Patent Foramen Ovale and Migraine Attacks: A Systematic Review

Background

Migraine headache and the presence of a patent foramen ovale have been associated with each other, although the precise pathophysiological mechanism(s) are uncertain. The purpose of this systematic review was to identify the extent of patent foramen ovale prevalence in migraineurs and to determine whether closure of a patent foramen ovale would improve migraine headache.

Methods

An electronic literature search was performed to select studies between January 1980 and February 2013 that were relevant to the prevalence of patent foramen ovale and migraine, and the effects of intervention(s) on migraine attacks. Of the initial 368 articles presented by the initial search, 20 satisfied the inclusion criteria assessing patent foramen ovale prevalence in migraineurs and 21 presented data on patent foramen ovale closure.

Results

In case series and cohort studies, patent foramen ovale prevalence in migraineurs ranged from 14.6% to 66.5%. Case-control studies reported a prevalence ranging from 16.0% to 25.7% in controls, compared with 26.8% to 96.0% for migraine with aura. The extent of improvement or resolution of migraine headache attack symptoms was variable. In case series, intervention ameliorated migraine headache attack in 13.6% to 92.3% of cases. One single randomized trial did not show any benefit from patent foramen ovale closure. The data overall do not exclude the possibility of a placebo effect for resolving migraine following patent foramen ovale closure.

Conclusion

This systematic review demonstrates firstly that migraine headache attack is associated with a higher prevalence of patent foramen ovale than among the general population. Observational data suggest that some improvement of migraine would be observed if the patent foramen ovale were to be closed. A proper assessment of any interventions for patent foramen ovale closure would require further large randomized trials to be conducted given uncertainties from existing trial data.     

Platypnée-orthodéoxie révélée par des syncopes à répétition

Platypnea-orthodeoxia is a rare clinical condition which must be examined as a differential diagnosis for any bout of faintness occurring during standing or dyspnea that is exacerbated by standing. This syndrome is often associated with a patent foramen ovale. Its physiopathology is not univocal and the association of many anatomical criteria seems to be mandatory. Contrast echocardiography confirms diagnosis and closure of the patent foramen ovale during interventional catheterization and is currently the therapeutic method of choice. After closure of the foramen ovale, clinical improvement is spectacular and durable.     

卵圆孔未闭与脑卒中的相关性及其治疗的研究新进展

近年来国内外相关研究表明卵圆孔未闭在脑卒中的病理生理过程中起一定作用,卵圆孔未闭治疗方法主要包括外科治疗、药物治疗及介入治疗。其中卵圆孔未闭封堵治疗可能会改善脑卒中预后,但近期有些相关前瞻性研究并未证实这一结论。因此卵圆孔未闭是否行介入治疗,其最佳适应证及其疗效等尚需进一步临床试验结果证实。现就以上情况做一综述。     

Minimally invasive retrieval of patent foramen ovale closure device after device migration to the descending aorta

Percutaneous treatment of patent foramen ovale with a septal closure device has become a common procedure, but it is associated with various complications. Migration of the device is uncommon, and migration through the aortic valve into the aorta is rare. Managing the migration of a patent foramen ovale occluder can be challenging; it usually requires surgical retrieval of the foreign body. We report a rare case in which a patient experienced migration of a large patent foramen ovale closure device to the descending aorta. Rarer still was its successful percutaneous management.     

Percutaneous occlusion of patent foramen ovale in patients with paradoxical embolism.

INTRODUCTION: A patent foramen ovale can be found in about one quarter of adults and in a small percentage it is a wide opening and may be associated with aneurysmal formation. The association between a wide patent foramen ovale and paradoxical embolism is well established. In such cases percutaneous closure is indicated, as an alternative to life-long anticoagulant therapy or surgery. Percutaneous closure is an attractive technique and is more advantageous than other methods. METHODOLOGY: We describe the first cases of percutaneous occlusion of patent foramen ovale performed in Portugal, using the Amplatzer PFO occluder, in three female patients with documented cerebrovascular accidents due to paradoxical embolism. We also analyze the rationale for using this technique in such patients and its preliminary results. RESULTS: All three patients submitted to percutaneous occlusion of patent foramen ovale had a similar history of ischemic cerebrovascular accident. Transesophageal echocardiography showed a wide-open foramen ovale ranging from 9 to 12 mm, with spontaneous right-to-left shunt in all patients, and one of them also had an aneurysmal formation. Total procedure time ranged from 30 to 55 minutes and fluoroscopic time from 9 to 12 minutes. There were no complications and during the short follow up all patients are asymptomatic and free of recurrent events. CONCLUSIONS: Percutaneous closure of patent foramen ovale is a safe and promising technique in the prevention of recurrent systemic thromboembolism in appropriately selected patients. Prospective studies comparing antithrombotic therapy or surgery with percutaneous closure should clarify its efficacy and therapeutic value.     

Transhepatic approach to closure of patent foramen ovale: report of 2 cases in adults

Patent foramen ovale is increasingly diagnosed in patients who are undergoing clinical study for cryptogenic stroke or migraine. In addition, patent foramen ovale is often suspected as a cause of paradoxical embolism in patients who present with arterial thromboembolism. The femoral venous approach to closure has been the mainstay. When the femoral approach is not feasible, septal occluder devices have been deployed via a transjugular approach.Herein, we describe 2 cases of patent foramen ovale in which the transhepatic approach was used for closure. To our knowledge, this is the 1st report of a transhepatic approach to patent foramen ovale closure in an adult patient. Moreover, no previous case of patent foramen ovale closure has been reported in a patient with interrupted inferior vena cava.     

Patent foramen ovale, systemic embolization and closure

The recognition, evaluation and treatment of patent foramen ovale has attracted increasing interest as the importance and frequency of paradoxical embolism has become better understood. The interest in this field has been driven largely by the widespread application of echocardiography with identification of a patent foramen ovale and/or an atrial septal aneurysm. The evaluation of the role of a patent foramen ovale in patients with a neurologic event is complex because the patent foramen ovale or atrial septal aneurysm may either be an innocent bystander or could be the etiologic mechanisms involved in the paradoxical embolus. In patients younger than 55 years, a causal relationship between a patent foramen ovale/atrial septal aneurysm and a neurologic ischemic event is considerably stronger than in those patients older than 55 years. In patients with a presumed diagnosis of paradoxical embolus in the setting of a patent foramen ovale, percutaneous closure is now possible and 2 devices are relatively widely used. Both of these devices reliably close the defect with a very acceptable risk profile and have been found in the longer term to be associated with excellent outcome. The exact role, however, that these devices play vis a vis continued medical therapy for prevention of recurrent events is being tested in 2 randomized clinical trials. The field continues to change with new technology being developed and with new applications. A recently exciting finding has been the identification that closure of a patent foramen ovale may be associated with dramatic improvement in symptoms of patients with disabling migraine headaches. Other potential applications of these devices include those patients who are deep-sea divers, in whom the potential for "bends" exists, or high altitude airplane pilots.     

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.     

Successful percutaneous closure of patent foramen ovale seven years after surgical closure

Through advancements in transcatheter technology, a patent foramen ovale (PFO) can now be closed by either a percutaneous or surgical procedure. This report presents a patient who suffered an embolic stroke secondary to a PFO. The PFO was successfully closed surgically, but 7 years later the foramen ovale was found to be widely patent. The patient underwent successful percutaneous PFO closure and the foramen ovale remains closed. This case demonstrates that percutaneous PFO closure may be viable in patients in whom surgical closure has not provided long-term closure.     

Stepwise Progression of Right-to-Left Atrial Shunting through a Combination of Patent Foramen Ovale and Tricuspid Regurgitation

Patent foramen ovale is a common clinical finding that generally becomes a concern in the presence of transient ischemic attack or stroke. Rarely, patent foramen ovale is associated with hypoxemia in the presence of substantial right-to-left atrial shunting.We present the case of an 86-year-old woman with a pacemaker, who was initially asymptomatic notwithstanding a patent foramen ovale. Over 1.5 years, her symptoms progressed in a stepwise fashion, in the setting of progressive pacemaker-associated tricuspid regurgitation. Ultimately, the patient''s symptoms and her hypoxemia resolved after percutaneous closure of her patent foramen ovale with use of a 25-mm “Cribriform” occluder device.This case highlights the fact that clinically significant right-to-left shunting requires an anatomic lesion, such as patent foramen ovale, together with elevated right atrial pressure, which in this case was contributed by severe tricuspid regurgitation.     

卵圆孔未闭封堵治疗预防脑卒中的再认识

卵圆孔未闭与缺血性卒中的关系一直倍受大家关注,围绕这个问题的众多研究结果却大相径庭,而该问题的争议直接影响到不明原因脑卒中伴卵圆孔未闭患者的二级预防策略.卵圆孔未闭的封堵治疗预防缺血性卒中应用于临床二十余年,目前尚无明确的证据证明其比药物预防更为有效.现就卵圆孔未闭封堵治疗预防脑卒中涉及的有争议的问题进行综述,期望业内学者针对这些问题展开更多有效的研究.     

Transient transcatheter balloon closure of patent foramen ovale following surgical repair of critical pulmonary stenosis

Severe cyanosis resulting from postoperative atrial right-to-left shunt is a life-threatening complication. We present a technique of transient transcatheter balloon closure of a patent foramen ovale in a newborn operated on for critical pulmonary stenosis, where the foramen ovale had been left open intraoperatively. Cardiac catheterization was performed under echocardiographic control in the intensive care unit and the foramen ovale was occluded with a water-filled balloon-catheter. Significant improvement of arterial oxygen tension allowed delayed definitive surgical closure in a second step. Unfortunately, the child developed right-sided pneumothorax postoperatively and died of cardiopulmonary failure. Nevertheless, this procedure seems a suitable way to relieve atrial right-to-left shunt temporarily until definitive surgical closure can be performed.     

Transcatheter closure of patent foramen ovale in patients with platypnea-orthodeoxia

Platypnea-orthodeoxia is a rare syndrome characterized by the occurrence of dyspnea and hypoxemia on adoption of an upright posture (i.e., orthodeoxia) and by the absence of symptoms and hypoxemia in decubitus. This syndrome is frequently related to patent foramen ovale and right-to-left shunting. We describe two patients in whom patent foramen ovale with right-to-left shunting was observed on transthoracic and transesophageal echocardiography and who had platypnea-orthodeoxia in the absence of pulmonary disease. They underwent transcatheter closure using an Amplatz device. The echocardiographic diagnosis and closure procedure are discussed. These case reports demonstrate that closure of patent foramen ovale is an effective treatment for platypnea-orthodeoxia.     

Inflammatory pseudothrombus on a patent foramen ovale occluder device

Herein, we describe late complications after the transcatheter device closure of a patent foramen ovale in a patient with migraine headaches. The clinical presentation included acute neurologic symptoms and new-onset atrial fibrillation. A mass on the left atrial side of the occluder was surgically removed. Histologic results showed an inflammatory lesion that consisted predominantly of lymphocytes, plasma cells, and macrophages. Despite complete surgical closure and the termination of atrial fibrillation, the patient continued to experience neurologic events. Although transcatheter patent foramen ovale closure is associated with low complication rates, a careful risk-benefit evaluation is warranted in view of the potentially severe complications and the current lack of robust pathophysiologic and clinical trial data to support this therapy in the treatment of migraine headaches.     

Stroke due to late device thrombosis following successful percutaneous patent foramen ovale closure

We report a case of stroke due to device thrombosis occurring three years following percutaneous patent foramen ovale (patent foramen ovale) closure with an Amplatzer atrial septal occluder device. We discuss risk factors that may have contributed to device thrombosis and raise concerns regarding the lack of a dedicated PFO closure device for clinical use in the United States.     

Transcatheter closure of a patent foramen ovale in an adult with hypoxemia after cardiac transplantation

We describe a case of refractory hypoxemia secondary to a patent foramen ovale immediately after orthotopic heart transplantation in a 60-year-old woman. The patent foramen ovale was successfully closed with a septal occlusion device, with resolution of the hypoxemia. To our knowledge, transcatheter closure of a patent foramen ovale in an adult patient with refractory hypoxemia during the immediate post-transplant period has not previously been reported.     

Stroke as a complication of congenital heart disease

Patent foramen ovale is a common finding in the general population. It is associated with an increased risk of stroke, but it may not have a significant effect on recurrent stroke risk in medically treated patients. Recently, many questions have arisen with respect to best treatment for preventing recurrent stroke. Some data from a clinical trial of anticoagulation compared with antiplatelet therapy support anti-platelet treatment for secondary prevention. There are not enough data currently to support surgical or percutaneous closure of patent foramen ovale for stroke prevention.     

Acute ischaemic stroke in a young male with patent foramen ovale

We present a case of a 35-year old patient with a patent foramen ovale and acute ischaemic stroke. The patient underwent successful percutaneous closure of foramen ovale with an Amplatzer device. Epidemiology, diagnosis and treatment of this condition are discussed.     

Secondary prevention after cryptogenic cerebrovascular events in patients with patent foramen ovale

BACKGROUND: Patients with patent foramen ovale and cryptogenic stroke are at risk of recurrence, but there are few data on strategies to prevent this. METHODS: We studied 280 consecutive patients with cryptogenic cerebrovascular events and a patent foramen ovale examined by multiplane transesophageal echocardiography. Patients received platelet inhibitors (n = 66) or anticoagulation (n = 47) or underwent device closure (n = 167). During the mean follow-up of 2.6 years, we compared the frequency of recurrent events, death and severe treatment complications. RESULTS: A total of 33 (12%) patients had a recurrent cerebrovascular event. The annual recurrence rates were 13% in patients treated with platelet inhibitors, 5.6% in those on oral anticoagulation, and 0.6% in those after device closure. Independent predictors of recurrent cerebrovascular events were a patent foramen ovale larger than 4 mm (hazard ratio 3.8, 95% CI 1.2-11.2; p = 0.017) or previous strokes (hazard ratio 4.3, 95% CI 2.0-9.2; p < 0.001). Interventional closure of the patent foramen ovale decreased the risk of a recurrent event compared with oral anticoagulation (hazard ratio 0.06, 95% CI 0.12-0.29; p < 0.001), whereas antiplatelet therapy showed a trend to an increased risk (hazard ratio 2.3; 95% CI 0.9-5.5; p = 0.055). Major side effects occurred in 7 anticoagulated patients and in 13 patients after device closure. There were two non-vascular deaths and one fatal hemorrhagic stroke. CONCLUSIONS: Patients with a large patent foramen ovale and a cryptogenic cerebrovascular event had a substantial risk of recurrence even with medical treatment. Risk of recurrence was lower after device closure of the patent foramen ovale.     

Transcatheter closure of patent foramen ovale after presumed paradoxical embolism.

BACKGROUND. Many have proposed a relation between presence of a patent foramen ovale, with or without atrial septal aneurysm, and cryptogenic stroke. The effect of foramen ovale closure on the risk for subsequent strokes is unknown. METHODS AND RESULTS. Transcatheter closure of a patent foramen ovale was undertaken in 36 patients with known right-to-left atrial shunting and presumed paradoxical emboli (31 strokes, 25 transient neurological events, four systemic arterial emboli, and two brain abscesses). Individual patients had between one and four such events. None had a left heart or carotid source of embolism; 31 of 35 had no known risk factors for stroke. Events occurred in 12 patients while they were taking warfarin. At cardiac catheterization, patent foramina ovalia were significantly larger than predicted for age in 67% of the patients. Implantation of a double-umbrella device in the patent foramen ovale was achieved in all without serious procedural complications. Of 34 who have returned for follow-up, one has a residual atrial communication that may be clinically important, five had trivial leaks, and 28 have complete closure. There have been no strokes during a mean follow-up of 8.4 months. CONCLUSIONS. Transcatheter closure of a patent foramen ovale can be accomplished with little morbidity and may reduce the risk of recurrence. Further investigations directed toward identifying the population at risk and assessing the effect of intervention are warranted.