The Role of Patent Foramen Ovale Closure in the Secondary Prevention of Cryptogenic Stroke: a Meta-Analysis Report

Abstract Background: Patent foramen ovale (PFO) closure has been compared to medical therapy for secondary prevention of recurrent cryptogenic stroke. Objectives: To produce an updated meta-analysis including only data from the primary analyses of clinical trials and to evaluate the role of PFO closure in the secondary prevention of recurrent stroke. Methods: Search in Medline (PubMed) and in ISI Web of Knowledge. Parameters under analysis and meta-analyses were: stroke, transient ischemic attack (TIA) and atrial fibrillation (AF). Comprehensive Meta-analysis Software V.2.0 (Biostat) was used. Random-effects analyses were carried out. A level of significance of 5% was used. Results: In this study six, randomized trials enrolling 3,750 patients were included. Unlike other published meta-analyses on the same topic, in this case, only clinical trial data, and not follow-up data, were used. PFO closure, as compared with medical therapy alone, demonstrated superiority in reducing the rate of recurrent stroke (risk ratio with PFO closure vs. medical therapy, 0.37; 95% confidence interval [CI], 0.17 to 0.78; p = 0.01). PFO closure did not offer a significant benefit in prevention of TIA (risk ratio with PFO closure vs. medical therapy, 0.96; 95% CI, 0.64 to 1.44; p = 0.85). Among patients assigned to closure group, an increased risk of atrial fibrillation was seen (risk ratio with PFO closure vs. medical therapy, 4.64; 95% CI, 2.38 to 9.01; p < 0.01). Conclusions: In patients with cryptogenic stroke who had a patent foramen ovale, a protective effect of closure was seen concerning the risk of recurrent stroke, but not regarding the prevention of TIA.

Value of Contrast Transesophageal Echocardiography in the Detection of Intrapulmonary Vascular Dilatations in Hepatosplenic Schistosomiasis / Valor do Ecocardiograma Transesofágico com Contraste no Diagnóstico da Dilatação Vascular Intrapulmonar na Esquistossomose Hepatoesplênica

Abstract Background: Hepatopulmonary syndrome (HPS), found in cirrhotic patients, has been little studied in hepatosplenic schistosomiasis (HSS) and includes the occurrence of intrapulmonary vascular dilatations (IPVD). Contrast transesophageal echocardiography (cTEE) with microbubbles is more sensitive than contrast transthoracic echocardiography (cTTE) with microbubbles in the detection of IPVD in cirrhosis. Objective: To assess the performance of the cTEE, compared with that of cTTE, in detecting IPVD for the diagnosis of HPS in patients with HSS. Methods: cTEE and cTTE for investigation of IPVD and laboratory tests were performed in 22 patients with HSS. Agitated saline solution was injected in peripheral vein during the cTEE and cTTE procedures. Late appearance of the microbubbles in the left chambers indicated the presence of IPVD. Results of the two methods were compared by the Student's t-test and the chi-square test (p < 0.05). Results: cTEE was performed in all patients without complications. Three patients were excluded due to the presence of patent foramen ovale (PFO). The presence of IPVD was confirmed in 13 (68%) of 19 patients according to the cTEE and in only six (32%, p < 0.01) according to the cTTE. No significant differences in clinical or laboratory data were found between the groups with and without IPVD, including the alveolar-arterial gradient. The diagnosis of HPS (presence of IPVD with changes in the arterial blood gas analysis) was made in five patients by the cTEE and in only one by the cTTE (p = 0.09). Conclusion: In HSS patients, cTEE was safe and superior to cTTE in detecting IPVD and allowed the exclusion of PFO.

Resumo Fundamento: A síndrome hepatopulmonar (SHP), presente em pacientes cirróticos, é pouco estudada na esquistossomose hepatoesplênica (EHE) e inclui a ocorrência de dilatações vasculares intrapulmonares (DVP). O ecocardiograma transesofágico com contraste (ETEc) de microbolhas é mais sensível que o ecocardiograma transtorácico com contraste (ETTc) de microbolhas na identificação de DVP na cirrose. Objetivo: Avaliar o desempenho do ETEc comparado ao ETTc na identificação de DVP para diagnóstico de SHP em pacientes com EHE. Métodos: Incluímos 22 pacientes com EHE submetidos a ETEc e ETTc para pesquisa de DVP, além de exames laboratoriais. Os ETEc e ETTc foram realizados empregando-se solução salina agitada, injetada em veia periférica. A visualização tardia das microbolhas em câmaras esquerdas indicava presença de DVP. Os resultados foram comparados entre os dois métodos pelos testes t de Stu dent e qui-quadrado (significância p < 0,05). Resultados: Todos os 22 pacientes realizaram ETEc sem intercorrências. Foram excluídos três pela presença de forame oval patente (FOP), e a análise final foi realizada nos outros 19. A DVP esteve presente ao ETEc em 13 pacientes (68%) e em apenas seis ao ETTc (32%, p < 0,01). Não houve diferenças significativas nos dados clínicos e laboratoriais entre os grupos com e sem DVP, incluindo a diferença alveoloarterial de oxigênio. O diagnóstico de SHP (presença de DVP com alterações gasométricas) ocorreu em cinco pacientes pelo ETEc e em apenas um pelo ETTc (p = 0,09). Conclusão: Em pacientes com EHE, o ETEc foi seguro e superior ao ETTc na detecção de DVP não identificada ao ETTc, o que possibilitou adicionalmente excluir FOP.

Ruptura traumática de músculo papilar da valva tricúspide com forame oval patente adquirido e ruptura atrial direita oculta / Traumatic tricuspid valve papillary muscle case with concomitant acquired patent foramen ovale and covert right atrial rupture

RESUMO O traumatismo cardíaco é comum em acidentes com veículos automotores. Uma mulher com 50 anos de idade foi transportada para nosso hospital após sofrer múltiplos traumatismos em um acidente de automóvel quando dirigia em alta velocidade. Após admissão à unidade de terapia intensiva, uma ultrassonografia cardíaca revelou ruptura traumática de músculo papilar da valva tricúspide e forame oval patente, enquanto se observou, no exame físico, o sinal de Lancisi. Foi realizado tratamento cirúrgico com anuloplastia da valva e fechamento do forame oval patente; durante o ato cirúrgico, diagnosticou-se ruptura oculta do átrio direito.

ABSTRACT Cardiac trauma often occurs in motor vehicle accidents. A 50-year-old female driver was transported to our hospital with multiple trauma after a high-speed car accident. After admission to the intensive care unit, cardiac ultrasound examination revealed traumatic tricuspid valve papillary muscle rupture and patent foramen ovale, while Lancisi's sign was noted on physical examination. Surgical treatment was performed with valve annuloplasty and closure of the patent foramen ovale and a covert right atrial defect that was detected intraoperatively.

Giant thrombus entrapped by a patent foramen ovale in a patient with polycystic kidney disease

Polycystic kidney disease (PKD) is the most common genetic cause of chronic kidney disease (CKD). The most common cause of death in patients with this condition is cardiovascular disease, mainly due to hypertension and its consequences. We report a case of a 42-year-old male patient with polycystic kidney disease who developed a giant thrombus entrapped by a patent foramen ovale after an acute myocardial infarction (AU)

Foramen oval permeable / Patent foramen ovale

La frecuencia del foramen oval permeable es del 25% en la población general. En 40% de los eventos cerebrales isquémicos no hay una causa demostrable, pero en este grupo de pacientes el 46% tienen foramen oval permeable demostrable; una vez que este es capaz de permitir un cortocircuito de derecha a izquierda, existe la posibilidad del paso de un trombo que cause un evento isquémico vascular cerebral. Caso clínico: Paciente de 24 años que sufrió dos episodios de ataque isquémico transitorio sin causa determinada, dentro de los estudios de imágenes se le realizó eco-cardiograma y se encontró presencia de foramen oval permeable. Una vez que se diagnosticó la presencia del foramen oval sin otra causa que explicara el evento isquémico transitorio y además por tener cortocircuito espontáneo, se decidió el cierre percutáneo. Conclusión: en este caso se decidió por el procedimiento quirúrgico y se tomó el tamaño del foramen, los ataques isquémicos reincidentes y la edad de la paciente. Los resultados en un periodo de 2 años han sido totalmente satisfactorios...(AU)

Oclusão de artéria central da retina associada ao forame oval patente / Central retinal artery occlusion associated with patent foramen ovale

Oclusão da artéria central da retina é uma doença comumente encontrada em pacientes idosos, mas pode também ser vista em crianças e adultos jovens. Nestes, as principais causas são anomalias cardíacas, sendo o forame oval patente o mais observado. O objetivo do trabalho é relatar o caso de um paciente jovem com oclusão da artéria central da retina apresentando persistência de forame oval e, também, salientar a importância de uma propedêutica detalhada nos casos de oclusões vasculares da retina.

Central retinal artery occlusion it’s a disease most encountered in older patients, however it can be seen in children and young persons. In this situation the principal causes are cardiac abnormalities, and the patent foramen ovale is the most observed. The purpose of this study is to report a case of central retinal artery occlusion in a young patient with patent foramen ovale and, also, describe the importance of a detailed management in cases of retinal vascular occlusions.

Occluding the pulmonary artery to improve detection of patent foramen ovale during ventricular assist device placement.

Unrecognized patent foramen ovale (PFO) in patients after left ventricular assist device (VAD) placement could cause significant hypoxemia and paradoxical embolism. We aim to improve the techniques for PFO detection in this patient population before left ventricular device initiation. We evaluated the effects of main pulmonary artery occlusion on patients' hemodynamic and detection of PFO by transesophageal echocardiography (TEE). We compared between the standard and pulmonary artery occlusion technique. Sixty-two patients with ASA physical status class IV were studied. They presented with end-stage heart failure for left VAD placement. All patients received both Valsava maneuver and occlusion of their pulmonary arteries to assess their influence on detection of PFO. Occlusion of the main pulmonary artery consistently increased right atrial to left atrial pressure gradient. The PFO detection rate using TEE was significantly improved from 0% to 10% by this maneuver compared with the Valsava maneuver. Occlusion of the main pulmonary artery is a simple and effective method to improve PFO detection by TEE before left VAD initiation.

Forame oval permeável e sua relação com acidente vascular cerebral isquêmico (AVC) e enxaqueca / Permeable foramen ovale and its relation to ischemic stroke (stroke)and migraine

O forame oval permite, durante o período fetal, a passagem de sangue oxigenado oriundo da placenta para o átrio direito, possibilitando oxigenação adequada do cérebro e do coração. Após o nascimento, com o início da respiração e com a desconexão da placenta, há um aumento da pressão do lado esquerdo e uma diminuição do lado direito do coração, empurrando a lâmina do forame oval para a direita, o que ocasiona o seu fechamento funcional. Entretanto, em aproximadamente 25% da população ele pode permanecer patente. Sua relação com o acidente vascular isquêmico e com enxaqueca com aura tem sido sugerida em várias publicações. Na presença de acidente vascular isquêmico idiopático, tem sido sugerido por vários autores o fechamento percutâneo do forame oval patente (FOP), quando comprovada a existência de shunt da direita para a esquerda, espontaneamente ou com manobra de Valsalva. Contudo, hã necessidade de maior tempo de observação para avaliar a sua superioridade em relação ao tratamento clínico.

Foramen ovale allows the passage, during the fetal period, of oxygenated blood coming from the placenta to the right atrium, supplying adequate oxygenation for brain and heart. After birth, with onset of breathing and disconnection of the placenta, there are an increased pressure on the left side ofthe heart and a decreasing in its right side pushing the blade of the foramen ovale to the right, causing its functional closure. However, the patent foramen ovale (PFO) occurs in approximately 25% of the population. The relationship between cryptogenic stroke, migraine with aura and PFO has been suggestedin several publications. In the presence of cryptogenic stroke, percutaneous closure of PFO, when shown the existente of a shunt from right to left spontaneously or with the Valsalva maneuver, has been suggested by several authors. However, there is need of more observation time to assess its superiority over medica1 treatment.

Utilização de prótese bioabsorvível para oclusão de defeitos do septo atrial: um passo em direção ao futuro / Use of bioabsorbable device to close atrial septal defects: one step towards the future

INTRODUÇÃO: Apesar do sucesso das intervenções por cateter nos defeitos congênitos em geral, a possibilidade de se dispor de um dispositivo percutaneamente implantável e que desapareça sem deixar vestígios é altamente desejável. Neste estudo apresentamos a experiência inicial dos autores com uma nova prótese parcialmente bioabsorvível. Método: Foram selecionados pacientes portadores de forame oval patente (FOP) com pelo menos um evento embólico prévio, sem defeitos associados, passíveis de correção cirúrgica. O diagnóstico foi feito por meio de ecocardiograma transesofágico (ETE) e teste de bolhas. Durante o procedimento as próteses foram escolhidas de acordo com as medidas de comprimento e abertura do FOP, ao ETE. O seguimento foi realizado por meio de avaliação clínica e ecocardiograma transtorácico com um mês e três meses de ETE aos seis meses após o implante. Os pacientes utilizaram a associação de ácido acetilsalicilico e clopidogrel por três meses a ácido acetilsalicilico isolado nos três meses subsequentes. A profilaxia antimicrobiana...

BACKGROUND: Despite the overall high success rate of per-cutaneous intervention in congenital defects, the possibility of having a percutaneous bioabsorbable implantable device is extremely desirable. The initial experience of the authors with a new partially bioabsorbable prosthesis is reported in this study. METHOD: Patients with patent foramen ovale (PFO), with at least one previous embolic event, without additional surgical defects were selected. Diagnosis was made by transesophageal echocardiography (TEE) and the bubble test. Devices were chosen according to length and opening of PFO at the TEE. Patients were followed-up by transthoracic echocardiogram at 1 and 3 months and TEE at 6 months post implantation. Patients received a combination of acetylsalicylic acid and clopidogrel for 3 months and acetylsalicylic acid for another 3 months. Patients were maintained on antimicrobial prophylaxis for infectious endocarditis for 6 months. RESULTS: Nine patients (5 male and 4 female) were treated from February to August 2010. Mean age was 43.4 ± 13.5 years and mean weight was 71.4 ± 16.3 kg. Pulmonary arterial pressure was normal in all of the patients. PFO tunnel lengths ranged from 6-11 mm and the opening ranged from 2-3 mm. Mean range from rest to stretched PFO opening was 2.1 ± 0.8 mm. Prosthesis implantation was possible in all of the cases. Thirteen devices were used in 9 patients, and one of them required a second device for an additional orifice. No major complications or procedure-related deaths were observed. CONCLUSION: The use of the BioSTAR TM device was safe and effective. It is an excellent alternative for PFO closure.

Non-invasive assessment of secundum atrial septal defect [ASD] versus patent foramen ovale by the use of transthoracic echocardiography [TTE] and 12 lead ECG in adults and adolescence. Efficacy of the procedure and results compared to transoesphageal echocardiography [TEE]

Transthoracic echocardiography represents a non-invasive technique for assessment of secundum atrial septal defect. However in some patients it is not always simple to identify the edges of the defect due to technical problems, obesity or echocardiographic experience. Transoephageal echocardiography represents the golden tool in assessment of secundum defects but may represent probable hazards of invasive procedures. Retrograde study in all patients who were diagnosed to have secundum ASD by TEE. All patients were subjected to TTE by different investigator and the results was calculated for sensitivity and specificity. The results were added to 12 lead ECG to assess the efficacy of 12 lead ECG to increased sensitivity and specificity of presence of secundum atrial defect than transthoracic echocardiography alone. All patients were adults and adolescence. Randomized study using 143 cases 96 females and 47 males with mean age 30 +/- 14 years youngest 14 years old and eldest 59 years old, referred to the National Heart Institute with suspected atrial septal defect by echocardiography. All patients were analyzed for clinical problems namely chest pain or dyspnoea and patients with atrial fibrillation were excluded from the study. Transthoracic echocardiography was used to prove the presence of secundum defect by apical 4 chamber, apical 2 chamber, parasternal and subcostal views, and blood flow by Doppler across the defect was analyzed and dimensions of the defect were calculated in millimeter together with the presence of tricuspid regurge +/- paradoxical septal wall motion abnormality. 12 lead ECG was used to prove the presence of right bundle block [RBBB] namely rsR, rSr or qRc. Right axis deviation and right ventricular strain are also detected. Transoephageal echocardiography was used in all patients to prove the secundum defect and analyze the results compared to transthoracic echocardiography and 12 lead ECG. The presence of right bundle block [RBBB] rsR was 48%, rSr 16%, and qRc 8%. All patients had incidence of RBBB in 62% of cases. Transthoracic echocardiography was used to prove the presence of secundum defect by apical 4 chamber, apical 2 chamber, parastemal and subcostal views were effective in only 24%, and blood flow by Doppler across the defect was not possible in all patients. The size of the defect were not calculated in all patients. Tricuspid regurge with different significant grades was present in 18% in of all patients and 75% in patients with secundum defect. Paradoxical septal wall motion abnormality was present in 9.1%. Transoephageal echocardiography was used in all patients, secundum defect were present in 42% of all patients and 100% of all patients with documented transthoracic data of secundum ASD +/- ECG of RBBB. The presence of secundum ASD is more common in females. Transthoracic echocardiography alone is not effective in giving proven data of secundum ASD except in 24% of patients. Combined use of 12 lead ECG of presence of RBBB and experienced non-invasive transthoracic echocardiography increase the possibility of proving the presence of secundum atrial septal defect with sensitivity of 85% and specificity 89%. Right axis deviation is detected in 52% and right ventricular strain in 15%, TEE remains the gold standard in proving the presence of secundum ASD with high sensitivity and specificity

Percutaneous transvenous mitral commissurotomy [PTMC] through patent foramen ovale [PFO] a novel approach

To evaluate the safety and efficacy of percutaneous transvenous mitral commissurotomy [PTMC] via patent foramen ovale [PFO] in patients with severe mitral stenosis [MS]. All patients underwent trans-thoracic and trans-esophageal echocardiogram before PTMC. Patent foramen ovale was probed with assembly pointing posteriorly, a little below aortic valve in lateral view. If access to the left atrium could not be gained, transeptal puncture with Bronkenbrough needle was performed and the rest of the PTMC performed with standard Inoue balloon. Out of 500 patients 370 [64%] were females and 130 [36%] were males. The mean age was 27.51 +/- 7.82 years. PFO was probed and crossed in 435/500 [87%] patients. All PFO's were crossed within 15 +/- 04 minutes of commencement of probing. Spending a longer time searching for PFO did not increase the yield. Mean valve area was 0.86 +/- 0.19 cm[2], which increased to 1.86 +/- 0.17 cm[2] immediately after PTMC [p <0.05]. The mean mitral valve gradient decreased from 17 +/- 4.04 mmHg to 6.8 + 0.25 mmHg immediately after PTMC [p <0.005]. No pericardial effusion/tamponade observed in PFO group. The time to cross mitral valve was significantly reduced while accessing through PFO as compared to interatrial septal puncture. PTMC performed via patent foramen ovale is safe. It associated reduces the time of the procedure and complications

Forame oval patente e acidente vascular cerebral isquêmico em jovens: associação causal ou estatística? / Patent foramen ovale and ischemic stroke in young people: statistical association or causal relation?

OBJETIVOS: Determinar se há evidências de uma relação causal entre forame oval patente (FOP) e acidente vascular cerebral isquêmico (AVCI) criptogênico em jovens. Analisar essa relação à luz dos critérios de causalidade. MÉTODOS: Avaliaram-se, retrospectivamente, 168 pacientes jovens com AVCI, divididos em dois grupos: criptogênico e de causa definida. Como parte da rotina, os pacientes foram submetidos a pesquisa de FOP por ecocardiograma transesofágico e/ou Doppler transcraniano, ambos associados ao teste de bolhas. Demonstrada a associação estatística univariada entre FOP e AVCI, procedeu-se a análise multivariada. RESULTADOS: Após análise multivariada, a associação FOP e AVCI criptogênico mostrou-se ainda estatisticamente significante, com razão de chance (RCajustada de 3,3 (IC95 por cento 1,5-7,4). O número total de lesões no encéfalo também apresentou associação significativa com o AVCI criptogênico (RCajustada= 0,4 IC95 por cento 0,2-0,9). A associação FOP e AVCI criptogênico satisfez todos os critérios de causalidade. CONCLUSÃO: A relação causal entre o FOP e o AVCI criptogênico em jovens é altamente provável. Esse fato deve ser considerado na decisão terapêutica.

OBJECTIVES: To determine if there are evidences of a causal relation between patent foramen ovale (PFO) x cryptogenic ischemic stroke (IS) in the young population and to analyze this relation in terms of causal criteria. METHODS: A total of 168 young patients with IS was retrospectively evaluated and divided into two groups: cryptogenic and with a defined cause. As a routine procedure, the patients underwent investigation of the PFO by means of transesophageal echocardiogram and/or transcranial Doppler sonography, both of them associated with the bubble test. Multivariate analysis was performed after demonstration of univariate statistical association between PFO x IS. RESULTS: After multivariate analysis, the association between PFO x cryptogenic IS was still statistically significant with odds ratio (adjusted OR = 3.3; 95 percent CI: 1.5-7.4). The total number of cerebral lesions also presented a significant association with cryptogenic IS (adjusted OR = 0.4; 95 percent CI: 0.2-0.9). The association between PFO and cryptogenic IS met all the causality criteria. CONCLUSION: The causal relation between PFO and cryptogenic IS in the young population is highly probable. This fact should be considered in the therapeutic decision.