Percutaneous transcatheter closure of interatrial septal defect in adults: procedural outcome and long-term results.

BACKGROUND: Percutaneous transcatheter closure of patent foramen ovale (PFO) and atrial septal defect (ASD) has been shown to be feasible. AIM: The aim of this study was to evaluate the safety and efficacy of transcatheter interatrial septal shunt closure with prosthesis implantation in adults patients during long-term follow-up. In addition, the impact of thrombophilia and pulmonary hypertension on the outcome were investigated. METHODS: Between June 1999 and November 2009, 287 patients (112 males, 43 ± 14 years) were treated in our institution by transcatheter closure of PFO (N = 175) or ASD (N = 112). Clinical and echocardiographic follow-up were prospectively performed at 1, 6 and 12 months followed by a 1 once a year evaluation. RESULTS: All procedures were successful with eight procedural complications (2.7%): one stroke, two femoral pseudoaneurysms, three transient atrial fibrillation, two minors pericardial effusions. Among patients with presumed paradoxical embolism, thrombophilia was observed in 29 patients (17%); only one of them experienced a recurrent stroke. Among patients with ASD, pulmonary hypertension was observed in 32 cases (28%) and significantly reduced 6 months after shunt closure (from 47 ± 7 to 31 ± 11 mm Hg, P < 0.0001). 99% of patients achieved a complete follow-up. Clinical improvement was observed in 93%. Freedom from death, cardiac surgery or recurrent embolism was 98 ± 1% at 5 years. CONCLUSION: Percutaneous transcatheter interatrial septal defect closure is a safe and effective treatment in adults patients, even in case of thrombophilia or pulmonary hypertension, during a long-term follow-up, up to 11 years.

Early ischemic lesions following subarachnoid hemorrhage: common cold remedy as precipitating factor?

A 46-year-old woman presented with tetraplegia contrasting with a relatively preserved consciousness following aneurysmal subarachnoid hemorrhage (SAH). Multiple ischemic lesions were detected by magnetic resonance imaging (MRI), in the absence of vasospasm or signs of increased intracranial pressure. During the weeks before SAH, the patient had repeatedly used a nasal decongestant containing phenylephrine. After coiling of the aneurysm harboured by the right posterior cerebral artery, symptomatic vasospasm developed in the territory of the right middle cerebral artery and required aggressive therapy by intra-arterial infusion of milrinone followed by continuous intravenous administration. Follow-up MRI did not reveal new ischemic lesions. Echocardiography had demonstrated the presence of a patent foramen ovale. At 3 months follow-up, a major motor deficit persisted with akinetic mutism. The mechanisms of multiple early infarction following aneurysmal SAH are still debated, as vasospasm is usually not seen on the first imaging. Among precipitating factors of microvascular vasospasm, vasoactive substances like phenylephrine, may play a significant role.

Possible overlap between reversible cerebral vasoconstriction syndrome and symptomatic vasospasm after aneurysmal subarachnoid hemorrhage.

A 34-year-old woman with a previous history of severe headache ("thunderclap") was admitted with a diagnosis of aneurysmal subarachnoid hemorrhage (SAH). The patient developed symptomatic vasospasm on day 5 that resolved rapidly after having increased arterial blood pressure. She experienced also short-lasting excruciating headache. On day 12, while velocities had normalised, as revealed by transcranial Doppler (TCD), for more than 48 h, she developed aphasia and right hemiplegia associated with diffuse segmental vasospasm on the left middle cerebral artery. Intra-arterial infusion of vasodilatory agents was required. Recurrence of symptomatic vasospasm was noted on day 25, with a great number of territories involved as shown in the cerebral angiogram. A second intra-arterial treatment was needed. The patient complained of multiple episodes of extremely severe headache ("thunderclap"), with also transient dysarthria and hemiparesia on day 30. She was discharged on day 38 after full recovery. The clinical and TCD/radiological findings were consistent with a reversible cerebral vasoconstriction syndrome overlapping SAH related symptomatic vasospasm.

Absence of recurrent stroke after percutaneous closure of patent foramen ovale despite residual right-to-left cardiac shunt assessed by transcranial Doppler.

BACKGROUND: Percutaneous transcatheter closure of patent foramen ovale has been proposed to prevent recurrent strokes in young adults. Contrast transcranial Doppler ultrasonography provides a functional, semiquantitative evaluation of right-to-left cardiac shunt. AIMS: To evaluate the efficacy of percutaneous closure of patent foramen ovale in suppressing right-to-left shunt (assessed using transcranial Doppler) and in preventing secondary stroke. METHODS: Sixty-six patients less than 55 years of age were selected from 81 consecutive patients evaluated for percutaneous closure of patent foramen ovale after one or more cryptogenic stroke. All patients presented with a right-to-left cardiac shunt and passage of more than 50 microbubbles or curtain pattern on transcranial Doppler. Follow-up tests included cardiac and neurological clinical evaluation, contrast transcranial Doppler, and echocardiography. RESULTS: Percutaneous closure was successful in all patients, without major persistent side-effects. Before closure, the rate of recurrent stroke events was 16.57 per 100 patient-years; after closure, no recurrent stroke events (including transient ischaemic attacks) occurred during a mean follow-up period of 3.73 years (p=0.0001). Contrast transcranial Doppler detected residual right-to-left cardiac shunt in 25/60 (41.7%) patients evaluated after 12 months; 20.0% of these patients had passage of more than 50 microbubbles on transcranial Doppler. CONCLUSION: Contrast transcranial Doppler is a useful tool in the selection of patients for percutaneous closure of patent foramen ovale. The absence of recurrent stroke events after transcatheter closure suggests that this procedure may prevent stroke by changing the foramen ovale configuration, even in cases of persisting shunt. Larger studies are needed to confirm these data.

Intravenous magnesium sulfate administration in a patient with refractory vasospasm following subarachnoid hemorrhage.

OBJECTIVE: Magnesium sulfate is being investigated for the prevention or treatment of vasospasm following subarachnoid hemorrhage. PATIENT: A 45-year-old woman suffered subarachnoid hemorrhage and developed after 8 days symptomatic vasospasm in the left middle cerebral artery (MCA) while she was receiving nimodipine prophylactically. METHODS AND RESULTS: Transcranial Doppler monitoring was performed. Cerebral autoregulation was abolished in the left MCA. Despite this finding the administration of a bolus dose of MgSO(4), followed by a continuous infusion in order to achieve serum magnesium levels in the range of 4-4.5 mg/dl (1.65-1.85 mmol/l), resulted in a marked decrease (12.2%) of the left MCA mean blood flow velocity, without clinically relevant change in systemic blood pressure (3%). This effect was maintained for at least 4 h. It did not prevent the development of ischemic lesions.