Abstract: Because patent foramen ovale (PFO) represents a lesion which may be repaired a number of expert clinicians believe that mechanical closure should be the primary treatment modality for patients with PFO after cryptogenic stroke; interest has grown on percutaneous devices and in the last years there has been great technological advancement of percutaneous techniques for PFO closure. However, we should not close a PFO before establishing the evidence-based indications. At the same time, efforts to develop safer and more effective closure devices are under way. These devices include those with little or no metal component and those with biodegradable discs. Ideally, we should be able to identify at-risk patients before they sustain a stroke and to prevent stroke by closing the PFO with a device that should result in complete closure, be made of material that conforms to both sides of the septum, and have no risk of erosion, infection, arrhythmia, or thrombogenicity. Randomised trials comparing medical and percutaneous closure approaches are underway, but large patient enrollment is necessary because of the low event rate in the younger patients. Meanwhile, as the complication rate from device implantation decreases and simpler devices are developed with reliability further demonstrated, the threshold for percutaneous closure is likely to decline.
Abstract: BACKGROUND AND PURPOSE: Right to left shunt is involved in conditions in which postural changes may be pathogenically relevant. The aim of this work was to assess the frequency of posturally dependent right to left shunt. METHODS: In 109 consecutive right to left shunt-positive subjects (male/female=40/69, age 43+/-12 years), we assessed with contrast-enhanced transcranial Doppler the bubble load during normal breathing and after the Valsalva maneuver in both standing and recumbent position randomizing the order of testing. RESULTS: During normal breathing, the average bubble count was 11+/-20 in the recumbent and 26+/-60 in the standing position. After the Valsalva maneuver, it was 40+/-38 and 42+/-37, respectively. The increase of bubble load in standing position occurred in 42% of patients and was independent of the order of testing. CONCLUSIONS: The amount of permanent right to left shunt is posture-dependent in 40% of patients. Testing in the sitting position may thus be warranted in doubtful or inconclusive results obtained with the subject in the horizontal position.
Abstract: We herein report a case of ischemic stroke due to paradoxical brain embolism in a young man, a trumpet player. Extensive diagnostic investigations revealed the presence of an isolated pulmonary arteriovenous fistula as the only risk factor for stroke. The peculiarity of this case is the early onset of neurological symptoms in the absence of Hereditary Hemorrhagic Teleangiectasia. The Authors suppose the repeated Valsalva maneuvers as a possible factor promoting fistula enlargement and symptoms development.
Abstract: The authors analyzed the extent of right-to-left shunting in patients with migraine, patients with cryptogenic stroke, and controls. Patients with both migraine and stroke had larger shunts than did patients with migraine without stroke (p = 0.038), patients with no migraine with stroke (p = 0.007), and control patients (p < 0.0001). Patients with migraine have overall larger shunts than nonmigraineurs, particularly if they have had a stroke. Right-to-left shunting may be causally related to migraine and to the increased stroke risk of migraine.
Abstract: BACKGROUND AND PURPOSE: Transcatheter closure of patent foramen ovale (PFO) has been reported to improve migraine in patients with cerebrovascular disorders in noncontrolled studies. The aim of the study was to compare the course of migraine assessed prospectively over a 12-month period in symptomatic (for cerebrovascular disease) and asymptomatic patients undergoing PFO closure and in patients with PFO treated medically. METHODS: Twenty-three stroke symptomatic (SS; 39+/-10 years of age; males/females [M/F] 5/18) and 27 stroke asymptomatic (SA; 40+/-12 years of age; M/F 5/22) patients with migraine underwent PFO closure. Twenty-seven patients with migraine and PFO (controls [CTRLS]; 36+/-11 years of age; M/F 4/23) were followed up medically. Migraine severity was assessed at baseline with a scale that takes into account the frequency, duration, and intensity of the attacks and the occurrence of aura (score range 0 to 10). Six months later, the patients were given a structured diary to annotate monthly with the same scale the characteristics of the attacks for the next 6 months. By the end of 1 year, the migraine score was averaged for the last 6 months. RESULTS: Baseline severity of migraine did not differ between groups (6.3 to 6.1 and 6.7 in SS, SA, and CTRLS groups, respectively). At the 1-year assessment, the overall migraine score had significantly improved by 3.7 and 2.8 points in SS and SA, respectively (P<0.001 on repeated-measure ANOVA), whereas it had nonsignificantly worsened by 0.1 points in CTRLS. Multiple linear regression analysis showed that the improvement in SS and SA was independent of migraine type, age, and cerebrovascular risk factors. Twenty-one of 21 patients with migraine with aura in the CTRLS group still had aura at the end of follow-up, whereas only 3 of 14 among SA and 4 of 19 among SS continued to have migraine preceded by aura (P<0.0001 on Fisher exact test). CONCLUSIONS: Compared with medical treatment, closure of PFO brings about a significant overall improvement in migraine. This seems to occur irrespective of migraine type and of previous cerebrovascular disease. In addition to the overall improvement, in migraine with aura, the occurrence of aura is dramatically reduced.
Abstract: The aim of this report is to quantify the amount of spontaneous microembolism detected in brain vessels by transcranial Doppler (TCD) during transcatheter closure of right-to-left shunt (RLS). We examined 29 patients who had had a stroke or a transient ischaemic attack (17 females and 12 males; mean age 45+/-15 years). They all underwent TCD monitoring during the procedure and microembolic signals (MES) were recorded. Detection of MES was distributed as follows: during femoral catheterisation in 8 patients (25%), during atrial catheterisation in 5 patients (17%), during transeptal crossing in 14 patients (48%), during left disc opening in 28 patients (96%) and during right disc opening in 7 patients (24%). The highest rates of MES were observed during left disc opening and less during transeptal crossing with an average count of 31 (range 3-135) and 3 (range 1-18) respectively. Brain embolism occurs throughout the procedure after femoral catheterisation for PFO closure. Our results indicate that the majority of MES reached the brain during the opening of the left disc in the left atrium: 28/29 patients exhibited MES with an average of 31 (3-135), thus supporting the notion that gas embolism accounted for the findings.
Abstract: The aim of this preliminary case-control study was to compare, in patients with migraine and PFO, transcatheter closure of PFO vs. medical treatments. Twelve patients were treated with antimigraine drugs and twelve underwent percutaneous transcatheter closure. All patients were followed-up for 12 months. Our preliminary results seem to confirm that, compared to medical treatment, PFO closure is by far more effective in reducing both frequency, duration and intensity of migraine attacks. Furthermore, the occurrence of prodromal aura is almost abolished.
Abstract: Valsalva sinus aneurysms are usually congenital and relatively rare and tend to be more frequent in adults. Rupture of these aneurysms can result in sudden death or in an abrupt and rapid progressive heart failure. Surgical repair is the traditional treatment of choice. We report the case of a 48-year-old female with a ruptured posterior non-coronary Valsalva sinus aneurysm, resulting in an anomalous aorto-right atrial fistula. Successful percutaneous catheter closure of the massive left-to-right shunt by using the Amplatzer duct occluder is presented.
Abstract: The treatment of very large patent ductus arteriosus (PDA) was thought to be solely surgical. There is not enough experience in transcatheter closure of large hypertensive PDA. In this report, successful catheter closure of a large and hypertensive ductus using the Amplatzer Muscular VSD Occluder and a literature review are presented.
Abstract: BACKGROUND AND PURPOSE: Transcatheter closure of patent foramen ovale (PFO) is increasingly being performed and monitored with transthoracic or transesophageal echocardiography, whereas contrast-enhanced transcranial Doppler (ce-TCD), which probably represents the most suitable tool to quantify right-to-left shunt (RLS) in the brain vessels, has been systematically overlooked. Our goal is to prospectively assess efficacy and safety of PFO transcatheter closure using ce-TCD. METHODS: A total of 140 consecutive patients (mean age, 46+/-13 years; male/female ratio, 63/77) with PFO-related large RLS and no other recognized cause of focal cerebral ischemia underwent transcatheter closure. TCD was done preoperatively and 1 month after the procedure in all patients, after 3 months in 120, after 6 months in 112, and after 1 year in 104 patients. RESULTS: Implantation was successful in all patients. During Valsalva strain, a large shunt was still detectable in 31 of 140 (22%), 15 of 120 (13%), 9 of 112 (8%), and 9 of 104 (9%) patients at the 1-, 3-, 6-, and 12-month visits, respectively. Periprocedural and postprocedural complications included atrial fibrillation in 8% and scintillating scotomata in 6% of patients. During the 1-year follow-up period, only 1 transient ischemic attack was recorded in a patient with paroxysmal atrial fibrillation and complete PFO closure. CONCLUSIONS: Transcatheter PFO closure in patients with cryptogenic stroke and large RLS may be less successful than reported previously. TCD appears the ideal tool to follow up the closure process and to identify early, during follow-up, those patients who will be left with a significant shunt. Atrial fibrillation is more common than believed previously and may underlie the occurrence of further cerebrovascular events despite complete PFO closure. Irritative visual phenomena may occur as a consequence of nickel toxicity.
Abstract: The purpose of this study was to assess the safety and feasibility of percutaneous interventional closure of patent foramen ovale (PFO) with or without atrial septal aneurysm (ASA) in symptomatic patients. Between June 1999 and June 2002, we performed transcatheter closure of PFO in 256 consecutive symptomatic patients (female/male = 1.45; mean age 48 +/- 16 years; range 14-75): ischemic stroke (n = 101), transient ischemic attack (n = 144), peripheral and coronary arterial embolism (n = 17); multiple events (n = 23); platypnea-orthodeoxia syndrome (n = 2); refractory hypoxemia (n = 1); and migraine aura (n = 27). The implanted devices were an Amplatzer PFO Occluder (n = 248), a Gore-HELEX Septal Occluder (n = 4), and PFO STAR (n = 4). Most procedures (n = 176.69%) were done under two-dimensional intracardiac echocardiography (ICE) guidance alone; in the last 30 patients, 3D/4D ICE reconstruction (TomTec Imaging Systems) 6mbH was obtained. In 30 cases, ICE and contrast enhanced-TCD have been used simultaneously in the catheterization laboratory. The devices were placed correctly in all patients. Mean fluoroscopy time was 9.45 +/- 5 minutes (range = 2.5-35 minutes); mean procedural time was 57 +/- 21 minutes (range = 15-135 minutes). Total occlusion rate at follow-up (mean 19 months, range 1-33) was 98.1%. No significant recurrent neurological events were observed. Transcatheter closure of PFO with or without ASA is a safe and effective, minimally invasive procedure that ensures high closure rate and avoids life-long anticoagulation. Mid-term follow-up results appear favorable with respect to recurrent thromboembolic events.
Abstract: Recent clinical trials have demonstrated a better ability of low-molecular-weight heparin, compared to unfractionated heparin, in reducing ischemic cardiac events in patients with acute coronary syndromes without ST-segment elevation. No data are available concerning the in-vivo comparison of enoxaparin and unfractionated heparin on thrombin generation in patients with unstable angina or non-Q-wave myocardial infarction. We measured the plasma levels of prothrombin fragment 1+2 (a marker of prothrombin activation) and thrombin/antithrombin complex (a marker of thrombin generation) in 45 patients with non ST-elevation acute coronary syndromes who were randomized to receive enoxaparin, 3000 IU anti-Xa as an i. v. bolus, followed by 70 IU anti-Xa/Kg every 8 h for 3 days (23 pts. Group 1) or a bolus of 100 IU/kg of unfractionated heparin followed by infusion for 3 days titrated to maintain the aPTT between 70 and 90 s (22 pts, Group 2). Plasma levels of prothrombin fragment 1+2 reduced significantly at 3rd h of treatment in both groups (-42% in Group 1 and -45% in Group 2), reached the lowest plasma concentration at the 24th h and exhibited a slight increase at the 72nd h; no differences were observed between the two groups at any time points. Plasma thrombin/antithrombin complex levels had a similar behaviour: reduced markedly in both groups at the 3rd h (-52% in Group 1 and -46% in Group 2), remained lower during the first two days and slightly rose at 72nd h. No differences between the two groups in plasma levels of this marker were apparent during drug infusion. In Group 1 the aPTT did not show significant changes: in Group 2 the mean value of aPTT doubled the basal value at any time point of determination. Both enoxaparin and unfractionated heparin produced a marked and similar reduction of thrombin generation. Other unknown mechanisms might explain the different clinical effects of the two heparins.
