Effect of Patent Foramen Ovale Closure on Obstructive Sleep Apnea

Rimoldi, Stefano F.; Ott, Sebastian Robert; Rexhaj, Emrush; Arx, Robert von; Marchi, Stefano F. de; Brenner, Roman; Scherrer, Urs; Meier, Bernhard; Gugger, Matthias; Allemann, Yves; Seiler, Christian

doi:10.1016/j.jacc.2015.01.062

Cited by 11 publications

(8 citation statements)

References 4 publications

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“…Patients who underwent PFO closure demonstrated a significant improvement in ODI/ AHI, nocturnal systolic blood pressure, right-ventricular to right-atrial systolic blood pressure gradient and left ventricular diastolic function. 32 However, Shaikh et al did not demonstrate any significant improvement in objective or qualitative parameters in the subgroup of 6 patients with large shunts who underwent percutaneous PFO closure. 13 However, 3 of the 6 patients who underwent PFO closure had residual shunts at 12 months.…”

Section: Discussionmentioning

confidence: 92%

Sleep Apnea in Patients with and without a Right-to-Left Shunt

Mojadidi

Bokhoor

Gevorgyan

et al. 2015

Journal of Clinical Sleep Medicine

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BRIEF SUMMARYCurrent Knowledge/Study Rationale: Right-to-left shunt (RLS) occurs more frequently in patients with sleep apnea, and may be involved in the pathophysiology of sleep apnea. In this observational study, we determined the prevalence of RLS among patients with sleep apnea and compared clinical characteristics and the results of sleep studies of patients with and without RLS. Study Impact: Patients with OSA and RLS have hypoxemia out of proportion to the observed respiratory disturbance, highlighting the likely role of RLS in the resultant nocturnal desaturation. Such observational studies support the hypothesis that the presence of a RLS from a PFO may exacerbate sleep apnea symptoms Objectives: To assess the presence of right-to-left shunting (RLS) in patients with obstructive sleep apnea (OSA), and compare clinical characteristics and parameters of the sleep studies of patients with and without RLS. Background: The most common cause of RLS is due to intermittent fl ow through a patent foramen ovale (PFO). PFO occurs more frequently in patients with OSA and may be involved in the exacerbation of OSA. Methods: Patients with an abnormal polysomnogram seen at UCLA-Santa Monica Sleep Medicine Clinic were enrolled. A diagnosis of RLS was made using a transcranial Doppler (TCD) bubble study. Gender and age-matched controls were drawn from patients referred for cardiac catheterization who underwent a TCD. The frequency of RLS in OSA patients and the controls was evaluated. Clinical characteristics and polysomnogram parameters were compared between OSA patients with and without a RLS. Results: A total of 100 OSA patients and 200 controls participated in the study. The prevalence of RLS was higher in patients with OSA compared to the control group (42% versus 19%; p < 0.0001). Patients with OSA and a RLS had a lower apnea-hypopnea index (AHI), less obstructive apnea, and fewer hypopnea episodes than patients with OSA without a RLS. The baseline and nadir SpO 2 were similar in both groups and did not correlate with the level of RLS assessed by TCD. The degree of desaturation for a given respiratory disturbance, as measured by oxygen desaturation index (ODI)/AHI ratio, was higher in OSA patients with RLS versus OSA patients without RLS (0.85 ± 0.07 versus 0.68 ± 0.04; p < 0.0001). Conclusion: RLS, most commonly due to a PFO, occurs 2.2 times more frequently in OSA patients compared to a control population that was matched for age and gender. The severity of sleep apnea is not greater in OSA patients who have a PFO. However, patients with OSA and a PFO are more likely to become symptomatic at a younger age with an equivalent decrease in nocturnal SpO 2 , and have greater arterial desaturation in proportion to the frequency of respiratory disturbances. Keywords: sleep apnea, patent foramen ovale, right-to-left shunt Citation: Mojadidi MK, Bokhoor PI, Gevorgyan R, Noureddin N, MacLellan WC, Wen E, Aysola R, Tobis JM. Sleep apnea in patients with and without a right-to-left shunt. J Clin Sleep Med 2015;11(11):1299 -...

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Section: Discussionmentioning

confidence: 92%

Sleep Apnea in Patients with and without a Right-to-Left Shunt

Mojadidi

Bokhoor

Gevorgyan

et al. 2015

Journal of Clinical Sleep Medicine

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“…Data on AHI, pulmonary artery pressure, and 24-h nighttime systolic BP have been previously published in form of a research letter. 5 …”

Section: Resultsmentioning

confidence: 99%

“…5 Moreover, circumstantial evidence shows that intermittent hypoxia is associated with systemic endothelial dysfunction and arterial hypertension. 6,7 In line with these observations, systemic endothelial function is impaired in OSA patients without any traditional cardiovascular risk factors.…”

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confidence: 99%

Patent Foramen Ovale Closure in Obstructive Sleep Apnea Improves Blood Pressure and Cardiovascular Function

et al. 2015

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O bstructive sleep apnea (OSA) is characterized by intermittent hypoxemia and associated with increased prevalence of vascular dysfunction and arterial hypertension, but the underlying mechanisms are incompletely understood.1 In OSA, apneas are related to excessive throat muscle relaxation with consequent inspiratory efforts against the closed glottis, finally resulting in the patient's arousal associated with sympathetic activation and hyperventilation. The hyperventilation, in turn, contributes to the next apnea by reducing the arterial partial pressure of CO 2 toward the apnea threshold. In this scenario, arterial oxygen desaturation plays a pivotal role by narrowing the gap between the eupneic and apneic CO 2 pressure level, thereby rendering the CO 2 -controlled breathing regulation more unstable and, thus, prone to periodic breathing. 2In patients with OSA, the presence of patent foramen ovale (PFO) is associated with a marked increase in the frequency and severity of nocturnal oxygen desaturations.3 This could be related, at least in part, to right to left shunting across a PFO, as evidenced by invasive hemodynamic measurements in healthy humans, demonstrating that during the onset of simulated OSA, the right atrial pressure exceeds left atrial pressure in response to the steep decline in intrathoracic pressure. 4 Improvement of arterial oxygen saturation by PFO closure may prevent this problem.We recently reported preliminary findings showing that PFO closure in patients with newly diagnosed OSA was associated with a reduction of nocturnal apnea-hypopnea events and oxygen desaturations and decreased pulmonary artery pressure.5 Moreover, circumstantial evidence shows that intermittent hypoxia is associated with systemic endothelial dysfunction and arterial hypertension. 6,7 In line with these observations, systemic endothelial function is impaired in OSA patients without any traditional cardiovascular risk factors.8 Systemic endothelial dysfunction precedes the development of arteriosclerosis and contributes to the pathogenesis of arterial hypertension.9 Accordingly, the prevalence of arterial Abstract-Obstructive sleep apnea (OSA) is a frequent syndrome characterized by intermittent hypoxemia and increased prevalence of arterial hypertension and cardiovascular morbidity. In OSA, the presence of patent foramen ovale (PFO) is associated with increased number of apneas and more severe oxygen desaturation. We hypothesized that PFO closure improves sleep-disordered breathing and, in turn, has favorable effects on vascular function and arterial blood pressure. In 40 consecutive patients with newly diagnosed OSA, we searched for PFO. After initial cardiovascular assessment, the 14 patients with PFO underwent initial device closure and the 26 without PFO served as control group. Conventional treatment for OSA was postponed for 3 months in both groups, and polysomnographic and cardiovascular examinations were repeated at the end of the follow-up period. PFO closure significantly improved the apnea-hypopnea index ...

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“…SDB induces vascular dysfunction, but the underlying mechanisms are incompletely understood [48]. Recent evidence suggests that the presence of a PFO may contribute to this problem [16,49,50]. In a prospective open-label interventional clinical trial we searched for PFO with tran-soesophageal echocardiography in 40 consecutive patients with newly diagnosed OSA [16,50].…”

Section: Pfo and Cardiovascular Function In Sleep Disordered Breathingmentioning

confidence: 99%

Patent foramen ovale: a novel cardiovascular risk factor in patients with sleep disordered breathing and high altitude dwellers?

2016

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Diseases associated with chronic hypoxaemia are a leading cause of morbidity and mortality in Western countries. Epidemiological data indicate that cardiovascular diseases contribute substantially to this problem, but the underlying mechanisms are incompletely understood. Sleep disordered breathing and high altitude exposure are frequent conditions associated with hypoxaemia. Recent evidence suggests that in these conditions the concomitant presence of a patent foramen ovale plays an important pathogenic role. For example, in patients with obstructive sleep apnoea the presence of a patent foramen ovale is associated with more severe sleep disordered breathing, nocturnal oxygen desaturation, generalised endothelial dysfunction and arterial hypertension. After patent foramen ovale closure, both sleep disordered breathing and cardiovascular phenotype improve, suggesting the existence of a possible causal link. During short-term high altitude exposure, the presence of a patent foramen ovale, by aggravating altitude-induced hypoxaemia, facilitates exaggerated pulmonary hypertension. Interestingly, there is increasing evidence showing that in high-altitude dwellers a patent foramen ovale also alters the cardiovascular phenotype. In this article we will summarise recent evidence demonstrating how a patent foramen ovale alters the cardiovascular phenotype and increases cardiovascular risk in patients with sleep disordered breathing and high-altitude dwellers.

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Effect of Patent Foramen Ovale Closure on Obstructive Sleep Apnea

Cited by 11 publications

References 4 publications

Sleep Apnea in Patients with and without a Right-to-Left Shunt

Sleep Apnea in Patients with and without a Right-to-Left Shunt

Patent Foramen Ovale Closure in Obstructive Sleep Apnea Improves Blood Pressure and Cardiovascular Function

Patent foramen ovale: a novel cardiovascular risk factor in patients with sleep disordered breathing and high altitude dwellers?

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