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Journal of Echocardiography

, Volume 17, Issue 1, pp 44–51 | Cite as

Implications of detection of foramen ovale patent after cryptogenic ischemic stroke

  • Rita MarinheiroEmail author
  • Leonor Parreira
  • Pedro Amador
  • Isabel Silvestre
  • Carla Antunes
  • Rui Caria
Original Investigation
  • 146 Downloads

Abstract

Background

Therapeutic uncertainty is inherent in decisions in patients with patent foramen ovale (PFO) and cryptogenic stroke. We aimed to determine clinical implications of PFO identification in transesophageal echocardiography (TEE) after a cryptogenic ischemic stroke.

Methods

Consecutive TEE done between 2011 and 2015 in patients with previous cryptogenic stroke was evaluated. Clinical implications of PFO identification (closure and/or medical therapy) were retrieved from the medical records and discharge summaries. Adverse events related to therapy, stroke recurrence and death were analyzed during follow-up.

Results

Three-hundred one patients (mean age 59 ± 11 years; 61% male) underwent a TEE, of which 77 (26%) patients had a diagnosis of PFO. Patients with PFO were younger (56 ± 13 versus 60 ± 14, p = 0.03). Of those with PFO, 23 (30%) underwent percutaneous closure of PFO and these patients had more frequently complex or large PFO (p < 0.001 and p = 0.004, respectively). The remaining 54 (70%) were treated with medical therapy: 30 (39%) with antiplatelet therapy and 24 (31%) with oral anticoagulation. During follow-up (44 ± 17 months), only two patients had another stroke (both referred for PFO closure, while they were waiting for the procedure) and two patients, on whom PFO closure was not performed, died (not for cardiovascular causes).

Conclusion

PFO’s (size and complexity) and patients’ characteristics influenced clinical decision when PFO was detected on TEE. The risk for recurrent stroke was not increased in patients who did not undergo PFO closure; although two patients waiting for PFO closure had recurrent stroke, demonstrating its importance.

Keywords

Cryptogenic stroke Patent foramen ovale Percutaneous closure Transesophageal echocardiography 

Abbreviations

AF

Atrial fibrillation

ASA

Atrial septal aneurysm

ECG

Electrocardiogram

h

Hour

LA

Left atrium

OAC

Oral anticoagulation

PFO

Patent foramen ovale

RA

Right atrium

TEE

Transesophageal echocardiography

TTE

Transthoracic echocardiography

Notes

Compliance with ethical standards

Conflict of interest

Rita Marinheiro, Leonor Parreira, Pedro Amador, Isabel Silvestre, Carla Antunes and Rui Caria declare that they have no conflict of interest.

Human rights statements and informed consent

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1964 and later revisions. Informed consent was obtained from all patients for being included in the study.

References

  1. 1.
    Calvet D, Mas JL. Closure of patent foramen ovale in cryptogenic stroke: a never ending story. Curr Opin Neurol. 2014;27:13–9.CrossRefGoogle Scholar
  2. 2.
    Furlan AJ, Reisman M, Massaro J, et al. Closure or medical therapy for cryptogenic stroke with patent foramen ovale. N Engl J Med. 2012;366:991–9.CrossRefGoogle Scholar
  3. 3.
    Carroll JD, Saver JL, Thaler DE, et al. Closure of patent foramen ovale versus medical therapy after cryptogenic stroke. N Engl J Med. 2013;368:1092–100.CrossRefGoogle Scholar
  4. 4.
    Meier B, Kalesan B, Mattle HP, et al. Percutaneous closure of patent foramen ovale in cryptogenic embolism. N Engl J Med. 2013;368:1083–91.CrossRefGoogle Scholar
  5. 5.
    Rengifo-Moreno P, Palacios IF, Junpaparp P, et al. Patent foramen ovale transcatheter closure vs. medical therapy on recurrent vascular events: a systematic review and meta-analysis of randomized controlled trials. Eur Heart J. 2013;34:3342–52.CrossRefGoogle Scholar
  6. 6.
    Mas JL, Derumeaux G, Guillon B, et al. Patent foramen ovale closure or anticoagulation vs. antiplatelets after stroke. N Engl J Med. 2017;377:1011–21.CrossRefGoogle Scholar
  7. 7.
    Søndergaard L, Kasner SE, Rhodes JF, et al. Patent foramen ovale closure or antiplatelet therapy for cryptogenic stroke. N Engl J Med. 2017;377:1033–42.CrossRefGoogle Scholar
  8. 8.
    Ay H, Furie KL, Smith WS, et al. An evidence-based causative classification system for acute ischemic stroke. Ann Neurol. 2005;58(5):688–97.CrossRefGoogle Scholar
  9. 9.
    Pinto FJ. When and how to diagnose patent foramen ovale. Should it always be repaired? Heart. 2005;91:438–40.CrossRefGoogle Scholar
  10. 10.
    Vitarelli A, Mangieri E, Capotosto L, et al. Echocardiographic findings in simple and complex patent foramen ovale before and after transcatheter closure. Eur Heart J Cardiovasc Imaging. 2014;15(12):1377–85.CrossRefGoogle Scholar
  11. 11.
    Pepi M, Evangelista A, Nihoyannopoulos P, et al. Recommendations for echocardiography use in the diagnosis and management of cardiac sources of embolism European Association of Echocardiography. Eur J Echocardiogr. 2010;11:461–76.CrossRefGoogle Scholar
  12. 12.
    Kaatz S, Ahmad D, Spyropoulus C, et al. Definition of clinically relevant non-major bleeding in studies of anticoagulants in atrial fibrillation and venous thromboembolic disease in non-surgical patients: communication from the SSC of the ISTH. J Thromb Haemost. 2015;13:2119–26.CrossRefGoogle Scholar
  13. 13.
    Saric M, Armour AC, Arnaout MS, et al. Guidelines for the use of echocardiography in the evaluation of a cardiac source of embolism. J Am Soc Echocardiogr. 2016;29(1):1–42.CrossRefGoogle Scholar
  14. 14.
    McGrath ER, Paikin JS, Motlagh B, et al. Transesophageal echocardiography in patients with cryptogenic ischemic stroke: a systematic review. Am Heart J. 2014;168:706–12.CrossRefGoogle Scholar
  15. 15.
    Handke M, Harloff A, Olschewski M, et al. Patent foramen ovale and cryptogenic stroke in older patients. N Engl J Med. 2007;357:2262–8.CrossRefGoogle Scholar
  16. 16.
    Rodrigues AC, Picard MH, Carbone A, et al. Importance of adequately performed valsalva maneuver to detect patent foramen ovale during transesophageal echocardiography. J Am Soc Echocardiogr. 2013;26:1337–43.CrossRefGoogle Scholar
  17. 17.
    Buttignoni SC, Khorsand A, Mundigler G, et al. Agitated saline versus polygelatine for the echocardiographic assessment of patent foramen ovale. J Am Soc Echocardiogr. 2004;17:1059–65.CrossRefGoogle Scholar
  18. 18.
    Gladstone D, Spring M, Dorian P, et al. Atrial fibrillation in patients with cryptogenic stroke. N Engl J Med. 2014;370:2467–77.CrossRefGoogle Scholar
  19. 19.
    Sanna T, Diener HC, Passman RS, et al. Cryptogenic stroke and underlying atrial fibrillation. N Engl J Med. 2014;370(26):2478–86.CrossRefGoogle Scholar

Copyright information

© Japanese Society of Echocardiography 2018

Authors and Affiliations

  1. 1.Cardiology DepartmentCentro Hospitalar de SetubalSetubalPortugal

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