Skip to main content

Advertisement

SpringerLink
Log in

Implications of detection of foramen ovale patent after cryptogenic ischemic stroke

  • Original Investigation
  • Published:
Journal of Echocardiography Aims and scope Submit manuscript

Abstract

Background

Therapeutic uncertainty is inherent in decisions in patients with patent foramen ovale (PFO) and cryptogenic stroke. We aimed to determine clinical implications of PFO identification in transesophageal echocardiography (TEE) after a cryptogenic ischemic stroke.

Methods

Consecutive TEE done between 2011 and 2015 in patients with previous cryptogenic stroke was evaluated. Clinical implications of PFO identification (closure and/or medical therapy) were retrieved from the medical records and discharge summaries. Adverse events related to therapy, stroke recurrence and death were analyzed during follow-up.

Results

Three-hundred one patients (mean age 59 ± 11 years; 61% male) underwent a TEE, of which 77 (26%) patients had a diagnosis of PFO. Patients with PFO were younger (56 ± 13 versus 60 ± 14, p = 0.03). Of those with PFO, 23 (30%) underwent percutaneous closure of PFO and these patients had more frequently complex or large PFO (p < 0.001 and p = 0.004, respectively). The remaining 54 (70%) were treated with medical therapy: 30 (39%) with antiplatelet therapy and 24 (31%) with oral anticoagulation. During follow-up (44 ± 17 months), only two patients had another stroke (both referred for PFO closure, while they were waiting for the procedure) and two patients, on whom PFO closure was not performed, died (not for cardiovascular causes).

Conclusion

PFO’s (size and complexity) and patients’ characteristics influenced clinical decision when PFO was detected on TEE. The risk for recurrent stroke was not increased in patients who did not undergo PFO closure; although two patients waiting for PFO closure had recurrent stroke, demonstrating its importance.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

Abbreviations

AF:

Atrial fibrillation

ASA:

Atrial septal aneurysm

ECG:

Electrocardiogram

h:

Hour

LA:

Left atrium

OAC:

Oral anticoagulation

PFO:

Patent foramen ovale

RA:

Right atrium

TEE:

Transesophageal echocardiography

TTE:

Transthoracic echocardiography

References

  1. Calvet D, Mas JL. Closure of patent foramen ovale in cryptogenic stroke: a never ending story. Curr Opin Neurol. 2014;27:13–9.

    Article  PubMed  Google Scholar 

  2. Furlan AJ, Reisman M, Massaro J, et al. Closure or medical therapy for cryptogenic stroke with patent foramen ovale. N Engl J Med. 2012;366:991–9.

    Article  CAS  PubMed  Google Scholar 

  3. Carroll JD, Saver JL, Thaler DE, et al. Closure of patent foramen ovale versus medical therapy after cryptogenic stroke. N Engl J Med. 2013;368:1092–100.

    Article  CAS  PubMed  Google Scholar 

  4. Meier B, Kalesan B, Mattle HP, et al. Percutaneous closure of patent foramen ovale in cryptogenic embolism. N Engl J Med. 2013;368:1083–91.

    Article  CAS  PubMed  Google Scholar 

  5. Rengifo-Moreno P, Palacios IF, Junpaparp P, et al. Patent foramen ovale transcatheter closure vs. medical therapy on recurrent vascular events: a systematic review and meta-analysis of randomized controlled trials. Eur Heart J. 2013;34:3342–52.

    Article  PubMed  Google Scholar 

  6. Mas JL, Derumeaux G, Guillon B, et al. Patent foramen ovale closure or anticoagulation vs. antiplatelets after stroke. N Engl J Med. 2017;377:1011–21.

    Article  CAS  Google Scholar 

  7. Søndergaard L, Kasner SE, Rhodes JF, et al. Patent foramen ovale closure or antiplatelet therapy for cryptogenic stroke. N Engl J Med. 2017;377:1033–42.

    Article  PubMed  Google Scholar 

  8. Ay H, Furie KL, Smith WS, et al. An evidence-based causative classification system for acute ischemic stroke. Ann Neurol. 2005;58(5):688–97.

    Article  Google Scholar 

  9. Pinto FJ. When and how to diagnose patent foramen ovale. Should it always be repaired? Heart. 2005;91:438–40.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  10. Vitarelli A, Mangieri E, Capotosto L, et al. Echocardiographic findings in simple and complex patent foramen ovale before and after transcatheter closure. Eur Heart J Cardiovasc Imaging. 2014;15(12):1377–85.

    Article  PubMed  Google Scholar 

  11. Pepi M, Evangelista A, Nihoyannopoulos P, et al. Recommendations for echocardiography use in the diagnosis and management of cardiac sources of embolism European Association of Echocardiography. Eur J Echocardiogr. 2010;11:461–76.

    Article  PubMed  Google Scholar 

  12. Kaatz S, Ahmad D, Spyropoulus C, et al. Definition of clinically relevant non-major bleeding in studies of anticoagulants in atrial fibrillation and venous thromboembolic disease in non-surgical patients: communication from the SSC of the ISTH. J Thromb Haemost. 2015;13:2119–26.

    Article  CAS  PubMed  Google Scholar 

  13. Saric M, Armour AC, Arnaout MS, et al. Guidelines for the use of echocardiography in the evaluation of a cardiac source of embolism. J Am Soc Echocardiogr. 2016;29(1):1–42.

    Article  PubMed  Google Scholar 

  14. McGrath ER, Paikin JS, Motlagh B, et al. Transesophageal echocardiography in patients with cryptogenic ischemic stroke: a systematic review. Am Heart J. 2014;168:706–12.

    Article  PubMed  Google Scholar 

  15. Handke M, Harloff A, Olschewski M, et al. Patent foramen ovale and cryptogenic stroke in older patients. N Engl J Med. 2007;357:2262–8.

    Article  CAS  PubMed  Google Scholar 

  16. Rodrigues AC, Picard MH, Carbone A, et al. Importance of adequately performed valsalva maneuver to detect patent foramen ovale during transesophageal echocardiography. J Am Soc Echocardiogr. 2013;26:1337–43.

    Article  PubMed  Google Scholar 

  17. Buttignoni SC, Khorsand A, Mundigler G, et al. Agitated saline versus polygelatine for the echocardiographic assessment of patent foramen ovale. J Am Soc Echocardiogr. 2004;17:1059–65.

    Article  PubMed  Google Scholar 

  18. Gladstone D, Spring M, Dorian P, et al. Atrial fibrillation in patients with cryptogenic stroke. N Engl J Med. 2014;370:2467–77.

    Article  CAS  PubMed  Google Scholar 

  19. Sanna T, Diener HC, Passman RS, et al. Cryptogenic stroke and underlying atrial fibrillation. N Engl J Med. 2014;370(26):2478–86.

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Cardiology Department, Centro Hospitalar de Setubal, Rua Camilo Castelo Branco 175, 2910-446, Setubal, Portugal

    Rita Marinheiro, Leonor Parreira, Pedro Amador, Isabel Silvestre, Carla Antunes & Rui Caria

Authors
  1. Rita Marinheiro
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Leonor Parreira
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Pedro Amador
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Isabel Silvestre
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Carla Antunes
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Rui Caria
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Rita Marinheiro.

Ethics declarations

Conflict of interest

Rita Marinheiro, Leonor Parreira, Pedro Amador, Isabel Silvestre, Carla Antunes and Rui Caria declare that they have no conflict of interest.

Human rights statements and informed consent

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1964 and later revisions. Informed consent was obtained from all patients for being included in the study.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Marinheiro, R., Parreira, L., Amador, P. et al. Implications of detection of foramen ovale patent after cryptogenic ischemic stroke. J Echocardiogr 17, 44–51 (2019). https://doi.org/10.1007/s12574-018-0388-2

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12574-018-0388-2

Keywords

Search

Navigation