Morphology of the Patent Foramen Ovale in Asymptomatic Versus Symptomatic (Stroke or Transient Ischemic Attack) Patients

Goel, Sachin S.; Tuzcu, E. Murat; Shishehbor, Mehdi H.; Oliveira, Eduardo Infante de; Borek, Peter; Krasuski, Richard A.; Rodriguez, L. Leonardo; Kapadia, Samir

doi:10.1016/j.amjcard.2008.08.036

Cited by 121 publications

(85 citation statements)

References 21 publications

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“…Moreover, it confirms previous studies which suggested the relationships of permanent shunt, large ASA, tunnel-like anatomy, and high grade shunt and risk of stroke recurrence [15][16].…”

Section: Discussionsupporting

confidence: 78%

A Modified Anatomical-Functional-RoPE (AF-RoPE) Score Improves Patient Selection for Patent Foramen Ovale Closure

Rigatelli¹,

Zuin

Dell’Avvocata³

et al. 2018

ICFJ

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IntroductionAlthough recent trials [1] and meta-analysis about transcatheter closure of patent foramen ovale (PFO) [2][3][4][5][6][7] have suggested that PFO closure is both an effective and cost-effective treatment for recurrent embolic stroke, the management of patients with symptomatic PFO is not yet completely clarified. Recently, the RoPE score calculator has been proposed [8] in order to stratify the patients in whom PFO may be considered not a confounding but presumably a causative factor. This score is mainly based on clinical criteria and it doesn't include any anatomical or functional characteristics, such as permanent and/or large shunt, presence of atrial septum aneurysm (ASA) and long tunnelized PFO. Moreover, these PFO structural aspects have already been considered for both patient selection and clinical decision making

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“…Moreover, it confirms previous studies which suggested the relationships of permanent shunt, large ASA, tunnel-like anatomy, and high grade shunt and risk of stroke recurrence [15][16].…”

Section: Discussionsupporting

confidence: 78%

A Modified Anatomical-Functional-RoPE (AF-RoPE) Score Improves Patient Selection for Patent Foramen Ovale Closure

Rigatelli¹,

Zuin

Dell’Avvocata³

et al. 2018

ICFJ

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“…Among PFO carriers, those symptomatic for cerebrovascular disease have been found to exhibit a wider PFO (3.9 ± 1.6 vs. 2.9 ± 1.4 mm), a significantly higher proportion of ASA (45% vs. 21%), of greater or equal to 1 cm long tunnels (78% vs. 55%) and of severe right to left shunt (16% vs. 5%), compared with asymptomatic subjects, thus confirming earlier reports [14]. Of the above-mentioned features, the association with ASA appears to be the strongest indicator of the possible pathogenic role of PFO.…”

supporting

confidence: 78%

Patent foramen ovale (PFO) and cryptogenic stroke

Anzola

Giardino

Piras

2010

Journal of Thrombosis and Haemostasis

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To cite this article: Anzola GP, Giusti del Giardino L, Piras MP. Patent foramen ovale (PFO) and cryptogenic stroke. J Thromb Haemost 2010; 8: 1675-7.Julius Cohnheim, a German pathologist, is credited, in 1877, as the first to hypothesize that the failed closure after birth of the foramen ovale (the interatrial opening that allows the oxygenated blood from the placenta to bypass the non-functioning pulmonary circulation and enter the fetal systemic circulation) might underlie the spreading of venous emboli to the brain. However, although commonly accepted as a possible cause of stroke, paradoxical embolism was believed to merely represent a medical curiosity up until the end of the 1980s when, due to the advancement of echocardiography, it was recognized that the patency of the foramen ovale (PFO) was two to three times more frequent in patients with strokes of otherwise unknown cause (i.e. cryptogenic) than in healthy controls or in patients with stroke of known etiology [1]. The echocardiographic demonstration, in single case reports, of thrombi trapped across the foramen provided the evidence that emboli of venous origin may be able to bypass the pulmonary filter and enter the systemic circulation across the PFO, and so represent a risk factor for stroke [2].Recent meta-analyses of case-control studies have confirmed that the likelihood of cryptogenic stroke patients with a PFO is about three times that of controls [1,3,4] (Table 1). More recently, Alsheik et al. applied the Bayes theorem to the available data to ascertain the probability of PFO being incidental in a patient with cryptogenic stroke. They came to the conclusion that PFO may represent an incidental finding in 33-48% of cryptogenic strokes when in isolation, but only in 11% when associated with bulging of the interatrial wall (so called atrial septal aneurism -ASA). These figures drop to 20% and 9%, respectively, in patients less than 55 years old [5].Similarly, a prospective study conducted in France on the risk of recurrence in young patients with cryptogenic stroke [6] showed that, compared with patents with no atrial septal abnormalities, the PFO-ASA association conveyed a 4-fold risk of relapse (hazard ratio 4.17, 95% CI 1.47-11.84).That PFO may enhance the risk of getting brain emboli has been further elegantly shown by a recent prospective study that identified, by logistic regression analysis, PFO was found to be an independent predictor of silent brain infarction with an OR of 34.9 (95% CI 31-394.3, P = 0.004) [7].The difficulty in identifying those with truly cryptogenic stroke amongst aged patients (due to the frequent cooccurrence of vascular risk factors) probably explains why PFO was only marginally associated with stroke in patients aged over 55 years in older studies [1]. Recent evidence, however, strongly suggests that PFO is over-represented in cryptogenic strokes irrespective of the age of occurrence [4]. To mitigate the perception that PFO is a dangerous mate, two population-based studies both failed to identify PFO as an ind...

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“…Heterogeneity was classified as moderate (I 2 ≥30%), substantial (I 2 ≥50%), or considerable (I 2 ≥75%) 23. Potential sources of heterogeneity were investigated by (1) stratifying studies according to the type of medical treatment in the control group (antithrombotic therapy or antiplatelet therapy alone); (2) conducting a subgroup analysis based on PFO anatomical features (higher‐risk PFOs, defined as PFO associated with atrial septal aneurysm or large shunt,6, 24 versus lower‐risk PFOs); and (3) by meta‐regression. Potential publication bias was investigated using funnel plots and Egger's test 25…”

Section: Methodsmentioning

confidence: 99%

Closure, Anticoagulation, or Antiplatelet Therapy for Cryptogenic Stroke With Patent Foramen Ovale: Systematic Review of Randomized Trials, Sequential Meta‐Analysis, and New Insights From the CLOSE Study

Turc

Calvet

Guérin

et al. 2018

JAHA

140

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BackgroundWe conducted a systematic review and meta‐analysis of randomized controlled trials (RCTs) comparing patent foramen ovale (PFO) closure, anticoagulation, and antiplatelet therapy to prevent stroke recurrence in patients with PFO‐associated cryptogenic stroke.Methods and ResultsWe searched Medline, Cochrane Library, and EMBASE through March 2018. The primary outcome was stroke recurrence. Pooled incidences, hazard ratios, and risk ratios (RRs) were calculated in random‐effects meta‐analyses. PFO closure was associated with a lower risk of recurrent stroke compared with antithrombotic therapy (antiplatelet therapy or anticoagulation: 3560 patients from 6 RCTs; RR=0.36, 95% CI: 0.17–0.79; I2=59%). The effect of PFO closure on stroke recurrence was larger in patients with atrial septal aneurysm or large shunt (RR=0.27, 95% CI, 0.11–0.70; I2=42%) compared with patients without these anatomical features (RR=0.80, 95% CI, 0.43–1.47; I2=12%). Major complications occurred in 2.40% (95% CI, 1.03–4.25; I2=77%) of procedures. New‐onset atrial fibrillation was more frequent in patients randomized to PFO closure versus antithrombotic therapy (RR=4.33, 95% CI, 2.37–7.89; I2=14%). One RCT compared PFO closure versus anticoagulation (353 patients; hazard ratio=0.14, 95% CI, 0.00–1.45) and 2 RCTs compared PFO closure versus antiplatelet therapy (1137 patients; hazard ratio=0.18, 95% CI, 0.05–0.63; I2=12%). Three RCTs compared anticoagulation versus antiplatelet therapy, with none showing a significant difference.Conclusions PFO closure is superior to antithrombotic therapy to prevent stroke recurrence after cryptogenic stroke. The annual absolute risk reduction of stroke was low, but it has to be tempered by a substantial time at risk (at least 5 years) in young and middle‐aged patients. PFO closure was associated with an increased risk of atrial fibrillation.

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Morphology of the Patent Foramen Ovale in Asymptomatic Versus Symptomatic (Stroke or Transient Ischemic Attack) Patients

Cited by 121 publications

References 21 publications

A Modified Anatomical-Functional-RoPE (AF-RoPE) Score Improves Patient Selection for Patent Foramen Ovale Closure

A Modified Anatomical-Functional-RoPE (AF-RoPE) Score Improves Patient Selection for Patent Foramen Ovale Closure

Patent foramen ovale (PFO) and cryptogenic stroke

Closure, Anticoagulation, or Antiplatelet Therapy for Cryptogenic Stroke With Patent Foramen Ovale: Systematic Review of Randomized Trials, Sequential Meta‐Analysis, and New Insights From the CLOSE Study

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