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1.
Medicine (Baltimore) ; 99(2): e18675, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31914059

RESUMO

BACKGROUND: The efficacy of patent foramen ovale (PFO) closure remains controversial, and it is unclear which patient groups are best benefited. We performed this meta-analysis to clarify the efficacy of PFO closure of younger patients for prevention of recurrent ischemic neurological events. METHODS: We systematically searched for studies of PFO closure for younger patients under the age of 55, and pooled available data on PFO closure of younger vs older patients and on PFO closure of younger patients vs medical therapy. The primary endpoints were the composite outcome of recurrent ischemic neurological events [stroke and/or transient ischemic attack (TIA)]. The secondary endpoints included recurrent stroke, TIA, atrial fibrillation (AF) and bleeding events. We calculated the odds ratios (OR) and 95% confidence interval (CI) using fixed-effect and random-effect models. RESULTS: Three randomized controlled trials (RCT) and 13 observational studies were eligible. Compared with older patients undergoing PFO closure, younger patients undergoing closure had a lower risk of composite outcome (OR: 0.40, 95% CI: 0.28 to .56; P < .001) and AF (OR: 0.25, 95% CI: 0.10-0.61; P = .003). Compared with medical therapy, PFO closure of younger patients reduced the risk of composite outcome (OR: 0.50, 95% CI: 0.33-0.75; P<.001); there was no statistical difference in total complications of AF and bleeding events (OR: 2.15, 95% CI: 0.15-30.37; P = .57). Separate analysis of stroke and TIA showed that PFO closure in younger patients was more effective in preventing stroke (OR: 0.45, 95% CI: 0.28-0.72; P < .001) and TIA (OR: 0.35, 95% CI: 0.21-0.58); P < .001) compared with older patients. Compared with medical therapy, PFO closure of younger patients reduced the risk of stroke (OR: 0.26, 95% CI: 0.13-0.51; P < .001); but there was no difference in the risk of TIA (OR: 1.07, 95% CI: 0.16-7.01; P = .94). CONCLUSIONS: Compared with PFO closure of older patients and medical therapy, PFO closure of younger patients can benefit more for the prevention of recurrent ischemic neurological events. Our results indicate that PFO closure is the best treatment strategy for younger patients under the age of 55.


Assuntos
Forame Oval Patente/cirurgia , Ataque Isquêmico Transitório/prevenção & controle , Acidente Vascular Cerebral/prevenção & controle , Adulto , Fatores Etários , Fibrilação Atrial/etiologia , Fibrilação Atrial/prevenção & controle , Feminino , Forame Oval Patente/complicações , Humanos , Ataque Isquêmico Transitório/etiologia , Masculino , Pessoa de Meia-Idade , Acidente Vascular Cerebral/etiologia , Fatores de Tempo
2.
Dtsch Med Wochenschr ; 144(22): 1561-1569, 2019 11.
Artigo em Alemão | MEDLINE | ID: mdl-31658480

RESUMO

Secondary prevention of otherwise cryptogenic stroke in patients with patent foramen ovale (PFO) has been a matter of debate over nearly three decades. Main issues were that data essentially derived from case-control-studies for a long period and that results from the randomized controlled trials CLOSURE-I, PC Trial and RESPECT, which were published in 2012 and 2013, were interpreted in different ways. The likewise not blinded randomized controlled trials REDUCE, CLOSE and DEFENSE-PFO, which were published in 2017 and 2018, consistently demonstrated superiority of interventional PFO closure compared to secondary stroke prevention with antiplatelet therapy in patients 18 to 60 years with cryptogenic stroke and moderate to severe atrial right-to-left shunt. Consecutively, the German Society of Cardiology, the German Society of Neurology and the German Stroke Society published joint recommendations strongly recommending interventional PFO closure in these patients. This review article briefly summarizes current scientific knowledge. Furthermore, open questions regarding secondary prevention in otherwise cryptogenic stroke patients with PFO are discussed.


Assuntos
Isquemia Encefálica , Forame Oval Patente , Acidente Vascular Cerebral , Adolescente , Adulto , Isquemia Encefálica/complicações , Isquemia Encefálica/prevenção & controle , Isquemia Encefálica/terapia , Procedimentos Cirúrgicos Cardíacos , Estudos de Casos e Controles , Forame Oval Patente/complicações , Forame Oval Patente/cirurgia , Alemanha , Humanos , Pessoa de Meia-Idade , Inibidores da Agregação de Plaquetas/uso terapêutico , Ensaios Clínicos Controlados Aleatórios como Assunto , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/prevenção & controle , Acidente Vascular Cerebral/terapia , Adulto Jovem
4.
Interv Cardiol Clin ; 8(4): 341-356, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31445719

RESUMO

A patent foramen ovale (PFO) is found in about one-quarter of all adults, but the prevalence increases to approximately half of those with a history of a so-called cryptogenic stroke. The true efficacy of PFO closure for prevention of recurrent paradoxical embolism has been debated for years, as the early 3 randomized trials did not show a statistically significant benefit of PFO closure over standard-of-care medical therapy. However, 3 recent randomized trials along with the long-term follow-up data from the largest early trial demonstrated superiority of device closure for secondary stroke prevention.


Assuntos
Cateterismo Cardíaco/métodos , Embolia Paradoxal/prevenção & controle , Forame Oval Patente/cirurgia , Ensaios Clínicos Controlados Aleatórios como Assunto/métodos , Prevenção Secundária/métodos , Dispositivo para Oclusão Septal , Acidente Vascular Cerebral/prevenção & controle , Embolia Paradoxal/etiologia , Forame Oval Patente/complicações , Humanos , Fatores de Risco , Acidente Vascular Cerebral/etiologia , Resultado do Tratamento
5.
J Invasive Cardiol ; 31(8): E242-E248, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31368895

RESUMO

BACKGROUND: Randomized trials for percutaneous closure of patent foramen ovale (PFO) have demonstrated a lower rate of recurrent ischemic events compared with medical therapy. The aim of this long-term follow-up analysis was to validate the impact of PFO closure on recurrent ischemic events. METHODS AND RESULTS: A total of 570 patients were enrolled. Patients were followed for recurrent ischemic events for a median of 7.2 years. Mean age at the time of procedure was 49.3 ± 13.1 years. PFO closure was performed with the Amplatzer occluder in 44.9% of patients and with BioStar, Cardia or Premere occluders in 55.1% of patients. Within 10 years of follow-up, recurrent ischemic stroke occurred in 5.1% of patients in the Amplatzer group vs 7.6% with the other occluders (log rank P=.61). There was no difference in the rate of recurrent transient ischemic attack (1.86% vs 1.51%; log rank P=.52) or all-cause mortality (2.9% vs 3.8%; log rank P=.84) between the two groups, in patients with or without an atrial septal aneurysm or with respect to grade of preprocedural shunt. Recurrent stroke was lower in patients <45 years old at the time of occluder implantation (hazard ratio, 4.14; 95% confidence interval, 0.94-18.8; log rank P=.05). CONCLUSION: In this long-term follow-up after PFO closure, the rate of recurrent stroke was low. There were no significant differences in event rates between different occluder devices, the existence of an atrial septal aneurysm, or grade of preprocedural shunt at baseline. Patients <45 years old had lower rates of recurrent ischemic stroke.


Assuntos
Isquemia Encefálica/prevenção & controle , Cateterismo Cardíaco/métodos , Procedimentos Cirúrgicos Cardíacos/métodos , Forame Oval Patente/cirurgia , Prevenção Secundária/métodos , Dispositivo para Oclusão Septal , Isquemia Encefálica/epidemiologia , Isquemia Encefálica/etiologia , Ecocardiografia Transesofagiana , Feminino , Seguimentos , Forame Oval Patente/complicações , Forame Oval Patente/diagnóstico , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia
6.
Heart Lung Circ ; 28(10): e134-e136, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31213345

RESUMO

A 73-year-old farmer presented with platypnoea-orthodeoxia syndrome (POS). A transoesophageal echocardiogram (TOE) disclosed a patent foramen ovale (PFO) with significant right-to-left shunt on assuming upright posture. An initial attempt at PFO closure through the femoral vein was abandoned due to a completely occluded inferior vena cava. A second attempt through the internal jugular vein was also unsuccessful due to the steep angulation between superior vena cava and septum primum flap. Because of disabling symptoms, an attempt through a hepatic vein (HV) was scheduled and performed under general anaesthesia with TOE guidance. Ultrasound-guided access through an intercostal window to a peripheral HV was performed and the position confirmed with contrast injections. The PFO was easily crossed with a glide wire which was exchanged to a stiffer guide wire. A 25mm closure device was successfully deployed across the PFO. After retrieval of the delivery system, haemostasis of the HV was attained with a contrast-guided Gelfoam (Pfizer, New York, NY, USA) injection. Unfortunately, the patient had to undergo subsequent emergency coiling to an iatrogenically injured hepatic artery branch leading to full recovery and significant clinical improvement. Subsequent echocardiography demonstrated a well-positioned device with no residual shunt. This case illustrates that percutaneous PFO closure through a HV is a feasible procedure and should be considered in anatomy that is otherwise prohibitive for conventional approach. Extra care should be taken with initial vascular access into the HV and final haemostasis of the access site.


Assuntos
Cateterismo Cardíaco/métodos , Forame Oval Patente/cirurgia , Dispositivo para Oclusão Septal , Cirurgia Assistida por Computador/métodos , Idoso , Ecocardiografia Transesofagiana/métodos , Fluoroscopia , Forame Oval Patente/diagnóstico , Veias Hepáticas , Humanos , Masculino , Tomografia Computadorizada por Raios X
7.
Diving Hyperb Med ; 49(2): 80-87, 2019 Jun 30.
Artigo em Inglês | MEDLINE | ID: mdl-31177513

RESUMO

INTRODUCTION: Persistent (patent) foramen ovale (PFO) is a recognized risk for decompression sickness (DCS) in divers, which may be mitigated by conservative diving or by PFO closure. Our study aimed to compare the effectiveness of these two risk mitigation interventions. METHODS: This was a prospective study on divers who tested positive for PFO or an atrial septal defect (ASD) and either decided to continue diving without closure ('conservative group'), or to close their PFO/ASD and continue diving ('closure group'). Divers' characteristics, medical history, history of diving and history of DCS were reported at enrollment and annually after that. The outcome measures were the incidence rate of DCS, frequency and intensity of diving activities, and adverse events of closure. RESULTS: Divers in both groups dived less and had a lower incidence rate of confirmed DCS than before the intervention. In the closure group (n = 42) the incidence rate of confirmed DCS decreased significantly. Divers with a large PFO experienced the greatest reduction in total DCS. In the conservative group (n = 23), the post-intervention decrease in confirmed DCS incidence rate was not significant. Of note, not all divers returned to diving after closure. Seven subjects reported mild adverse events associated with closure; one subject reported a serious adverse event. CONCLUSIONS: PFO closure should be considered on an individual basis. In particular, individuals who are healthy, have a significant DCS burden, a large PFO or seek to pursue advanced diving may benefit from closure.


Assuntos
Doença da Descompressão , Mergulho , Forame Oval Patente , Forame Oval , Doença da Descompressão/etiologia , Doença da Descompressão/prevenção & controle , Forame Oval Patente/complicações , Forame Oval Patente/cirurgia , Humanos , Estudos Prospectivos
8.
Rev Bras Ter Intensiva ; 31(2): 262-265, 2019 May 30.
Artigo em Português, Inglês | MEDLINE | ID: mdl-31166560

RESUMO

Cardiac trauma often occurs in motor vehicle accidents. A 50-year-old female driver was transported to our hospital with multiple trauma after a high-speed car accident. After admission to the intensive care unit, cardiac ultrasound examination revealed traumatic tricuspid valve papillary muscle rupture and patent foramen ovale, while Lancisi's sign was noted on physical examination. Surgical treatment was performed with valve annuloplasty and closure of the patent foramen ovale and a covert right atrial defect that was detected intraoperatively.


Assuntos
Forame Oval Patente/etiologia , Átrios do Coração/cirurgia , Músculos Papilares/lesões , Valva Tricúspide/lesões , Acidentes de Trânsito , Anuloplastia da Valva Cardíaca/métodos , Feminino , Forame Oval Patente/diagnóstico , Forame Oval Patente/cirurgia , Átrios do Coração/lesões , Traumatismos Cardíacos/diagnóstico , Traumatismos Cardíacos/etiologia , Traumatismos Cardíacos/cirurgia , Humanos , Pessoa de Meia-Idade , Músculos Papilares/cirurgia , Valva Tricúspide/cirurgia
9.
J Card Surg ; 34(9): 867-870, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31233236

RESUMO

Thrombus straddling a patent foramen ovale and massive pulmonary embolism is a very rare and life-threatening condition. Optimal management can be controversial because different therapeutic options are available and individual approach based in individual risk is needed. We present a case of a thrombus straddling the patent foramen ovale with massive pulmonary embolism, hemodynamic instability, and upper extremity embolism. We performed surgical pulmonary embolectomy, and venous arterial extracorporeal membrane oxygenation was needed to successfully overcome severe right ventricular impairment and pulmonary injury.


Assuntos
Procedimentos Cirúrgicos Cardíacos/métodos , Embolectomia/métodos , Oxigenação por Membrana Extracorpórea/métodos , Forame Oval Patente/complicações , Ventrículos do Coração , Embolia Pulmonar/complicações , Trombose/etiologia , Ecocardiografia , Ecocardiografia Transesofagiana , Feminino , Forame Oval Patente/diagnóstico , Forame Oval Patente/cirurgia , Cardiopatias/diagnóstico , Cardiopatias/etiologia , Cardiopatias/cirurgia , Humanos , Pessoa de Meia-Idade , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/cirurgia , Trombose/diagnóstico , Trombose/cirurgia , Tomografia Computadorizada por Raios X
11.
Curr Cardiol Rep ; 21(6): 48, 2019 04 22.
Artigo em Inglês | MEDLINE | ID: mdl-31011896

RESUMO

PURPOSE OF REVIEW: This review summarizes the most recent randomized clinical trials that studied the role of device-mediated patent foramen ovale (PFO) closure in patients after an ischemic stroke presumed to have been caused by a paradoxical embolism. RECENT FINDINGS: Three major randomized trials published in 2017 studied the strategy of using PFO closure for secondary prevention in patients between the ages of 18 and 60 who presented with an index stroke having characteristics of an embolic mechanism. All patients had a PFO that potentially could have enabled paradoxical embolism and other causes of stroke were excluded by a thorough neurologic and cardiac evaluation. Patients were randomized to PFO closure versus medical therapy alone using a variety of guideline-recommended medications. After multiple years of follow-up, all three trials showed superiority in the device arm versus the medical arm with a relative risk reduction of recurrent stroke from 46 to 100% and an absolute recurrent stroke reduction from 0.49 to 1.32% per year. Complications related to the procedure and the device were infrequent and mostly transient. These results have transformed the care of these patients, lead to FDA approval of two PFO closure devices, and started the process of updating guidelines. Patient selection is critically important since the presence of a PFO may be incidental. Therefore, both a neurologist and a cardiologist, who can also perform this procedure safely and effectively, should complete the initial evaluation and discuss their findings and recommendations with the patient as part of a shared decision-making process. There are remaining questions regarding how these trial results relate to older patients, patients with overt venothrombotic disease, and those with thrombophilia.


Assuntos
Forame Oval Patente/cirurgia , Implantação de Prótese/instrumentação , Dispositivo para Oclusão Septal , Acidente Vascular Cerebral/cirurgia , Embolia/etiologia , Forame Oval Patente/complicações , Humanos , Seleção de Pacientes , Ensaios Clínicos Controlados Aleatórios como Assunto , Prevenção Secundária , Acidente Vascular Cerebral/etiologia , Resultado do Tratamento
12.
Expert Rev Med Devices ; 16(5): 429-435, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30999776

RESUMO

OBJECTIVES: To report long-term safety and efficacy of combined percutaneous LAA and PFO/ASD closure. METHODS: A retrospective study of 370 consecutive patients undergoing LAAC procedures using the Watchman (WM) device. Data were compared between 330 cases only with LAAC procedure (Group I) and 25/5 (PFO/ASD) cases with sequential procedures of LAAC and PFO/ASD closure (Group II). RESULTS: Compared to Group I, Group II had more males (86.7% vs. 65.8%, p < 0.05) and a higher rate of stroke (33.3% vs. 10.6%, p < 0.01), but there were no statistical differences in the remaining patient characteristics. During the follow-up period, there were no significant differences between the two groups in embolism events (6.1% vs. 0%, p = 0.39), device related thrombus (5.8% vs 3.3%, p = 1.0), major bleeding (9.4% vs. 6.7%, p = 1.0) and cardiac death (3.6% vs. 0%, p = 0.61). The observed rate of all thromboembolic events by Kaplan-Meier analysis was decreased by 39.9% and 100% and the observed annual rate of bleeding was reduced by 32.9% and 57.6% in Group I and Group II, respectively. CONCLUSIONS: LAAC combined with PFO/ASD closure might be an ideal choice to prevent stroke and other thrombotic complications in patients with both NVAF and PFO/ASD.


Assuntos
Procedimentos Cirúrgicos Cardiovasculares , Forame Oval Patente/cirurgia , Comunicação Interatrial/cirurgia , Idoso , Feminino , Seguimentos , Forame Oval Patente/complicações , Comunicação Interatrial/complicações , Humanos , Estimativa de Kaplan-Meier , Masculino , Estudos Retrospectivos , Acidente Vascular Cerebral/etiologia , Fatores de Tempo , Resultado do Tratamento
14.
Herz ; 44(4): 304-309, 2019 Jun.
Artigo em Alemão | MEDLINE | ID: mdl-30941472

RESUMO

Autopsy studies and echocardiographic investigations have shown that around 20-25% of the healthy population have a patent foramen ovale (PFO). In patients younger than 55 years the risk of a cryptogenic stroke is increased in the presence of a PFO. The first three randomized studies could not demonstrate superiority of an interventional closure of a PFO compared to antithrombotic treatment in patients with cryptogenic stroke. The results of three recently published studies and the extension of an earlier study showed a superiority of an interventional closure of a PFO compared to stroke prevention with antiplatelet therapy in patients aged 18-60 years after a cryptogenic stroke; however, PFO closure was not superior to oral anticoagulation but anticoagulation is associated with an increased risk of bleeding. The implantation of a PFO occluder can be associated with transient atrial fibrillation in some patients. The collaboration of neurologists and cardiologists is essential in order to select patients who are most likely to benefit from a PFO closure.


Assuntos
Forame Oval Patente , Dispositivo para Oclusão Septal , Acidente Vascular Cerebral , Adolescente , Adulto , Forame Oval Patente/cirurgia , Humanos , Pessoa de Meia-Idade , Recidiva , Prevenção Secundária , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle , Adulto Jovem
15.
J Med Econ ; 22(9): 883-890, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31025589

RESUMO

Aims: To evaluate the cost-effectiveness of percutaneous patent foramen ovale (PFO) closure, from a US payer perspective. Lower rates of recurrent ischemic stroke have been documented following percutaneous PFO closure in properly selected patients. Stroke in patients aged <60 years is particularly interesting because this population is typically at peak economic productivity and vulnerable to prolonged disability. Materials and methods: A Markov model comprising six health states (Stable after index stroke, Transient ischemic attack, Post-Transient Ischemic Attack, Clinical ischemic stroke, Post-clinical ischemic stroke, and Death) was constructed to evaluate the cost-effectiveness of PFO closure in combination with medical management versus medical management alone. The base-case model employed a 5-year time-horizon, with transition probabilities, clinical inputs, costs, and utility values ascertained from published and national costing sources. Incremental cost-effectiveness ratio (ICER) was evaluated per US guidelines, utilizing a discount rate of 3.0%. Results: At 5 years, overall costs and quality-adjusted life-years (QALYs) obtained from PFO closure compared with medical management were $16,323 vs $7,670 and 4.18 vs 3.77, respectively. At 5 years, PFO closure achieved an ICER of $21,049, beneficially lower than the conventional threshold of $50,000. PFO closure reached cost-effectiveness at 2.3 years (ICER = $47,145). Applying discount rates of 0% and 6% had a negligible impact on base-case model findings. Furthermore, PFO closure was 95.4% likely to be cost-effective, with a willingness-to-pay (WTP) threshold of $50,000 and a 5-year time horizon. Limitations: From a cost perspective, our economic model employed a US patient sub-population, so cost data may not extrapolate to other non-US stroke populations. Conclusion: Percutaneous PFO closure plus medical management represents a cost-effective approach for lowering the risk of recurrent stroke compared with medical management alone.


Assuntos
Procedimentos Endovasculares/economia , Procedimentos Endovasculares/métodos , Forame Oval Patente/cirurgia , Acidente Vascular Cerebral/prevenção & controle , Anticoagulantes/administração & dosagem , Anticoagulantes/economia , Análise Custo-Benefício , Procedimentos Endovasculares/efeitos adversos , Nível de Saúde , Humanos , Ataque Isquêmico Transitório/prevenção & controle , Cadeias de Markov , Modelos Econométricos , Anos de Vida Ajustados por Qualidade de Vida , Recidiva , Prevenção Secundária , Índice de Gravidade de Doença , Acidente Vascular Cerebral/economia , Estados Unidos
16.
Heart Vessels ; 34(9): 1499-1508, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-30895384

RESUMO

Percutaneous closure of atrial septal defect (ASD)/patent foramen ovale (PFO) can influence systemic hemodynamics. The aim of this research was to evaluate the influence of the closure procedure on morphological and functional characteristics of systemic vascular walls. Fourteen ASD (mean age 40 ± 16 years) and 14 PFO (45 ± 8 years) patients were enrolled in this retrospective study. All underwent percutaneous closure procedure; physical, clinical and biochemical evaluations; echocardiography; carotid evaluation; and brachial artery flow-mediated vasodilatation (FMD). All the evaluations were performed at the time of enrollment, 24 h post-procedure, at 1-6-12-month follow-up. FMD at enrollment was higher in PFO patients as compared to ASD (8.5% [7.6-10.7%] versus 6.5% [5.6-7.6%], p < 0.0001). FMD values in ASD patients significantly increased during follow-up (enrollment: 6.5% [5.6-7.6%], 12-month follow-up: 8.8% [7.2-10.3%], p < 0.01). PFO patients showed reduced FMD values 24 h after the procedure (enrollment: 8.5% [7.6-10.7%], 24 h post-procedure: 7% [6.3-9%], p < 0.001), while recovering endothelial function during follow-up period to baseline values (FMD at 12-month follow-up: 8.2% [7.6-10.5%]). At one-year follow-up, FMD remained inversely related to systolic pulmonary arterial pressure and right and left atrial/ventricle chambers dimensions (RV proximal diameter efflux tract, right atrium [RA] longitudinal diameter, RA transverse diameter, RA area, left ventricle [LV] end-diastolic diameter, left atrium [LA] anteroposterior diameter, LA area; p < 0.01) in ASD patients. Endothelial function improved after percutaneous closure of ASD, while remaining stable after PFO closure. Therefore, ASD patients seem to improve their cardiovascular risk profile after percutaneous closure of their defect.


Assuntos
Cateterismo Cardíaco/métodos , Forame Oval Patente/cirurgia , Comunicação Interatrial/cirurgia , Dispositivo para Oclusão Septal , Adulto , Ecocardiografia , Feminino , Forame Oval Patente/diagnóstico por imagem , Comunicação Interatrial/diagnóstico por imagem , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
18.
Neuroimaging Clin N Am ; 29(2): 261-270, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30926116

RESUMO

"Observational studies have identified a relationship between patent foramen ovale (PFO) and migraine headache. In people who have migraine with aura, 40% to 60% have a PFO, compared with 20% to 30% in the general adult population. It is hypothesized that migraine, especially migraine with aura, may be triggered by hypoxemia or vasoactive chemicals (eg, serotonin), which are ordinarily metabolized during passage through the lungs. Although PFO closure is currently not a FDA-approved therapy for migraines, randomized trials suggest that this intervention may benefit a subgroup of migraineurs."


Assuntos
Encéfalo/diagnóstico por imagem , Encéfalo/fisiopatologia , Forame Oval Patente/complicações , Forame Oval Patente/cirurgia , Transtornos de Enxaqueca/complicações , Transtornos de Enxaqueca/fisiopatologia , Ecocardiografia Transesofagiana , Forame Oval Patente/fisiopatologia , Humanos , Imagem por Ressonância Magnética/métodos
19.
Expert Rev Med Devices ; 16(3): 173-182, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30741039

RESUMO

INTRODUCTION: The patent foramen ovale (PFO) is a common anatomical variant in humans (prevalence 25%). Most often asymptomatic, it may engender paradoxically embolic strokes, myocardial infarctions, or visceral or peripheral ischemia. It is causatively related to migraine, positional or exertional hypoxemia with dyspnea, diving incidents, high altitude edema, and sleep apnea. Percutaneous closure of atrial septal defects was first performed in the seventies. A dedicated PFO occluder (Amplatzer PFO Occluder) was first used on 10 September 1997 by Kurt Amplatz and Bernhard Meier. Since, percutaneous PFO closure has evolved into one of the most common and the simplest and safest catheter-based intervention in adult cardiology. Randomized studies have proved its benefit for prevention of recurrent ischemic events (particularly strokes) in patients without competing stroke etiology. There are also supportive clinical data for PFO closure in other situations. Areas covered: The Amplatzer PFO Occluder, the first, most implanted, and best-studied PFO occluder, is reviewed, presenting implantation technique, possible complications, and pertinent scientific data of efficacy and safety. Expert commentary: Percutaneous PFO closure has grown to one of the most common procedures in interventional cardiology. Implantation of the Amplatzer PFO Occluder is simple, safe, and effective.


Assuntos
Forame Oval Patente/cirurgia , Dispositivo para Oclusão Septal/efeitos adversos , Seguimentos , Forame Oval Patente/etiologia , Humanos , Resultado do Tratamento
20.
Am J Cardiol ; 123(9): 1538-1545, 2019 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-30792001

RESUMO

No data exist on the optimal duration of antithrombotic therapy (AT) following patent foramen ovale (PFO) closure. We sought to assess the safety of AT discontinuation following PFO closure in patients with a cryptogenic ischemic event. A total of 453 consecutive patients (mean age: 48 ± 13years, men: 51%) who underwent PFO closure due to a cryptogenic ischemic event were included. All patients were on AT following PFO closure (antiplatelet therapy: 92.7%, anticoagulation: 7.3%). Ischemic and bleeding events, and AT were assessed at a median follow-up of 8 (IQR: 4 to 11) years, and follow-up was complete in 96% of patients. Stroke and transient ischemic attack occurred in 4 (0.9%) and 12 (2.6%) patients, respectively, and 27 (6.0%) patients had bleeding events (major in 6 [1.3%] patients, including 4 episodes of intracranial hemorrhage). All major bleeding events occurred under aspirin therapy. A total of 82 patients (18%) stopped the AT at a median of 7 (IQR: 5 to 34) months post-PFO closure (due to a bleeding event or gastrointestinal symptoms: 13 patients, no specific reason: 69 patients), and none of them had any ischemic event after a median time of 7 (IQR 3 to 10) years without any AT. A propensity score matched analysis including 46 patients who discontinued the AT within 1-year post-PFO closure and 120 patients with an ongoing AT showed the lack of differences in ischemic events between groups (0 vs 0.2 stroke/transient ischemic attack per 100 patient-years in the no-AT and AT groups, respectively). In conclusion, in young patients who underwent PFO closure, bleeding events occurred in ∼6% of patients after a median follow-up of 8years. AT was discontinued in about one fifth of patients (most of them within the year following PFO closure), and this was not associated with any increase in ischemic events at long-term follow-up. These results suggest that, in patients without other co-morbidities increasing the risk of stroke, temporary AT following PFO closure may be a reasonable strategy.


Assuntos
Isquemia Encefálica/prevenção & controle , Procedimentos Cirúrgicos Cardíacos/métodos , Fibrinolíticos/uso terapêutico , Forame Oval Patente/cirurgia , Complicações Pós-Operatórias/prevenção & controle , Prevenção Secundária/métodos , Suspensão de Tratamento , Isquemia Encefálica/epidemiologia , Isquemia Encefálica/etiologia , Feminino , Seguimentos , Forame Oval Patente/complicações , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Prognóstico , Quebeque/epidemiologia , Estudos Retrospectivos , Dispositivo para Oclusão Septal , Taxa de Sobrevida/tendências
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