Importance of saline contrast transthoracic echocardiography for evaluating large right-to-left shunt in patent foramen ovale associated with cryptogenic stroke

AbstractTranscatheter closure of patent foramen ovale (PFO) is an effective therapy for preventing recurrent stroke in very specific patient cohorts, such as cryptogenic stroke (CS). The identification of high-risk PFO, which is more likely to be linked to CS, is essential. This study aimed to assess the accuracy of saline contrast transthoracic echocardiography (TTE) for evaluating large right-to-left (RL) shunt. We enrolled 119 patients with or without CS who were confirmed to have PFO by transesophageal echocardiography (TEE) or catheterization. The severity of RL shunt evaluated by TTE and TEE was classified as follows: small (< 10 microbubbles), moderate (10–20 microbubbles), and large (> 20 microbubbles). With TTE, large RL shunt was observed in 94 (79%) of 119 patients, including 66 of 74 with CS and 28 of 45 without CS. With TEE, large RL shunt was observed in 33 (28 %) patients, including 26 with CS and 7 without CS. TTE showed large RL shunt more frequently than TEE (p < 0.01). Large RL shunt evaluated by TTE had a sensitivity of 89 % and an accuracy of 70 % for the association with CS, whereas large RL shunt evaluated by TEE had a sensitivity of 35% and an accuracy of 56 %. Accuracy was significantly greater in TTE than in TEE (p = 0.02). In conclusion, TTE identified large RL shunt associated with CS with higher sensitivity and accuracy compared to TEE. Our findings suggest that the decision for device closure should be made based on the severity of RL shunt by TTE.

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Importance of Contrast Transthoracic Echocardiography for Evaluating Large Right-to-Left Shunt in Patent Foramen Ovale Associated with Cryptogenic Stroke

10.21203/rs.3.rs-760835/v1 ◽

2021 ◽

Author(s):

Yoichi Takaya ◽

Rie Nakayama ◽

Teiji Akagi ◽

Fumi Yokohama ◽

Takashi Miki ◽

...

Keyword(s):

High Risk ◽

Transesophageal Echocardiography ◽

Transthoracic Echocardiography ◽

Patent Foramen Ovale ◽

Transcatheter Closure ◽

Cryptogenic Stroke ◽

Effective Therapy ◽

Foramen Ovale

Abstract Transcatheter closure of patent foramen ovale (PFO) is an effective therapy for preventing cryptogenic stroke (CS). The identification of high-risk PFO, which is more likely to be linked to CS, is essential. This study aimed to assess the accuracy of contrast transthoracic echocardiography (TTE) for evaluating large right-to-left (RL) shunt. We enrolled 119 patients with or without CS who were confirmed to have PFO. The severity of RL shunt evaluated by contrast TTE and transesophageal echocardiography (TEE) was classified as follows: small (<10 microbubbles), moderate (10–20 microbubbles), and large (>20 microbubbles). With contrast TTE, large RL shunt was observed in 94 (79%) of 119 patients, including 66 of 74 with CS and 28 of 45 without CS. With contrast TEE, large RL shunt was observed in 33 (28%) patients, including 26 with CS and 7 without CS. Contrast TTE showed large RL shunt more frequently than contrast TEE (p < 0.01). Large RL shunt evaluated by contrast TTE had a sensitivity of 89% and an accuracy of 70% for the association with CS, whereas large RL shunt evaluated by contrast TEE had a sensitivity of 35% and an accuracy of 56%. Accuracy was significantly greater in contrast TTE than in contrast TEE (p = 0.02). In conclusion, contrast TTE identified large RL shunt more frequently. Large RL shunt evaluated by contrast TTE provided greater accuracy for the association with CS. Our findings suggest that contrast TTE is valuable for evaluating large RL shunt as high-risk PFO.

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Importance of contrast transthoracic echocardiography for evaluating large right-to-left shunt in patent foramen ovale associated with cryptogenic stroke

10.22541/au.162376891.16321495/v1 ◽

2021 ◽

Author(s):

Yoichi Takaya ◽

Rie Nakayama ◽

Teiji Akagi ◽

Fumi Yokohama ◽

Takashi Miki ◽

...

Keyword(s):

High Risk ◽

Transesophageal Echocardiography ◽

Transthoracic Echocardiography ◽

Patent Foramen Ovale ◽

Transcatheter Closure ◽

Cryptogenic Stroke ◽

Effective Therapy ◽

Foramen Ovale

Background: Transcatheter closure of patent foramen ovale (PFO) is an effective therapy for preventing cryptogenic stroke (CS). The identification of high-risk PFO, which is more likely to be linked to CS, is essential. This study aimed to assess the accuracy of contrast transthoracic echocardiography (TTE) for evaluating large right-to-left (RL) shunt. Methods: We enrolled 119 patients with or without CS who were confirmed to have PFO. The severity of RL shunt evaluated by contrast TTE and transesophageal echocardiography (TEE) was classified as follows: small (<10 microbubbles), moderate (10–20 microbubbles), and large (>20 microbubbles). Results: With contrast TTE, large RL shunt was observed in 94 (79%) of 119 patients, including 66 of 74 with CS and 28 of 45 without CS. With contrast TEE, large RL shunt was observed in 33 (28%) patients, including 26 with CS and 7 without CS. Contrast TTE showed large RL shunt more frequently than contrast TEE (P < .01). Large RL shunt evaluated by contrast TTE had a sensitivity of 89% and an accuracy of 70% for the association with CS, whereas large RL shunt evaluated by contrast TEE had a sensitivity of 35% and an accuracy of 56%. Accuracy was significantly greater in contrast TTE than in contrast TEE (P = .02). Conclusion: Contrast TTE identified large RL shunt more frequently. Large RL shunt evaluated by contrast TTE provided greater accuracy for the association with CS. Our findings suggest that contrast TTE is valuable for evaluating large RL shunt as high-risk PFO.

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How does transcatheter device closure compare with medical therapy for preventing recurrent stroke in people with cryptogenic stroke and patent foramen ovale?

Cochrane Clinical Answers ◽

10.1002/cca.1248 ◽

2016 ◽

Keyword(s):

Medical Therapy ◽

Patent Foramen Ovale ◽

Recurrent Stroke ◽

Cryptogenic Stroke ◽

Foramen Ovale ◽

Device Closure ◽

Transcatheter Device

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Recurrent Stroke/TIA in Cryptogenic Stroke Patients with Patent Foramen Ovale

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/s0317167100005825 ◽

2007 ◽

Vol 34 (1) ◽

pp. 74-80 ◽

Cited By ~ 31

Author(s):

Leanne Casaubon ◽

Peter McLaughlin ◽

Gary Webb ◽

Erik Yeo ◽

Darren Merker ◽

...

Keyword(s):

Patent Foramen Ovale ◽

Recurrent Events ◽

Recurrent Stroke ◽

Cryptogenic Stroke ◽

Antiplatelet Agents ◽

Secondary Outcome ◽

Foramen Ovale ◽

Device Closure ◽

Surgical Closure ◽

Significant Difference

Background:Patent foramen ovale (PFO) is present in 40% of patients with cryptogenic stroke and may be associated with paradoxical emboli to the brain. Therapeutic options include antiplatelet agents, anticoagulation, percutaneous device and surgical closure. We assessed the hypothesis that there are differences in rates of recurrent TIA or stroke between patients in the four treatment groups.Methods:Patients presenting from January 1997 with cryptogenic stroke or TIA and PFO were followed prospectively until June 2003. Treatment choice was made on an individual case basis. The primary outcome was recurrent stroke. The secondary outcome was a composite of stroke, TIA, and vascular death.Results:Baseline. Our cohort consisted of 121 patients; 64 (53%) were men. Median age was 43 years. Sixty-nine percent presented with stroke and 31% with TIA. One or more vascular risk factor was present in 40%. Atrial septal aneurysm (ASA) was present in 24%. Treatment consisted of antiplatelet agents (34%), anticoagulation (17%), device (39%) and surgical closure (11%). Follow-up. Recurrent events occurred in 16 patients (9 antiplatelet, 3 anticoagulation, 4 device closure); 7 were strokes, 9 were TIA. Comparing individual treatments there was a trend toward more strokes in the antiplatelet arm (p=0.072); a significant difference was seen for the composite endpoint (p=0.012). Comparing closure versus combined medical therapy groups, a significant difference was seen for primary (p=0.014) and secondary (p=0.008) outcomes, favoring closure. Age and pre-study event predicted outcome.Conclusion:Patent foramen ovale closure was associated with fewer recurrent events. Complications of surgical and device closure were self-limited.

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Management of Patients with Patent Foramen Ovale and Cryptogenic Stroke: An Update

Cardiology ◽

10.1159/000501028 ◽

2019 ◽

Vol 143 (1-2) ◽

pp. 62-72 ◽

Cited By ~ 3

Author(s):

Mohammad Abdelghani ◽

Sahar A.O. El-Shedoudy ◽

Martina Nassif ◽

Berto J. Bouma ◽

Robbert J. de Winter

Keyword(s):

Healthy Subjects ◽

Patent Foramen Ovale ◽

Recurrent Stroke ◽

Cryptogenic Stroke ◽

Paradoxical Embolism ◽

Atrial Septal Aneurysm ◽

Evidence Based ◽

Foramen Ovale ◽

Device Closure ◽

Interatrial Shunt

Patent foramen ovale (PFO) is a common benign finding in healthy subjects, but its prevalence is higher in patients with stroke of unclear cause (cryptogenic stroke). PFO is believed to be associated with stroke through paradoxical embolism, and certain clinical and anatomical criteria seem to increase the likelihood of a PFO to be pathological. Recent trials have shown that closure of PFO, especially if associated with an atrial septal aneurysm and/or a large interatrial shunt, may reduce the risk of recurrent stroke as compared to medical treatment. However, it remains challenging to risk stratify patients with suspected PFO-related stroke and to decide if device closure is indicated. We sought to review contemporary evidence and to conclude an evidence-based strategy to prevent recurrence of PFO-related stroke.

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Importance of direct right-to-left shunt as high-risk patent foramen ovale associated with cryptogenic stroke

10.22541/au.162896461.11410200/v1 ◽

2021 ◽

Author(s):

Yoichi Takaya ◽

Rie Nakayama ◽

Teiji Akagi ◽

Fumi Yokohama ◽

Takashi Miki ◽

...

Keyword(s):

Multivariate Analysis ◽

High Risk ◽

Patent Foramen Ovale ◽

Detection Rate ◽

Transcatheter Closure ◽

Cryptogenic Stroke ◽

Atrial Septal Aneurysm ◽

Foramen Ovale ◽

Incremental Value ◽

Functional Features

Background: Because transcatheter closure of patent foramen ovale (PFO) has become effective for preventing cryptogenic stroke (CS), it is necessary to determine high-risk PFO associated with CS. This study aimed to clarify the importance of direct right-to-left (RL) shunt through the PFO for identifying high-risk PFO. Methods: We analyzed 137 patients with and without CS who were confirmed to have PFO. The timing of RL shunt through the PFO was evaluated by cardiac cycles after right atrium (RA) opacification on saline contrast transesophageal echocardiography. Direct RL shunt was defined as microbubbles crossing the PFO before and at the same time of RA opacification. Results: Cardiac cycles of microbubbles crossing the PFO were shorter in patients with CS than in those without CS (2.0 ± 2.2 vs. 0.5 ± 1.1, P < .01). Direct RL shunt was more frequently observed in patients with CS than in those without CS (77% vs. 29%, P < .01), with a sensitivity of 79% and a specificity of 71% for the association with CS. Multivariate analysis revealed that direct RL shunt was related to atrial septal aneurysm and low-angle PFO. Regarding functional features of PFO, the detection rate of CS was 50% for large RL shunt alone, and was increased to 83% when direct RL shunt was added. Conclusion: Direct RL shunt was associated with CS and had the incremental value in detecting PFO associated with CS for large RL shunt. The timing of RL shunt can be valuable for identifying high-risk PFO.

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Residual Shunt after Patent Foramen Ovale Device Closure in Patients With Cryptogenic Stroke: Serial Bubble Contrast Transesophageal Echocardiography Data

Journal of Stroke and Cerebrovascular Diseases ◽

10.1016/j.jstrokecerebrovasdis.2018.10.006 ◽

2019 ◽

Vol 28 (2) ◽

pp. 347-353 ◽

Cited By ~ 3

Author(s):

Jeonggeun Moon ◽

Minsu Kim ◽

Pyung Chun Oh ◽

Dong Hoon Shin ◽

Hyeon-MI Park ◽

...

Keyword(s):

Transesophageal Echocardiography ◽

Patent Foramen Ovale ◽

Cryptogenic Stroke ◽

Foramen Ovale ◽

Device Closure ◽

Residual Shunt

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Closure versus medical therapy for preventing recurrent stroke in patients with patent foramen ovale and a history of cryptogenic stroke or transient ischemic attack

10.1002/14651858.cd009938 ◽

2012 ◽

Author(s):

Jie Li ◽

Ming Liu ◽

Shihong Zhang ◽

Zilong Hao ◽

Canfei Zhang ◽

...

Keyword(s):

Medical Therapy ◽

Transient Ischemic Attack ◽

Patent Foramen Ovale ◽

Recurrent Stroke ◽

Cryptogenic Stroke ◽

Foramen Ovale ◽

History Of ◽

Ischemic Attack

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Abstract TMP13: Baseline DWMRI Characteristics In Patients With Cryptogenic Stroke And Patent Foramen Ovale: Results From The Closure I Trial

Stroke ◽

10.1161/str.44.suppl_1.atmp13 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Richard Jung ◽

Benny Kim ◽

Joseph Massaro ◽

Anthony J Furlan

Keyword(s):

Patent Foramen Ovale ◽

Cox Regression ◽

Recurrent Stroke ◽

Cryptogenic Stroke ◽

Patient Characteristics ◽

Paradoxical Embolism ◽

Foramen Ovale ◽

Anterior Circulation ◽

Significant Difference ◽

Multivariate Proportional Hazard

Background: Cryptogenic stroke may have several etiologies including paradoxical embolism through a patent foramen ovale (PFO). A cardiac source of embolism may be suggested by multiple infarcts, sometimes hemorrhagic, in different vascular distributions or a cortical wedge shaped infarct. We report the baseline diffusion weighted MRI (DWMRI) characteristics in patients with cryptogenic stroke and a patent foramen ovale (PFO) from the CLOSURE I trial. Methods: CLOSURE I compared device closure versus medical therapy for secondary prevention in patients with cryptogenic TIA or stroke and a PFO. Of 909 patients randomized, 562 patients demonstrated acute infarcts on baseline DWMRI and are included in this analysis. Multivariate proportional hazard Cox regression compared imaging subgroups with remaining randomized patients Results: Single infarcts were found in 62% of patients. Of these, 61% were anterior circulation, 30% posterior, and 8.5% were of uncertain territory. Of the anterior circulation infarcts, 40% were cortical, 36% subcortical, and 24% affected both the cortical and subcortical regions. Of the posterior circulation infarcts, 45% were thalamic or cerebellar. Of 562 patients, 18.5% had a single subcortical lesion <1.5cm in diameter and met the radiological definition of an acute lacunar infarct. Multiple infarcts were found in 38%. Infarcts in a single vascular territory were found in 23%, often in the anterior circulation (66%). Infarcts in multiple vascular territories were found in 15%. Hemorrhagic infarction was present in 9%. Adjusting for patient characteristics, no significant difference in 2 year rate of TIA, stroke or death was found compared to remaining randomized patients. Discussion: The specificity of infarct patterns for embolism in patients with cryptogenic stroke and a PFO is uncertain. We found no significant relationship between lacunar or subcortical infarction and the risk of recurrent TIA or stroke. Baseline infarct patterns on DWMRI in patients with cryptogenic stroke and PFO may not be useful in predicting recurrent stroke risk or determining best prevention therapy.

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