RESUMO
Patent foramen ovale (PFO) is frequently identified in young patients with ischemic stroke. Randomized controlled trials provide robust evidence supporting PFO closure in selected patients with cryptogenic ischemic stroke; however, several questions remain unanswered. This report summarizes current knowledge on the epidemiology of PFO-associated stroke, the role of PFO as a cause of stroke, and anatomic high-risk features. We also comment on breakthrough developments in patient selection algorithms for PFO closure in relation to the PFO-associated stroke causal likelihood risk stratification system. We further highlight areas for future research in PFO-associated stroke including the efficacy and safety of PFO closure in the elderly population, incidence, and long-term consequences of atrial fibrillation post-PFO closure, generalizability of the results of clinical trials in the real world, and the need for assessing the effect of neurocardiology teams on adherence to international recommendations. Other important knowledge gaps such as sex, race/ethnicity, and regional disparities in access to diagnostic technologies, PFO closure devices, and clinical outcomes in the real world are also discussed as priority research topics.
Assuntos
Forame Oval Patente , AVC Isquêmico , Acidente Vascular Cerebral , Humanos , Idoso , Forame Oval Patente/complicações , Forame Oval Patente/epidemiologia , Forame Oval Patente/cirurgia , Resultado do Tratamento , Recidiva Local de Neoplasia/complicações , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/prevenção & controle , Acidente Vascular Cerebral/diagnóstico , Fatores de Risco , AVC Isquêmico/complicações , Prevenção Secundária/métodos , Recidiva , Cateterismo CardíacoRESUMO
BACKGROUND: Previous studies have examined the impact of antithrombotic agents on Patent Foramen Ovale (PFO) in relation to migraine. However, differences in effectiveness of different antithrombotic agents and traditional migraine medications are not known. METHODS/DESIGN: This study is an investigator-initiated, randomized, multicenter, single-masked (outcomes assessor), and active-controlled parallel-group trial (ClinicalTrials.gov Identifier: NCT05546320), with the objective of evaluating the prevention efficacy of antithrombotic agents compared to first-line migraine medication in PFO patients. The trial involves 1,000 migraine patients with a right-to-left shunt at the atrial level, randomized in a 1:1:1:1 fashion to receive either aspirin 300 mg QD, clopidogrel 75 mg QD, rivaroxaban 20 mg QD, or the active-control metoprolol 25 mg BID. The primary efficacy end point is the response rate, defined as a 50% or greater reduction in the average migraine attack days per month or in the average number of migraine attacks per month at 12-week visit compared to baseline. CONCLUSIONS: The COMPETE trial aims to provide valuable insights into the comparative effectiveness of antithrombotic agents and standard migraine therapies in patients with PFO. This study holds the promise of advancing treatment approaches for individuals having migraines associated with PFO, thus addressing an important gap in current migraine management strategies.
Assuntos
Forame Oval Patente , Transtornos de Enxaqueca , Humanos , Forame Oval Patente/complicações , Forame Oval Patente/tratamento farmacológico , Fibrinolíticos , Transtornos de Enxaqueca/complicações , Transtornos de Enxaqueca/tratamento farmacológico , Projetos de Pesquisa , Resultado do TratamentoRESUMO
A patient presenting with acute ischemic stroke associated with patent foramen ovale (PFO) had concurrent deep vein thrombosis, pulmonary embolism, and new-onset atrial fibrillation. Upon initiation of anticoagulation therapy, the patient developed hemorrhagic transformation of the stroke. The patient's multiple potential sources of embolic stroke were treated with concomitant left atrial appendage occlusion and PFO closure through the PFO, made possible by using the Steerable Amulet Sheath under 3D-intracardiac echocardiography guidance.
Assuntos
Apêndice Atrial , Cateterismo Cardíaco , Ecocardiografia Tridimensional , Forame Oval Patente , Humanos , Forame Oval Patente/diagnóstico por imagem , Forame Oval Patente/terapia , Forame Oval Patente/complicações , Apêndice Atrial/diagnóstico por imagem , Apêndice Atrial/fisiopatologia , Cateterismo Cardíaco/instrumentação , Cateterismo Cardíaco/efeitos adversos , Resultado do Tratamento , AVC Isquêmico/etiologia , AVC Isquêmico/diagnóstico por imagem , Ultrassonografia de Intervenção , Masculino , Dispositivo para Oclusão Septal , Fibrilação Atrial/diagnóstico por imagem , Fibrilação Atrial/terapia , Fibrilação Atrial/fisiopatologia , Fibrilação Atrial/complicações , Idoso , AVC Embólico/etiologia , AVC Embólico/prevenção & controle , AVC Embólico/diagnóstico por imagem , Feminino , Ecocardiografia Transesofagiana , Pessoa de Meia-IdadeRESUMO
Patent foramen ovale (PFO) is a common cardiac anomaly linked with cryptogenic strokes and migraine, particularly migraine with aura. This study aims to explore the spectrum of headache disorders in PFO patients, focusing on identifying patterns beyond the well-established migraine-PFO connection. A retrospective observational study was conducted on patients diagnosed with PFO. Headache types were classified using the International Classification of Headache Disorders, 3rd edition. The study analyzed headache prevalence and patterns in PFO patients, comparing those with and without a history of stroke. Of 177 participants, 63 (35.59%) reported headaches. Tension-type headache was the most common (15.25%), followed by migraine without aura (11.30%) and migraine with aura (8.47%). Notably, migraine without aura was more prevalent than migraine with aura, contrasting previous assumptions. No significant differences were found in headache types based on stroke history. The study reveals a diverse spectrum of headache types in PFO patients, with migraine without aura being more common than migraine with aura. These findings suggest a need for broader diagnostic perspective and individualized treatment approaches in PFO patients with headaches.
Assuntos
Forame Oval Patente , Enxaqueca com Aura , Humanos , Forame Oval Patente/complicações , Forame Oval Patente/epidemiologia , Feminino , Masculino , Estudos Retrospectivos , Adulto , Pessoa de Meia-Idade , Enxaqueca com Aura/epidemiologia , Prevalência , Cefaleia/epidemiologia , Cefaleia/etiologia , Cefaleia/diagnóstico , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/epidemiologiaRESUMO
BACKGROUND AND AIMS: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: PFO screening and treatment may be considered feasible for patients with SVT who undergo TIPS placement.
Assuntos
Forame Oval Patente , Hipertensão Portal , Veia Porta , Derivação Portossistêmica Transjugular Intra-Hepática , Trombose Venosa , Humanos , Derivação Portossistêmica Transjugular Intra-Hepática/efeitos adversos , Forame Oval Patente/complicações , Forame Oval Patente/cirurgia , Forame Oval Patente/diagnóstico por imagem , Estudos Retrospectivos , Hipertensão Portal/cirurgia , Hipertensão Portal/etiologia , Hipertensão Portal/complicações , Feminino , Masculino , Pessoa de Meia-Idade , Trombose Venosa/etiologia , Trombose Venosa/diagnóstico por imagem , Trombose Venosa/cirurgia , Veia Porta/cirurgia , Adulto , Prevalência , Idoso , Ecocardiografia , Circulação Esplâncnica , Cirrose Hepática/complicações , Cirrose Hepática/cirurgia , Resultado do TratamentoRESUMO
BACKGROUND AND PURPOSE: There is scarce clinical information about the clinical profile of patients with acute ischaemic stroke with previously undiagnosed major vascular risk factors (UMRFs). METHODS: This was a retrospective analysis of data from the Acute Stroke Registry and Analysis of Lausanne registry between 2003 and 2018 with univariate and multivariate logistic regression analyses comparing clinical profiles of patients with UMRFs to patients with at least one previously diagnosed MRF (DMRF). RESULTS: In all, 4354 patients (median age 70 years [interquartile range 15.2], 44.7% female) were included after excluding 763 (14.9%) for lack of consent and three for missing information. Amongst 1125 (25.8%) UMRF patients, 69.7% (n = 784) had at least one newly diagnosed MRF and the others none. The newly detected MRFs were dyslipidaemia (61.4%), hypertension (23.7%), atrial fibrillation (10.2%), diabetes mellitus (5.2%), ejection fraction <35% (2.0%) and coronary disease (1.0%). Comparing UMRF patients to DMRF patients, multivariate analysis showed a positive association with lower age, non-Caucasian ethnicity, contraceptive use (<55 years old), smoking (≥55 years old) and patent-foramen-ovale-related stroke mechanism. A negative association was found with pre-stroke antiplatelet use and higher body mass index. Functional outcome did not differ. Cerebrovascular recurrences were similar between groups. CONCLUSIONS: In this large single-centre cohort, 69.7% of patients with acute ischaemic stroke and UMRF were newly diagnosed with at least one new MRF, the most common being dyslipidaemia, hypertension or atrial fibrillation. Patients of the UMRF group were younger, more often smokers and on contraceptives, and had more patent-foramen-ovale-related strokes.
Assuntos
Fibrilação Atrial , Isquemia Encefálica , Dislipidemias , Forame Oval Patente , Hipertensão , AVC Isquêmico , Acidente Vascular Cerebral , Humanos , Feminino , Idoso , Pessoa de Meia-Idade , Masculino , Acidente Vascular Cerebral/complicações , Isquemia Encefálica/complicações , Isquemia Encefálica/epidemiologia , Fibrilação Atrial/complicações , Fibrilação Atrial/epidemiologia , Fibrilação Atrial/diagnóstico , Estudos Retrospectivos , Fatores de Risco , AVC Isquêmico/epidemiologia , AVC Isquêmico/complicações , Forame Oval Patente/complicações , Hipertensão/complicações , Hipertensão/epidemiologia , Dislipidemias/complicaçõesRESUMO
BACKGROUND: Serum CGRP has been found to increase during migraine attack. However, whether CGRP can identify MA with PFO subtypes in MA remains unknown. This study aimed to investigate the differential expression of calcitonin gene-related peptide (CGRP) between migraine (MA) patients with and without patent foramen ovale (PFO), and to evaluate the predictive value of CGRP for MA with PFO. METHODS: A total of 153 patients with MA, 51 patients with PFO and 102 patients without. Venous blood was drawn and HIT-6 score was calculated during the onset of MA, and blood routine, inflammatory indexes and serum CGRP were detected. The differences in serum markers and HIT-6 scores were compared between the two groups, and the risk factors of MA with PFO were determined by univariate and multivariate logistics regression. Furthermore, the correlation between CGRP level with right-to-left shunt (RLS) grades and headache impact test-6 (HIT-6) score in MA patients with PFO were assessed. Independent risk factors were screened out by multivariate Logistic regression analysis. We used the receiver operating characteristic (ROC) curve to analyze the diagnostic value of these risk factors in MA complicated with PFO. RESULTS: The serum CGRP level and HIT-6 scores in the MA with PFO group were significantly higher than those in the MA group (P < 0.001). Multivariate regression analysis showed that CGRP was an independent risk factor for MA with PFO (OR = 1.698, 95% CI = 1.325-2.179, P < 0.001). CGRP values ââincreased with the increase of RLS grade(Spearmen rho = 0.703, P < 0.001). Furthermore, a positive correlation between CGRP and HIT-6 scores was found (Spearmen rho = 0.227; P = 0.016). ROC curve showed that the optimal cut-off value for diagnosing MA with PFO was 79 pg/mL, the area under the curve (AUC) for predicting MA with PFO was 0.845, with 72.55% sensitivity and 78.43% specificity. CONCLUSIONS: MA patients with PFO have higher serum CGRP level. elevated CGRP concentration was associated with higher RLS grade and increased HIT-6 score. Higher serum CGRP level has certain clinical value in predicting PFO in MA patients. TRIAL REGISTRATION: This study was approved by the Ethics Committee of Zhuhai Hospital of Integrated Traditional Chinese and Western Medicine (Ethics batch number: 20,201,215,005).
Assuntos
Forame Oval Patente , Transtornos de Enxaqueca , Enxaqueca com Aura , Humanos , Biomarcadores , Peptídeo Relacionado com Gene de Calcitonina , Forame Oval Patente/complicações , Transtornos de Enxaqueca/complicaçõesRESUMO
OBJECTIVE: Deep 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. METHODS: Medical 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. RESULTS: Three-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. CONCLUSION: DVT 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.
Assuntos
Forame Oval Patente , Ataque Isquêmico Transitório , Acidente Vascular Cerebral , Trombose Venosa , Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Forame Oval Patente/complicações , Forame Oval Patente/epidemiologia , Forame Oval Patente/diagnóstico por imagem , Ataque Isquêmico Transitório/epidemiologia , Ataque Isquêmico Transitório/diagnóstico por imagem , Ataque Isquêmico Transitório/diagnóstico , Ataque Isquêmico Transitório/complicações , Trombose Venosa/epidemiologia , Trombose Venosa/diagnóstico por imagem , Trombose Venosa/diagnóstico , Trombose Venosa/complicações , Estudos Retrospectivos , Idoso , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/etiologia , Fatores de Risco , AdultoRESUMO
BACKGROUND: The morphology of a patent foramen ovale (PFO) with a high-risk for cryptogenic ischemic stroke (CS) is an important factor in the selection of patients for transcatheter closure, but the morphological features of PFO in older patients with a history of CS are less known because the most data are obtained from younger patients. METHODS AND RESULTS: The study included 169 patients who had a history of CS and PFO. The prevalence of high-risk morphologies of PFO assessed by transesophageal echocardiography was compared between patients aged ≥60 years and patients aged <60 years. We also assessed the presence of septal malalignment of PFO on the aortic wall. The probability of CS due to PFO was evaluated using the PFO-Associated Stroke Causal Likelihood classification system. Patients aged ≥60 years had a significantly higher prevalence of atrial septal aneurysm than patients aged <60 years. The prevalence of large right-to-left shunt, long-tunnel of PFO, or Eustachian valve or Chiari's network was similar between patients aged ≥60 years and <60 years. Septal malalignment was observed more frequently in patients aged ≥60 years than in those <60 years old. Nearly 90% of patients aged ≥60 years were classified as 'possible' in the PFO-Associated Stroke Causal Likelihood classification system. CONCLUSIONS: High-risk morphologies of PFO are common in older patients with a history of CS, as well as in younger patients.
Assuntos
Forame Oval Patente , AVC Isquêmico , Humanos , Forame Oval Patente/complicações , Forame Oval Patente/diagnóstico por imagem , Forame Oval Patente/epidemiologia , Pessoa de Meia-Idade , AVC Isquêmico/epidemiologia , AVC Isquêmico/etiologia , AVC Isquêmico/diagnóstico por imagem , Masculino , Feminino , Idoso , Fatores Etários , Ecocardiografia Transesofagiana , Adulto , Prevalência , Fatores de RiscoRESUMO
Paradoxical embolism is a medical condition characterized by the migration of an embolus from a venous source into the systemic circulation. This occurs through a specific cardiac abnormality known as a right-to-left shunt, ultimately resulting in the possibility of arterial embolism. Patent foramen ovale (PFO) is the most common cause of intracardiac shunting. We reported a rare case of a 56-year-old man on hemodialysis with PFO and arteriovenous fistula dysfunction who suffered a paradoxical embolic ischemic stroke after percutaneous transluminal angioplasty. This case emphasized the potential risk of paradoxical embolism in hemodialysis patients with vascular access problems. We aimed to highlight the importance of searching for PFO, as it may serve as a possible source of embolism in these patients.
Assuntos
Angioplastia , Embolia Paradoxal , Diálise Renal , Humanos , Masculino , Pessoa de Meia-Idade , Diálise Renal/efeitos adversos , Embolia Paradoxal/etiologia , Embolia Paradoxal/diagnóstico , AVC Embólico/etiologia , Falência Renal Crônica/terapia , Falência Renal Crônica/complicações , Forame Oval Patente/complicações , Forame Oval Patente/terapia , Derivação Arteriovenosa Cirúrgica/efeitos adversosRESUMO
BACKGROUND: Migraine is a leading cause of disability worldwide. Several retrospective studies have suggested that the closure of the Patent Foramen Ovale (PFO) may provide relief from migraines. However, three randomized controlled trials did not meet their primary endpoints regarding migraine cessation, reduction in monthly migraine days, and responder rates. METHODS: The SPRING study is a multicenter, prospective, randomized, and open-label trial designed to compare the effectiveness and safety of PFO closure versus medication in the relief of migraines. The primary endpoint is the total cessation of migraines, as recorded in patient headache diaries during the follow-up period. Additional diagnostic tools include echocardiography with agitated saline contrast, transcranial Doppler, and routine laboratory measurements. CONCLUSION: The SPRING trial aims to assess the effectiveness and safety of PFO closure versus medication in mitigating migraines in real-world settings. (Clinical Trails ID: NCT04946734).
Assuntos
Forame Oval Patente , Transtornos de Enxaqueca , Humanos , Estudos Retrospectivos , Estudos Prospectivos , Resultado do Tratamento , Transtornos de Enxaqueca/diagnóstico , Transtornos de Enxaqueca/prevenção & controle , Transtornos de Enxaqueca/etiologia , Forame Oval Patente/diagnóstico por imagem , Forame Oval Patente/terapia , Forame Oval Patente/complicações , Cateterismo Cardíaco/efeitos adversos , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
Patients with previous interatrial shunt device (IASD) implantation may face greater challenges during future left atrial interventional procedures. Herein, we report the first case of left atrial appendage closure (LAAC) in a patient with previous IASD implantation. The patient successfully underwent LAAC using the LAmbre device without complications.
Assuntos
Apêndice Atrial , Fibrilação Atrial , Cateterismo Cardíaco , Humanos , Apêndice Atrial/fisiopatologia , Apêndice Atrial/diagnóstico por imagem , Fibrilação Atrial/fisiopatologia , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/cirurgia , Resultado do Tratamento , Cateterismo Cardíaco/instrumentação , Masculino , Feminino , Ecocardiografia Transesofagiana , Idoso , Função do Átrio Esquerdo , Forame Oval Patente/diagnóstico por imagem , Forame Oval Patente/terapia , Forame Oval Patente/complicações , Forame Oval Patente/fisiopatologia , Forame Oval Patente/cirurgia , Oclusão do Apêndice Atrial EsquerdoRESUMO
If a permanent pacemaker lead is misplaced in the left ventricle (LV), the lead may interfere with normal functioning of the heart leading various complications, including heart rhythm problems and blood clots. In our case, the LV lead that passed through the patent foramen ovale and was misplaced into the LV was detected in a 78-year-old patient who presented with embolic stroke. Thrombus regression was achieved with anticoagulation, and then the lead extraction was planned. The lead extraction is a priority in acute cases; but it is not the primary approach in long-term leads that were misplaced into the LV. A patient-based individual approach should be preferred in such cases.
Assuntos
Forame Oval Patente , AVC Isquêmico , Marca-Passo Artificial , Acidente Vascular Cerebral , Humanos , Idoso , AVC Isquêmico/complicações , Marca-Passo Artificial/efeitos adversos , Forame Oval Patente/complicações , Acidente Vascular Cerebral/complicaçõesRESUMO
Ischemic stroke patients with thrombophilia and patient foramen ovale (PFO) may have an increased risk of recurrent stroke and transient ischemic attack (TIA), and may benefit from PFO closure. However, screening for thrombophilia is not routinely performed and the impact of thrombophilia on prognosis after PFO closure is uncertain. We aim to compare the risk of recurrent stroke and TIA after PFO closure in patients with thrombophilia versus those without. We performed a systematic review and meta-analyses of the literature, with a comprehensive literature search performed on 12 January 2023. Studies comparing the outcomes of patients with and without thrombophilia after PFO closure were included. The primary outcome evaluated was a recurrence of acute cerebrovascular event (ACE), a composite of recurrent ischemic stroke and recurrent TIA. The secondary outcomes included recurrent ischemic stroke only or TIA only. A total of 8 cohort studies were included, with a total of 3514 patients. There was an increased risk of stroke/TIA in patients with thrombophilia compared to those without thrombophilia after PFO (OR: 1.42, 95% CI: 1.01-1.99, I2 = 50%). The association between risk of TIA only (OR: 1.36, 95% CI: 0.77-2.41, I2 = 0%) and stroke only (OR: 1.09, 95% CI: 0.54-2.21, I2 = 0%) with thrombophilia did not reach statistical significance. There is an increased risk of recurrent cerebral ischemia event in patients with thrombophilia compared to those without thrombophilia after PFO closure. Future large prospective studies are necessary to characterise the risk and benefits of PFO closure, as well as the appropriate medical treatment to reduce the risk of recurrent stroke and TIA in this high-risk population.
Assuntos
Forame Oval Patente , Ataque Isquêmico Transitório , AVC Isquêmico , Trombofilia , Humanos , AVC Isquêmico/etiologia , Trombofilia/etiologia , Forame Oval Patente/complicações , Forame Oval Patente/cirurgia , Ataque Isquêmico Transitório/etiologia , Recidiva , Fatores de RiscoRESUMO
BACKGROUND: The right comprehension of ischemic stroke pathogenesis guarantees the best prevention therapy. The term "patent foramen ovale (PFO) related stroke" has been proposed for those events where PFO is supposed to be pathogenetic, but their definition is challenging. A multidisciplinary evaluation in a "Heart & Brain" team (HBteam) including stroke neurologists and interventional cardiologists was therefore highly recommended in the recent guidelines of secondary stroke prevention. OBJECTIVE: We aimed at describing the organization of the HBteam of Careggi-University-Hospital of Florence (Italy), and the results of the first seven years of activity. METHODS: In 2016 Interventional Cardiologists and Stroke Neurologists set up an outpatient clinic for the joined evaluation of patients with PFO and other cardio/neurological conditions. A specific diagnostic-therapeutic hospital plan was produced for PFO patients. Patient empowerment was guaranteed by a hospital explicative webpage, a booklet regarding risks/benefits of PFO closure and a 3D heartmodel to simulate the intervention. Data were collected in a dedicated registry. RESULTS: We evaluated 594 patients for PFO, 40 for left atrial appendage closure and 38 for other conditions. In 20% of PFO-patients, HBteam diagnosis was discordant from that of referring physicians, 14% were stroke misdiagnoses. We advised against closure in 53% of patients. At follow-up 94% of closed patients had no/minimum residual shunt; 3 patients had a cerebral ischemic event. CONCLUSIONS: A dedicated HBteam represents a unique opportunity to share decisions with patients after a thorough empowerment process. The joining of cardioneurological skills allows a better classification of PFO-patients, reducing futile interventions.
Assuntos
Forame Oval Patente , Acidente Vascular Cerebral , Humanos , Forame Oval Patente/complicações , Forame Oval Patente/cirurgia , Recidiva Local de Neoplasia/complicações , Acidente Vascular Cerebral/diagnóstico , Encéfalo , Prevenção Secundária/métodos , Hospitais , Controle de Qualidade , Resultado do Tratamento , RecidivaRESUMO
BACKGROUND: Patent foramen ovale (PFO) is a known cause of ischemic stroke in young adults and combined oral contraceptives (COCs) are widely used by women of reproductive age. If young women with PFO are taking COCs, they may be subjected to a synergistic increase in the occurrence of stroke, though reports of ischemic stroke in this population are rare. We report a woman of reproductive age who was taking COC suffered repetitive ischemic strokes before a patent foramen ovale (PFO) was detected and closed, which may raise concerns in this field. CASE PRESENTATION: A 31-year-old woman presented to the emergency department with sudden-onset right upper- and lower-limb weakness and dysarthria for 1 hour, whose only risk factor of stroke was oral contraceptive use. On admission, she was alert with left gaze deviation, dysarthria, and right-sided hemiplegia. Her symptoms improved after receiving the revascularization therapy. About 24 hours later, her left eye experienced sudden painless vision loss. Then the PFO with a substantial right-to-left shunt was detected and then she received a trans-catheter closure of the defect. Over 3 months of follow-up, there were no signs of stroke, but visual loss persisted. CONCLUSION: This case of disabling stroke raises concerns regarding optimal management in primary and secondary prevention of stroke in young women on COCs with additional risk factors of stroke.
Assuntos
Forame Oval Patente , AVC Isquêmico , Acidente Vascular Cerebral , Adulto Jovem , Humanos , Feminino , Adulto , Forame Oval Patente/complicações , Forame Oval Patente/terapia , Disartria/complicações , Acidente Vascular Cerebral/etiologia , Fatores de Risco , AVC Isquêmico/complicações , Recidiva , Resultado do TratamentoRESUMO
BACKGROUND: Idiopathic nephrotic syndrome (NS) presents as a hypercoagulable state, of which thromboembolism (TE) is a well-known life-threatening complication. Although TE is more likely to occur in venous vessels than arterial vessels, arterial TE is important because it may cause after-effects, including tissue necrosis and cerebral infarction (CI); therefore, prompt diagnosis and appropriate treatment are required. We report a pediatric NS case with multiple CIs. CASE PRESENTATION: A 14-year-7-month-old Japanese girl was diagnosed with frequent relapsing NS, accompanied by headache and disturbance of consciousness during the second relapse. Brain magnetic resonance imaging (MRI) and four-dimensional computed tomography revealed multiple CIs, vasogenic edema, and cerebral venous sinus thrombosis (CVST). The patient had no underlying thrombophilia other than hypercoagulability due to NS and prednisolone (PSL), and no cardiac arrhythmia; however, a right-to-left shunt through the patent foramen ovale (PFO) was observed with the Valsalva maneuver by echocardiography. Therefore, we assumed that a potential cause of multiple CIs might be an embolic stroke, caused by thrombosis formed from a hypercoagulable state due to NS and PSL treatment and reached through PFO. Antiplatelet and anticoagulant therapies were administered for TE. She was treated with PSL and mycophenolate mofetil (MMF) for NS. Rituximab (RTX) was administered to prevent NS relapse after complete remission (CR). She underwent transcatheter PFO closure at age 14 years and 9 months because we considered that the right-to-left shunt through the PFO would be one of the risks for recurrent cerebral embolism when NS relapses. One year after the onset of CIs, an MRI indicated that the CVST had resolved, leaving no neurological sequelae due to CI; therefore, anticoagulant therapy was discontinued. And then she has been in CR for NS with only MMF therapy. CONCLUSIONS: CI is a serious complication in patients with NS. The pathogenesis of multiple CIs is various, including right-to-left shunt through PFO, in addition to the hypercoagulability due to NS. It is important to investigate and manage underlying risks such as PFO, besides preventing the relapses of NS by aggressive treatments using MMF and RTX, in patients with NS.
Assuntos
Infarto Cerebral , Forame Oval Patente , Síndrome Nefrótica , Recidiva , Trombose dos Seios Intracranianos , Humanos , Feminino , Trombose dos Seios Intracranianos/complicações , Trombose dos Seios Intracranianos/diagnóstico por imagem , Trombose dos Seios Intracranianos/etiologia , Trombose dos Seios Intracranianos/tratamento farmacológico , Síndrome Nefrótica/complicações , Adolescente , Forame Oval Patente/complicações , Forame Oval Patente/diagnóstico por imagem , Infarto Cerebral/etiologia , Infarto Cerebral/diagnóstico por imagemRESUMO
A 15-year-old male patient presented with a 3-year history of recurrent dizziness and headaches and was initially diagnosed with patent foramen ovale. A transcatheter closure procedure was planned and conducted under general anesthesia, utilizing ultrasound guidance through the femoral vein. Preadmission echocardiography confirmed the presence of a patent foramen ovale. However, further investigation with transesophageal echocardiography (TEE) performed under general anesthesia, revealed that the observed atrial septal anomaly was not a patent foramen ovale. Instead, real-time TEE identified it as the left atrial opening of the coronary vein. Subsequent detailed TEE tracking confirmed a rare case of coronary sinus ostium atresia with left atrial reflux of the coronary vein, leading to a significant revision of the initial diagnosis and planned treatment.
Assuntos
Seio Coronário , Erros de Diagnóstico , Forame Oval Patente , Humanos , Masculino , Forame Oval Patente/diagnóstico por imagem , Forame Oval Patente/complicações , Forame Oval Patente/diagnóstico , Seio Coronário/anormalidades , Seio Coronário/diagnóstico por imagem , Adolescente , Diagnóstico Diferencial , Ecocardiografia Transesofagiana/métodos , Anomalias dos Vasos Coronários/diagnóstico , Anomalias dos Vasos Coronários/diagnóstico por imagemRESUMO
BACKGROUND: This single-center observational study aimed to compare the echocardiographic and clinical features in patients diagnosed with migraine and embolic stroke of undetermined source (ESUS) who presented with a known patent foramen ovale (PFO). METHODS: Two-dimensional and color Doppler images were obtained using various transthoracic echocardiography views for both migraine and ESUS patients. Suspected PFO cases underwent further assessment through contrast echocardiography and transesophageal echocardiography (TEE). High-risk PFO characteristics were evaluated using TEE, and the Risk of Paradoxical Embolism (RoPe) score was calculated. RESULTS: The study included 310 participants (age range: 18-60, 73.2% female), with 43.5% diagnosed with migraine and 56.5% with ESUS. Common comorbidities included diabetes (26.1%). High-velocity shunting through the interatrial septum was observed in 35.5% of patients. ESUS patients were older, with higher rates of diabetes and hypertension, while active smoking was more prevalent among migraine patients. Basic echocardiographic parameters were mostly similar, except for elevated pulmonary artery systolic pressure in ESUS. ESUS patients exhibited a greater occurrence of large microbubble passage through the interatrial septum and longer PFO lengths compared to migraine patients. However, the RoPe and High-risk PFO scores were similar between the groups. CONCLUSIONS: ESUS patients, characterized by older age and higher rates of diabetes and hypertension, demonstrated increased pulmonary artery pressure, more significant microbubble crossings, and longer PFO lengths. Conversely, migraine patients had a higher prevalence of active smoking. Despite differing clinical profiles, the risk scores for PFO-related embolic events were comparable between the groups. These findings underscore potential distinctions between ESUS and migraine patients with PFO and their implications for management strategies.
Assuntos
Diabetes Mellitus , AVC Embólico , Forame Oval Patente , Hipertensão , Transtornos de Enxaqueca , Acidente Vascular Cerebral , Humanos , Feminino , Adolescente , Masculino , Forame Oval Patente/complicações , Forame Oval Patente/diagnóstico por imagem , Ecocardiografia/métodos , Transtornos de Enxaqueca/complicações , Transtornos de Enxaqueca/diagnóstico por imagem , Ecocardiografia Transesofagiana , Acidente Vascular Cerebral/diagnóstico por imagemRESUMO
BACKGROUND: In previous studies, the prevalence of patent foramen ovale (PFO) has been reported to be higher in scuba divers who experienced decompression illness (DCI) than in those who did not. OBJECTIVE: To assess the association between PFO and DCI in scuba divers. DESIGN: Prospective cohort study. SETTING: Tertiary cardiac center in South Korea. PARTICIPANTS: One hundred experienced divers from 13 diving organizations who did more than 50 dives per year. MEASUREMENTS: Participants had transesophageal echocardiography with a saline bubble test to determine the presence of a PFO and were subsequently divided into high- and low-risk groups. They were followed using a self-reported questionnaire while blinded to their PFO status. All of the reported symptoms were adjudicated in a blinded manner. The primary end point of this study was PFO-related DCI. Logistic regression analysis was done to determine the odds ratio of PFO-related DCI. RESULTS: Patent foramen ovale was seen in 68 divers (37 at high risk and 31 at low risk). Patent foramen ovale-related DCI occurred in 12 divers in the PFO group (non-PFO vs. high-risk PFO vs. low-risk PFO: 0 vs. 8.4 vs. 2.0 incidences per 10 000 person-dives; P = 0.001) during a mean follow-up of 28.7 months. Multivariable analysis showed that high-risk PFO was independently associated with an increased risk for PFO-related DCI (odds ratio, 9.34 [95% CI, 1.95 to 44.88]). LIMITATION: The sample size was insufficient to assess the association between low-risk PFO and DCI. CONCLUSION: High-risk PFO was associated with an increased risk for DCI in scuba divers. This finding indicates that divers with high-risk PFO are more susceptible to DCI than what has been previously reported and should consider either refraining from diving or adhering to a conservative diving protocol. PRIMARY FUNDING SOURCE: Sejong Medical Research Institute.