Foramen Ovale – ABC CARDIOL

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Original Article

Registry of Percutaneous Closure of Patent Foramen Ovale in the Secondary Prevention of Stroke

Eduardo S. Silveira et al. Guilherme P. Machado Julia K. Teixeira Felipe Fuchs … Antonio F. Pinotti Sheila Martins Marco V. Wainstein

Abstract

Background

The foramen ovale remains patent in about 25% of the adult population. In adult life, thrombi form in the venous circulation and can cross the interatrial septum and trigger an ischemic stroke – called paradoxical embolism. The treatment can be performed through percutaneous closure of the patent foramen ovale (PFO), but still rarely performed in Brazil because it is not available in the public health care.

Objectives

To evaluate the reproducibility of clinical trial results in real-life studies due to the low number of records published about the topic.

Methods

This study is a retrospective cohort study including 121 patients who underwent percutaneous PFO closure for secondary prophylaxis of ischemic stroke between January 2012 and June 2022.

Results

We observed a mean age of 50.3 years and most females . Severe interatrial shunt was observed in 82.6% and the presence of atrial septal aneurysm in 84.2%. After 6 months of the procedure, no patient still had a residual shunt. There were no serious bleeding or vascular complications. Recurrence of a new cerebrovascular event occurred in 1.6% of patients.

Conclusion

We observed a low recurrence of new ischemic neurological events and lack major complications related to the procedure.

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Review Article

My Approach to Transcranial Doppler Combined With Transthoracic and Transesophageal Echocardiography to Investigate PFO

Gracielly Barros et al. Patrick Ventorim Costa

Abstract

This review article explores the combined use of Transcranial Doppler (TCD) with transthoracic (TTE) and transesophageal (TEE) echocardiography to investigate Patent Foramen Ovale (PFO), a condition found in approximately 25-27% of the adult population. PFO is a remnant of fetal circulation and the most common cause of interatrial shunt. It is associated with clinical complications such as platypnea-orthodeoxia syndrome, obstructive sleep apnea, migraine, and stroke.

PFO assessment is generally performed using TTE and TEE, but TCD, a highly sensitive and less used method, is also important. TCD indirectly detects shunts in awake patients and uses the microembolic signal (MES) grading score to classify shunt severity. This technique involves injecting a contrast solution into the antecubital vein during the Valsalva maneuver to detect intracardiac shunt by observing microbubble appearance in the first cardiac cycles.

The case report illustrates the effectiveness of TCD in the initial screening of a patient with suspected PFO using TTE, TCD and TEE. The conclusion highlights that TCD is a crucial diagnostic tool, particularly relevant for the therapeutic management of patients with cryptogenic stroke. Several scientific publications are referenced, providing a theoretical foundation for the combined use of TCD, TTE, and TEE in PFO investigation.

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Review Article

My Approach to Patent Foramen Ovale Closure

Fernando Melo Netto et al. Maria Estefânia Bosco Otto

Abstract

The patent foramen ovale (PFO), a relatively common and generally benign finding, has been associated with paradoxical embolisms. The closure of PFO, performed in patients with cryptogenic stroke, has been shown to reduce the recurrence rates of ischemic events, as evidenced by recent clinical trials. In this article, the authors synthesize the crucial role played by echocardiography in this context, from diagnosis and risk stratification to planning and monitoring of percutaneous intervention.

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Case Report

Patent Forame Ovale: Contribution of Transcranial Doppler in Patient Diagnosis

Eliza de Almeida Gripp et al. Ana Carolina de Freitas Portela Flávio Luis da Costa Junior Rafael Rabishoffsky … Jéssica Rizkalla Corrêa Medeiros Arnaldo Rabischoffsky

Introduction

Patent forame ovale (PFO) is the most common type of interatrial shunt, with a prevalence between 25% and 27% of the adult population. It has a flap-like functioning and is generally asymptomatic. In some cases, it can be associated with clinical complications, such as brain strokes, paradoxical embolism, platypnea-orthodeoxia syndrome, and obstructive sleep apnea. The diagnosis is mainly found in young patients who present brain strokes, with no other apparent risk factor.

The evaluation of PFO is commonly performed by means of transthoracic echocardiogram (TTE) and transesophageal echocardiogram (TEE). However, another important method of evaluation that is rarely used in our area is the Transcranial Doppler (TCD), which evaluates the presence of an indirect shunt in an awake patient and with high sensitivity.

[…]

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Case Report

Pulmonary Thromboembolism Associated with Paradoxical Embolism in a Patient with Patent Foramen Ovale

Arthur Barroso Vidal Vilarinho et al. Danielly Bernardes Silva Ana Rosaria Medeiros Peres Rodolfo Loureiro Borges de Souza … Carlos Eduardo de Sousa Amorelli Fábio Lemos Campedelli Luciano Moreira Alves Fabio Augusto Cypreste de Oliveira

Introduction

Patent foramen ovale (PFO) is a pathological condition characterized by an opening in the interatrial septum, that allows blood to flow from one atrium to the other. It is found in approximately 25% of the adult population, with no hemodynamic implications in most cases. However, due to persistence of the foramen, paradoxical embolism may occur as a cause of ischemic events; in some cases, closure of the PFO is indicated as a secondary prevention strategy for thromboembolic events.

Studies have demonstrated an association between PFO and many clinical conditions, some potentially severe, such as ischemic stroke and pulmonary thromboembolism (PTE).

[…]

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Case Report

Thrombus-in-transit and Paradoxical Embolism in Patient with ST-Segment Elevation Acute Coronary Syndrome

Daniel Lucena de Aguiar et al. Gisele Nogueira Bezerra Isabella Cabral Marinho Plens Lúcia de Sousa Belém Danielli Oliveira da Costa Lino

[…]

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Point of view

Echocardiographic Evaluation of Patients with Patent Foramen Ovale and Cryptogenic Stroke

Carlos Antônio da Mota Silveira et al. José Maria Del Castillo

Abstract

Recent studies have indicated that patent foramen ovale (PFO) may cause cryptogenic stroke in young patients presenting anatomical conditions that can favor it and that transcatheter occlusion reduces the incidence of stroke versus clinical treatment. A transesophageal echocardiographic study with agitated saline injection associated with the Valsalva maneuver can evidence right-to-left shunt with high sensitivity (89%) and specificity (92%). The Risk of Paradoxical Embolism trial evaluated the clinical characteristics of stroke patients with PFO; established a risk score for cryptogenic stroke; and used a multivariate regression model to identify six variables including age, presence of cortical ischemia, diabetes, hypertension, stroke, and previous transient ischemic attack. The highest scores were observed in young stroke patients without vascular risk factors, and the lowest scores were identified in older patients with vascular risk factors in which the PFO appeared to be incidental. Anatomical PFO conditions predispose patients to systemic embolism (PFO separation > 2 mm, PFO tunnel > 10 mm, angle between the inferior vena cava and the PFO flap < 10°, shunt intensity with Valsalva maneuver, and presence of interatrial septal aneurysm and Chiari network or prominent Eustachian valve). PFO closure can prevent paradoxical embolism by decreasing the incidence of stroke in high-risk patients.

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Artigo Original

Mobility of the Septum primum does not depend on the foramen ovale diameter in normal fetuses

Paulo Zielinsky et al. Marcelo Sallum Fabíola Satler Eduardo Ioschpe Gus … Luiz Henrique Nicoloso João Luiz Mânica Antônio Luiz Piccoli Jr

OBJECTIVE: To test the hypothesis that a correlation exists between the maximum foramen ovale diastolic diameter and the excursion index (EI) of the septum primum in normal fetuses. METHODS: One hundred and two normal fetuses with gestational ages ranging from 20 to 40 weeks were submitted to echocardiography. The foramen ovale diameter and the “maximal excursion” of the septum primum were measured in a 4-chamber view. The data were analyzed by Pearson’s correlation coefficient. RESULTS: The mean foramen ovale (FO) diameter was 5.06 ± 1.29 mm; the maximal excursion of the septum primum was 5.42 ± 1.41 mm; the left atrium diameter 11.47 ± 2.76 mm; the septum primum “excursion index” was 0.48 ± 0.09. Mean FO/EI ratio was 11.35 ± 3.94 mm. No FO/EI correlation (r = -0.03) existed, and a weak foramen ovale/left atrium correlation (r = 0.31) was observed, as well as a weak foramen ovale/excursion of septum primum correlation (r = 0.21). CONCLUSION: Septum primum mobility does not depend on the foramen ovale diameter in normal fetuses, suggesting that the modifications of its diastolic displacement is not influenced by the size of the interatrial opening.

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