[Efficacy and outcome of transcatheter closure of patent foramen ovale in patients with cryptogenic stroke].
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Objective: To investigate the efficacy and outcome of transcatheter patent foramen ovale (PFO) closure in patients with cryptogenic stroke (CS). Methods: Sixty consecutive patients with cryptogenic stroke who undertook transcatheter PFO closure between May 2015 and September 2017 in Beijing Tiantan Hospital were enrolled in this prospective study.Transcranial Doppler (TCD) bubble test was performed and right-left shunt(RLS) was confirmed in all patients.Closure success rate,effective closure rate, complications, recurrence of ischemic stroke and new onset atrial fibrillation were evaluated. Results: A total of 60 patients (42 male,age range 24-68 (47±11)years) were included in the study.PFO size (motionless state) was (1.6±0.6)mm.RLS before closure was graded and 11 patients had moderate RLS and 48 patients had large RLS (include 41 patients who experienced shower or curtain effect).Closure success rate was 100% (60/60).No severe complications were observed.At 6 months,45 patients completed TCD bubble test.Of these, 4 patients suffered from moderate to large residual and thus effective closure rate was 91%(41/45).The mean follow-up period was 2-29 (median 12) months. During the follow-up, only 1 patient experienced recurrent cerebral infarction.New onset atrial fibrillation was not detected. Conclusion: Transcatheter PFO closure is effective,safe and related with a good outcome in reduction of recurrent CS for patients with PFO.目的： 探讨经导管封堵术治疗不明原因卒中合并卵圆孔未闭（PFO）的临床疗效及预后。 方法： 本研究为前瞻性研究。连续入选2015年5月至2017年9月在北京天坛医院心血管内科接受经导管PFO封堵术治疗的不明原因卒中合并PFO患者60例。所有入选患者均经颅多普勒超声（TCD）增强试验证实存在右向左分流。随访观察经导管PFO封堵术成功率、有效封堵率、并发症、脑缺血事件及新发心房颤动的发生情况。 结果： 本研究最终入选不明原因卒中合并PFO患者60例，其中男性42例，女性18例，年龄24~68（47±11）岁，PFO直径（静息状态）（1.6±0.6）mm。术前右向左分流量，中量者11例，大量者48例（其中淋浴状及雨帘状分流者41例）。经导管PFO封堵术成功率为100%（60/60），无严重围手术期并发症。术后随访2~29个月（中位数12个月），术后6个月45例患者完成TCD增强试验随访，其中，中、大量残余右向左分流者4例，有效封堵率达91%（41/45）。随访期间，仅1例患者脑梗死复发，无新发心房颤动发生。 结论： 经导管PFO封堵术治疗不明原因卒中合并PFO安全、有效，预后良好。.Keywords:
Transcranial Doppler
Stroke
Paradoxical Embolism
Paradoxical Embolism
Closure (psychology)
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Transcranial Doppler
Stroke
Right-to-left shunt
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Paradoxical Embolism
Transcranial Doppler
Stroke
Right-to-left shunt
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OBJECTIVE: Patent foramen ovale is associated with paradoxical embolism (PE) and stroke. Hypercoagulable states, such as antiphospholipid syndrome (APS), can exacerbate PE by increasing clot formation. The aim of this study was to verify whether patients with APS and stroke present a right-to-left shunt (RLS) with greater frequency than patients with APS but without stroke. METHODS: Fifty-three patients with APS were tested for RLS using contrast-enhanced transcranial Doppler (cTCD): 23 patients had a history of stroke (Stroke Group) and 30 had no history of stroke (No-stroke Group). RESULTS: cTCD was positive in 15 patients (65%) from the Stroke Group and in 16 patients (53%) in the No-stroke Group (p=0.56). The proportion of patients with a small RLS (<10 high-intensity transient sign or HITS) and a large RLS (>10 HITS) was similar between the groups without significant difference. CONCLUSIONS: Our data do not support the theory that paradoxical embolism may play an important role in stroke in APS patients.
Paradoxical Embolism
Stroke
Transcranial Doppler
Right-to-left shunt
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Abstract Background: It has been suggested that prominent Eustachian valve (EV) and Chiari's network (CN) predispose to paradoxical embolism but their presence in patients with presumed paradoxical stroke is not always easily detectable by transesophageal echocardiography (TEE). We sought to prospectively assess the frequency of EV/CN as assessed by intracardiac echocardiography (ICE) in patients submitted to patent foramen ovale (PFO) transcatheter closure in order to investigate their role in determining shunt severity and risk of multiple paradoxical embolisms. Methods: Over a 36‐month period, we prospectively enrolled 98 consecutive patients (mean age 37 ± 12.5 years, 68 females) with previous stroke referred to our center for PFO catheter‐based closure. All patients underwent transcranial Doppler ultrasound (TC‐D), TEE and ICE‐guided transcatheter closure. Results: After ICE study and measurements, a prominent EV or CN were diagnosed on ICE in 72 patients (73.4%), whereas in 45 (45.9%, P < 0.01) on TEE. Patients with EV/CN had more frequently a curtain pattern on TC‐D, a larger right‐to‐left shunt, and recurrent cerebral paradoxical embolisms before closure. EV/CN and medium‐large shunt on TEE were the strongest predictors of recurrent paradoxical embolisms. Conclusions: This study suggests that EV and CN have a deep impact on the pathophysiology of paradoxical embolism: EV and CN should be considered as adjunctive risk factors for paradoxical embolism in the decision‐making process involving PFO patients. © 2008 Wiley‐Liss, Inc.
Paradoxical Embolism
Transcranial Doppler
Valsalva maneuver
Stroke
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ABSTRACT PURPOSE Paradoxical thrombotic embolism via right‐to‐left cardiac shunt (RLS) is a risk factor of cryptogenic ischemic stroke. Transtemporal Doppler (TTD) is a valid method used in the detection of patent foramen ovale (PFO). Temporal acoustic bone windows are missing with increasing age and in some younger subjects. We studied prospectively whether Doppler ultrasound of the cervical arteries (submandibular internal carotid artery [ICA] and vertebral artery [VA]) is an alternative, when compared to TTD, in the detection and quantification of PFO. MATERIAL AND METHODS A total of 94 patients with sufficient temporal bone windows suffering from recent ischemic stroke underwent TTD and ICA ( n = 51) or TTD and VA ( n = 43). After injection of microbubbles, the numbers of artificial high‐intensity signals (HITS) were recorded at rest and after Valsalva maneuver. RESULTS For 47 patients in the ICA group, an RLS was found at rest in 23 patients and after Valsalva in 28 patients. At rest, sensitivity was 100%, specificity 96%, positive predictive value (ppv) 95.6%, and negative predictive value (npv) 100%. After Valsalva, sensitivity was 100%, specificity 95%, ppv 96.4%, npv 100%. For 43 patients in the VA group an RLS was found at rest in 14 patients and after Valsalva in 19 patients. At rest, sensitivity was 71.4%, specificity 100%, ppv 100%, and npv 87.8%. After Valsalva, 94.4%, 96%, 94.4%, and 96%, respectively. Pearson's correlations of the number of HITS between TTD and ICA and between TTD and VA were highly significant. CONCLUSIONS When transcranial acoustic bone windows are missing, Doppler ultrasound of the cervical submandibular ICA and VAs are valid screening methods to detect RLS due to a PFO.
Valsalva maneuver
Transcranial Doppler
Paradoxical Embolism
Right-to-left shunt
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Patent foramen ovale (PFO) is a potential risk factor for ischaemic stroke in young individuals. An interventional method of secondary stroke prevention in PFO patients is its percutaneous closure.To assess safety and effectiveness (i.e. lack of residual shunt) of percutaneous PFO closure in patients with history of cryptogenic cerebrovascular event.149 patients (56 men/93 women), aged 39 ± 12 years, underwent percutaneous PFO closure. The implantation was performed under local anaesthesia, guided by trans-oesophageal echocardiography (TEE) and fluoroscopy. Follow-up trans-thoracic echocardiography (TTE) was performed at 1 month and follow-up TEE at 6-months. In cases of residual shunt, additional TEE was performed after ensuing 6 months.Effective PFO closure (no residual shunt) was achieved in 91.3% patients at 6 months and 95.3% patients at 12 months. In 2 patients transient atrial fibrillation was observed during the procedure. In 2 patients, a puncture site haematoma developed and in 1 patient superficial thrombophlebitis was noted. In 1 patient a small pericardial effusion was observed, which resolved at day 3 post-procedurally, after administration of non-steroidal anti-inflammatory drugs.Percutaneous PFO closure seems to be a safe procedure when performed in a centre with adequate expertise with regard to these procedures.
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Right-to-left shunt
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Background: Recurrent paradoxical embolism after catheter‐based closure of right‐to‐left shunt (RLS) can be related to residual RLS. To improve closure success, we need a better understanding of the anatomic and device‐related factors associated with closure efficacy. Methods: Patients with cryptogenic neurologic events and severe RLS (Valsalva Spencer transcranial Doppler [TCD] grade 5/5+) who underwent patent foramen ovale (PFO) closure by either central pin (Amplatzer ® PFO [A‐PFO]) or central occluding (Amplatzer ® SO [A‐SO]) devices were evaluated for residual shunt by quantitative TCD evaluation at 3 months. The findings were correlated with atrial septal aneurysm (ASA), device type, and device size. Results: We closed 628 consecutive patients with either the A‐PFO (n = 327) or A‐SO (n = 301) device. The frequency of large defects, small defects, and ASA was 12%, 88%, and 44% of cases, respectively. Severe residual shunt was detected in 13% of A‐PFO and 7% of A‐SO recipients (P = 0.005). This difference was attributable to a much higher frequency of severe residual shunt among patients with large defects closed with the A‐PFO compared to the A‐SO device (12 out of 29 [41%] vs. 3 out of 42 [7%], respectively; P < 0.001). There was no significant difference in device failure frequency for small defects. The presence of ASA increased the frequency of severe residual shunt compared to those without this feature (36 out of 275 [13%] vs. 28 out of 353 [8%], respectively; P = 0.046) but did not influence device‐related differences. Conclusions: (1) Both noncentering and central occluding closure devices effectively reduce RLS after PFO closure. (2) Large PFO defects with or without ASA have lower residual shunt grades at 3 months when closed by central occluding devices. (J Interven Cardiol 2010;23:575–580)
Transcranial Doppler
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Shunting
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Transcranial Doppler
Paradoxical Embolism
Right-to-left shunt
Stroke
Risk Stratification
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