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The International Journal of Cardiovascular Imaging

Published in:

01-12-2018 | Review Paper

Echocardiographic features of PFOs and paradoxical embolism: a complicated puzzle

Authors: Constantina Aggeli, Athanasios Verveniotis, Efstathia Andrikopoulou, Emmanouil Vavuranakis, Konstadinos Toutouzas, Dimitrios Tousoulis

Published in: The International Journal of Cardiovascular Imaging | Issue 12/2018

Abstract

Patent foramen ovale (PFO) is a residual, oblique, slit or tunnel like communication in the atrial septum that persists into adulthood. It is usually an incidental finding with no clinical repercussions. Nevertheless, recent evidence supports the association between the presence of a PFO and a number of clinical conditions, most notably cryptogenic stroke (CS). There is enough evidence that paradoxical embolism is a mechanism which can explain this association. Patient characteristics and certain echocardiography-derived anatomical and hemodynamic features of PFO provide great assistance in estimating the probability of paradoxical embolism. In this review, we initially describe PFO embryology and anatomy. We extensively present the available data on clinical, anatomical and hemodynamic features of PFOs which have been correlated with increased likelihood of paradoxical embolism and recent evidence of therapeutic management.

Hara H, Virmani R, Ladich E et al (2005) Patent foramen ovale: current pathology, pathophysiology, and clinical status. J Am Coll Cardiol 46(9):1768–1776CrossRef

Mojadidi M, Christia P, Salamon J et al (2015) Patent foramen ovale: unanswered questions. Eur J Intern Med 26:743–751CrossRef

Kutty S, Sengupta PP, Khandheria BK (2012) Patent foramen ovale the known and the to be known. J Am Coll Cardiol 59(19):1665–1671CrossRef

Pizzino F, Khandheria B, Carerj S et al (2016) PFO: button me up, but wait…comprehensive evaluation of the patient. J Cardiol 67(6):485–492CrossRef

Hardt SE, Eicken A, Berger F et al (2017) Closure of patent foramen ovale defects using GORE® CARDIOFORM septal occluder: results from a prospective European multicenter study. Catheter Cardiovasc Interv 90(5):824–829CrossRef

Søndergaar L, Kasner SE, Rhodes JF, for the Gore REDUCE Clinical Study Investigators et al (2017) Patent foramen ovale closure or antiplatelet therapy for cryptogenic stroke. N Engl J Med 377:1033–1042CrossRef

Mas J-L, Derumeaux G, Guillon B for the CLOSE Investigators et al (2017) Patent foramen ovale closure or anticoagulation vs. antiplatelets after stroke. N Engl J Med 377:1011–1021CrossRef

Saver JL, Carroll JD, Thaler DE for the RESPECT Investigators et al (2017) Long-term outcomes of patent foramen ovale closure or medical therapy after stroke. N Engl J Med 377:1022–1032CrossRef

Bhatia N, Abushora MY, Donneyong MM et al (2014) Determination of the optimum number of cardiac cycles to differentiate intra-pulmonary shunt and patent foramen ovale by saline contrast two- and three-dimensional echocardiography. Echocardiography 31(3):293–301CrossRef

10.

Mahmoud AN, Elgendy IY, Agarwal N et al (2017) Identification and quantification of patent foramen ovale- mediated shunts: echocardiography and transcranial Doppler. Interv Cardiol Clin 6(4):495–504PubMed

11.

Silvestry FE, Cohen MS, Armsby LB et al (2015) Guidelines for the echocardiographic assessment of atrial septal defect and patent foramen ovale: from the American Society of Echocardiography and Society for Cardiac Angiography and Interventions.; American Society of Echocardiography; Society for Cardiac Angiography and Interventions. J Am Soc Echocardiogr 28:910–958CrossRef

12.

Carroll JD, Saver JL, Thaler DE RESPECT Investigators et al (2013) Closure of patent foramen ovale versus medical therapy after cryptogenic stroke. N Engl J Med 368(12):1092–1100CrossRef

13.

Olivares-Reyes A, Chan S, Lazar EJ et al (1997) Atrial septal aneurysm: a new classification in two hundred five adults. J Am Soc Echocardiogr 10(6):644–656CrossRef

14.

Kijima Y, Bokhoor P (2015) Patent foramen ovale with right atrial septal pouch. Catheter Cardiovasc Interv 89(5):169–171CrossRef

15.

Lee JY, Song JK, Song JM et al (2010) Association between anatomic features of atrial septal abnormalities obtained by omni-plane transesophageal echocardiography and stroke recurrence in cryptogenic stroke patients with patent foramen ovale. Am J Cardiol 106(1):129–134CrossRef

16.

Goel SS, Tuzcu EM, Shishehbor MH et al (2009) Morphology of the patent foramen ovale in asymptomatic versus symptomatic (stroke or transient ischemic attack) patients. Am J Cardiol 103(1):124–129CrossRef

17.

Fukuoka T, Dembo T, Nagoya H et al (2012) Factors related to recurrence of paradoxical cerebral embolism due to patent foramen ovale. J Neurol 259(6):1051–1055CrossRef

18.

Meissner I, Khandheria BK, Heit JA et al (2006) Patent foramen ovale: innocent or guilty? Evidence from a prospective population-based study. J Am Coll Cardiol 47(2):440–445CrossRef

19.

Rana BS, Shapiro LM, McCarthy KP (2010) Three-dimensional imaging of the atrial septum and patent foramen ovale anatomy: defining the morphological phenotypes of patent foramen ovale. Eur J Echocardiogr 11(10):19–25CrossRef

20.

Vitarelli A, Mangieri E, Capotosto L et al (2014) Echocardiographic findings in simple and complex patent foramen ovale before and after transcatheter closure. Eur Heart J Cardiovasc Imaging 15(12):1377–1385CrossRef

21.

Inglessis I, Elmariah S, Rengifo-Moreno PA et al (2013) Long-term experience and outcomes with transcatheter closure of patent foramen ovale. JACC Cardiovasc Interv 6(11):1176–1183CrossRef

22.

Kent DM, Dahabreh IJ, Ruthazer R et al (2016) Device Closure of patent foramen ovale after stroke pooled analysis of completed randomized trials. J Am Coll Cardiol 67(8):907–917CrossRef

23.

Kernan WN, Ovbiagele B, Black HR et al (2014) Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 45(7):2160–2236CrossRef

24.

Kent DM, Ruthazer R, Weimar C et al (2013) An index to identify stroke-related vs incidental patent foramen ovale in cryptogenic stroke. Neurology 81(7):619–625CrossRef

25.

Katsanos AH, Giannopoulos S, Frogoudaki A et al (2016) The diagnostic yield of transesophageal echocardiography in patients with cryptogenic cerebral ischaemia: a meta-analysis. Eur J Neurol 23(3):569–579CrossRef

26.

Stortecky S, da Costa BR, Mattle HP et al (2015) Percutaneous closure of patent foramen ovale in patients with cryptogenic embolism: a network meta-analysis. Eur Heart J 36(2):120–128CrossRef

27.

Katsanos AH, Spence JD, Bogiatzi C et al (2014) Recurrent stroke and patent foramen ovale: a systematic review and meta-analysis. Stroke 45(11):3352–3359CrossRef

28.

Di Tullio M, Sacco R, Sciacca R,et al (2007) Patent foramen ovale and the risk of ischemic stroke in a multiethnic population. J Am Coll Cardiol 49:797–802CrossRef

29.

Furlan AJ, Reisman M, Massaro J CLOSURE I Investigators et al (2012) Closure or medical therapy for cryptogenic stroke with patent foramen ovale. N Engl J Med 366(11):991–999CrossRef

30.

Meier B, Kalesan B, Mattle HP, PC Trial Investigators et al (2013) Percutaneous closure of patent foramen ovale in cryptogenic embolism. N Engl J Med 368(12):1083–1091CrossRef

31.

Brauser D (2015) RESPECT 10-year data strengthens case for PFO closure after cryptogenic stroke. Medscape. Available at http://www.medscape.com/viewarticle/852810. Accessed 29 Dec 2015

32.

http://www.tctmd.com/news/final-respect-data-support-pfo-closure-cryptogenic-stroke-prevention

33.

Messé SR, Gronseth G, Kent DM et al (2016) Practice advisory: recurrent stroke with patent foramen ovale (update of practice parameter), Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology 87(8):815–821CrossRef

34.

Ropper AH (2017) Tipping point for patent foramen ovale closure. N Engl J Med 377(11):1093–1095CrossRef

35.

Farb A, Ibrahim NG, Zuckerman BD (2017) Patent foramen ovale after cryptogenic stroke—assessing the evidence for closure. N Engl J Med 377(11):1006–1100CrossRef

36.

http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm527096.htm

37.

European Stroke Organisation(ESO) Executive Committee; ESO Writing Committee (2008) Guidelines for management of ischaemic stroke and transient ischaemic attack 2008. Cerebrovasc Dis 25(5):457–507CrossRef

38.

Nietlispach F, Meier B (2016) Percutaneous closure of patent foramen ovale: an underutilized prevention? Eur Heart J 37(26):2023–2028CrossRef

39.

Tobis J, Shenoda M (2012) Percutaneous treatment of patent foramen ovale and atrial septal defects. J Am Coll Cardiol 60(18):1722–1732CrossRef

Title: Echocardiographic features of PFOs and paradoxical embolism: a complicated puzzle
Authors: Constantina Aggeli
Athanasios Verveniotis
Efstathia Andrikopoulou
Emmanouil Vavuranakis
Konstadinos Toutouzas
Dimitrios Tousoulis
Publication date: 01-12-2018
Publisher: Springer Netherlands
Published in: The International Journal of Cardiovascular Imaging / Issue 12/2018
Print ISSN: 1569-5794
Electronic ISSN: 1875-8312
DOI: https://doi.org/10.1007/s10554-018-1406-1

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