Patent foramen ovale closure in over-60-years old patients with diastolic dysfunction

Background Patent foramen ovale (PFO)-related stroke is a possible and not easily manageable occurrence in ≤60-years-old patients due to the presence of different comorbidities and in particular of diastolic dysfunction which is considered as a contraindication to PFO closure.The grade of diastolic dysfunction for which PFO closure is contraindicated and whether there are changes in diastolic dysfunction class after closure have not been investigated in deep yet.Methods We prospectively enrolled patients who were referred to our centre over a 12 months period for PFO transcatheter closure having echocardiographic demonstration of diastolic dysfunction (≤Ⅲ class diastolic dysfunction).Echocardiography was scheduled at 1,6 and 12 months in order to assess changes in haemodynamic parameters of left ventricle function.Results Thirteen out of 80 patients referred to our centre (16.2%,mean age 65 + 6.4 years) over a 24-month period were enrolled in the study (Table 1).Eighteen Amplatzer PFO Occluder 25 mm and one 35 mm,two Amplatzer 25/25 mm Cribriform Occluder and two 25 nun Premere Occlusion System were successfully implanted with no intraoperative complications.As collateral findings on ICE 8/12 patients (66.7 %) had hypertrophy of the interatrial septum (thickness of the rims ＞ 1.2 mm) probably imputable to hypertensive cardiomyopathy.Four patients developed atrial fibrillation during the first month post-implantation,all successfully treated with antiarrhythmic drugs.After a mean follow-up of 40±4.3 months left ventricle performance indices (ejection fraction and end-diastolic volume) and diastolic dysfunction parameters (E/A,deceleration time,diastolic dysfunction class) did not change significantly.Conclusion The present study suggests that PFO transcatheter closure may be safely performed in aged patients with diastolic dysfunction class 1-2.(J Geriatr Cardio12008;5:3-6.)     

Patent foramen ovale in the elderly:what to do?

The increase in life expectance makes the diagnosis of PFO a possible and not easily manageable event in patients > 60-years-old due to the presence of different comorbidities and in particular of diastolic dysfunction which is considered as a contraindication to PFO closure. The literature review suggests that aged patients with PFO cannot be excluded"a priori"from PFO closure that should evaluated as therapeutic options in presence of anatomical and functional indications. Moreover in the elderly many other syndromes than paradoxical stroke mediated by PFO required full assessment and, if needed, transcather PFO closure:deoxygenating in obstructive sleeping apnoea, unexplained increased dyspnoea associated with hypoxemia after lung surgery, paralysis of the hemidiaphragm, and platypnea orthodeoxia. Differently from in the young and middle age, the management of PFO in aged patients should obligatory include the careful evaluation of potential comorbidities and eventual contraindications, such as severe diastolic dysfunction due to for example to hypertensive cardiomyopathy and coronary heart disease, the main causes of diastolic dysfunction.(J Geriatr Cardiol 2007;4:254-256.)     

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.     

Percutaneous closure of patent foramen ovale

AIM: To review the safety and efficacy of percutaneous closure of patent foramen ovale (PFO) in symptomatic patients without the use of general anaesthesia or echocardiographic guidance. METHOD: All patients accepted for percutaneous PFO closure by our service from August 2002 to August 2004 were included. Patient demographics and clinical information were obtained from clinical records and by telephone interview. Follow-up outcomes recorded were recurrence of systemic thromboembolism, residual shunt, and change in pattern of migraines. RESULTS: Forty consecutive adult patients, of whom 19 (48%) had an atrial septal aneurysm (ASA), underwent PFO closure using the Amplatzer occluder device with fluoroscopic guidance alone. Their mean age was 45 +/- 10 years (range 23-63 years) and 24 (60%) were male. The indications for closure were ischaemic stroke (n = 26), transient ischaemic attack (TIA) (n = 8), both stroke and TIA (n = 2), refractory hypoxia (n = 2), platypnoea-orthodeoxia (n = 1) and severe migraine with seizures (n = 1). Twenty patients suffered a single neurological event and 16 suffered >1 event, including six with only radiographic evidence of >1 event. Mean procedure time was 17.7 +/- 9.6 min and fluoroscopy time was 6.7 +/- 7.3 min. Implanted device sizes were 18 mm (n = 1), 25 mm (n = 37) and 35 mm (n = 2). In 33 patients, the procedure was performed as a day-case. No complications were encountered. No further neurological events occurred in 39 patients at a mean follow-up time of 11 +/- 7 months (3-25 months) nor was a significant shunt detected in the 34 who underwent follow-up echocardiography. CONCLUSIONS: Percutaneous closure of PFO with or without ASA, under local anaesthesia and without echocardiographic guidance, is a safe and effective procedure which can be performed as a day-case. This has now become our standard clinical practice.     

Premere occlusion system for transcatheter patent foramen ovale closure: Mid‐term results of a single‐center registry

Background: Transcatheter closure of patent foramen ovale (PFO) with rigid devices may be problematic in patients with long channel PFO: alternative devices with asymmetrical opening and more physiological positioning may be preferable in such cases. We present the mid‐term results of transcatheter closure of PFO with Premere Occlusion System, a device studied for this specific anatomy, in a single‐center registry of adults with previous cerebral ischemia. Methods: During a 53‐months period (July 1, 2005 to December 1, 2009) 70 patients (48 females and 22 males, mean age 38 ± 6.7 years) with previous stroke were admitted in our center for transcatheter closure of PFO with Premere Occlusion System on the basis of absence of moderate or severe atrial septal aneurysm (ASA) on Transesophageal echocardiography and intracardiac echocardiography (< 3RL or 3LR ASA and length of PFO channel >10 mm). Results: The procedure was successful in all of the patients with no peri‐operative and in‐hospital complications. Forty‐six 20 mm and twenty‐four 25 mm Premere devices were implanted. Rates of procedural success, predischarge occlusion, and complication were: 100%, 95.7% and 0%, respectively. On mean follow‐up of 40 ± 10.9 months (range 6–54), the follow‐up occlusion rate was 98.5%. During follow‐up, no cases of permanent atrial fibrillation, aortic/atrial erosion, device thrombosis, or atrioventricular valve inferences were noted. Conclusion: The mid‐term outcomes of our registry suggests that the Premere Occlusion System may be an excellent device for patients with long‐channel PFO and absence of moderate/severe ASA, offering a physiological and anatomically respective closure of PFO also in patients with hypertrophic rims. © 2010 Wiley‐Liss, Inc.     

Resolution of migraine by transcatheter patent foramen ovale closure with Premere Occlusion System in a preliminary series of patients with previous cerebral ischemia.

BACKGROUND: Transcatheter closure of PFO with nitinol devices may be problematic in young patients with migraine due the risk of late erosions. Alternative devices with less amount of metal as the last generation devices may be preferable in such cases. We present the results of transcatheter closure of PFO with the last generation Premere Occlusion System device in a preliminary series of young adults with migraine and previous cerebral ischemia. METHODS: During a 12-month period (January 31, 2006 to December 31, 2006) 26 patients (18 female and 8 male, mean age 40 +/- 3.7 years) with previous stroke and severe disabling migraine were referred to our center for transcatheter closure of PFO. Migraine disability assessment score (MIDAS) was used to assess MHA incidence and severity. Patients were selected for Premere occlusion system (absence of atrial septal aneurysm and length >15 mm) on the basis of presence/absence of right and left bulging atrial septal aneurysm and length of PFO channel (<15 mm or >15 mm) on transesophageal echocardiography. Transesophageal echocardiography and transcranial Doppler were performed at 1 month, transthoracic echocardiography and cerebral magnetic resonance imaging at 6 and 12 months. Cardiologic and neurological visit was scheduled at 1, 6, and 12 months with MIDAS questionnaire administration. RESULTS: Ten patients (2 males, mean age 32 +/- 7.6 years, mean MIDAS score 38.9 +/- 5.8) underwent transcatheter PFO closure with the Premere occlusion system. Mean fossa ovalis diameters by ICE measurement was 20.6 +/- 3.1 mm. Thus, two 20-mm and eight 25-mm Premere devices were implanted. The procedure was successful in all of the patients with no perioperative and in-hospital complications. After a mean follow-up of 10.9 +/- 5.8 months, all patients were free from migraine symptoms (mean MIDAS score 2.9 +/- 1.9) with PFO complete closure in all patients on transesophageal and transcranial Doppler ultrasound. CONCLUSION: While waiting for larger studies evaluating the impact of new generation devices in curing PFO-related migraine, this preliminary anecdotal series suggests that the Premere occlusion system may be an effective and safe device for young patients with previous cerebral ischemia and migraine at least in the midterm period.     

Decline in mean platelet volume in patients with patent foramen ovale undergoing percutaneous closure

Patent foramen ovale (PFO) is a haemodynamically insignificant communication that is present in 24% of the general population.1 In 1988 Lechat et al. performed transthoracic echocardiography (TTE) with contrast injection and showed that patients with stroke of unknown cause had PFOs more frequently than the controls.2 Since then, many studies have confirmed this association. In 2000, a meta-analysis summarised the evidence that PFO was more likely to be found in stroke patients than in stroke-free individuals.3In about 50 to 60% of patients younger than 55 years, the cause of acute ischaemic stroke remains undefined.4 In this group, interatrial septal abnormalities are found in 55 to 60% of cases, which is higher than in the normal population.In another meta-analysis, Mattle et al. reported a higher prevelance of PFO in patients with cryptogenic stroke than in patients with a stroke of known causes.1 The postulated possible mechanisms underlying the stroke in the presence of PFO are: paradoxycal embolism, thrombus formation within the conduit of the PFO, or susceptibility of patients with PFO to atrial arrhythmias with possible intra-atrial thrombus formation.4-8Although paradoxycal embolism, which is associated with deep-vein thrombosis (DVT), is the favoured hypothesis, DVT in patients with PFO is usually undetectable.9 Therefore, increased platelet activity as well as disorders in the coagulation cascade may contribute to the association between PFO and stroke.Mean platelet volume (MPV) is a measure of platelet size and is a potential marker of platelet reactivity. It has been shown that larger platelets are metabolically and enzymatically more active and have greater prothombotic potential.10,11The aim of this study was (1) to compare MPVs of PFO patients with and without a history of cryptogenic stroke, and (2) to determine the effect of percutaneous PFO closure on MPV.     

Orthodeoxia-platypnea due to intracardiac shunting relief with transcatheter double umbrella closure

The safety and efficacy of transcatheter clamshell occlusion of patent foramen ovale for relief of severe arterial desaturation and dyspnea in the upright position due to intracardiac shunting were examined in eight patients with excessive risk of surgical patent foramen ovale closure. All patients had successful reduction of intracardiac shunting with an immediate rise in oxygen saturation ?95% by implantation of a clamshell device on the atrial septum. Despite two early incidents of device embolization, retrieval and immediate re-implantation, and one patient with nonsustained atrial and ventricular arrhythmias, there were no adverse clinical sequelae. In follow-up evaluation transcatheter clamshell closure of patent foramen ovale has provided persistent relief from shuntrelated arterial desaturation and symptomatology in all living patients. © 1995 Wiley-Liss, Inc.     

Persistent redundant Eustachian valve interfering with Amplatzer PFO occluder placement: anatomico-clinical and technical implications.

A 28-year-old man with patent foramen ovale and a prominent Eustachian valve with a history of transient ischemic attack underwent transcatheter closure using Amplatzer patent foramen ovale occluder. During deployment, some of the prominent valve tissue was entrapped on the delivery cable and a piece of the valve was extracted unintentionally. Anatomico-clinical and technical implications are discussed.     

Preliminary experience with a new 18 mm Amplatzer PFO occluder for small persistent foramen ovale.

We report our initial experience with a new 18 mm Amplatzer PFO device for the closure of small PFO. Patients were selected by a semiquantitative sizing procedure using the circle of a diagnostic pigtail catheter instead of a sizing balloon. In all eight patients, the device was easy to implant without problems. Due to its size, it has the potential to minimize the risk of inadvertent atrial erosion or perforation after deployment and thus will enhance the safety of interventional PFO closure.     

Avoiding pacemaker lead entrapment during PFO closure

We present a case of a patient with a history of cryptogenic stroke and implanted dual‐chamber pacemaker referred for transcatheter closure of patent foramen ovale (PFO). During the procedure ventricular lead of the pacemaker was found to run alongside the PFO. This interrupted correct positioning and deployment of the Amplatzer occluder without sandwiching of the lead. A self‐prepared pigtail catheter with a cut off tip was used to move the lead away from the PFO. Subsequently, an occluder was successfully placed. In conclusion, difficulties in Amplatzer occluder placement in patients with implanted pacemaker may be overcome by a manoeuvre which prevents lead entrapment by the device. © 2008 Wiley‐Liss, Inc.     

Approaches to correct device malposition in percutaneous PFO closure: anatomical and technical implications.

We describe three patients with initial failure of transcatheter patent foramen ovale closure. Two patients had residual defects successfully closed during the initial session, and one patient had a persistent shunt, which was corrected at a later time. Anatomical and technical considerations and the role of intracardiac ultrasound are discussed.     

How to Understand Patent Foramen Ovale Clinical Significance - Part II: Therapeutic Strategies in Cryptogenic Stroke

In the first part of this review, we reminded that patent foramen ovale (PFO) is a slit or tunnel-like passage in the interatrial septum occurring in approximately 25% of the population and that a number of conditions have been linked to its presence, the most important being cryptogenic stroke (CS) and migraine. We have also shown how, in the setting of neurological events, it is not often clear whether the PFO is pathogenically-related to the index event or an incidental finding, and therefore we thought to provide some useful key points for understanding PFO clinical significance in a case by case evaluation. The controversy about PFO pathogenicity has consequently prompted a paradigm shift of research interest from medical therapy with antiplatelets or anticoagulants to percutaneous transcatheter closure, in secondary prevention. Observational data and meta-analysis of observational studies previously suggested that PFO closure with a device was a safe procedure with a low recurrence rate of stroke, as compared to medical therapy. However, so far, published randomized controlled trials (CLOSURE I^®, RESPECT^® and PC Trial^®) have not shown the superiority of PFO closure over medical therapy. Thus, the optimal strategy for secondary prevention of paradoxical embolism in patients with a PFO remains unclear. Moreover, the latest guidelines for the prevention on stroke restricted indications for PFO closure to patients with deep vein thrombosis and high-risk of its recurrence. Given these recent data, in the second part of the present review, we aim to discuss today treatment options in patients with PFO and CS, providing an updating on patients’ management.     

Outcome after percutaneous closure of a patent foramen ovale using the Intrasept™ device

Objectives : This multi‐centre study reports safety and efficacy of percutaneous patent foramen ovale (PFO) closure, using the fourth generation Intrasept? device. Background : PFO has been associated with paradoxical embolism and cryptogenic stroke. Percutaneous PFO closure seems to reduce the risk for recurrent paradoxical thrombo‐embolism. Currently, different devices are used for PFO closure. Methods : Patients, who underwent a PFO closure with the Intrasept device (Cardia, Eagan, MN) between July 2002 and September 2006, were included in the study. The primary endpoint was defined as reoccurrence of stroke, transient ischemic attack (TIA), or peripheral thrombo‐embolism. Peri‐procedural and mid‐term complications were reported. Results : Four‐hundred thirty patients (mean age 50.7 ± 13.0 years, 231 men) underwent closure. The indications were cryptogenic stroke (69.8%), TIA (23.5%), peripheral embolism (3.3%), and other (3.5%). The median follow‐up time was 0.8 years, range 3.9 years. The primary endpoint occurred in 0.5% for stroke, in 2.5% for TIA, and in none for peripheral embolism. Peri‐procedural complications were reported in 11.5% of cases, from which 0.2% was defined as major. No severe complications occurred during mid‐term follow‐up. A residual shunt was present in 12.5% of patients who did not suffer from a recurrent event, compared to 36.4% of patients who reached the primary endpoint (P = 0.04). Conclusion : This multi‐centre study suggests that percutaneous closure of a symptomatic PFO with the fourth generation Intrasept device is safe and might be effective to prevent the recurrence of paradoxical thrombo‐embolic events. © 2008 Wiley‐Liss, Inc.     

Effect of atrial septal mobility on transcatheter closure of interatrial communications

BACKGROUND: Transcatheter techniques have evolved as alternatives to surgical closure of interatrial communications due to its less invasive nature and low morbidity. The technique may be limited by the inability to deploy the device and, thus, may be complicated by significant residual shunting. Mobile or redundant septal tissue has been implicated as a possible cause of unsuccessful closure. METHODS: To determine if atrial septal hypermobility precludes successful transcatheter device closure of interatrial communications, 69 patients (mean age 46.4 +/- 17.5 years [male:female ratio 34:35]) with periprocedural transesophageal echocardiograms were reviewed. Septal excursion was defined as the maximal transit of the interatrial septum between either side of the plane connecting the superior and inferior attachment points. Unsuccessful closure was defined as subsequent cardiac surgery to close the defect, inability to deploy the device, recurrent attempts at closure, device malalignment, residual shunting greater than mild in degree on follow-up transthoracic study, and procedural complications. RESULTS: Reasons for closure were the following: embolic events (n = 48); platypnea/orthodeoxia (n = 15); atrial septal defect with right ventricular dilatation and paroxysmal atrial tachycardia (n = 2); atrial septal defect (n = 3); and prophylactic patent foramen ovale closure in a scuba diver (n = 1). Successful closure occurred in 76% of patients (n = 53). Compared with those patients with successful transcatheter closure, the mean septal excursion in patients with failed closure was 0.66 +/- 0.56 cm versus 0.76 +/- 0.47 cm (P = not significant [NS]). CONCLUSION: Our results do not support the concern that exaggerated septal mobility compromises successful device closure of interatrial communications.