Diagnosis of Secondary Source of Right-to-Left Shunt With Balloon Occlusion of Patent Foramen Ovale and Power M-Mode Transcranial Doppler

Jesurum, Jill T.; Fuller, Cindy J.; Renz, Joshua; Krabill, Kimberly A.; Spencer, Merrill P.; Reisman, Mark

doi:10.1016/j.jcin.2009.04.010

Cited by 27 publications

(19 citation statements)

References 22 publications

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“…Second, TCD does not provide anatomic information and does not stand alone as a sole means of evaluation of patients. It is possible that some of our device “failures” may overestimate residual shunt and may have been due to a concurrent pulmonary bubble conductance 15 . Third, 3‐month evaluation represents an early assessment of mechanical and early healing and improvement over time of these very favorable results may still occur.…”

Section: Discussionmentioning

confidence: 99%

Transcranial Doppler Quantification of Residual Shunt after Percutaneous Patent Foramen Ovale Closure: Correlation of Device Efficacy with Intracardiac Anatomic Measures

Sorensen¹,

Spruance²,

Smout³

et al. 2012

J Interven Cardiology

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In an intracardiac echocardiography-defined PFO population, characterized by severe baseline Valsalva shunt and a high incidence of persistent (rest) shunting, association of six intracardiac measurements to closure device failure by multivariate logistic regression showed that the width of the left atrial opening was a strong predictor of residual shunting. An unanticipated finding was that use of a large sizing balloon was also strongly associated with failure.

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Section: Discussionmentioning

confidence: 99%

Transcranial Doppler Quantification of Residual Shunt after Percutaneous Patent Foramen Ovale Closure: Correlation of Device Efficacy with Intracardiac Anatomic Measures

Sorensen¹,

Spruance²,

Smout³

et al. 2012

J Interven Cardiology

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“…Microemboli after transcatheter percutaneous closure can occur due to an extra cardiac shunt such as a pulmonary arteriovenous fistula 18,19 . The timing from contrast injection to identification of the first bubble on the medium cerebral artery can be used to differentiate between a cardiac and an extra cardiac shunt.…”

Section: Discussionmentioning

confidence: 99%

Is the patent foramen ovale closure the best option?

Zétola

Silva

Lange

et al. 2012

Arq. Neuro-Psiquiatr.

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Patent foramen ovale (PFO) is a congenital heart disease remnant of fetal circulation. The flap of the foramen ovale (septum primum) closes against the atrial septum (septum secundum) and normally fuses within the first two years of life. If the septum secundum covers the oval foramen, but does not seal to the septum primum, then a probable PFO exists that can be "opened" by the Valsalva or other maneuvers that increase right atrial pressure 1,2 . Prevalence of incomplete fusion is approximately 25-27% 1,3 and is associated with atrial septum aneurysm (ASA) in 50-80% patients in a global population 3 . The opening between the left and right atria can introduce venous blood or venous thrombus to the arterial system by crossing into the left heart through a right-to-left shunt (RLS) [1][2][3][4][5] . Studies have demonstrated that RLS emboli and PFO are significantly associated with cryptogenic ischemic stroke, transient ischemic attack (TIA) and migraine with aura in young adults (below 55 years of age) [2][3][4][5] . Prevention against further embolic events by PFO closure is a controversial issue, however the procedure is indicated in some restricted cases [6][7][8][9][10][11][12][13] . The aim of this study was to certify whether or not the PFO method of closure confirmed by transcranial Doppler prevented microemboli after a minimum of 12 months. ABSTRACT Patent foramen ovale (PFO) closure is indicated in some cases to protect patients against embolic events. The aim of this study was to certify that the method of PFO closure to prevent microemboli (MES) is reliable, using contrast enhanced transcranial Doppler (cTCD) as a diagnostic and follow-up tool. Methods: cTCD was performed before and after PFO closure in 20 patients. Results obtained a minimum of 12 months after the procedure were analyzed in this study. Results: After the procedure, 14 patients (82%) showed no microemboli in cTCD at rest, but after provocative Valsalva maneuver (VM) microembolic phenomenon were still detected in 14 (70%): 7 (35%) <10 MES, 3 (15%) 10-20 MES and 4 (20%) had more than 20 MES ("curtain"). Only six of the total patients presented no MES in both resting and VM. Conclusion: These results showed a large percentage of patients with MES detection in a bubble study with transcranial Doppler more than one year after the procedure of PFO closure, showing right-to-left residual shunting. Despite the small number of patients, this study provides important data about this therapeutic decision.Key words: foramen ovale, patent, ultrasonography, Doppler, transcranial, embolism, treatment. RESUMOO fechamento do forame oval patente (FOP) é indicado em alguns casos para prevenir eventos embólicos. O objetivo deste estudo foi certificar que o fechamento do FOP previne contra microembolia usando o Doppler transcraniano contrastado (cTCD) como método diagnóstico e de controle. Métodos: O cTCD foi realizado antes e depois do fechamento do FOP em 20 pacientes. Foram analisados somente os resultados obtidos após 12 meses do procedimento. Resulta...

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“…In conclusion, Jesurum et al (3) report that secondary RLS are common (20%) in patients referred for transcatheter PFO closure. This would make intrapulmonary shunting almost as common as PFOs are in the normal population.…”

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confidence: 83%

Eliminating Right-to-Left Shunt With Patent Foramen Ovale Closure

Rogers

Smith

2009

JACC: Cardiovascular Interventions

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Patent foramen ovale (PFO) is associated with numerous clinical conditions, such as cryptogenic stroke, paradoxical embolism, migraine headaches, decompression illness, and shunt-related hypoxemia. As a result, transcatheter closure of PFO has become relatively common, driven by the apparent ease of the procedure, patient and clinician preference over medical therapy, and numerous retrospective analyses demonstrating clinical benefit. The procedure is performed under conscious sedation and, in experienced hands, can been done routinely in under 30 min. The fact that there have been no large prospective randomized trials to prove the efficacy of PFO closure has done little to dissuade the enthusiastic use of closure devices. See page 561The immediate and long term goal of transcatheter PFO closure is elimination of right-to-left shunt (RLS) through the interatrial septum. When detected, RLS is generally secondary to an atrial level shunt (i.e., PFO), but noncardiac RLS (primarily intrapulmonary) has also been implicated in the pathophysiology of clinical conditions resulting from paradoxical embolism (1). Intrapulmonary RLS can coexist with PFO and in some cases can be mistaken as a source of RLS in a patient presumed to have a PFO. For instance, in the MIST (Migraine Intervention With STARFlex Technology) trial, 5 of the 74 patients with RLS randomized to PFO closure actually had no PFO found at the time of the procedure. The cause of the RLS in these patients was presumably due to an intrapulmonary shunt (2). The presence of coexisting intrapulmonary shunting would clearly have major implications when designing trials to assess the efficacy of PFO closure to eliminate RLS. Methods to identify these confounding patients have not been welldescribed in published reports to date.Jesurum et al. (3), in this issue of JACC: Cardiovascular Interventions, describe a novel method to assess the prevalence of secondary (intrapulmonary) RLS in patients undergoing transcatheter closure of PFO. During sizing-balloon inflation within the PFO (and presumed occlusion of the PFO due to lack of color flow seen with intracardiac echocardiography [ICE] around the balloon), agitated saline was injected into the inferior vena cava with calibrated respiratory strain, followed by assessment of RLS via transcranial Doppler (TCD). If Ͼ10 embolic tracks were detected, this was defined as a "secondary RLS." After PFO closure, residual RLS was assessed immediately with agitated saline and TCD and in late follow-up with TCD and transthoracic echocardiography. This study demonstrated that those subjects with RLS during balloon inflation (secondary RLS) were significantly more likely to have RLS during immediate and late follow-up when compared with those patients without RLS during balloon inflation. Patients with secondary RLS also had more atrial septal aneurysms (p ϭ NS) and significantly larger PFO waist diameters than those without secondary RLS (p ϭ 0.013). With these data, the authors concluded that ICE, TCD, and balloon occlusion can be...

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Diagnosis of Secondary Source of Right-to-Left Shunt With Balloon Occlusion of Patent Foramen Ovale and Power M-Mode Transcranial Doppler

Abstract: This is the first report to systematically assess the prevalence of secondary RLS in patients undergoing PFO closure. Residual RLS detected by TCD may be due to secondary RLS, which may have implications for clinical outcomes.

Cited by 27 publications

References 22 publications

Transcranial Doppler Quantification of Residual Shunt after Percutaneous Patent Foramen Ovale Closure: Correlation of Device Efficacy with Intracardiac Anatomic Measures

Transcranial Doppler Quantification of Residual Shunt after Percutaneous Patent Foramen Ovale Closure: Correlation of Device Efficacy with Intracardiac Anatomic Measures

Is the patent foramen ovale closure the best option?

Eliminating Right-to-Left Shunt With Patent Foramen Ovale Closure

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