Proposal for Updated Nomenclature and Classification of Potential Causative Mechanism in Patent Foramen Ovale–Associated Stroke

2020 ◽  
Vol 77 (7) ◽  
pp. 878 ◽  
Author(s):  
Akram Y. Elgendy ◽  
Jeffrey L. Saver ◽  
Zahid Amin ◽  
Konstantinos Dean Boudoulas ◽  
John D. Carroll ◽  
...  
Keyword(s):  
Patent Foramen Ovale ◽  
Foramen Ovale ◽  
Causative Mechanism

Ticagrelor for Refractory Migraine/Patent Foramen Ovale (TRACTOR)

Neurology ◽  
2018 ◽  
Vol 91 (22) ◽  
pp. 1010-1017 ◽  
Author(s):  
Adam M. Reisman ◽  
Barbara T. Robbins ◽  
Denise E. Chou ◽  
Marianna Shnayderman Yugrakh ◽  
Giti J. Gross ◽  
...  
Keyword(s):  
Side Effects ◽  
Randomized Trial ◽  
Patent Foramen Ovale ◽  
Additional Treatment ◽  
Foramen Ovale ◽  
Small Pilot Study ◽  
Serious Adverse Events ◽  
Medication Side ◽  
Refractory Migraine

ObjectiveAfter finding that the thienopyridines clopidogrel and prasugrel reduced migraine headache (MHA) symptoms in some patients with patent foramen ovale (PFO), this small pilot study was undertaken to determine whether ticagrelor, a nonthienopyridine P2Y12 inhibitor, would have similar MHA effects and might be better suited for a future randomized trial.MethodsMHA patients were screened for PFO. Participants with documented right to left shunt (RLS) and ≥6 monthly MHA days received ticagrelor therapy for 28 days. Those with ≥50% reduction in monthly MHA days were deemed responders and completed 2 additional treatment months.ResultsThe 40 participants had a mean age of 36.2 years and mean MHA frequency of 17.4 d/mo. A total of 39/40 were female. A total of 14/40 met criteria for episodic MHA, 26/40 for chronic MHA, 14/40 had migraine with aura, and 22/40 had a moderate–large RLS (Spencer grade ≥4). Seventeen of 40 participants (43%) were responders. MHA reduction continued through 3 treatment months in all responders. MHA responder rates were not statistically different in participants with episodic or chronic MHA, with or without aura, or with small/larger RLS shunt magnitude. Thirteen (32%) patients had medication side effects, without serious adverse events.ConclusionP2Y12 inhibition with ticagrelor reduced MHA symptoms similarly to our previous thienopyridine experience, but participants seemed to have a less robust MHA benefit and more frequent side effects than with the thienopyridines, making it an inferior choice for a randomized trial.Classification of evidenceThis study provides Class IV evidence that ticagrelor reduced MHA symptoms in patients with PFO.

Retrospective review of thienopyridine therapy in migraineurs with patent foramen ovale

Neurology ◽  
2018 ◽  
Vol 91 (22) ◽  
pp. 1002-1009 ◽  
Author(s):  
Robert J. Sommer ◽  
Tamim Nazif ◽  
Lauren Privitera ◽  
Barbara T. Robbins
Keyword(s):  
Patent Foramen Ovale ◽  
Migraine Headache ◽  
Platelet Inhibition ◽  
Foramen Ovale ◽  
Off Label ◽  
Study Population ◽  
The Right ◽  
Pfo Closure ◽  
Class Iv

ObjectiveWe retrospectively reviewed our clinical experience using off-label thienopyridine agents in patients with migraine headache (MHA) and patent foramen ovale (PFO).MethodsBetween 2011 and 2017, MHA/PFO patients referred to our practice were clinically treated with clopidogrel specifically for MHA. Those with ≥50% reduction in monthly MHA days compared with baseline were deemed MHA responders. MHA nonresponders with inadequate platelet inhibition by PRU testing were offered prasugrel. Thienopyridine-responsive patients were then offered PFO closure.ResultsOf 136 patients (86% female, mean age 37.9 years, mean MHA burden 14.7 days/month), 80 (59%) were MHA responders to clopidogrel. The clopidogrel responder rate was equivalent in episodic, chronic, aura, and nonaura subgroups. A total of 19/45 (40%) MHA nonresponders had inadequate platelet inhibition by PRU testing on clopidogrel. Sixteen of those patients received prasugrel, were adequately platelet inhibited by PRU, and 10/16 (62%) converted to MHA responders. A total of 56/90 thienopyridine-responsive patients underwent subsequent PFO closure with thienopyridine discontinuation after 3 months. Ninety-four percent had ongoing MHA relief. A total of 8/8 responders who stopped thienopyridine without PFO closure had resumption of MHA symptoms.ConclusionSuccessful P2Y12 platelet inhibition seemed to reduce MHA symptoms in some patients with PFO, suggesting a platelet-based mechanism/trigger. The nearly parallel response to PFO closure may mechanistically link venous platelet activation with the right-to-left shunt of PFO. Thienopyridine responsiveness could be used to enrich the study population for a new MHA/PFO trial.Classification of evidenceThis study provides Class IV evidence that in patients with PFO, P2Y12 inhibition improved MHA symptoms.

Percutaneous Treatment of Congenital Defects of the Inter-atrial Septum in Adults – Recent Advances and Persistent Pitfalls

2009 ◽  
Vol 4 (1) ◽  
pp. 76
Author(s):  
James Slater ◽  
Mark Fisch ◽  
◽  
Keyword(s):  
Atrial Septal Defect ◽  
Adult Patient ◽  
Patent Foramen Ovale ◽  
Septal Defect ◽  
Percutaneous Treatment ◽  
Atrial Septum ◽  
Congenital Defects ◽  
Foramen Ovale ◽  
Anatomy And Physiology ◽  
Specific Tissue

William Harvey was the first scientist to describe the heart as consisting of separate right- and left-sided circulations. Our understanding of the heart’s anatomy and physiology has grown significantly since this landmark discovery in 1628. Today, we recognise not only the importance of these separate systems, but also the specific tissue that divides them. Our growing understanding of the inter-atrial septum has allowed us to identify defects within this structure and develop effective percutaneous devices for closure of these defects in the adult patient. This article discusses the formation of a patent foramen ovale (PFO) and atrial septal defect (ASD). In addition, we describe the medical illnesses caused by these defects and summarise the indications and risks related to percutaneous closure of these defects. We also report the most up-to-date transcatheter therapeutic options for closure of these common congenital defects in the adult patient.

Stroke Prophylaxis by Percutaneous Closure of Patent Foramen Ovale and Left Atrial Appendage

2011 ◽  
Vol 6 (1) ◽  
pp. 67
Author(s):  
Antonio L Bartorelli ◽  
Claudio Tondo ◽  
◽  
Keyword(s):  
Left Atrial ◽  
Patent Foramen Ovale ◽  
Stroke Risk ◽  
Left Atrial Appendage ◽  
Cryptogenic Stroke ◽  
Atrial Appendage ◽  
Foramen Ovale ◽  
Percutaneous Procedures ◽  
Cerebrovascular Events

Innovative percutaneous procedures for stroke prevention have emerged in the last two decades. Transcatheter closure of the patent foramen ovale (PFO) is performed in patients who suffered a cryptogenic stroke or a transient ischaemic attach (TIA) in order to prevent recurrence of thromboembolic events. Percutaneous occlusion of the left atrial appendage (LAA) has been introduced to reduce stroke risk in patients with atrial fibrillation (AF). The role of PFO and LAA in the occurrence of cerebrovascular events and the interventional device-based therapies to occlude the PFO and LAA are discussed.

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