18/18 mm) device was successfully implanted without complications. The patient was discharged home the following day in good clinical condition. Dual antiplatelet therapy was recommended for the first 2 months and then single antiplatelet therapy up to 6 months. At the 6-month follow-up, the cTTE color Doppler showed the stable position of the two nitinol double-disc devices and the c-transcranial Doppler confirmed the abolition of the residual RLS.

Sex differences in baseline profiles and short-term outcomes in patients undergoing closure of patent foramen ovale.

Objectives: Although sex differences have been emphasized in stroke and congenital heart disease, there has been limited investigation into their role in patent foramen ovale (PFO) closure for secondary prevention of stroke. We aimed to explore differences by sex in baseline profiles, procedural characteristics, and short-term outcomes of patients undergoing transcatheter PFO closure. Methods: Data of adult patients undergoing transcatheter PFO closure at the Toronto General Hospital from 1997 to 2017 was retrospectively analyzed. Baseline information included demographic characteristics, medical history, diagnostic, and procedural information, and periprocedural complications. Post-closure outcomes were captured at index hospitalization and during the first follow-up. Results: From 1031 patients in the cohort sample, 80.7 % underwent closure for cryptogenic stroke and 44.7 % (n = 461) were females. We observed significant sex-related differences in baseline characteristics; females were younger, less likely to have a history of smoking, and less likely to have several cardiovascular risk factors at baseline (p < 0.05). The median time to first follow-up was 89 days for both groups. Recurrent stroke was observed in 0.1 % and TIA observed in 0.4 % of in the 'cryptogenic stroke/TIA' group; in the 'other indications' group, 1.4 % stroke and no TIA were reported. No significant differences were present between sexes. Conclusions: There were no differences in procedural and short-term outcomes between males and females undergoing transcatheter PFO closure, but significant baseline differences in risk factors were identified. There is a critical need for long-term, systematic studies to understand sex and gender differences in the PFO population.

Multidisciplinary assessment of patients with ischemic stroke, the structure of a stroke team, and first Egyptian experience in adults undergoing transcatheter PFO closure for PFO-related stroke.

BACKGROUND: Patent foramen ovale closure in the setting of stroke was debatable until the recent data from the long-term follow-up of multiple randomized control trials. These recent data have led to increase the number of the procedure worldwide. To our knowledge, there was no previous formal structured program in Egypt between cardiologists and neurologists for investigation and management of patients with cryptogenic stroke. The first Egyptian-dedicated stroke team was created in two large tertiary centers with collaboration between cardiologists, dedicated cardiac imagers, and neurologists for investigation and management of patients with cryptogenic stroke. RESULTS: Sixty-three patients with cryptogenic stroke were identified from a total of 520 patients admitted to the stroke units between 2016 and 2019. Twenty-five patients had a proven PFO-related stroke. Three patients were referred for surgical closure, 19 patients underwent transcatheter PFO closure, and procedural success was met in 18 patients (94.7%). We did not experience any major procedure-related complication. Complete closure was achieved in 83.3% of patients at 6 months. One patient had a single attack TIA within the first 3 months after device closure; one patient had a device-related thrombosis; both were managed successfully. CONCLUSION: Our initial experience in collaboration between cardiologist and neurologist with the establishment of a dedicated cryptogenic stroke team added significantly to the management of patients with stroke. The results of the first Egyptian cohort who underwent transcatheter PFO closure demonstrated procedural feasibility, safety, and efficacy with very low incidence of major complications. A nationwide program is needed to reduce the ischemic stroke disease burden and the risk of recurrence.

The 'dreaded PFO': anatomical and functional features of high risk for stroke.

Patent foramen ovale (PFO) has a high prevalence in general population and can be implicated in cryptogenic stroke among young people. Recent trials have shown that transcatheter PFO closure is superior to medical treatment in the secondary prevention of ischaemic stroke. The benefit in the reduction of stroke recurrence is particularly evident in patients who have documentation of a PFO with high-risk characteristics. Therefore, after the assessment of a clear causal relationship with the event, a thoughtful documentation of anatomic (height, length, presence of an aneurysmatic or a floppy atrial septum, a prominent Eustachian valve or Chiari's network, an acute angle with the inferior vena cava) and functional high-risk characteristics is mandatory.

A Review of Transcatheter Closure of Patent Foramen Ovale.

A patent foramen ovale (PFO) is a common variant in cardiac anatomy found in 25% to 30% of U.S. adults. While PFOs are a normal part of fetal development and commonly seen in asymptomatic adults, they have been implicated in a variety of pathophysiologic conditions. The most clinically important of these is paradoxical embolization of venous thrombus resulting in stroke or systemic embolism. Various devices can be used to close PFOs via a transcatheter approach to prevent recurrent stroke. Data regarding the safety and effectiveness of these devices is rapidly evolving, with recent long-term results suggesting efficacy in preventing secondary stroke in carefully selected patients. This review discusses historical data on PFO occurrence and treatment, a risk score that can assess the likelihood of a stroke being attributable to a PFO, a variety of other conditions that may be linked to PFOs, and current research regarding the role transcatheter closure plays in their treatment.

close: Closure of patent foramen ovale, oral anticoagulants or antiplatelet therapy to prevent stroke recurrence: Study design.

RATIONALE: Currently available data do not provide definitive evidence on the comparative benefits of closure of patent foramen ovale, oral anticoagulants and antiplatelet therapy in patients with patent foramen ovale-associated cryptogenic stroke AIM: To assess whether transcatheter patent foramen ovale closure plus antiplatelet therapy is superior to antiplatelet therapy alone and whether oral anticoagulant therapy is superior to antiplatelet therapy, for secondary stroke prevention in patients aged 16 to 60 years with a large patent foramen ovale or a patent foramen ovale associated with an atrial septal aneurysm, and an otherwise unexplained ischaemic stroke or retinal ischaemia. SAMPLE SIZE: Six hundred and sixty-four patients were included in the study. METHODS AND DESIGN: CLOSE is an academic-driven, multicentre, randomized, open-label, three-group, superiority trial with blinded adjudication of outcome events. The trial has been registered with Clinical Trials Register (Clinicaltrials.gov, NCT00562289). Patient recruitment started in December 2007. Patient follow-up will continue until December 2016. Expected mean follow-up = 5.6 years. STUDY OUTCOMES: The primary efficacy outcome is the occurrence of fatal or nonfatal stroke. Safety outcomes include fatal, life-threatening or major procedure- or device-related complications and fatal, life-threatening or major haemorrhagic complications. DISCUSSION: CLOSE is the first specifically designed trial to assess the superiority of patent foramen ovale closure over antiplatelet therapy alone and the superiority of oral anticoagulants over antiplatelet therapy to prevent stroke recurrence in patients with patent foramen ovale-associated cryptogenic stroke.