经导管封堵卵圆孔未闭预防脑的矛盾栓塞

目的:经导管封堵卵圆孔未闭(PFO)预防脑的矛盾栓塞并评价其疗效。 方法:本组共32例,年龄15-68(50.2±8.1)岁,体重40-72(53.7±4.3)kg。均经临床及经胸超声心动图(TTE)或经食道超声心动图(TEE)检查证实为PFO合并右向左分流伴脑缺血事件、单纯PFO、PFO合并房间隔瘤或房间隔瘤合并多孔房间隔缺损(房缺)。32例术前均有不同程度的偏头痛,不明原因的晕厥22例,用力性晕厥3例,短暂性语言障碍3例,缺血性脑梗塞4例。20例声学造影显示微泡从右心房进入左心房。PFO合并房间隔瘤、房间隔瘤合并多孔房缺的患者在TTE或TEE下测量房间隔的伸展径,选用房缺封堵器进行介入治疗;对单纯PFO的患者选用PFO封堵器经9-12F的鞘管置入,进行介入治疗。 结果:本组技术成功率为100％。所有患者均能成功置放封堵器。术后24 h,1个月,3个月,6个月,12个月行TTE检查未见封堵器移位。术后1个月复发偏头痛患者1例,1例房间隔瘤患者术后3个月用力时发生头晕症状。 结论:经导管封堵PFO是一种较有效的非手术方法,可用于预防脑的矛盾栓塞。     

肺动脉压力正常及轻度增高的成年房间隔缺损患者心房水平隐性右向左分流探查

目的:探查正常及轻度肺动脉压力增高的成年房间隔缺损(ASD)患者的右向左分流发生情况。方法:17例中央型ASD患者,男8例,女9例,年龄18~66(47±16)岁,均经胸心脏超声(TTE)检查诊断ASD、心房水平血流分流方向及肺动脉压力。封堵治疗前在静息状态及(或)Valsalva动作时行经颅多普勒超声(TCD)发泡试验联合TTE右心声学造影检查。所有患者在介入封堵治疗前通过右心导管测定肺动脉压力,在封堵治疗后即刻及术后3d、1个月、3个月及6个月再次行TCD发泡试验联合TTE右心声学造影检查。结果:TTE证实房间隔缺损直径5~24mm,所有患者心房水平左向右单向分流。11例患者静息TCD发泡试验联合TTE右心声学造影出现心房水平存在右向左分流,6例静息状态下检查未提示存在右向左分流患者Valsalva动作后均出现右向左分流现象。封堵治疗前经右心导管检查测得肺动脉压力(18~41)/(5~11)mmHg(1mmHg=0.133kPa)。所有患者均成功进行介入封堵治疗。1例患者在封堵治疗术后3d、1个月、3个月存在少量右向左分流,术后6个月17例患者均未见心房水平分流存在。结论:正常及轻度肺动脉高压的ASD患者心房水平存在隐性右向左分流,介入封堵治疗后分流消失。TCD发泡试验联合TTE右心声学造影检查可准确判定心房水平右向左分流。     

右心声学造影在卵圆孔未闭检测中的应用价值

目的 探讨超声右心声学造影（cTTE）在卵圆孔未闭（PFO）检测中的应用价值。方法回顾性分析2017年1月至2020年9月于山西省心血管病医院因怀疑PFO行cTTE的患者354例,均在cTTE前常规行经胸超声心动图（TTE）,其中147例行经食管超声心动图（TEE）。结果 TTE的PFO检出率为60.5%(89/147)低于TEE的70.7%(104/147),差异具有统计学意义（P<0.05）;TEE低于cTTE的76.8%(113/147),差异无统计学差异（P>0.05）。cTTE检测存在心内右向左分流的16例患者中,TEE显示房间隔未见明显异常,3例经皮介入封堵手术后,行cTTE检测右向左分流分级下降至1级及阴性,证实为PFO相关的右向左分流。经皮介入封堵PFO术后1周Valsalva动作后右向左分流检出率为46.3%。结论CTTE检测右向左分流具有独特价值,是TTE和TEE检测PFO中的有益补充。     

脑卒中患者经导管封堵卵圆孔临床资料分析

目的:探讨经导管封堵卵圆孔未闭(PFO),预防脑部矛盾栓塞并评价其疗效。方法:本组共6例,年龄16～67岁,均经临床经胸超声心动图或经食道超声心动图检查,证实为PFO合并右向左分流患者。6例术前均有缺血性脑梗死。患者选用PFO封堵器经导管置入,进行介入治疗。结果:本组封堵成功率为100%。所有患者均能成功置入并释放封堵器。术后1个月、3个月及6个月行经胸超声心动图检查,未见封堵器移位。术后未有脑卒中事件。结论:经导管封堵PFO是一种较有效的介入治疗方法,可用于预防由于DFO导的致脑部矛盾栓塞。     

TTE结合cTTE在卵圆孔未闭介入治疗中的应用

目的 探讨经胸超声心动图（TTE）结合经胸超声心动图右心声学造影（cTTE）在卵圆孔未闭（PFO）介入治疗中的应用价值。方法 入选我院90例行介入封堵治疗的PFO患者,年龄（40±15）岁。用TTE、cTTE及食管超声心动图（TEE）评估、检测及随访。结果 90例PFO患者,TTE或TEE检查符合简单型PFO 52例（58%）、复杂型PFO 38例（42%）。术前cTTE检查,38例（42%）于静息状态下检出右向左分流（RLS）,其中少量24例(27%)、中量11例(12%)和大量3例(3%),Valsalva动作除8例（9%）为中量RLS外,余均为大量RLS。Valsalva动作后大量RLS检出率明显高于静息状态（P<0.01）。52例简单型PFO患者均用PFO封堵器,其中18/25 mm、30/30 mm和25/35 mm封堵器各用38例（73%）、6例（12%）和8例（15%）,18/25 mm封堵器使用率明显高于30/30 mm和25/35 mm封堵器（P<0.01）。38例复杂型PFO患者,37例用单封堵器,其中30/30 mm和25/35 mmPFO封堵器分别为16例（42%）和17例（45%）、房间隔缺损（ASD）封堵器4例（11%）。1例PFO并发ASD的患者,孔间距为20 mm,应用18/18 mm和25/35 mm双封堵器。术后cTTE随访:3个月、半年、1年完全堵闭率（无RLS）分别为40%、67%和74%。术后1年残余RLS为23例,其中22例(96%)微泡出现时间超过5个心动周期。结论 TTE结合cTTE在PFO封堵术前病例筛查、术中指导封堵器选择及术后疗效评价中均有着不可或缺的作用,对保证PFO封堵治疗成功具有重要价值。     

卵圆孔未闭结构特征对介入治疗封堵器选择的影响

目的 探讨卵圆孔未闭（PFO）结构特征对介入治疗封堵器选择的影响。方法 回顾性分析98例拟进行PFO封堵治疗患者临床资料,按经胸超声心动图(TTE)和（或）经食管超声心动图(TEE)检查结果分为简单PFO组和复杂PFO组,比较两组患者封堵器的选择及疗效。结果 PFO患者98（男41,女57）例,年龄8~74(41±14)岁。92例封堵成功,6例未成功,其中导丝无法到达左房4例,肺动静脉瘘1例,并发肺动脉高压患者1例。手术总成功率为94%。简单PFO组42例,复杂PFO组56例,简单PFO以18/25 mm PFO封堵器为主,复杂PFO以30/30 mm和25/35 mm PFO封堵器为主,两组间封堵器的选择有显著差异（P<0.01）。术后半年复查经胸超声心动图声学造影（cTTE）,完全堵闭65例（71%）,Valsalva动作后有右向左分流（RLS）27例（29%）,其中少量20例(22%),中量4例(4%),大量3例(3%)。大量RLS均发生在复杂PFO组应用30/30 mm和25/35 mmPFO封堵器的患者。复杂PFO组有1例新发阵发性心房纤颤。结论 封堵器选择与PFO特征有关,简单PFO以18/25 mm PFO封堵器为主,复杂PFO以30/30 mm和25/35 mm PFO封堵器为主。     

TTE联合右心声学造影筛查PFO的价值及介入封堵治疗中期疗效

目的 应用经胸超声心动图（transthoracic-echocardiography,TTE）及经胸右心声学造影（contrast transthoracic-echocardiography,cTTE）筛查隐源性卒中、不明原因晕厥及偏头痛患者中卵圆孔未闭（patent foramen ovale,PFO）的检出率及经皮介入封堵治疗PFO的中期疗效。 方法 选取167例临床诊断为隐源性卒中、不明原因晕厥及偏头痛的患者,均行TTE检查及cTTE检查,根据微气泡右向左分流（the right-to-left shunt,RLS）数量进行量化分级,分为I级、Ⅱ级和Ⅲ级。选取Ⅲ级RLS患者22例,右心选择性造影证实为PFO并根据形态选择合适封堵器行封堵治疗,术后1、3、6个月门诊及电话随访,术后6个月行cTTE复查。 结果 167例患者行cTTE,静息状态下RLS有67例（40.1%）,Valsalva动作后RLS有85例（50.9%）,其中I级分流23例（13.8%）,Ⅱ级分流12例（7.2%）,Ⅲ级分流50例（29.9%）。在3种不同疾病中,隐源性卒中并发PFO检出率为43.5%;不明原因晕厥并发PFO检出率68.0%;偏头痛并发PFO检出率为47.9%;22例行PFO封堵患者,随访6个月,临床症状改善,无并发症,复查cTTE均未见残余分流。 结论 TTE联合cTTE是筛查PFO重要的无创检查手段;两者结合对隐源性卒中、不明原因晕厥及偏头痛并发PFO有较高的检出率。介入封堵治疗PFO能有效预防隐源性卒中、晕厥再发、明显减轻偏头痛症状。     

两种不同封堵器对不明原因脑卒中合并大量右向左分流患者卵圆孔未闭的疗效对比

目的:对比两种不同封堵器对不明原因脑卒中(CS)合并大量右向左分流(RLS)患者卵圆孔未闭(PFO)封堵治疗的疗效。方法:2013-05至2016-08期间连续入选CS合并大量RLS的123例PFO患者,应用Cardi-O-fix PFO封堵器(Cardi-O-fix PFO封堵器组,80例)或Amplatzer PFO封堵器(Amplatzer PFO封堵器组,43例)行经皮PFO介入封堵术。所有患者先行影像学检查并经3位经验丰富的神经内科专家明确CS的诊断,然后经胸超声心动图及右心声学造影诊断PFO及大量RLS。回顾患者的基线特征、临床症状、手术及随访数据,观察两种封堵器封堵治疗的疗效。结果:术后两组各有1例发生阵发性心房颤动,Cardi-O-fix PFO封堵器组1例术后出现腹股沟血肿。随访期间两组无复发性脑卒中及死亡事件发生。两组各随访时期残余分流的差异无统计学意义。结论:在预防脑卒中复发方面,PFO介入封堵可为CS伴大量RLS的PFO患者带来获益。Cardi-O-fix PFO封堵器与Amplatzer PFO封堵器在安全性和有效性方面相似。     

经胸超声心动图右心声学造影在“反常栓塞”卵圆孔未闭封堵治疗中的临床应用

目的 探讨经胸超声心动图右心声学造影(c TTE)在“反常栓塞”卵圆孔未闭(PFO患者封堵治疗中的临床应用。方法 收集2017年12月至2019年11月于新疆维吾尔自治区人民医院心血管内科收治的10例行PFO封堵术患者资料。所有患者均因反复发作的不明原因缺血性脑卒中于神经内科就诊,排除血管性及神经性原因,经由cTTE诊断为PFO合并反常栓塞。分析c TTE结果、PFO封堵术成功率及术中并发症发生情况。采用头痛影响测验-6(HIT-6)对偏头痛患者进行评价,观察治疗效果。结果 cTTE共检出右向左分流(RLS)Ⅰ级1例,Ⅱ级4例,Ⅲ级5例。10例患者均成功行PFO封堵术,共发生并发症2例,分别为急性血栓及心包积液各1例,经积极处理均治愈。在术后3 d及术后1个月、术后3个月分别行cTTE检查,仅1例患者在术后3个月的c TTE显示仍有残余RLS分流;所有患者均未再发缺血性脑卒中,亦无短暂性脑缺血发作、心肌梗死等情况发生。术前合并偏头痛的6例患者,在术后1个月偏头痛症状明显改善,HIT-6评分术后1个月较术前、术后3个月较术后1个月均明显降低,差异有统计学意义(t=6.158、5.357,P 0.01)。结论 cTTE可有效诊断PFO-RLS及其分流情况,为PFO封堵术的成功实施提供了良好的条件。     

TEE联合cTCD检测小型卵圆孔未闭RLS

目的:探讨经食管超声心动图(transesophageal echocardiography,TEE)联合经颅多普勒超声声学造影(con-trast transcranial Doppler,cTCD)对小型卵圆孔未闭(patent foramen ovale,PFO)右向左分流(right-to-left shunt,RLS)的检测。方法:单纯小型PFO患者32(男18,女14)例,年龄16~52(35.4±14.6)岁。其中并发隐性脑卒中21例、短暂脑缺血发作(TIA)6例和偏头痛5例。隐性脑卒中均经头颅CT或MRI证实有脑梗死病灶,排除其他脑梗死原因,如主动脉和脑血管病变,及左心系统疾病等。TEE检查PFO裂隙宽度<2 mm,均不并发房间隔瘤。结果:32例患者,TEE测量PFO裂隙宽度为0.6~2.0(1.4±0.5)mm,彩色多普勒均无RLS。cTCD分流量Ⅰ级4例(12.5%),Ⅱ级11例(34.4%),Ⅲ级9例(28.1%)以及Ⅳ级8例(25%)。4例(12.5%)PFO无RLS,20例(62.5%)Valsalva动作后发生RLS,8例(25%)静息状态就有RLS。32例有28例行介入封堵治疗,其中cTCDⅢ级以上的17例均顺利完成手术,平均手术时间(23.5±7.3)min。cTCDⅡ级11例患者有5例为10个以下微栓子信号,均未封堵成功,6例有10~20个微栓子信号均封堵成功,但平均手术时间为(65.5±18.4)min,明显长于cTCDⅢ级以上组(P<0.01)。结论:同时测定PFO大小和RLS,才能准确反映PFO反常栓塞的临床状况。     

Role of real-time three-dimensional transoesophageal echocardiography for guiding transcatheter patent foramen ovale closure

Patent foramen ovale (PFO) is a relatively common congenitalcondition which has been implicated in cryptogenic stroke asa result of paradoxical thromboembolism by right-to-left shunting.Many studies have demonstrated that transcatheter PFO closuresignificantly reduced the incidence of recurrent strokes ina small group of high-risk patients with PFO and atrial septalaneurysm compared with antithrombotic drugs. Two-dimensionaltransoesophageal echocardiography (2D TEE) has become the electiontechnique for guiding patent foramen ovale closure. Real-timeThree-dimensional transoesophageal echocardiography (3D TEE)may be potentially superior to 2D TEE in the accurate assessmentof the morphology and efficacy of transcatheter closure devicesbecause of a better spacial orientation.     

Cardiac magnetic resonance imaging and transesophageal echocardiography in patients with transcatheter closure of patent foramen ovale.

OBJECTIVES: We studied the value of cardiac magnetic resonance imaging (CMRI) before and after closure of patent foramen ovale (PFO) in patients with cryptogenic ischemic events. BACKGROUND: Cardiac magnetic resonance imaging is a powerful noninvasive tool for detailed assessment of cardiac anatomy and function. The relevance of CMRI compared with transesophageal echocardiography (TEE) in patients undergoing transcatheter PFO closure has not been evaluated so far. METHODS: Contrast-enhanced CMRI and TEE were performed in 75 patients before and after PFO closure. Twelve months after PFO closure, both imaging techniques were repeated in 61 patients with contrast application. To determine provokable atrial right-to-left shunting in CMRI, we applied a contrast-enhanced perfusion imaging technique. Detection of atrial septal aneurysm (ASA) was achieved by means of a high-resolution cine imaging technique. RESULTS: Before PFO closure, ASA was seen with CMRI in 28 of 75 cases (37.3%), compared with 47 of 75 (62.7%) cases using TEE. There were a total of 211 CMRI studies with a corresponding TEE performed in 75 patients. No shunt was present in 107 of 211 studies with both techniques. Contrast-enhanced right-to-left shunting was detected by CMRI in 48 of 72 (66.6%) cases with moderate or severe shunts seen with TEE, but only in 6 of 32 (18.8%) studies with mild shunts with TEE. Anomalous venous returns were excluded in all patients. In two patients, coronary anomalies were seen. CONCLUSIONS: The present CMRI technique is inferior to TEE in detection of contrast-enhanced right-to-left shunting and identification of ASA.     

Embolic Implications of Combined Risk Factors in Patients with Patent Foramen Ovale (the CARPE Criteria): Consideration for Primary Prevention Closure?

Background: Large patent foramen ovale (PFO), spontaneous right‐to‐left shunt, large atrial septal aneurysm (ASA), coagulation abnormalities, and prominent eustachian valve (EV) have all been independently suggested as risk factors for recurrent stroke. We sought to retrospectively evaluate risk of stroke and impact of transcatheter PFO closure in patients with concurrent large PFO, spontaneous right‐to‐left shunt, large ASA, coagulation abnormalities, and prominent EV. Methods: Between March 2006 and October 2008, 36 (mean age 44 ± 10.9 years, 28 females) out of 120 consecutive patients referred to our center for transcatheter PFO closure had concomitant diagnosis of (a) large PFO on transcranial Doppler (TCD) and transesophageal echocardiography (TEE), (b) spontaneous right‐to‐left shunt on TCD, (c) large ASA, (d) prominent EV, and (e) coagulation abnormalities. All patients fulfilled the standard current indications for transcatheter closure and underwent preoperative TEE and brain magnetic resonance imaging (MRI), with subsequent intracardiac echocardiographic‐guided transcatheter PFO closure. Results: Compared to the remaining PFO population in the same period, patients with all five concomitant features had more ischemic brain lesions on MRI, previous history of recurrent stroke, more frequently a history of venous thromboembolism, and more severe migraine with aura. The concomitance of all the features confers the highest risk of recurrent stroke (OR 9.9, 3.0–18 [95% CI], P < 0.001). Conclusions: Despite its small sample size and nonrandomized retrospective nature, this is the first study to suggest that patients with concurrence of all the investigated characteristics have potentially a higher risk of stroke compared to controls. We thus propose the CARP criteria as a basis for further larger, longitudinal studies to assess the potential benefits of transcatheter closure in this patient subset in the absence of clinical recurrent stroke.     

Inflammatory, abscess-forming foreign body reaction mimics a thrombus formation on an atrial septal defect closure device: A commented case report.

We are presenting a case of floating left and right atrial formations on an atrial septal defect occluder system (23mm StarFLEX)-Occluder) initially supposed to be thrombotic appositions in a 57-year-old man. The closure was performed on the background of left hemispheric stroke and atrial septal aneurysm (ASA) with patent foramen ovale (PFO). The suspect structures were detected in the 6-month follow-up by transesophageal echocardiography (TEE). The patient underwent a successful surgical explantation of the closure device and closure of the patent foramen ovale (PFO) using a pericardial patch. The pathological evaluation of the biatrial device associated appositions revealed hytrophic heart muscle tissue with perifocal scarring and purulent abscess-forming, granulating and foam-cell including inflammatory foreign body reaction instead of the expected thrombus formation.     

Discrepancy in the assessment of jailed side branch lesions by visual estimation and quantitative coronary angiographic analysis: comparison with fractional flow reserve

A 59‐year‐old man suffered a transient ischemic attack (TIA) and was found to have a patent foramen ovale (PFO). Six months after closure with a 25 mm Amplatzer PFO occluder there was a significant residual shunt at transesophageal echocardiography (TEE). A coil was implanted and TEE 4 months later showed complete closure. © 2011 Wiley‐Liss, Inc.     

Patent Foramen Ovale: Comparison among Diagnostic Strategies in Cryptogenic Stroke and Migraine

Objective: The aim of this study was to compare transthoracic echocardiography (TTE) and transcranial Doppler ultrasonography (TCD) with transesophageal echocardiography (TEE) in order to define the best clinical approach to patent foramen ovale (PFO) detection. Methods: In total, 72 consecutive patients (33 men) with a mean age of 49 ± 13 years were prospectively enrolled. The TEE indication was cryptogenic stroke (36 patients) or migraine (36 patients, 22 with aura). All patients underwent standard TTE, TCD, and TEE examination. For any study, a contrast test was carried on using an agitated saline solution mixed with urea-linked gelatine (Haemaccel), injected as a rapid bolus via a right antecubital vein. A prolonged Valsalva maneuver was performed to improve test sensitivity. Results: TEE identified a PFO in 65% of the whole population: 56.5% in the migraine cohort and 43.5% in the cryptogenic stroke cohort. TTE was able to detect a PFO in 55% of patients positive at TEE (54% negative predictive value, 100% positive predictive value, 55% sensitivity, and 100% specificity). TCD was able to identify a PFO in 97% of patients positive at TEE (89% negative predictive value, 98% positive predictive value, 94% sensitivity, and 96% specificity). Conclusions: In patients with cryptogenic stroke and migraine, there is a fair concordance (k = 0.89) between TCD and TEE in PFO recognition. Accordingly, TCD should be recommended as a simple, noninvasive, and reliable technique, whereas TEE indication should be restricted to selected patients. TTE is a very specific technique, whose major advantage is the ability to detect a large right-to-left shunt, particularly if associated with an atrial septal aneurysm.     

Transthoracic echocardiography guidance during percutaneous closure of patent foramen ovale

Background: Percutaneous closure of patent foramen ovale (PFO) has been increasingly performed for several indications; mostly due to cryptogenic stroke. In this study we aimed to evaluate the safety and efficacy of transthoracic echocardiographic (TTE) guidance during percutaneous closure of PFO in using the Amplatzer and Occlutech Figulla PFO occluder devices. Methods: Between October 2005 and March 2011, 139 patients (74 male, mean age: 40.4 ± 10.3) underwent transcatheter PFO closure. In all patients transesophageal echocardiography performed subsequently to diagnose, assess the size and evaluate for suitability of the defect for percutaneous closure. During the procedure fluoroscopy and TTE were used for guidance. Results: Among 139 patients, Amplatzer PFO occluder was used in 74 patients and in 65 of them Occlutech Figulla device was selected for occlusion. The indications for PFO closure were ischemic stroke in 98 (70.5%), recurrent transient ischemic attacks (TIA) in 40 (28.7%), peripheral embolism in 1 (0.8%) of the patients. In all patients, percutaneous intervention was performed successfully under TTE guidance. There have been no neurologic (recurrent strokes or TIAs) and cardiovascular complications during the immediate and long‐term follow‐up period (2–67 months, median 29). There was significant difference between the mean fluoroscopic time from the beginning which is 8.6 ± 3.4 min in the former versus 3.4 ± 1.9 min in the latter (P < 0.05). Conclusion: Our study confirms the efficacy and safety of TTE guidance during percutaneous closure of PFO, which shortens the procedural time and obviates the need for general anesthesia or endotracheal intubation. (Echocardiography 2011;28:1074‐1080)     

Patent foramen ovale in a large population of ischemic stroke patients: diagnosis, age distribution, gender, and race

BACKGROUND: Patent foramen ovale (PFO) is a well-recognized risk factor for ischemic strokes. The true prevalence of PFO among stroke patients is still under debate. Transesophageal echocardiography (TEE) is the "gold standard" in diagnosing PFO but the physiology requires right-to-left atrial shunting. In this report, we evaluate the prevalence of PFO in a diverse group of ischemic stroke patients studied by TEE. METHODS: TEE of 1,663 ischemic stroke patients were reviewed for cardiac source of embolism, including PFO and atrial septal aneurysm (ASA). Agitated saline bubble injection was performed to look for right to left atrial shunting. Success of maneuvers to elevate right atrial pressure (RAP) was noted by looking at the atrial septal bulge. RESULTS: Among 1,435 ischemic stroke patients analyzed, the presence or absence of PFO could not be determined in 32.1% because bulging of the septum could not be demonstrated in patients with negative contrast study despite aggressive maneuvers to elevate RAP. Of the remaining 974 patients, 294 patients (30.2%) had a PFO. The mean age was 61.5 years in both groups, with a bimodal distribution of PFO and the highest prevalence occurring in < or =30-year-old group. Prevalence of PFO was similar in men (32.4%) and women (28.15%, P = 0.15); and in Caucasian (32.1%) and African American (27.7%; P = 0.15). ASA was present in 2.02% and hypermobile septum in 2.49% of the 1,435 patients. PFO was seen in 79.3% of the patients with ASA. CONCLUSION: Successful elevation of RAP cannot be achieved in a significant number of patients undergoing TEE and determination of PFO may be difficult. In our series, the true prevalence of PFO among ischemic stroke patients was 30.2% taking into account only those patients who showed no shunting despite bulging of the atrium septum into the left atrium (PFO absent group) during the contrast study. There was no gender or racial difference in the prevalence of PFO, but there was a bimodal distribution in prevalence with age.