Incomplete Aneurysm Coverage after Patent Foramen Ovale Closure in Patients with Huge Atrial Septal Aneurysm: Effects on Left Atrial Functional Remodeling

Background: Large devices are often implanted to treat patent foramen ovale (PFO) and atrial septal aneurysm (ASA) with increase risk of erosion and thrombosis. Our study is aimed to assess the impact on left atrium functional remodeling and clinical outcomes of partial coverage of the approach using moderately small Amplatzer ASD Cribriform Occluder in patients with large PFO and ASA. Methods: We prospectively enrolled 30 consecutive patients with previous stroke (mean age 36 ± 9.5 years, 19 females), significant PFO, and large ASA referred to our center for catheter‐based PFO closure. Left atrium (LA) passive and active emptying, LA conduit function, and LA ejection fraction were computed before and after 6 months from the procedure by echocardiography. The preclosure values were compared to values of a normal healthy population of sex and heart rate matched 30 patients. Results: Preclosure values demonstrated significantly greater reservoir function as well as passive and active emptying, with significantly reduced conduit function and LA ejection fraction, when compared normal healthy subjects. All patients underwent successful transcatheter closure (25 mm device in 15 patients, 30 mm device in 6 patients, mean ratio device/diameter of the interatrial septum = 0.74). Incomplete ASA coverage in both orthogonal views was observed in 21 patients. Compared to patients with complete coverage, there were no differences in LA functional parameters and occlusion rates. Conclusions: This study confirmed that large ASAs are associated with LA dysfunction. The use of relatively small Amplatzer ASD Cribriform Occluder devices is probably effective enough to promote functional remodeling of the left atrium. (J Interven Cardiol 2010;23:362–367)     

Experience with ASDOS for Transcatheter Closure of Atrial Septal Defect and Patent Foramen Ovale

The atrial septal defect occluder system (ASDOS) (Osypka Corp., Grenzach-Wyhlen, Germany) has been used clinically for transcatheter closure of secundum atrial septal defect (ASD) and patent foramen ovale (PFO) after episodes of cerebral embolism over the last 10 years. In this article, the up-to-date experience with this system is reviewed.     

Atrial Septal Aneurysm,Shunt Size,and Recurrent Stroke Risk in Patients With Patent Foramen Ovale

BackgroundIn patients with patent foramen ovale (PFO)–associated stroke, the presence of large shunt or atrial septal aneurysm (ASA) has been suggested to convey a high risk of stroke recurrence.ObjectivesThe purpose of this study was to assess the respective influence of PFO size and ASA status on stroke recurrence under medical therapy in patients with recent PFO-associated stroke without alternative cause.MethodsThe authors pooled individual patient data from 2 prospective observational studies and the medical arms of 2 randomized trials, in which shunt size and ASA status was assessed by independent reading of echocardiographic images. Associations between PFO anatomical features and recurrent ischemic stroke were assessed by mixed effects Cox models.ResultsOf 898 patients (mean age 45.3 years), 178 (19.8%) had ASA with large PFO, 71 (7.9%) ASA with nonlarge PFO, 397 (44.2%) large PFO without ASA, and 252 (28.1%) nonlarge PFO without ASA. Over a median follow-up of 3.8 years (interquartile range: 2.6 to 5.5 years), 47 (5.2%) patients experienced a recurrent stroke. There was a heterogeneity across studies for the association between PFO size and stroke recurrence (p_interaction = 0.01). In a model accounting for age, hypertension, antithrombotic therapy, and PFO anatomy, ASA was independently associated with recurrent stroke (adjusted hazard ratio: 3.27; 95% confidence interval: 1.82 to 5.86; p < 0.0001), whereas large PFO was not (average adjusted hazard ratio across studies: 1.43; 95% confidence interval: 0.50 to 4.03; p = 0.50).ConclusionsIn patients with PFO-associated stroke, ASA is a more important predictor of recurrent stroke than shunt size. These results can help to better identify those patients with a high risk of stroke recurrence under medical therapy who may derive the most benefit from PFO closure. (Patent Foramen Ovale Closure or Anticoagulants Versus Antiplatelet Therapy to Prevent Stroke Recurrence [CLOSE]; NCT00562289) (Device Closure versus Medical Therapy in Patients with Cryptogenic Stroke and High-Risk Patent Foramen Ovale [DEFENSE-PFO]; NCT01550588)     

Cardiac Procedures to Prevent Stroke: Patent Foramen Ovale Closure/Left Atrial Appendage Occlusion

Stroke is a major contributor to population morbidity and mortality. Cardiac thromboembolic sources are an important potential cause of stroke. Left atrial appendage (LAA) thromboembolism in association with atrial fibrillation is a major contributor to stroke occurrence, particularly in elderly individuals. Patent foramen ovale (PFO) acts as a potential conduit from the right-sided circulation to the brain, and has been suggested to be an important factor in cryptogenic stroke in the young patients. Advances in interventional cardiology have made it possible to deal with these potential stroke sources (LAA and PFO), but the available methods have intrinsic limitations that must be recognized. Furthermore, the potential value of LAA and PFO closure depends on our ability to identify when the target structure is importantly involved in stroke risk; this is particularly challenging for PFO. This article addresses the clinical use of PFO and LAA closure in stroke prevention. We discuss technical aspects of closure devices and methods, questions of patient selection, and clinical trials evidence. We conclude that for PFO closure, the clinical trials evidence is thus far negative in the broad cryptogenic stroke population, but closure might nevertheless be indicated for selected high-risk patients. LAA closure has an acceptable balance between safety and efficacy for atrial fibrillation patients with high stroke risk and important contraindications to oral anticoagulation. Much more work needs to be done to optimize the devices and techniques, and better define patient selection for these potentially valuable procedures.     

封堵卵圆孔未闭在偏头痛中的应用

回顾偏头痛和卵圆孔未闭的发病情况和病理生理学机制,以及经导管封堵卵圆孔未闭对偏头痛的影响,评价其应用价值.     

Ischemic Attacks and Patent Foramen Ovale: Transcatheter Closure of Patent Foramen Ovale in Adults with Cryptogenic Systemic Embolism

In the presence of a patent foramen ovale with otherwise unexplained (cryptogenic) cerebral embolism, the usual therapy is oral anticoagulation or antiplatelet therapy. Surgery is considered only in cases of recurrence. Percutaneous transcatheter occlusion of the patent foramen ovale (PFO) is a new valuable alternative. This article presents the current knowledge and our data concerning nonsurgical closure of patent foramen ovale to prevent paradoxical arterial embolism. Transcatheter PFO closure represents an elegant therapeutic approach in patients with suspected paradoxical embolism because it avoids open heart surgery and is minimally invasive. Even if the recurrence rate of embolism were identical, transcatheter closure would be preferable to anticoagulation because the annual risk of bleeding complications of 2%-3% and the long-term costs of anticoagulation can be avoided. Randomized studies are needed to compare transcatheter closure of patent foramen ovale with anticoagulation, platelet inhibitors, or surgery.     

Long-Term Follow-Up After Closure of Patent Foramen Ovale in Patients With Cryptogenic Embolism

Background

Patent foramen ovale (PFO) closure is the gold standard for treating patients with cryptogenic stroke and PFO. However, scarce data exist on the long-term outcomes following PFO closure.

Percutaneous Closure of Patent Foramen Ovale and Secundum Atrial Septal Defects with the GORE® CARDIOFORM Septal Occluder: Incidence and Implications of Device Wire Frame Fracture

Background: Trans-catheter closure has become the treatment of choice for patent foramen ovale (PFO) and ostium secundum atrial septal defects (ASD). A wide variety of devices are commercially available, however, concerns have been raised about the risk of cardiac erosion associated with stiff/rigid devices. The GORE® CARDIOFORM Septal Occluder (GSO) is a double-disc, soft and conformable device with no reported incidence of cardiac erosions. However, wire frame fracture (WFF) have been reported. Aim: To assess the incidence and clinical significance of WFF after GSO implantation in paediatric patients. Methods: Seventy-seven consecutive patients were enrolled. Periprocedural and follow-up assessments included clinical, echocardiographic, and X-ray fluoroscopy examinations. Results: Mean patient age was 10.0 ± 3.9 years. In 7 patients the indication was PFO closure, in 70 patients ASD closure. Mean follow-up period was 3.1 ± 1.3 years. X-ray fluoroscopy evaluations were available for 60 patients. WFF was detected in a total of 22 (35.4%) GSO devices. Three WFF compromised the outer perimeter of the device. Incidence of WFF was higher for the 30 mm GSO device (58%; p = 0.001). A multivariate analysis confirmed that the GSO device diameter (p = 0.013; F = 6.7) and stretched ASD diameter (p = 0.034; F = 4.38) were independent factors related to WFF. WFF did not result in any clinical sequelae/patient harm. Residual shunt was observed in 4 patients (5%) at 24 hours following procedure. Conclusion: The GSO device is safe and effective for PFO and ASD closure. WFF was not associated with clinical sequelae or device instability. Device diameter strongly correlates with incidence of WFF.     

Importance of Persistent Right-to-Left Shunt After Patent Foramen Ovale Closure in Cryptogenic Stroke Patients

Percutaneous closure of patent foramen ovale (PFO) is widely performed to prevent recurrent stroke or transient ischemic attack in patients with cryptogenic stroke. However, the influence of different degrees of right-to-left shunting (RLS) has rarely been reported.We retrospectively evaluated the cases of 268 patients with cryptogenic stroke who underwent PFO closure at our hospital from April 2012 through April 2015. In accordance with RLS severity, we divided the patients into 2 groups: persistent RLS during normal breathing and the Valsalva maneuver (n=112) and RLS only during the Valsalva maneuver (n=156). Baseline characteristics, morphologic features, and procedural and follow-up data were reviewed. The primary endpoint was stroke or transient ischemic attack.More patients in the persistent group had multiple or bilateral ischemic lesions, as well as a larger median PFO diameter (2.5 mm [range, 1.8–3.9 mm]) than did patients in the Valsalva maneuver group (1.3 mm [range, 0.9–1.9 mm]) (P <0.001). Atrial septal aneurysm was more frequent in the persistent group: 25 patients (22.3%) compared with 18 (11.5%) (P=0.018). Three patients in the persistent group had residual shunting. The annual risk of recurrent ischemic stroke was similar between groups: 0.298% (persistent) and 0.214% (Valsalva maneuver).Our findings suggest that patients with persistent RLS have more numerous severe ischemic lesions, larger PFOs, and a higher incidence of atrial septal aneurysm than do those without. Although our persistent group had a greater risk of residual shunting after PFO closure, recurrence of ischemic events did not differ significantly from that in the Valsalva maneuver group.