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.

scholarly journals Tilting the balance: hemidiaphragm paralysis leading to right to left cardiac shunt

2018 ◽  
Vol 11 (1) ◽  
pp. bcr-2018-227944
Author(s):  
Ali Raza Ghani ◽  
Mohsin Hamid ◽  
Puneet Dhillon ◽  
Waqas Ullah
Keyword(s):  
Pulmonary Hypertension ◽  
Patent Foramen Ovale ◽  
Congenital Abnormality ◽  
Rare Case ◽  
Foramen Ovale ◽  
X Ray ◽  
Chest X Ray ◽  
The Right ◽  
Pfo Closure ◽  
Cardiac Shunt

Patent foramen ovale (PFO) is a congenital abnormality present in 25%–30% of healthy adults and rarely leads to any sequelae. 1 2 It is associated with a left-to-right shunt which usually does not lead to any haemodynamic compromise. Occasionally, the shunt can get reversed; that is, right-to-left shunt occurs due to worsening pulmonary hypertension and can lead to persistent hypoxia. It is rare for the shunt reversal to happen in the absence of pulmonary hypertension. Here, we present an exceedingly rare case in a 61-year-old man presenting with hypoxia, was found to have shunt reversal due to unilateral diaphragmatic paralysis. He was successfully treated with PFO closure. The purpose of this report is to consider rare possibilities of PFO shunt reversal when the right-sided heart pressure is normal and to highlight that a simple chest X-ray can be a clue to the diagnosis.

Patent Foramen Ovale, the Role of Antiplatelet Therapy Alone or Anticoagulant Therapy Alone Versus Device Closure for Cryptogenic Stroke: A Review of the Literature and Current Recommendations

2020 ◽  
Vol 18 (2) ◽  
pp. 135-150
Author(s):  
Harsha S. Nagarajarao ◽  
Chandra P. Ojha ◽  
Archana Kedar ◽  
Debabrata Mukherjee
Keyword(s):  
Patent Foramen Ovale ◽  
Cryptogenic Stroke ◽  
Narrow Channel ◽  
Paradoxical Embolism ◽  
Current Evidence ◽  
Foramen Ovale ◽  
The Right ◽  
The Relationship ◽  
Current Guidelines

: Cryptogenic stroke and its relation to the Patent Foramen Ovale (PFO) is a long-debated topic. Recent clinical trials have unequivocally established the relationship between cryptogenic strokes and paradoxical embolism across the PFO. This slit-like communication exists in everyone before birth, but most often closes shortly after birth. PFO may persist as a narrow channel of communication between the right and left atria in approximately 25-27% of adults. : In this review, we examine the clinical relevance of the PFO with analysis of the latest trials evaluating catheter-based closure of PFO’s for cryptogenic stroke. We also review the current evidence examining the use of antiplatelet medications versus anticoagulants for stroke prevention in those patients with PFO who do not qualify for closure per current guidelines.

scholarly journals Short- and long-term haemodynamic consequences of transcatheter closure of atrial septal defect and patent foramen ovale

2021 ◽  
Author(s):  
X. Jin ◽  
Y. M. Hummel ◽  
W. T. Tay ◽  
J. F. Nauta ◽  
N. S. S. Bamadhaj ◽  
...  
Keyword(s):  
Atrial Septal Defect ◽  
Diastolic Function ◽  
Patent Foramen Ovale ◽  
Septal Defect ◽  
Transcatheter Closure ◽  
Foramen Ovale ◽  
Short And Long Term ◽  
Interatrial Shunt ◽  
Pfo Closure

Abstract Background Transcatheter atrial septal defect (ASD) and patent foramen ovale (PFO) closure might have opposite short- and long-term haemodynamic consequences compared with restricted interatrial shunt creation, which recently emerged as a potential treatment modality for patients with heart failure with preserved ejection fraction (HFpEF). Given the opposing approaches of ASD and PFO closure versus shunt creation, we investigated the early and sustained cardiac structural and functional changes following transcatheter ASD or PFO closure. Methods In this retrospective study, adult secundum-type ASD and PFO patients with complete echocardiography examinations at baseline and at 1‑day and 1‑year follow-up who also underwent transcatheter closure between 2013 and 2017 at the University Medical Centre Groningen, the Netherlands were included. Results Thirty-nine patients (mean age 48 ± standard deviation 16 years, 61.5% women) were included. Transcatheter ASD/PFO closure resulted in an early and persistent decrease in right ventricular systolic and diastolic function. Additionally, transcatheter ASD/PFO closure resulted in an early and sustained favourable response of left ventricular (LV) systolic function, but also in deterioration of LV diastolic function with an increase in LV filling pressure (LVFP), as assessed by echocardiography. Age (β = 0.31, p = 0.009) and atrial fibrillation (AF; β = 0.24, p = 0.03) were associated with a sustained increase in LVFP after transcatheter ASD/PFO closure estimated by mean E/e’ ratio (i.e. ratio of mitral peak velocity of early filling to diastolic mitral annular velocity). In subgroup analysis, this was similar for ASD and PFO closure. Conclusion Older patients and patients with AF were predisposed to sustained increases in left-sided filling pressures resembling HFpEF following ASD or PFO closure. Consequently, these findings support the current concept that creating a restricted interatrial shunt might be beneficial, particularly in elderly HFpEF patients with AF.

Does persistent (patent) foramen ovale closure reduce the risk of recurrent decompression sickness in scuba divers?

2021 ◽  
Vol 51 (1) ◽  
pp. 63-67
Author(s):  
Björn Edvinsson ◽  
◽  
Ulf Thilén ◽  
Niels Erik Nielsen ◽  
Christina Christersson ◽  
...  
Keyword(s):  
Patent Foramen Ovale ◽  
Decompression Sickness ◽  
Foramen Ovale ◽  
Residual Shunt ◽  
Interatrial Communication ◽  
Scuba Divers ◽  
Increased Risk ◽  
History Of ◽  
Catheter Closure ◽  
Pfo Closure

Introduction: Interatrial communication is associated with an increased risk of decompression sickness (DCS) in scuba diving. It has been proposed that there would be a decreased risk of DCS after closure of the interatrial communication, i.e., persistent (patent) foramen ovale (PFO). However, the clinical evidence supporting this is limited. Methods: Medical records were reviewed to identify Swedish scuba divers with a history of DCS and catheter closure of an interatrial communication. Thereafter, phone interviews were conducted with questions regarding diving and DCS. All Swedish divers who had had catheter-based PFO-closure because of DCS were followed up, assessing post-closure diving habits and recurrent DCS. Results: Nine divers, all with a PFO, were included. Eight were diving post-closure. These divers had performed 6,835 dives (median 410, range 140–2,200) before closure, and 4,708 dives (median 413, range 11–2,000) after closure. Seven cases with mild and 10 with serious DCS symptoms were reported before the PFO closure. One diver with a small residual shunt suffered serious DCS post-closure; however, that dive was performed with a provocative diving profile. Conclusion: Divers with PFO and DCS continue to dive after PFO closure and this seems to be fairly safe. Our study suggests a conservative diving profile when there is a residual shunt after PFO closure, to prevent recurrent DCS events.

Patient with systemic emboli in the setting of Klebsiella oxytoca tricuspid valve endocarditis and patent foramen ovale treated with NobleStitch and AngioVac

2021 ◽  
Vol 14 (8) ◽  
pp. e243370
Author(s):  
John Leso ◽  
Majd Al-Ahmad ◽  
Drinnon O Hand
Keyword(s):  
Tricuspid Valve ◽  
Patent Foramen Ovale ◽  
Klebsiella Oxytoca ◽  
Signs And Symptoms ◽  
Foramen Ovale ◽  
Surgical Debulking ◽  
History Of ◽  
Infectious Disease Specialists ◽  
High Index Of Suspicion ◽  
Pfo Closure

A 34-year-old man with a medical history of injection drug use presented with 2 weeks of weakness, nausea, vomiting and septic shock secondary to infective endocarditis of a native tricuspid valve. On admission, CT chest demonstrated multiple cavitary lesions as well as numerous small infarcts seen on MRI brain concerning for systemic septic emboli. Subsequent transthoracic echo with bubble study revealed a large patent foramen ovale (PFO). The patient later received surgical debulking of his tricuspid valve vegetation with AngioVac. Subsequently, PFO closure was performed with a NobleStitch device. The case presented here demonstrates the importance of having a high index of suspicion with right-sided endocarditis and the development of other systemic signs and symptoms. It also underscores the necessity of a multidisciplinary team of cardiologists, surgeons, infectious disease specialists and intensivists in the treatment of these complicated patients.

Patent Foramen Ovale and Migraine Headache

2017 ◽  
Vol 6 (4) ◽  
pp. 539-545 ◽  
Author(s):  
David Hildick-Smith ◽  
Timothy M. Williams
Keyword(s):  
Patent Foramen Ovale ◽  
Migraine Headache ◽  
Foramen Ovale

Is Migraine Associated with Right-to-Left Shunt a Separate Disease? Results of the SAM Study

Cephalalgia ◽  
2008 ◽  
Vol 28 (4) ◽  
pp. 360-366 ◽  
Author(s):  
GP Anzola ◽  
G Meneghetti ◽  
C Zanferrari ◽  
A Adami ◽  
L Dinia ◽  
...  
Keyword(s):  
Family History ◽  
Observational Study ◽  
Transcranial Doppler ◽  
Patent Foramen Ovale ◽  
Genetic Linkage ◽  
Personal History ◽  
Coagulation Disorders ◽  
Foramen Ovale ◽  
History Of ◽  
Pfo Closure

Migraine with aura (MA) is associated with the persistence of patent foramen ovale (PFO) in about 50% of cases, and migraineurs tend to have larger shunts than controls, suggesting that right-to-left shunt (RILES) determined by PFO could play a role in triggering migraine attacks. Moreover, some preliminary reports have suggested that PFO closure may give relief to both migraine and aura attacks. The aim of this study was to clarify if shunt-associated migraine (SAM) has clinical features that allow a distinction from shunt-unrelated migraine (SUM), in a prospective, multicentre, observational study (SAM study). We enrolled consecutive MA patients, who underwent a structured, standardized questionnaire for family and personal history and for detailed migraine features. All were systematically screened for RILES with transcranial Doppler, and for coagulation disorders. Overall, 460 patients were included; the SUM and SAM classes comprised 58% and 42% of patients, respectively. SAM patients were significantly younger (34.1 ± 10 vs. 37.1 ± 11 years), had a more frequent family history of migraine (76% vs. 66%) and a higher frequency of sensory symptoms of aura (51% vs. 41%); by contrast, there was a lesser association of SAM with other cardiac abnormalities and with coagulation disorders. The SAM study suggests that the effect of RILES on migraine features is not relevant. The higher family history of migraine in SAM suggests a possible genetic linkage between migraine and RILES.

A retrospective review of clopidogrel as primary therapy for migraineurs with right to left shunt lesions

Cephalalgia ◽  
2014 ◽  
Vol 34 (11) ◽  
pp. 933-937 ◽  
Author(s):  
Barbara T Spencer ◽  
Yasir Qureshi ◽  
Robert J Sommer
Keyword(s):  
Migraine Headache ◽  
Primary Therapy ◽  
Foramen Ovale ◽  
Trial Period ◽  
Complete Elimination ◽  
Open Label ◽  
Platelet Inhibitor ◽  
Open Label Trial ◽  
Severe Migraine ◽  
Pfo Closure

Background: The association of patient foramen ovale (PFO) and migraine headache (migraine) with aura (MA) is well established. Current research suggests a mechanistic link between platelet activation, paradoxical embolization and migraine in some patients. Methods: Clopidogrel, a platelet inhibitor, was added to existing migraine therapy, as a 4-week open-label trial in 15 women, aged 16–56 years, with severe migraine and documented right to left shunt (RLS). Results: 13/15 had >50% reduction or complete elimination of migraine symptoms. After completing the trial period, five responders remain on clopidogrel with ongoing benefit at 11.9 ± 4.5 months (6.5–20), one stopped clopidogrel because of side effects. Nine other responders underwent PFO closure and clopidogrel discontinuation. Eight of nine have had ongoing benefit. Conclusions: Clopidogrel may have a primary prophylactic role in migraine/RLS patients, but may also help select candidates who would benefit from PFO closure. A randomized clinical trial is being established.

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