Atrial Cardiopathy and Likely Pathogenic Patent Foramen Ovale in Embolic Stroke of Undetermined Source

Abstract

Background Atrial cardiopathy and likely pathogenic patent foramen ovale (PFO) are two potential embolic sources in patients with embolic stroke of undetermined source (ESUS). The relationship between these two mechanisms among ESUS patients remains unclear. Methods Atrial cardiopathy was defined as increased left atrial diameter index (> 23 mm/m2) or left atrial volume index (> 34 mL/m2), or PR prolongation (≥ 200 ms), or presence of supraventricular extrasystoles in the electrocardiograms performed during hospitalization for the index stoke. The presence of PFO was assessed by transthoracic echocardiography with microbubble test or by transesophageal echocardiography. The presence of PFO was considered as likely pathogenic if the Risk of Paradoxical Embolism score was 7 to 10. Results Among 367 ESUS patients with available information about the presence of PFO and the presence of atrial cardiopathy (median age: 61 years, 40.6% women), likely pathogenic PFO was diagnosed in 62 (16.9%) and atrial cardiopathy in 122 (33.2%). Only 4 patients (1.1%) had both likely pathogenic PFO and atrial cardiopathy. The prevalence of atrial cardiopathy was lower in patients with likely pathogenic PFO (6.5%) compared with patients with likely incidental PFO (31.2%) or without PFO (40.6%) (Pearson's chi-square test: 26.08, p < 0.001; adjusted odds ratio [OR]: 0.28, 95% confidence interval [CI]: 0.09–0.86). The prevalence of likely pathogenic PFO was lower in patients with atrial cardiopathy compared with patients without atrial cardiopathy (3.3% vs. 23.7%, respectively [Pearson's chi-square test: 24.13, p < 0.001; adjusted OR: 0.2, 95% CI: 0.02–0.6]). Conclusion The presence of atrial cardiopathy is inversely related to the presence of likely pathogenic PFO in patients with ESUS.

Advances in the management of cardioembolic stroke associated with patent foramen ovale

“…For instance, the presence of a pathogenic PFO is inversely related to the presence of non-stenotic ipsilateral carotid atherosclerosis in patients with ESUS 40. Additionally, the prevalence of a likely pathogenic PFO was found to be markedly lower in ESUS patients with atrial cardiopathy compared with those without atrial cardiopathy (3.3% v 23.7%; adjusted odds ratio 0.2, 0.02 to 0.6) 41…”

“…40 Additionally, the prevalence of a likely pathogenic PFO was found to be markedly lower in ESUS patients with atrial cardiopathy compared with those without atrial cardiopathy (3.3% v 23.7%; adjusted odds ratio 0.2, 0.02 to 0.6). 41 Paradoxical embolization refers to any passage of material between the right and left sides of the heart and can occur by way of a PFO, atrial septal defect, ventricular septal defect, or pulmonary arteriovenous fistula. This presumed mechanism of stroke associated with PFO is supported by several observations.…”

A Nomogram for the Prediction of Causative Patent Foramen Ovale in Cryptogenic Stroke

“…The patients were diagnosed with CS following multidisciplinary team assessment based on the classification of the trial of Org 10172 in acute stroke treatment (TOAST). [7] The major exclusion criteria were as follows: (1) more than one plausible cause of stroke, incomplete diagnostic assessments; (2) potential cardioembolic sources: heart failure, atrial fibrillation, moderate or higher valve regurgitation or stenosis, congenital heart disease except PFO; (3) malignant tumor, severe hepatic and renal insufficiency; (4) intrapulmonary shunt; (5) inadequate provocative maneuver. In the control group, MRI examinations were performed to confirm no cerebral ischemic lesion.…”

“…[3] However, recent research reported that LA dysfunction combined with PFO only accounted for 6.5% in CS patients. [4] LA dysfunction might be associated with overweight and hypertension in patients with PFO-attributable CS. [5] The size of LA could be easily determined in the clinic.…”

Embolic Stroke of Undetermined Source: The Need for an Integrated and Holistic Approach to Care

“…In this issue of Thrombosis and Haemostasis, Leventis et al 23 reported that the presence of atrial cardiopathy was inversely related to the presence of likely PFO in patients with ESUS. The prevalence of atrial cardiopathy was lower in patients with likely pathogenic PFO compared with patients with likely incidental PFO (31.2%) or without PFO, indicating that atrial cardiopathy and likely pathogenic PFO were two competing etiologies for ESUS.…”