Clinical Research in Cardiology

, Volume 101, Issue 4, pp 297–303

Sustained risk of recurrent thromboembolic events in patients with patent foramen ovale and paradoxical embolism: long-term follow-up over more than 15 years

  • Dieter Fischer
  • Ajmal Gardiwal
  • Jonas Haentjes
  • Gunnar Klein
  • Gerd-Peter Meyer
  • Helmut Drexler
  • Dirk Hausmann
  • Arnd Schaefer
Original Paper

Abstract

Background

Patients with patent foramen ovale (PFO) and cryptogenic stroke are at risk of recurrence. Therapeutic regimens range from no treatment to anticoagulation treatment to surgical or interventional closure. However, long-term follow-up is only available for up to 4 years.

Methods

Among ~5,000 transesophageal echocardiographies in stroke/TIA-patients between 1988 and 1997, a PFO was found and considered a possible mediator for the neurological event in 97 patients. In these patients, the PFO was judged to be responsible for the neurological event. Patients with cardiac or other reasons for embolism were excluded. The therapy for stroke was chosen by the attending physician. Follow-up information was obtained through telephone interviews.

Results

Follow-up was available for 86 patients (89%) with a mean period of 15.4 years (range, 11.2–25.9 years). Thirteen patients (15%) suffered from recurrent ischemic events (7 TIAs, 5 strokes, 1 peripheral embolism) after a mean period of 4.9 years. Four patients died, not associated with recurrent thromboembolism. The risk of recurrence was increased over the entire length of the mean follow-up period. The occurrence of recurrent events was not associated with differences in baseline data, the presence of ASA, PFO size or the chosen treatment.

Conclusion

In patients with paradoxical embolism, recurrent ischemic events are frequent despite medical therapy. These events are not limited to the early years after the index event; this long-term follow-up revealed a risk of occurrence over the entire follow-up. These patients have a sustained risk of recurrence, requiring lifetime protection, which should be considered in tailoring individual therapeutic strategies.

Keywords

Patent foramen ovale Stroke Paradoxical embolism Follow-up Prognosis 

References

  1. 1.
    Di Tullio M, Sacco RL, Gopal A, Mohr JP, Homma S (1992) Patent foramen ovale as a risk factor for cryptogenic stroke. Ann Intern Med 117:461–465PubMedGoogle Scholar
  2. 2.
    Lechat P, Mas JL, Lascault G, Loron P, Theard M, Klimczac M, Drobinski G, Thomas D, Grosgogeat Y (1988) Prevalence of patent foramen ovale in patients with stroke. N Engl J Med 318:1148–1152PubMedCrossRefGoogle Scholar
  3. 3.
    Bogousslavsky J, Garazi S, Jeanrenaud X, Aebischer N, Van Melle G (1996) Stroke recurrence in patients with patent foramen ovale: the Lausanne study. Lausanne stroke with paradoxal embolism study group. Neurology 46:1301–1305PubMedGoogle Scholar
  4. 4.
    Hanna JP, Sun JP, Furlan AJ, Stewart WJ, Sila CA, Tan M (1994) Patent foramen ovale and brain infarct. Echocardiographic predictors, recurrence, and prevention. Stroke 25:782–786PubMedCrossRefGoogle Scholar
  5. 5.
    Hausmann D, Mugge A, Daniel WG (1995) Identification of patent foramen ovale permitting paradoxic embolism. J Am Coll Cardiol 26:1030–1038PubMedCrossRefGoogle Scholar
  6. 6.
    Homma S, Di Tullio MR, Sacco RL, Mihalatos D, Li Mandri G, Mohr JP (1994) Characteristics of patent foramen ovale associated with cryptogenic stroke. A biplane transesophageal echocardiographic study. Stroke 25:582–586PubMedCrossRefGoogle Scholar
  7. 7.
    Cabanes L, Mas JL, Cohen A, Amarenco P, Cabanes PA, Oubary P, Chedru F, Guerin F, Bousser MG, de Recondo J (1993) Atrial septal aneurysm and patent foramen ovale as risk factors for cryptogenic stroke in patients less than 55 years of age. A study using transesophageal echocardiography. Stroke 24:1865–1873PubMedCrossRefGoogle Scholar
  8. 8.
    Stone DA, Godard J, Corretti MC, Kittner SJ, Sample C, Price TR, Plotnick GD (1996) Patent foramen ovale: association between the degree of shunt by contrast transesophageal echocardiography and the risk of future ischemic neurologic events. Am Heart J 131:158–161PubMedCrossRefGoogle Scholar
  9. 9.
    Homma S, Sacco RL, Di Tullio MR, Sciacca RR, Mohr JP (2002) Effect of medical treatment in stroke patients with patent foramen ovale: patent foramen ovale in cryptogenic stroke study. Circulation 105:2625–2631PubMedCrossRefGoogle Scholar
  10. 10.
    Furlan AJ (2010) Closure I: a prospective, multicenter, randomized controlled trial to evaluate the safety and efficacy of the starflex® septal closure system versus best medical therapy in patients with a stroke or transient ischemic attack due to presumed paradoxical embolism through a patent foramen oval. In: Abstract at the Annual Meeting of the American Heart Association 2010Google Scholar
  11. 11.
    Mas JL, Arquizan C, Lamy C, Zuber M, Cabanes L, Derumeaux G, Coste J (2001) Recurrent cerebrovascular events associated with patent foramen ovale, atrial septal aneurysm, or both. N Engl J Med 345:1740–1746PubMedCrossRefGoogle Scholar
  12. 12.
    Schuchlenz HW, Weihs W, Berghold A, Lechner A, Schmidt R (2005) Secondary prevention after cryptogenic cerebrovascular events in patients with patent foramen ovale. Int J Cardiol 101:77–82PubMedCrossRefGoogle Scholar
  13. 13.
    Feurer R, Sadikovic S, Sepp D, Esposito L, Schleef M, Bockelbrink A, Schwarze J, Hemmer B, Sander D, Poppert H (2010) Patent foramen ovale is not associated with an increased risk of stroke recurrence. Eur J Neurol 17(11):1339–1345Google Scholar
  14. 14.
    Almekhlafi MA, Wilton SB, Rabi DM, Ghali WA, Lorenzetti DL, Hill MD (2009) Recurrent cerebral ischemia in medically treated patent foramen ovale: a meta-analysis. Neurology 73:89–97PubMedCrossRefGoogle Scholar
  15. 15.
    Mugge A, Daniel WG, Angermann C, Spes C, Khandheria BK, Kronzon I, Freedberg RS, Keren A, Denning K, Engberding R et al (1995) Atrial septal aneurysm in adult patients. A multicenter study using transthoracic and transesophageal echocardiography. Circulation 91:2785–2792PubMedGoogle Scholar
  16. 16.
    Webster MW, Chancellor AM, Smith HJ, Swift DL, Sharpe DN, Bass NM, Glasgow GL (1988) Patent foramen ovale in young stroke patients. Lancet 2:11–12PubMedCrossRefGoogle Scholar
  17. 17.
    Windecker S, Wahl A, Nedeltchev K, Arnold M, Schwerzmann M, Seiler C, Mattle HP, Meier B (2004) Comparison of medical treatment with percutaneous closure of patent foramen ovale in patients with cryptogenic stroke. J Am Coll Cardiol 44:750–758PubMedCrossRefGoogle Scholar
  18. 18.
    Thanopoulos BV, Dardas PD, Karanasios E, Mezilis N (2006) Transcatheter closure versus medical therapy of patent foramen ovale and cryptogenic stroke. Catheter Cardiovasc Interv 68:741–746PubMedCrossRefGoogle Scholar
  19. 19.
    Steiner MM, Di Tullio MR, Rundek T, Gan R, Chen X, Liguori C, Brainin M, Homma S, Sacco RL (1998) Patent foramen ovale size and embolic brain imaging findings among patients with ischemic stroke. Stroke 29:944–948PubMedCrossRefGoogle Scholar
  20. 20.
    Overell JR, Bone I, Lees KR (2000) Interatrial septal abnormalities and stroke: a meta-analysis of case–control studies. Neurology 55:1172–1179PubMedGoogle Scholar
  21. 21.
    Balzer J, Kühl H, Rassaf T, Hoffmann R, Schauerte P, Kelm M, Franke A (2008) Real-time transesophageal three-dimensional echocardiography for guidance of percutaneous cardiac interventions: first experience. Clin Res Cardiol 97:565–574PubMedCrossRefGoogle Scholar
  22. 22.
    Krizanic F, Sievert H, Pfeiffer D, Konorza T, Ferrari M (2008) Figulla HR Clinical evaluation of a novel occluder device (Occlutech®) for percutaneous transcatheter closure of patent foramen ovale (PFO). Clin Res Cardiol 97:872–877PubMedCrossRefGoogle Scholar
  23. 23.
    Fischer D, Haentjes J, Klein G, Schieffer B, Drexler H, Meyer GP, Schaefer A (2011) Transcatheter closure of patent foramen ovale (PFO) in patients with paradoxical embolism: Procedural and follow-up results after implantation of the Amplatzer®-occluder device. J Interv Cardiol 24:85–91PubMedCrossRefGoogle Scholar
  24. 24.
    Braun M, Gliech V, Boscheri A, Schoen S, Gahn G, Reichmann H, Haass M, Schraeder R, Strasser RH (2004) Transcatheter closure of patent foramen ovale (PFO) in patients with paradoxical embolism. Periprocedural safety and mid-term follow-up results of three different device occluder systems. Eur Heart J 25:424–430PubMedCrossRefGoogle Scholar
  25. 25.
    Laufs U, Hoppe UC, Rosenkranz S, Kirchhof P, Böhm M, Diener HC, Endres M, Grond M, Hacke W, Meinertz T, Ringelstein EB, Röther J, Dichgans M (2010) Cardiological evaluation after cerebral ischaemia: consensus statement of the Working Group Heart and Brain of the German Cardiac Society-Cardiovascular Research (DGK) and the German Stroke Society (DSG). Clin Res Cardiol 99:609–625PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2011

Authors and Affiliations

  • Dieter Fischer
    • 1
  • Ajmal Gardiwal
    • 1
  • Jonas Haentjes
    • 1
  • Gunnar Klein
    • 1
  • Gerd-Peter Meyer
    • 1
  • Helmut Drexler
    • 1
  • Dirk Hausmann
    • 1
  • Arnd Schaefer
    • 1
  1. 1.Klinik für Kardiologie und AngiologieMedizinische Hochschule HannoverHannoverGermany

Personalised recommendations