The evolving role of echocardiography in the assessment of patent foramen ovale in patients with left‐side thromboembolism

Filomena, Domenico; Cimino, Sara; Maestrini, Viviana; Monosilio, Sara; Birtolo, Lucia Ilaria; Vicenzini, Edoardo; Mancone, Massimo; Fedele, Francesco; Agati, Luciano

doi:10.1111/echo.15018

Cited by 3 publications

(1 citation statement)

References 70 publications

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“…Even though some case reports suggest the generation of a thrombus in a transit position [e.g., (33)], no systematic analysis of this presentation is available. However, the following characteristics qualify a high-risk PFO with increased risk of cerebrovascular events: Large shunt, larger PFO diameter during Valsalva, large septum excursion, and associated atrial septum aneurysm (ASA) (34,35). Further morphological characteristics with an increased risk are: Tunneled PFO, coexisting right atrial septal pouch (RASP), hybrid defect, Eustachian ridge, significant shunt at rest, and PFO > 3 mm (36).…”

Section: Pathophysiological Conceptmentioning

confidence: 99%

Current Challenges and Future Directions in Handling Stroke Patients With Patent Foramen Ovale—A Brief Review

Huber

Wachter²,

Michalski

2022

Front. Neurol.

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The role of patent foramen ovale (PFO) in stroke was debated for decades. Randomized clinical trials (RCTs) have shown fewer recurrent events after PFO closure in patients with cryptogenic stroke (CS). However, in clinical practice, treating stroke patients with coexisting PFO raises some questions. This brief review summarizes current knowledge and challenges in handling stroke patients with PFO and identifies issues for future research. The rationale for PFO closure was initially based on the concept of paradoxical embolism from deep vein thrombosis (DVT). However, RCTs did not consider such details, limiting their impact from a pathophysiological perspective. Only a few studies explored the coexistence of PFO and DVT in CS with varying results. Consequently, the PFO itself might play a role as a prothrombotic structure. Transesophageal echocardiography thus appears most appropriate for PFO detection, while a large shunt size or an associated atrial septum aneurysm qualify for a high-risk PFO. For drug-based treatment alone, studies did not find a definite superiority of oral anticoagulation over antiplatelet therapy. Remarkably, drug-based treatment in addition to PFO closure was not standardized in RCTs. The available literature rarely considers patients with transient ischemic attack (TIA), over 60 years of age, and competing etiologies like atrial fibrillation. In summary, RCTs suggest efficacy for closure of high-risk PFO only in a small subgroup of stroke patients. However, research is also needed to reevaluate the pathophysiological concept of PFO-related stroke and establish strategies for older and TIA patients and those with competing risk factors or low-risk PFO.

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Section: Pathophysiological Conceptmentioning

confidence: 99%

Current Challenges and Future Directions in Handling Stroke Patients With Patent Foramen Ovale—A Brief Review

Huber

Wachter²,

Michalski

2022

Front. Neurol.

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Patent foramen ovale—When to close and how?

Maloku

Hamadanchi

Franz

et al. 2021

Herz

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The diagnostic value of contrast-enhanced transcranial Doppler and contrast-enhanced transthoracic echocardiography for right to left shunt in patent foramen ovale: a systematic review and meta-analysis

Zhang,

Jiang,

Chen

et al. 2024

Front. Neurol.

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PurposeTo evaluate and compare the diagnostic value of contrast-enhanced transcranial Doppler (c-TCD) and contrast-enhanced transthoracic echocardiography (c-TTE) for right to left shunt (RLS) in patent foramen ovale (PFO) by meta-analysis.MethodsThe literature included in the Cochrane Library, PubMed, and Embase were searched by using “contrast-enhanced transcranial Doppler (c-TCD), contrast-enhanced transthoracic echocardiography (c-TTE), patent foramen ovale (PFO), and right to left shunt (RLS)” as the keywords from inception through April 30, 2024. The diagnostic accuracy research quality assessment tool (QUADAS-2) was used to evaluate the quality of the included literature. The combined sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), and Diagnostic odds ratio (DOR) were pooled, and a comprehensive ROC curve analysis was performed. Statistical software StataSE 12.0 and Meta-Disc 1.4 were used for data analysis.ResultsA total of 8,536 articles were retrieved, and 9 articles that met all inclusion criteria were included in this meta-analysis. The meta-analysis results show that the combined sensitivity, specificity, PLR, NLR, DOR, and area under the SROC curve of c-TCD for the diagnose of PFO-RLS were 0.91 (95% CI, 0.88–0.93), 0.87 (95% CI: 0.84–0.91), 6.0 (95% CI, 2.78–12.96), 0.10 (95% CI, 0.06–0.18), 91.61 (95% CI, 26.55–316.10), and 0.9681, respectively; the corresponding values of c-TTE were 0.86 (95% CI, 0.84–0.89), 0.88 (95% CI, 0.84–0.91), 5.21 (95% CI, 2.55–10.63), 0.16 (95% CI, 0.09–0.31), 71.43 (95% CI, 22.85–223.23), and 0.9532. The ROC curve shows that c-TCD has slightly higher diagnostic value for PFO than c-TTE, but there is no significant statistical difference (Z = 0.622, p > 0.05). Deek funnel pattern showed no significant publication bias.ConclusionBoth c-TCD and c-TTE have high diagnostic values for PFO-RLS. However, c-TCD has slightly higher sensitivity and lower specificity in diagnosing PFO-RLS compared to c-TTE.Systematic review registration: identifier [CRD42024544169].

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The evolving role of echocardiography in the assessment of patent foramen ovale in patients with left‐side thromboembolism

Cited by 3 publications

References 70 publications

Current Challenges and Future Directions in Handling Stroke Patients With Patent Foramen Ovale—A Brief Review

Current Challenges and Future Directions in Handling Stroke Patients With Patent Foramen Ovale—A Brief Review

Patent foramen ovale—When to close and how?

The diagnostic value of contrast-enhanced transcranial Doppler and contrast-enhanced transthoracic echocardiography for right to left shunt in patent foramen ovale: a systematic review and meta-analysis

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