Identification of candidates for PFO closure in the echocardiography laboratory

Abstract

A patent foramen ovale (PFO) is implicated in several pathologic processes, including that of cryptogenic stroke (cCVA). Recent trials identify “high‐risk” PFOs in patients with cCVA as likely to benefit from percutaneous closure. The younger the patient (<60 years old) the more likely a PFO may be attributable to the cCVA. The RoPE Score index helps determine the likelihood that an existing PFO is related to a cCVA. This may help guide the clinician and patient when contemplating percutaneous PFO closure. When evaluating a patient for possible percutaneous closure, one should identify the CVA as a typical ischemic type stroke. In order to “rule‐out” other causes of CVA, imaging of the intracranial arteries, cervical, and aortic arch vessels should be performed. Small vessel disease or a lacunar‐type infarct should be excluded. To rule out atrial fibrillation, prolonged monitoring should be performed. An index has been developed to determine the probability that a PFO is the causative etiology and calculates the risk of recurrence. This may help guide the clinician and patient in the decision for PFO closure. In addition, one should consider a work‐up for a hypercoagulable state. We will obtain an ultrasound of the lower extremities or consider deep pelvic vein thrombosis (prolonged sitting or malignancy). If the closure is to be performed, the Food and Drug Administration (FDA) has approved the Amplatzer PFO Occluder and the GORE Cardioform Septal Occluder for percutaneous closure. These devices are both approved in patients predominately between ages 18 and 60 years with a cCVA due to presumed paradoxical embolism as verified by a neurologist and cardiologist and when other causes of ischemic CVA have been excluded. “High‐risk” PFOs appear to achieve the most potential benefit from percutaneous closure.

Recurrent arterial ischemic strokes in a patient with patent foramen ovale and ductus arteriosus: Presentation of our management and review of the literature

“…Collaborative, observational studies have provided insight into risk-stratification to identify patients in whom PFO closure may provide the greatest potential. According to studies, it seems to be reasonable that patients with cryptogenic stroke, particularly those ≤60 years old and those who additionally have an ASA (atrial septal aneurysm), may benefit most from device (mechanical) closure of PFO 28–30 .…”

“…The United States Food and Drug Administration (FDA), in October 2016, approved the use of the Amplatzer PFO Occluder for percutaneous transcatheter closure of a PFO in order to reduce the risk of a recurrent ischemic CVA in patients predominately between ages of 18 and 60 years. Prerequisite was that patients would have suffered a verified cCVA due to presumed paradoxical embolism, in order to exclude other known causes of ischemic CVA 28 .…”

“…PFO is well known to be implicated in several pathologic processes, one them being cCVA. Recognition of patients most likely to have had a neurological ictus etiologically related to paradoxical embolism through a PFO is of paramount importance, as most recent trials identify “high-risk” PFOs as more likely to benefit more from percutaneous closure, compared to the best medical therapy alone 28 .…”

Peripheral saline contrast with Valsalva and a modified Müller's maneuver may improve detection of atrial level right‐to‐left shunts: A preliminary observation

“…If able to perform a VAL, most patients (except one) were able to perform the VAL + MUL. The laboratory did not record other associated anatomical findings such as a Chiari network, prominent Eustachian valve or atrial septal aneurysm . Also, many of these patients did not have a confirmatory transesophageal echocardiogram (TEE).…”

“…The laboratory did not record other associated anatomical findings such as a Chiari network, prominent Eustachian valve or atrial septal aneurysm. 12 Also, many of these patients did not have a confirmatory transesophageal echocardiogram (TEE). The saline injections during VAL were performed with documentation of "bowing" of the septum toward the left with full opacification of the RA.…”