Clinical and Brain Magnetic Resonance Imaging Follow-up After Percutaneous Closure of Patent Foramen Ovale in Patients With Cryptogenic Stroke

doi:10.1016/j.amjcard.2007.11.050

The American Journal of Cardiology

Volume 101, Issue 7, 1 April 2008, Pages 1051-1055

https://doi.org/10.1016/j.amjcard.2007.11.050 Get rights and content

Patent foramen ovale (PFO) closure is reported to result in fewer episodes of clinically manifest recurrent cerebral ischemia than medical treatment. We evaluated by means of magnetic resonance imaging (MRI) whether silent cerebral ischemic episodes are also decreased by PFO closure. Seventy-one patients with PFO were selected for percutaneous closure of PFO at our center. All had PFO with large right-to-left shunt documented by transcranial Doppler ultrasound and transesophageal echocardiography, ≥1 previous stroke or transient ischemic attack with MRI documentation at the index event, and no alternative cause for cerebral ischemia. MRI studies were performed in all patients 24 hours before the procedure and at 1-year follow-up (or before in the case of a suspected new neurologic event). Eight patients (11%) had >1 clinical event before the procedure. Comparing the 2 MRI studies before the procedure, silent ischemic lesions were observed in 14 other patients (20%). Thus, considering clinical and silent events together, >1 event was present at baseline in 22 patients (31%). After PFO closure (follow-up 16 ± 7 months), 1 recurrent neurologic event occurred (1%, p = 0.02 vs preprocedural clinical events); however, urgent brain MRI results were negative. Moreover, only 1 patient showed 1 new silent lesion at brain MRI at follow-up (1%, p <0.001 vs preprocedural silent brain lesions). Considering clinical and silent events, relapses occurred in 2 patients only (p <0.001 vs before procedure). Recurrent events were limited to those with incomplete PFO closure at postprocedural transcranial Doppler ultrasound (p = 0.02). In conclusion, percutaneous PFO closure results in few clinical or silent events after 1-year follow-up, especially when complete PFO closure is successfully accomplished.

Section snippets

Methods

The study population comprised 71 consecutive patients <60 years old who underwent transcatheter closure of a PFO at our institution from June 2003 to January 2006. All patients had (1) a large PFO with spontaneous or inducible atrial right-to-left shunt documented by contrast transcranial Doppler ultrasound (TCD) and transesophageal echocardiography, (2) ≥1 ischemic stroke or transient ischemic attack with MRI documentation of the index event, and (3) no alternative cardiac, aortic, or

Results

Clinical characteristics of our study population are presented in Table 1. All 71 patients had large right-to-left shunt at TCD (grade ≥3); grade 4 was present in 20 patients (28%); grade 5 was present in 13 patients (18%); 16 patients (23%) had ASA at transesophageal echocardiography and 12 of these (75%) had a grade 4 or 5 shunt; concomitant coagulation disorders were present in 10 patients (14%). Considering clinically manifest and silent events together, >1 event was present in 22 patients

Discussion

The present study, exploiting careful clinical and imaging follow-up, shows that percutaneous closure of a large PFO results in very few relapses and thus may offer very favorable clinical benefits that should be definitively established by a large randomized clinical trial. In addition, our original brain MRI follow-up data show that new silent brain lesions very rarely occur after PFO occluder device implantation, in striking contrast to the relatively high rate of events before PFO closure

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Cited by (14)

Residual shunt after patent foramen ovale closure: Preliminary results from italian patent foramen ovale survey
2013, Journal of Stroke and Cerebrovascular Diseases
Citation Excerpt :
rRLS was evident in about 20% of patients at the 6- and 12-month follow-up. These data are in line with those present in the literature,3-19,28-30 even if these appear highly variable, even rising to 33% of rRLS.16 It might thus depend on the entire number of population studied in those reports and the method utilized for RLS detection.
Percutaneous patent foramen ovale (PFO) closure is accepted as treatment for cryptogenic ischemic stroke/transient ischemic attack in young subjects. However, a thorough evaluation of residual right-to-left shunt (rRLS) after PFO closure is needed. Our aims were to analyze the characteristics related to PFO diagnosis and closure, focusing on rRLS and clinical recurrences until 24-month follow-up. Data were extrapolated from the 12-month Italian PFO Survey.
In all, 1035 patients were included. PFO diagnosis and right-to-left shunt (RLS) were assessed by contrast-enhanced transesophageal and/or transthoracic echocardiography and/or transcranial Doppler.
PFO diagnosis with RLS data were available in 894 of 1035 (86.4%) patients. rRLS was investigated in 49.6% (6 months), 27.1% (12 months), and 3.5% (24 months), and observed in 19.5% (6 months) and 18.2% (12 months) of subjects. Large permanent rRLS was observed in less than 3% of RLS-positive patients after 1 year. Eleven of 14 and 3 of 14 neurological recurrences were observed in 10 of 444 (2.25%) and 2 of 243 (0.8%) patients within the 6- and 12-month follow-up, respectively. Among these, no large rRLS was reported. There were no neurological events at 2-year follow-up. Forty of 444 subjects had non-neurological complications, mostly cardiac arrhythmias within the sixth month.
PFO closure is a safe procedure. rRLS is not uncommon but large rRLS is rare. Clinical complications, mostly related to cardiac arrhythmias, are not unusual. Evaluation of the data of the whole survey is underway.
Dementia, stroke and migraine - Some common pathological mechanisms
2010, Journal of the Neurological Sciences
Citation Excerpt :
In this case, paradoxical embolization may be the causal link between migraine and PFO, but solid evidence is lacking if migraine frequency and thus ischaemic stroke are reduced by the PFO closure. One prospective, randomized, double-blind study suggested a reduction of headache days after PFO closure relative to the sham group [144] and an improvement was seen after the procedure in patients with subclinical WMLs [145]. These observations suggest that PFO–migraine–stroke is a possibility, but further evidence is needed to confirm this theory.
Dementia, stroke and migraine are very common neurological disorders affecting a large percentage of the population, and leading to a high degree of disability. Often, adequate therapy is not available. Although the symptoms, the progression and the outcome differ in these disorders, to some extent they may share some common pathophysiological mechanisms.
The genetic background, an energy deficit, and excitotoxicity, vascular and thrombotic properties can influence all three disorders, resulting in a neuronal dysfunction, increased cellular vulnerability, neurodegeneration and ultimately cell death. All these cellular events occur in dementias and stroke, moreover recent studies suggest that, besides a dysfunction, neuronal damage may be an issue in migraine too. One of the most central events in the multiple mechanisms involved in the pathogenesis of these disorders is a metabolic disturbance of certain brain cells. As mitochondria provide the cells with energy, realization of the importance of these organelles in the aetiopathogenesis of several disorders has emerged in recent years.
This review surveys the most important features of the pathogenesis of dementia, stroke and migraine from the aspect of mitochondrial malfunction highlighting some of the considerable connections between these neurological disorders.
Improvement of Migraine After Patent Foramen Ovale Percutaneous Closure in Patients With Subclinical Brain Lesions. A Case-Control Study
2009, JACC: Cardiovascular Interventions
Citation Excerpt :
We achieved TCDD according to the recommendations of the Venice Consensus Conference (18). On the basis of microembolic signals (MES) count, we adopted a previously described 6-level scale for classification of shunt (19): 0 = absence of shunt (0 MES); 1 = latent shunt of mild degree (1 to 20 MES) after Valsalva maneuver (VM); 2 = latent shunt of moderate degree (>20 MES after VM, without curtain); 3 = latent shunt of high degree (curtain after VM); 4 = permanent shunt of mild/moderate degree (>10 MES at rest and curtain after VM); 5 = permanent shunt of high degree (curtain at rest). All patients recruited had a large RLS (at least grade 3 at TCCD).
We sought to evaluate the benefits on frequency and severity of migraine recurrence after patent foramen ovale (PFO) closure in patients with subclinical brain lesions at magnetic resonance imaging (MRI).
Migraine improvement has been reported after PFO closure in patients with cerebrovascular symptomatic events. Subclinical brain MRI lesions are detectable in patients with PFO and in migraineurs.
A total of 82 patients with moderate/severe migraine, PFO, large right-to-left shunt, and subclinical brain MRI lesions were prospectively examined for a 6-month period. Patients were subdivided into closure (n = 53) and control (n = 29) group according to their consent to undergo percutaneous PFO closure. In controls, therapy for migraine was optimized. Six-month frequency and severity of migraine recurrence were compared with baseline.
The number of total attacks decreased more in the closure group (32 ± 9 to 7 ± 7, p < 0.001) than in the control group (36 ± 13 to 30 ± 21, p = NS) (p < 0.001). A significant reduction in disabling attacks was observed only in the closure group (20 ± 12 to 2 ± 2, p < 0.001; controls: 15 ± 12 to 12 ± 12, p = NS). Migraine disappeared in 34% of the closure group patients and 7% of controls (p = 0.007); >50% reduction of attacks was reported by 87% and 21%, respectively (p < 0.001). Disabling attacks disappeared in 53% of closure group patients and 7% of controls (p < 0.001); >50% reduction occurred in 89% and 17%, respectively (p < 0.001).
In migraineurs with a large PFO and subclinical brain MRI lesions, a significant reduction in frequency and severity of migraine recurrence can be obtained by PFO closure when compared with frequency and severity in controls.
Clinical and brain magnetic resonance imaging long-term follow-up in patients with cryptogenic stroke undergoing PFO closure with the NobleStitch EL system. A single-centre experience
2022, Postepy w Kardiologii Interwencyjnej
Appropriate selection of echocardiographic guidance for transcatheter atrial septal defect closure
2020, International Journal of Cardiovascular Imaging
Patent foramen ovale closure with GORE HELEX or CARDIOFORM Septal Occluder vs. antiplatelet therapy for reduction of recurrent stroke or new brain infarct in patients with prior cryptogenic stroke: Design of the randomized Gore REDUCE Clinical Study
2017, International Journal of Stroke

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MiscellaneousClinical and Brain Magnetic Resonance Imaging Follow-up After Percutaneous Closure of Patent Foramen Ovale in Patients With Cryptogenic Stroke

Section snippets

Methods

Results

Discussion

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Recurrent thromboembolic events after percutaneous device closure of patent foramen ovale

Interact CardioVasc Thorac Surg

Secondary prevention of cerebral ischemia in patent foramen ovale: systematic review and meta-analysis

South Med J

Transcatheter closure versus medical therapy of patent foramen ovale and presumed paradoxical thromboemboli: a systematic review

Ann Intern Med

Stroke recurrence in patients with patent foramen ovale: the Lausanne StudyLausanne Stroke with Paradoxal Embolism Study Group

Neurology

Interatrial septal abnormalities and stroke: a meta-analysis of case-control studies

Neurology

Recurrent cerebrovascular events associated with patent foramen ovale, atrial septal aneurysm, or both

N Engl J Med

Miscellaneous
Clinical and Brain Magnetic Resonance Imaging Follow-up After Percutaneous Closure of Patent Foramen Ovale in Patients With Cryptogenic Stroke