Management of Patients with Patent Foramen Ovale and Cryptogenic Stroke: An Update.

Patent foramen ovale (PFO) is a common benign finding in healthy subjects, but its prevalence is higher in patients with stroke of unclear cause (cryptogenic stroke). PFO is believed to be associated with stroke through paradoxical embolism, and certain clinical and anatomical criteria seem to increase the likelihood of a PFO to be pathological. Recent trials have shown that closure of PFO, especially if associated with an atrial septal aneurysm and/or a large interatrial shunt, may reduce the risk of recurrent stroke as compared to medical treatment. However, it remains challenging to risk stratify patients with suspected PFO-related stroke and to decide if device closure is indicated. We sought to review contemporary evidence and to conclude an evidence-based strategy to prevent recurrence of PFO-related stroke.

Aortic Root Geometric and Dynamic Changes After Device Closure of Interatrial Shunts.

BACKGROUND: The spatial relationship between atrial septal occluders and the aorta and the subsequent impact on the geometry and mechanics of the aortic root have been underinvestigated. The aim of this study was to evaluate occluder-aorta interaction after device closure of an atrial septal defect (ASD) or a patent foramen ovale (PFO) using three-dimensional transesophageal echocardiography and two-dimensional speckle-tracking echocardiography. METHODS: In 65 adult patients (mean age, 47 ± 14 years; 71% women) who underwent ASD (n = 35) or PFO (n = 30) closure with the Amplatzer Septal Occluder or Amplatzer PFO Occluder, occluder-aorta contact was evaluated on three-dimensional transesophageal echocardiography and defined as continuous, intermittent, or absent. Sinus of Valsalva diameter, height, eccentricity, and strain were measured before and immediately after occluder implantation. RESULTS: The occluder/total septal length and occluder/body surface area ratios were significantly larger after PFO than after ASD closure. The occluder was in contact with the aorta in 93.8% of cases (ASD, 91.4%; PFO, 96.7%). After ASD closure, occluder-aorta contact was very common, in patients with an aortic rim < 5 mm (100%) and those with an aortic rim ≥ 5 mm (79%). However, continuous occluder-aorta contact was more frequent in those with an aortic rim < 5 mm (95% vs 50%). Factors influencing aortic root strain after occluder implantation included the pattern of occluder-aorta relationship and the occluder/body surface area ratio. CONCLUSIONS: Most interatrial septal occluders are in contact with the aortic root, even in patients with ASDs with a sufficient aortic rim and in patients with PFOs. However, continuous occluder-aorta contact is more likely in patients with ASDs with a deficient aortic rim. The pattern of occluder-aorta relationship and the occluder/body surface area ratio affect aortic root strain.