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2.
Arch Cardiovasc Dis ; 113(8-9): 513-524, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32680737

RESUMO

BACKGROUND: Closure of patent foramen ovale is well-managed in adults, but is performed less frequently in children. AIM: To analyse all patent foramen ovale closures performed in the past 20 years in French paediatric centres. METHODS: Retrospective study of patent foramen ovale closures in children without cardiopathy in nine centres between 2000 and 2019. RESULTS: Forty-one procedures were carried out in children (median age: 14.9 years). Thirty-one patent foramen ovales were closed after a transient ischaemic attack or stroke, six for a left-to-right shunt and four for other reasons. Transthoracic echocardiography was used for 72.2% of the diagnoses and transoesophageal echocardiography for 27.8%. A substantial degree of shunting was found in 42.9% of patients and an atrial septal aneurysm in 56.2%. General anaesthesia with transoesophageal echocardiography guidance was performed in 68.3% of the procedures; local anaesthesia and transthoracic echocardiography or intracardiac echocardiography was performed in 31.7%. The success rate was 100%. The median fluoroscopy time was 4.14minutes: 3.55minutes with transoesophageal echocardiography; and 4.38minutes with transthoracic echocardiography (P=0.67). There was only one periprocedural complication (2.4%). Postoperatively, 80,5% of patients were treated with aspirin and 12,2% with an anticoagulant. The rate of complete occlusion was 56.8% immediately after the procedure, 68.6% at 1 year and 92.3% at the last follow-up. There were no delayed complications or cases of recurrent stroke during follow-up (median follow-up: 568 days). CONCLUSION: Closure of patent foramen ovale in children appears to be safe and effective, as we noted a low rate of immediate complications, no delayed complications and no stroke recurrence in this indication.


Assuntos
Cateterismo Cardíaco/instrumentação , Forame Oval Patente/terapia , Dispositivo para Oclusão Septal , Adolescente , Fatores Etários , Cateterismo Cardíaco/efeitos adversos , Feminino , Forame Oval Patente/complicações , Forame Oval Patente/diagnóstico por imagem , França , Humanos , Ataque Isquêmico Transitório/etiologia , Masculino , Recidiva , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/etiologia , Fatores de Tempo , Resultado do Tratamento
3.
Med Hypotheses ; 143: 110022, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32634734

RESUMO

The current SARS-Cov-2 virus pandemic challenges critical care physicians and other caregivers to find effective treatment for desperately ill patients - especially those with sudden and extreme hypoxemia. Unlike patients with other forms of Acute Respiratory Distress Syndrome, these patients do not exhibit increased lung stiffness or dramatic dyspnea., even in the presence of arterial blood oxygen levels lower than that seen normally in mixed venous blood. Urgent intubation and mechanical ventilation with high inflation pressures and raised inhaled oxygen concentration have proved unhelpful or worse, but why? Our Hypothesis is that sudden opening of a previously undetected probe-patent foramen ovale (PPFO) may explain this mystery. As hypoxemia without acidosis is a rather weak stimulus of dyspnea or increased ventilation, and opening of such an intracardiac shunt would not worsen lung mechanical properties, the absence of dramatic symptom changes would not be surprising. We point out the high frequency of PFO both in life and at autopsy, and the physiological evidence of large shunt fractions found in Covid-19 patients. Published evidence of hypercoagulability and abundant evidence of pulmonary emboli found at autopsy are in accord with our hypothesis, as they would contribute to raised pressure in the pulmonary arteries and right heart chambers, potentially causing a shunt to open. We review the interaction between viral corona spike protein and ACE-2 receptors present on the surface of alveolar lining cells, and contribution to hypercoagulabilty caused by the spike protein. Search for an open PFO after a large drop in arterial oxygen saturation can be performed at the bedside with a variety of well-established techniques including bedside echocardiography, nitrogen washout test, and imaging studies. Potential treatments might include balloon or patch closure of the shunt, and various drug treatments to lower pulmonary vascular resistance.


Assuntos
Betacoronavirus , Infecções por Coronavirus/complicações , Forame Oval Patente/complicações , Hipóxia/etiologia , Pneumonia Viral/complicações , Betacoronavirus/patogenicidade , Betacoronavirus/fisiologia , Infecções por Coronavirus/sangue , Infecções por Coronavirus/fisiopatologia , Forame Oval Patente/sangue , Forame Oval Patente/fisiopatologia , Humanos , Hipóxia/sangue , Hipóxia/fisiopatologia , Modelos Biológicos , Pandemias , Peptidil Dipeptidase A/fisiologia , Pneumonia Viral/sangue , Pneumonia Viral/fisiopatologia , Circulação Pulmonar , Receptores Virais/fisiologia , Mecânica Respiratória , Glicoproteína da Espícula de Coronavírus/fisiologia , Trombofilia/etiologia
4.
Medicine (Baltimore) ; 99(24): e20569, 2020 Jun 12.
Artigo em Inglês | MEDLINE | ID: mdl-32541485

RESUMO

RATIONALE: Fat embolism syndrome with cerebral fat embolism, rarely observed at our neurology department, is often associated with long bone fractures. Its diagnosis is based on medical history and supportive imaging data and is usually not difficult. However, its pathogenesis remains poorly understood. PATIENT CONCERNS: A 46-year-old woman was urgently presented to a nearby hospital because of a femur fracture caused by an accident. She rapidly developed somnolence and was suspected to have fat embolism syndrome. DIAGNOSES: Due to patients history of trauma and supportive imaging data, she was diagnosed with fat embolism syndrome obviously. However, severe brain damage confused our understanding of the pathogenesis. The subsequent diagnosis of fat embolism syndrome with patent foramen ovale provided a reasonable explanation. INTERVENTIONS: Initially, we did not consider the fact that the patient had developed fat embolism syndrome and thus designed a comprehensive treatment program for fat embolism syndrome. Then the routine cardiac and vascular ultrasound screening were followed up, but patent foramen ovale was diagnosed unexpectedly, which led to a more aggressive treatment of brain injury. OUTCOMES: After relevant symptomatic treatment continued for nearly 3 months, an overall improvement was observed. Patients consciousness was restored but language disorders were left. LESSONS: Clinicians should consider patent foramen ovale as the embolization pathway, particularly in young and middle-aged patients with cerebral embolism because it is often mistaken for a rare situation.


Assuntos
Embolia Gordurosa/etiologia , Fraturas do Fêmur/complicações , Forame Oval Patente/complicações , Embolia Intracraniana/etiologia , Feminino , Fraturas do Fêmur/diagnóstico por imagem , Forame Oval Patente/diagnóstico por imagem , Humanos , Embolia Intracraniana/diagnóstico por imagem , Pessoa de Meia-Idade
5.
Medicine (Baltimore) ; 99(19): e20054, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32384468

RESUMO

RATIONALE: Patent foramen ovale (PFO) is not considered to be the main cause of stroke and is classified as the infarction of undetermined cause. The relationship between PFO and cerebral embolism is still unclear and cerebral embolism accompanied with coronary artery embolization in PFO patient is rare. In this case, we reported a patient with PFO suffered acute cerebral and myocardial infarction simultaneously, and analyzed the source of emboli and potential pathogenesis. PATIENT CONCERNS: A 53-year-old female presented with chief complaints of intermittent palpitations and chest tightness for 6 years, aggravated for 3 days. DIAGNOSES: During the hospitalization, acute cerebral infarction and acute myocardial infarction occurred at the same time in the patient. The patient felt paroxysmal abdominal pain repeatedly. Finally, we detected PFO in the patient INTERVENTIONS:: Double antiplatelet therapy was given to the patient of acute cerebral and myocardial infarction with PFO. OUTCOMES: Two weeks after the onset of the disease, the condition was relatively stable. But after 2 months, the patient experienced repeated heart failure, transthoracic echocardiography manifested no significant change in the PFO gap but significant cardiac function reduction. LESSONS: Although a growing number of people are aware that PFO is a risk factor for arterial embolization especially when coexisting with atrial septal aneurysm, a significant proportion of patients have paradoxical embolism after PFO closure. Therefore, transesophageal echocardiography should be routinely performed to find the possible cause of embolism when infarction of undetermined cause occurs, and PFO closure and anti-platelet aggregation or anticoagulant therapy should be given at the same time in order to reduce the occurrence of arterial thrombosis.


Assuntos
Infarto Cerebral/etiologia , Forame Oval Patente/complicações , Infarto do Miocárdio/etiologia , Doença Aguda , Feminino , Humanos , Pessoa de Meia-Idade
6.
Neurology ; 94(20): 876-885, 2020 05 19.
Artigo em Inglês | MEDLINE | ID: mdl-32350058

RESUMO

OBJECTIVE: To update the 2016 American Academy of Neurology (AAN) practice advisory for patients with stroke and patent foramen ovale (PFO). METHODS: The guideline panel followed the AAN 2017 guideline development process to systematically review studies published through December 2017 and formulate recommendations. MAJOR RECOMMENDATIONS: In patients being considered for PFO closure, clinicians should ensure that an appropriately thorough evaluation has been performed to rule out alternative mechanisms of stroke (level B). In patients with a higher risk alternative mechanism of stroke identified, clinicians should not routinely recommend PFO closure (level B). Clinicians should counsel patients that having a PFO is common; that it occurs in about 1 in 4 adults in the general population; that it is difficult to determine with certainty whether their PFO caused their stroke; and that PFO closure probably reduces recurrent stroke risk in select patients (level B). In patients younger than 60 years with a PFO and embolic-appearing infarct and no other mechanism of stroke identified, clinicians may recommend closure following a discussion of potential benefits (absolute recurrent stroke risk reduction of 3.4% at 5 years) and risks (periprocedural complication rate of 3.9% and increased absolute rate of non-periprocedural atrial fibrillation of 0.33% per year) (level C). In patients who opt to receive medical therapy alone without PFO closure, clinicians may recommend an antiplatelet medication such as aspirin or anticoagulation (level C).


Assuntos
Aspirina/uso terapêutico , Forame Oval Patente/prevenção & controle , Prevenção Secundária , Acidente Vascular Cerebral/prevenção & controle , Adulto , Fibrilação Atrial/complicações , Forame Oval Patente/complicações , Humanos , Inibidores da Agregação de Plaquetas/uso terapêutico , Medição de Risco , Fatores de Risco , Dispositivo para Oclusão Septal/efeitos adversos , Acidente Vascular Cerebral/epidemiologia , Estados Unidos
7.
Medicine (Baltimore) ; 99(15): e19507, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32282700

RESUMO

RATIONALE: Paradoxical embolism (PE) is an important cause of cryptogenic stroke, particularly in young patients, which usually have a relation with an unexpected route in circulation. Here we report a rare case of cryptogenic stroke carried 2 uncommon malformations. PATIENT CONCERNS: A 48-year-old female experienced double neurological events in just 2 months. DIAGNOSIS: Patent foramen ovale was diagnosed with transesophageal echocardiography and successfully occluded in the first admission due to stroke. In the second admission, chest tomographic angiography found a chordae shadow in the right middle lobe, was the first clue for pulmonary arteriovenous fistula (PAVF), thereafter further confirmed by the enhanced pulmonary computed tomographic angiography. INTERVENTIONS: This patient then received intervention occlusion therapy with coils for PAVF under the help of microcatheter. Given the possible native origin of the thrombus in PAVF due to the spiral morphology, dual antiplatelet therapy was prescribed for this patient for the first 3 months to prevent device-related embolism after discharge, and the following single antiplatelet therapy was mandated. OUTCOMES: No recanalization was detected on the follow-up enhanced pulmonary computed tomographic angiography (PCTA), no neurological defect event recurred in the 16 months of follow-up. LESSONS: Computed tomograph (CT) deserved more value in screening and depicting the morphology of the PAVF, particular in young adults with no apparent arteriosclerotic risk factor. Microcatheter would be helpful for intervention treatment. Antiplatelet therapy might be adequate in specific patients, yet definitely need more evidence to verify.


Assuntos
Fístula Arteriovenosa/complicações , Embolia Paradoxal/etiologia , Forame Oval Patente/complicações , Artéria Pulmonar/anormalidades , Veias Pulmonares/anormalidades , Acidente Vascular Cerebral/etiologia , Fístula Arteriovenosa/diagnóstico por imagem , Fístula Arteriovenosa/terapia , Angiografia por Tomografia Computadorizada , Feminino , Forame Oval Patente/terapia , Humanos , Pessoa de Meia-Idade , Acidente Vascular Cerebral/diagnóstico por imagem
8.
Open Heart ; 7(1): e001176, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32257245

RESUMO

Objective: The role of transoesophageal echocardiography (TOE) in identifying ischaemic stroke aetiology is debated. In 2018, the American Heart Association/American Stroke Association (AHA/ASA) issued class IIa recommendation for echocardiography, with the qualifying statement of use in cases where it will alter management. Hence, we sought to determine the rate at which TOE findings altered management in cases of confirmed ischaemic stroke. Methods: We retrospectively analysed TOE cases with confirmed ischaemic stroke at our centre between April 2015 and February 2017. We defined a change in management as the initiation of anticoagulation therapy, antibiotic therapy or patent foramen ovale closure as a direct result of TOE findings. Results: There were 185 patients included in this analysis; 19 (10%) experienced a change in management. However, only 7 of the 19 (4% of all subjects) experienced a change in management due to TOE findings. The remaining 12 were initiated on oral antigoagulation as a result of discoveries during routine workup, mainly atrial fibrillation on telemetry monitoring. Conclusions: This work suggests an overuse of TOE and provides support for the 2018 AHA/ASA stroke guidelines, which recommend against the routine use of echocardiography in the work up of cerebrovascular accident due to a cardioembolic source.


Assuntos
Isquemia Encefálica/etiologia , Ecocardiografia Transesofagiana , Embolia/diagnóstico por imagem , Forame Oval Patente/diagnóstico por imagem , Cardiopatias/diagnóstico por imagem , Acidente Vascular Cerebral/etiologia , Idoso , Antibacterianos/administração & dosagem , Anticoagulantes/administração & dosagem , Isquemia Encefálica/diagnóstico por imagem , Isquemia Encefálica/prevenção & controle , Tomada de Decisão Clínica , Bases de Dados Factuais , Embolia/complicações , Embolia/terapia , Feminino , Forame Oval Patente/complicações , Forame Oval Patente/terapia , Cardiopatias/complicações , Cardiopatias/terapia , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Reprodutibilidade dos Testes , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/prevenção & controle
9.
Cerebrovasc Dis ; 49(2): 124-134, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32289794

RESUMO

BACKGROUND: Randomized-controlled trials (RCTs) reported a finding on the safety and efficacy of percutaneous patent foramen ovale (PFO) closure to prevent stroke recurrence. It showed that the Amplatzer (AMP) device appears to be superior to medical therapy (MT) in preventing strokes and episodes of atrial fibrillation (AF), than other devices. We performed a network meta-analysis (NMA) to evaluate the closure of PFO in preventing subsequent neurological events while investigating the results obtained by specific devices. METHODS: We searched 3 databases (MEDLINE, EMBASE, CENTRAL/CCTR) and identified 6 RCTs until March 2019. We performed an NMA and used pooled ORs. Analyses were done in NetMetaXL1.6-WinBUGS1.4. RESULTS: Six RCTs with 3,560 patients (mean age 45.2-46.2 years) were included in the present NMA. Depending on the device, 4 groups of patients were compared with MT: 1,889 patients undergoing PFO closure were significantly less likely to experience a stroke than 1,671 patients treated with MT (ORs 0.41; 95% Cr.I. 0.27-0.60 with fixed-effects model and ORs 0.22; 95% Cr.I. 0.05-0.70 with random-effects model). The patients with AMP showed a similar risk than those treated with Helex/Cardioform (HLX/CF) or with a group of 11 multiple devices. This suggests the equality between the 2 most currently used devices. When assessing TIA and, for the safety analysis, major bleeding, both models confirm no significant difference between any devices and MT. PFO closure increased the risk of new-onset AF: MT induces AF significantly less than all the devices. In favor of the AMP, there is a reduced number of cases of AF versus MT; however, no device superiority has been established in comparing HLX/CF and other devices in a random effect model. CONCLUSIONS: Our NMA provides evidence in favor of PFO closure with all the devices currently in use. We can conclude that these devices are better than MT, but not that 1 device is better than the rest in reducing stroke recurrences and AF episodes in the follow-up.


Assuntos
Cateterismo Cardíaco/instrumentação , Embolia Paradoxal/prevenção & controle , Forame Oval Patente/terapia , Embolia Intracraniana/prevenção & controle , Ataque Isquêmico Transitório/prevenção & controle , Dispositivo para Oclusão Septal , Acidente Vascular Cerebral/prevenção & controle , Adolescente , Adulto , Idoso , Teorema de Bayes , Cateterismo Cardíaco/efeitos adversos , Embolia Paradoxal/diagnóstico por imagem , Embolia Paradoxal/etiologia , Feminino , Forame Oval Patente/complicações , Forame Oval Patente/diagnóstico por imagem , Humanos , Embolia Intracraniana/diagnóstico por imagem , Embolia Intracraniana/etiologia , Ataque Isquêmico Transitório/diagnóstico por imagem , Ataque Isquêmico Transitório/etiologia , Masculino , Pessoa de Meia-Idade , Metanálise em Rede , Desenho de Prótese , Ensaios Clínicos Controlados Aleatórios como Assunto , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/etiologia , Resultado do Tratamento , Adulto Jovem
10.
J Stroke Cerebrovasc Dis ; 29(4): 104632, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32037269

RESUMO

AIMS: The REDUCE study demonstrated a reduction in the risk of recurrent stroke with patent foramen ovale closure and antiplatelet therapy compared to antiplatelet therapy alone. The clinicians were allowed to choose among aspirin, clopidogrel, or aspirin/dipyridamole with the expectation that all antiplatelet therapies would have similar efficacy in this population. We tested that presumption by comparing recurrent stroke rates among antiplatelet agents within the control arm of the trial. METHODS: We evaluated patients in REDUCE study who were randomized to the medical arm. The primary endpoint for this analysis was freedom from clinical ischemic stroke through at least 2 years of follow-up, to a maximum of 5 years. In the primary analysis, antiplatelet treatment was defined as the agent during the week prior to a recurrent stroke or last known contact. RESULTS: Of 223 patients in the medical treatment arm, the initial agent was aspirin 52%, clopidogrel 30%, and aspirin/dipyridamole 12%. Patients treated with aspirin were similar to those treated with alternatives, but were more likely to be enrolled in the United States. The last reported agent was aspirin alone in 55%, clopidogrel alone in 31%, aspirin/dipyridamole in 7%, and other/nothing/missing in 7%. Recurrent stroke rates were similar for all 3 antiplatelet regimens in unadjusted and adjusted analyses, with no overall difference among agents (P= .17). CONCLUSIONS: Among patients with patent foramen ovale-associated stroke who were managed medically, there were no differences among antiplatelet agents in the risk of recurrent stroke, though confidence intervals were wide.


Assuntos
Aspirina/uso terapêutico , Clopidogrel/administração & dosagem , Dipiridamol/administração & dosagem , Forame Oval Patente/tratamento farmacológico , Inibidores da Agregação de Plaquetas/uso terapêutico , Prevenção Secundária , Acidente Vascular Cerebral/prevenção & controle , Adolescente , Adulto , Aspirina/efeitos adversos , Clopidogrel/efeitos adversos , Dipiridamol/efeitos adversos , Quimioterapia Combinada , Feminino , Forame Oval Patente/complicações , Forame Oval Patente/diagnóstico por imagem , Humanos , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação de Plaquetas/efeitos adversos , Intervalo Livre de Progressão , Estudos Prospectivos , Recidiva , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/etiologia , Fatores de Tempo , Adulto Jovem
11.
Cerebrovasc Dis ; 49(1): 105-109, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32062661

RESUMO

BACKGROUND: In acute infarction patients, small cortical cerebellar infarctions (SCCI) on MRI (assessed on diffusion-weighted imaging, with SCCI often chronic and asymptomatic) are associated with acute cardioembolic infarction. In young cryptogenic stroke patients, patent foramen ovale (PFO) is thought to be a potential source of cardioembolic infarction. We hypothesize that SCCI on MRI would be associated with PFO in young cryptogenic stroke patients. METHODS: A total of 321 consecutive young (≤50 years) stroke patients admitted between January 2015 and July 2019 were screened. Of these patients, 287 patients had diagnostic work-up including early-phase MRI, intra- and extracranial vessel imaging, contrast transoesophageal or contrast transthoracic echocardiography, and ≥24 h ECG-monitoring. We retrospectively analyzed MRI scans of the 112 patients with cryptogenic stroke, including 63 with and 49 without PFO. Between both groups, we compared baseline characteristics (including cardiovascular risk factors and history of stroke), MRI characteristics of acute symptomatic infarction (cortical/subcortical localization, arterial territory, lesion number, and lesion size in case of subcortical infarction), atrial septum aneurysm (ASA) presence, and acute and chronic SCCI and non-SCCI lesions assessed on diffusion-weighted imaging. RESULTS: Groups with and without PFO were comparable in regard to performed vessel imaging and echocardiography modalities, baseline characteristics, and acute infarction characteristics, except for more frequent current smoking (67 vs. 44%, p = 0.022) and multiterritorial infarction (14 vs. 0%, p = 0.0024) and less frequent ASA (10 vs. 48%, p < 0.001) in the group without PFO. Risk of Paradoxal Embolism score was >6 in 76% of patients with PFO. SCCI was more frequent in patients with than without PFO (33 vs. 10%, p = 0.0061; OR 4.4, 95% CI 1.5-12.7), with chronic and asymptomatic SCCI in the vast majority of cases. No difference was observed for non-SCCI lesions. CONCLUSIONS: Chronic SCCI are strongly associated with PFO in young cryptogenic stroke patients. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT04043559.


Assuntos
Infartos do Tronco Encefálico/diagnóstico por imagem , Cerebelo/irrigação sanguínea , Cerebelo/diagnóstico por imagem , Imagem de Difusão por Ressonância Magnética , Embolia Paradoxal/diagnóstico por imagem , Forame Oval Patente/diagnóstico por imagem , Adulto , Fatores Etários , Infartos do Tronco Encefálico/etiologia , Doença Crônica , Bases de Dados Factuais , Embolia Paradoxal/etiologia , Feminino , Forame Oval Patente/complicações , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Retrospectivos , Fatores de Risco
12.
Cerebrovasc Dis ; 49(1): 1-9, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32097931

RESUMO

INTRODUCTION: It is still disputable whether specific morphometric features of the patent foramen ovale (PFO) may stratify patients by the related probability that a discovered PFO is incidental or stroke related. OBJECTIVE: We aimed to determine whether certain morphometrical characteristics of PFO are associated with an increased risk of cerebrovascular accidents, using a meta-analytical approach. METHODS: We performed a systematic review of electronic databases for studies that compared morphometric parameters of PFO assessed by transesophageal echocardiography (TEE) in subjects with cryptogenic cerebrovascular accidents (Group 1) and control (Group 2). Data were extracted and pooled into a meta-analysis. RESULTS: A total of 895 patients with PFO were reported (Group 1: 493, Group 2: 402). No difference was found in the PFO channel length (Group 1: 10.8 [8.6-12.9] mm vs. Group 2: 10.4 [9.1-11.7] mm), as well as in PFO height measured at rest (Group 1: 2.4 [1.5-3.3] mm vs. Group 2: 1.8 [1.4-2.2] mm). The PFO height measured during a Valsalva maneuver was larger in Group 1 (3.5 [2.8-4.1] mm) than in Group 2 (1.7 [1.2-2.2] mm). Also, the septal excursion distance was found to be larger in Group 1 (6.4 [5.1-7.8] mm) than in Group 2 (3.1 [1.8-4.4] mm). The risk of cerebrovascular accident was higher in patients with PFO and concomitant septal aneurysm (OR 4.00; 95% CI 2.63-6.09; p < 0.001) and with large right-to-left shunt PFO (OR 3.81; 95% CI 2.21-6.55; p < 0.001), no such relationship was found for the presence of a Eustachian valve or Chiari's network (OR 1.90; 95% CI 0.90-4.05; p = 0.094). CONCLUSIONS: The TEE may help in identifying PFO that are of high risk of cerebrovascular accident. Greater PFO height during a Valsalva maneuver, larger septal excursion distance, concomitant atrial septal aneurysm, and large right-to-left shunt are associated with stroke-related PFOs.


Assuntos
Ecocardiografia Transesofagiana , Forame Oval Patente/diagnóstico por imagem , Forame Oval/diagnóstico por imagem , Acidente Vascular Cerebral/etiologia , Adulto , Idoso , Feminino , Forame Oval/anormalidades , Forame Oval Patente/complicações , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico por imagem , Manobra de Valsalva , Adulto Jovem
13.
JACC Cardiovasc Interv ; 13(3): 293-302, 2020 02 10.
Artigo em Inglês | MEDLINE | ID: mdl-32029246

RESUMO

OBJECTIVES: This study sought to evaluate the long-term effect of transcatheter patent foramen ovale (PFO) closure on migraineurs with and without aura and examine the effect of residual right-to-left shunt. BACKGROUND: Many studies reported improvement in migraine symptoms after PFO closure, yet randomized trials failed to reach its clinical endpoints. METHODS: The study retrospectively analyzed data from 474 patients who underwent transcatheter PFO closure at Massachusetts General Hospital. Patients completed a migraine burden questionnaire at baseline and at follow-up. Migraine severity is reported as migraine frequency (days/month), average duration (min), and migraine burden (days × min/month). Improvement following closure was defined as complete abolishment of symptoms or >50% reduction in migraine burden. RESULTS: A total of 110 migraineurs who underwent PFO closure were included; 77.0% had aura and 23.0% were without aura, and 91.0% had a cryptogenic stroke. During long-term median follow-up of 3.2 (interquartile range: 2.1 to 4.9) years, there was a significant improvement in migraine symptoms in migraineurs with or without aura. Migraine burden was reduced by >50% in 87.0% of patients, and symptoms were completely abolished in 48%. Presence of aura was associated with abolishment of migraine (odds ratio: 4.30; 95% confidence interval: 1.50 to 12.30; p = 0.006). At 6 months after PFO closure, residual right-to-left shunt was present in 26% of patients. Absence of right-to-left shunt was associated with improvement in migraine burden by >50% (odds ratio: 4.60; 95% confidence interval: 1.30 to 16.10; p = 0.017). CONCLUSIONS: Long-term follow-up after transcatheter PFO closure was associated with significant improvement in migraine burden. Aura was a predictor of abolishing symptoms. Absence of residual right-to-left shunt was a predictor of significant reduction in migraine burden.


Assuntos
Cateterismo Cardíaco , Circulação Coronária , Forame Oval Patente/terapia , Transtornos de Enxaqueca/prevenção & controle , Adulto , Cateterismo Cardíaco/efeitos adversos , Cateterismo Cardíaco/instrumentação , Feminino , Forame Oval Patente/complicações , Forame Oval Patente/diagnóstico por imagem , Forame Oval Patente/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Transtornos de Enxaqueca/diagnóstico , Transtornos de Enxaqueca/etiologia , Transtornos de Enxaqueca/fisiopatologia , Estudos Retrospectivos , Fatores de Risco , Dispositivo para Oclusão Septal , Fatores de Tempo , Resultado do Tratamento
14.
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
15.
J Cardiothorac Surg ; 15(1): 11, 2020 Jan 09.
Artigo em Inglês | MEDLINE | ID: mdl-31918738

RESUMO

BACKGROUND: Percutaneous closure of patent foramen ovale (PFO) is routinely performed using plain fluoroscopy in the catheter room. This method results in inevitable radiation damage, adverse effects of contrast agents on kidneys, and high cost. We performed PFO closure with a simplified and economical transesophageal echocardiography (TEE)-only guided approach in the operating room. This study aimed to investigate the feasibility, safety, and effectiveness of the percutaneous closure of PFO by only using TEE. METHODS: We reviewed the medical records of patients who underwent percutaneous PFO closure at our center from December 2013 to December 2017. A total of 132 patients with PFO and cryptogenic strokes underwent PFO closure by using cardi-O-fix PFO device under TEE guidance. The participants comprised 64 and 68 male and female patients, respectively. The mean age and body weight of the patients were 39.40 ± 13.22 years old (12-68 years old) and 65.42 ± 9.70 kg (40-95 kg), respectively. All patients only received aspirin (3-5 mg/kg body weight, oral administration) for 6 months. Contrast-enhanced transthoracic echocardiography (c-TTE) with Valsalva maneuver was performed during follow-up, and questionnaire surveys were obtained at 3, 6, and 12 months after the procedure. RESULTS: All (100%) patients were successfully closed. Follow-ups were conducted for 13 months to 48 months, with an average of 27 months. No severe complications were found during the follow-up period. Paroxysmal atrial fibrillation occurred in 4 patients within 3 months after the procedure. No recurrent stroke or death occurred in all patients during the follow-up period. Transient ischemic attack occurred in one patient 6 months after the procedure. Ten (7.6%) patients had a right-to-left shunt, as demonstrated by c-TTE at 12 months of follow-up. Among the 57 patients suffering from migraine, significant relief or resolution was reported by 42 (73.7%) patients. CONCLUSION: TEE-only guided PFO closure was a safe, feasible, and effective method that did not require the use of X-rays and contrast agents.


Assuntos
Procedimentos Cirúrgicos Cardíacos/métodos , Ecocardiografia Transesofagiana/métodos , Forame Oval Patente/cirurgia , Acidente Vascular Cerebral/etiologia , Cirurgia Assistida por Computador/métodos , Adolescente , Adulto , Idoso , Aspirina/uso terapêutico , Cateterismo Cardíaco/métodos , Criança , Meios de Contraste , Estudos de Viabilidade , Feminino , Forame Oval Patente/complicações , Humanos , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação de Plaquetas/uso terapêutico , Dispositivo para Oclusão Septal , Resultado do Tratamento , Adulto Jovem
18.
Am J Med ; 133(6): e290-e293, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-31870665

RESUMO

BACKGROUND: Recent trials failed to demonstrate that anticoagulation was superior to antiplatelet agents in preventing recurrent stroke after embolic stroke of undetermined source (ESUS), which may be as a result of the heterogeneity of etiology. We thus investigated whether the use of 2-phase cardiac computed tomography (CT) could help to evaluate the etiology in patients with ESUS. METHODS: We performed 2-phase cardiac CT in patients with ESUS and evaluated whether there was positive cardiac findings. RESULTS: A total of 74 patients with ESUS were enrolled. Positive cardiac findings were found in 21 (28.4%) patients, including intracardiac thrombus (n = 5), complex aortic plaque (n = 9), and patent foramen ovale (PFO) (n = 8). Both complex aortic plaque and patent foramen ovale were identified in 1 patient. CONCLUSIONS: Two-phase cardiac CT is a useful tool for stroke etiology evaluation, providing diagnostic information in a quarter of patients with ESUS.


Assuntos
Doenças da Aorta/diagnóstico por imagem , Forame Oval Patente/diagnóstico por imagem , Cardiopatias/diagnóstico por imagem , Embolia Intracraniana/etiologia , Placa Aterosclerótica/diagnóstico por imagem , Trombose/diagnóstico por imagem , Tomografia Computadorizada por Raios X/métodos , Idoso , Idoso de 80 Anos ou mais , Doenças da Aorta/complicações , Meios de Contraste , Feminino , Forame Oval Patente/complicações , Cardiopatias/complicações , Humanos , Masculino , Pessoa de Meia-Idade , Placa Aterosclerótica/complicações , Trombose/complicações
19.
J Vet Cardiol ; 26: 1-9, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31747625

RESUMO

A 2-year-old Airedale terrier was presented with exercise intolerance since birth and newly developed chylous pleural effusion. Imaging procedures including echocardiography, cardiac magnetic resonance imaging, computed tomography, and selective angiography revealed an aberrant connection of the azygos vein and the left atrium, a membrane in the right atrium consistent with cor triatriatum dexter, and a patent foramen ovale with right-to-left shunt. Balloon dilation of the membrane in the right atrium seemed to result in transient improvement of exercise tolerance compared with the previous 2 years. When chylothorax relapsed after three months, the dog was euthanized. Necropsy confirmed the azygos vein to left atrial connection, the patent foramen ovale, and the cor triatriatum dexter.


Assuntos
Veia Ázigos/patologia , Doenças do Cão/patologia , Forame Oval Patente/veterinária , Animais , Doenças do Cão/diagnóstico por imagem , Doenças do Cão/etiologia , Cães , Feminino , Forame Oval Patente/complicações , Forame Oval Patente/diagnóstico por imagem , Forame Oval Patente/patologia
20.
Cerebrovasc Dis ; 48(3-6): 99-108, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31694010

RESUMO

BACKGROUND: The role of patent foramen ovale is a field of debate and current publications have increasing controversies about the patients' management in young undetermined stroke. Work up with echocardiography and transcranial Doppler (TCD) can aid the decision with better anatomical and functional characterization of right-to-left shunt (RLS). Medical and interventional strategy may benefit from this information. SUMMARY: a group of experts from the Latin American participants of the Neurosonology Research Group (NSRG) of World Federation of Neurology created a task force to review literature and describe the better methodology of contrast TCD (c-TCD). All signatories of the present consensus statement have published at least one study on TCD as an author or co-author in an indexed journal. Two meetings were held while the consensus statement was being drafted, during which controversial issues were discussed and voted on by the statement signatories. The statement paper was reviewed and approved by the Executive Committee of the NSRG of the World Federation of Neurology. The main objective of this consensus statement is to establish a standardization of the c-TCD technique and its interpretation, in order to improve the informative quality of the method, resulting in expanding the application of TCD in the clinical setting. These recommendations optimize the comparison of different diagnostic methods and encourage the use of c-TCD for RLS screening and complementary diagnosis in multicenter studies.


Assuntos
Circulação Cerebrovascular , Meios de Contraste/administração & dosagem , Forame Oval Patente/complicações , Acidente Vascular Cerebral/diagnóstico por imagem , Ultrassonografia Doppler Transcraniana/normas , Consenso , Forame Oval Patente/diagnóstico por imagem , Forame Oval Patente/fisiopatologia , Humanos , Valor Preditivo dos Testes , Fatores de Risco , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/fisiopatologia
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