Przetrwały otwór owalny – Rokowania, prognozy i postęp choroby

Przetrwały otwór owalny
Rokowania, prognozy i postęp choroby

Przetrwały otwór owalny (PFO) występuje u około 25% populacji, a jego obecność jest szczególnie istotna u pacjentów z udarem kryptogennym (30-40%) oraz masywnym zatorem płucnym, gdzie wiąże się z wyższą śmiertelnością (33% vs 14%, P=0,015). Niezależne predyktory śmiertelności w tej grupie to obecność PFO (OR 11,4; P<.001) oraz hipotensja tętnicza przy przyjęciu (OR 26,3; P<.001). U pacjentów z poważnym zatorem płucnym PFO zwiększa ryzyko zgonu i powikłań zakrzepowo-zatorowych, prawdopodobnie przez paradoksalną zatorowość. Wskaźnik nawrotu udaru u pacjentów z udarem kryptogennym i PFO wynosi 1-2 udary na 100 pacjento-lat, a korzyści z zamknięcia PFO są największe u osób poniżej 60 roku życia, bez licznych czynników ryzyka naczyniowego i z udarem o charakterze kryptogennym.

Przetrwały otwór owalny (PFO) – Rokowanie i przewidywanie wyników leczenia

Przetrwały otwór owalny (ang. Patent Foramen Ovale, PFO) występuje u około 25% populacji ogólnej. Jego obecność ma szczególne znaczenie u pacjentów z udarem kryptogennym, gdzie częstość występowania PFO szacuje się na 30-40%. Przewidywanie wyników leczenia oraz ocena rokowania u pacjentów z PFO zależy od wielu czynników, w tym wieku pacjenta, chorób współistniejących oraz zastosowanego leczenia.¹

Rokowanie u pacjentów z PFO i zatorem płucnym

Obecność przetrwałego otworu owalnego ma istotne znaczenie prognostyczne u pacjentów z masywnym zatorem płucnym. Badania wykazały, że pacjenci z zatorem płucnym i współistniejącym PFO charakteryzują się wyższą śmiertelnością (33%) w porównaniu do pacjentów bez PFO (14%) (P=.015). Analiza regresji logistycznej wykazała, że niezależnymi predyktorami śmiertelności w tej grupie są:

Obecność przetrwałego otworu owalnego (iloraz szans [OR], 11,4; P<.001)
Hipotensja tętnicza przy przyjęciu (OR, 26,3; P<.001)

U pacjentów z poważnym zatorem płucnym, echokardiograficzne wykrycie PFO wskazuje na szczególnie wysokie ryzyko zgonu i tętniczych powikłań zakrzepowo-zatorowych. Mechanizmem odpowiedzialnym za te powikłania może być paradoksalna zatorowość, gdy skrzeplina z układu żylnego przedostaje się przez PFO do krążenia systemowego.³⁴

Ryzyko nawrotu udaru po zamknięciu PFO

Wskaźnik nawrotu udaru u pacjentów z udarem kryptogennym i PFO jest stosunkowo niski, szacowany na 1-2 udary na 100 pacjento-lat. Trudno jednak jednoznacznie określić, czy nawracające udary są przyczynowo związane z PFO.⁵⁶

Korzyści z zamknięcia PFO zależą od starannego doboru pacjentów. Najlepszymi kandydatami są osoby:

W wieku poniżej 60 lat
Z niewielką liczbą lub brakiem naczyniowych czynników ryzyka
Z udarem o charakterze zatorowym uznanym za kryptogenny po dokładnej ocenie

⁷

Wpływ wieku na rokowanie po zamknięciu PFO

Badania porównujące wyniki zamknięcia PFO u pacjentów starszych i młodszych wykazały różnice w rokowaniu. Przezskórne zamknięcie PFO wydaje się być skuteczne w profilaktyce wtórnej udaru kryptogennego u młodszych pacjentów, natomiast u osób starszych wiąże się z mniej korzystnym wynikiem.⁸

W analizie wieloczynnikowej, wiek ≥55 lat pozostał predyktorem pierwotnego punktu końcowego (HR 3,2; 95% CI 1,1-9,1; p=0,03). Roczny wskaźnik nawrotu udaru lub TIA po leczeniu zachowawczym u osób starszych z udarem kryptogennym i udokumentowanym PFO wynosi około 10%. W porównaniu, u osób starszych po przezskórnym zamknięciu PFO z powodu kryptogennego incydentu zatorowego, roczny wskaźnik nawrotu udaru lub TIA wynosi 2,4%.⁹

Wyższy wskaźnik nawrotu udaru lub TIA u starszych pacjentów w porównaniu z młodszymi może być przypisywany innym czynnikom, sugerując, że albo przezskórne zamknięcie PFO może być mniej korzystne u osób starszych, albo stanowią oni populację o wyższym ryzyku.¹⁰

Czynniki determinujące niekorzystne wyniki po zamknięciu PFO u osób starszych

W badaniu obejmującym 689 starszych pacjentów (mediana wieku 65 lat) po zamknięciu PFO, po medianie obserwacji wynoszącej 2 lata (zakres międzykwartylowy 1-5 lat), zaobserwowano:¹¹

Śmiertelność wynoszącą 9,6% (66 pacjentów)
Częstość incydentów naczyniowo-mózgowych (CVE) na poziomie 1,21 na 100 pacjento-lat
Częstość udarów wynoszącą 0,55 na 100 pacjento-lat
Nowo powstałe migotanie przedsionków (AF) z częstością 3,30 na 100 pacjento-lat, przy czym 51,3% przypadków wystąpiło w ciągu miesiąca po zabiegu

¹²

Czynnikami zwiększającymi ryzyko niekorzystnych zdarzeń klinicznych u starszych pacjentów po zamknięciu PFO były:

Obecność cukrzycy
Tętniak przegrody międzyprzedsionkowej (ASA)
Bardziej zaawansowany wiek

¹³

Skala RoPE w ocenie ryzyka

Trudności z przypisaniem PFO jako rzeczywistej przyczyny udaru doprowadziły do opracowania skali Risk of Paradoxical Embolism (RoPE) w udarze kryptogennym, opartej na bazie danych 3023 pacjentów z udarem kryptogennym, u których PFO badano za pomocą przezprzełykowej echokardiografii (TEE) lub przezczaszkowego badania dopplerowskiego (TCD).¹⁴¹⁵

Frakcja udarów przypisana PFO wynosi 60% u osób z wynikiem RoPE 6 lub wyższym, przy czym wyniki 9-10 osiągają prawie 90%. Oznacza to, że u pacjentów z wysokim wynikiem RoPE istnieje wysokie prawdopodobieństwo, że PFO było przyczyną udaru.¹⁶¹⁷

Heterogeniczność i niespójna kolekcja danych w bazach uniemożliwiły włączenie do modelu RoPE niektórych zmiennych predykcyjnych cytowanych w poprzednich badaniach, takich jak:¹⁸¹⁹

Wskaźnik otyłości
Ciężkość udaru
Historia zakrzepicy żył głębokich (DVT) lub zatorowości płucnej (PE)
Stany nadkrzepliwości
Przedłużona podróż/wymuszona bezruchowość
Migrena
Bezdech senny
Próba Valsalvy w momencie wystąpienia udaru
Udar/TIA po przebudzeniu

Znaczenie prognostyczne PFO u pacjentów z migotaniem przedsionków

Obecność współistniejącego PFO w grupie pacjentów z migotaniem przedsionków (AF) otrzymujących antykoagulanty nie wiązała się ze zwiększonym ryzykiem udaru niedokrwiennego. Jest to głównie spowodowane faktem, że przepływ przez przeciek w warunkach podstawowych (bez prowokacji) jest skierowany od lewej do prawej strony u większości pacjentów z AF.²⁰

Obecność PFO u pacjentów z AF nie wiązała się z ryzykiem zatorowym przekraczającym ryzyko u osób z przeciekiem prawo-lewo i innymi ustalonymi czynnikami ryzyka w tej populacji AF, która w przeważającej mierze była antykoagulowana.²¹

Korzyść z zamknięcia PFO w profilaktyce wtórnej udaru

U pacjentów w wieku 18-60 lat z udarem kryptogennym, niewielką liczbą naczyniowych czynników ryzyka i cechami PFO wysokiego ryzyka, takimi jak duży przeciek i tętniak przegrody międzyprzedsionkowej (ASA), przezskórne zamknięcie PFO zmniejszy ryzyko nawrotu udaru. Warunkiem jest niski odsetek powikłań proceduralnych w danej instytucji oraz zrozumienie niewielkiego ryzyka migotania przedsionków po zabiegu.²²²³

Przezskórne zamknięcie PFO jest korzystne i względnie bezpieczne w profilaktyce wtórnej udaru wśród dorosłych poniżej 60 roku życia, z niewielką liczbą konwencjonalnych naczyniowych czynników ryzyka, którzy przeszli dokładną diagnostykę etiologii udaru i uznano go za kryptogenny, z wyjątkiem obecności PFO, oraz którzy mogą mieć duże przecieki lub związane ASA.²⁴

Rokowanie długoterminowe

Wiele dzieci z PFO doświadcza samoistnego zamknięcia otworu w ciągu pierwszych trzech lat życia. U dorosłych, u których PFO utrzymuje się, większość może prowadzić długie, pełne życie bez powikłań. Jednakże, szczególnej uwagi wymagają osoby z udarem kryptogennym w wywiadzie, zwłaszcza młodsze, u których korzyści z zamknięcia PFO są najlepiej udokumentowane.²⁵

Ostatnie badania sugerują, że zamknięcie PFO może pomóc w zapobieganiu przyszłym udarom u osób z PFO, które doświadczyły niewyjaśnionego udaru, przy czym najlepsze wyniki obserwuje się u pacjentów młodszych, z mniejszą liczbą czynników ryzyka naczyniowego.²⁶²⁷

Przyszłe badania analizujące leczenie przeciwzakrzepowe (w tym doustne antykoagulanty niebędące antagonistami witaminy K) w porównaniu z zamknięciem PFO u osób z udarem kryptogennym oraz kliniczne znaczenie przejściowego migotania przedsionków po zabiegu będą miały dużą wartość w optymalizacji postępowania u tych pacjentów.²⁸

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Materiały źródłowe

#1 Patent Foramen Ovale (PFO): Symptoms, Causes & Treatment
https://my.clevelandclinic.org/health/diseases/17326-patent-foramen-ovale-pfo
Patent foramen ovale affects about 25% of people worldwide. PFO impacts about 30% to 40% of people whove had an unexplained stroke. This does not mean that everyone who has PFO will experience a stroke or mini-stroke. […] Recent research suggests that PFO closure may help prevent future strokes in people with PFO whove had an unexplained stroke. […] Many children with PFO find the flap seals completely on its own during their first three years. Many people who still have PFO as adults lead long, full lives. […] Patent foramen ovale (PFO) is a small communication between the upper right and left chambers of your heart. PFO affects about 25% of people. PFO often doesnt cause any symptoms and may not require treatment. But it can sometimes indicate stroke or mini-stroke. If you have a history of stroke or blood clots, your provider may suggest treatment. Treatments include medications, catheterization and surgery. Most people with patent foramen ovale can lead full lives.
#2 Patent foramen ovale is an important predictor of adverse outcome in patients with major pulmonary embolism – PubMed
https://pubmed.ncbi.nlm.nih.gov/9609088/
Patent foramen ovale is an important predictor of adverse outcome in patients with major pulmonary embolism. […] Its prognostic significance in patients with pulmonary thromboembolism, however, is unknown. […] Patent foramen ovale was diagnosed in 48 patients (35%). These patients had a death rate of 33% as opposed to 14% in patients with a negative echo-contrast examination (P=.015). […] Logistic regression analysis demonstrated that the only independent predictors of mortality in the study population were a patent foramen ovale (odds ratio [OR], 11.4; P.001) and arterial hypotension at presentation (OR, 26.3; P.001). […] In patients with major pulmonary embolism, echocardiographic detection of a patent foramen ovale signifies a particularly high risk of death and arterial thromboembolic complications.
#3 Patent foramen ovale is an important predictor of adverse outcome in patients with major pulmonary embolism – PubMed
https://pubmed.ncbi.nlm.nih.gov/9609088/
Patent foramen ovale is an important predictor of adverse outcome in patients with major pulmonary embolism. […] Its prognostic significance in patients with pulmonary thromboembolism, however, is unknown. […] Patent foramen ovale was diagnosed in 48 patients (35%). These patients had a death rate of 33% as opposed to 14% in patients with a negative echo-contrast examination (P=.015). […] Logistic regression analysis demonstrated that the only independent predictors of mortality in the study population were a patent foramen ovale (odds ratio [OR], 11.4; P.001) and arterial hypotension at presentation (OR, 26.3; P.001). […] In patients with major pulmonary embolism, echocardiographic detection of a patent foramen ovale signifies a particularly high risk of death and arterial thromboembolic complications.
#4 Patent foramen ovale and cryptogenic stroke: diagnosis and updates in secondary stroke prevention
https://pmc.ncbi.nlm.nih.gov/articles/PMC6047340/
A PFO is postulated to serve as a conduit for paradoxical embolism to the brain from deep vein thrombosis (DVT) with pulmonary embolism (PE). […] The data on shunt size and risk of stroke have been nebulous: while some studies suggest larger shunt increases the risk of stroke, others note no difference based on shunt size. […] A meta-analysis by Almekhlafi et al found that recurrent stroke or TIA rates of cryptogenic stroke with PFO did not increase compared with cryptogenic stroke without PFO (relative risk (RR)=1.1, 95%CI 0.8 to 1.5). […] The difficulty with attributing PFO as the actual cause of stroke has led to the development of the Risk of Paradoxical Embolism (RoPE) score in cryptogenic stroke, drawing from a database of 3023 patients with cryptogenic stroke who had PFO studied by TEE or TCD.
#5 Patent foramen ovale and cryptogenic stroke: diagnosis and updates in secondary stroke prevention
https://pmc.ncbi.nlm.nih.gov/articles/PMC6047340/
The patent foramen ovale (PFO), given its high prevalence in the general population and especially in patients with cryptogenic stroke, has long generated investigation and debate on its propensity for stroke by paradoxical embolism and its management for stroke prevention. […] The benefit from PFO closure relies on careful patient selection: those under the age of 60 years with few to no vascular risk factors and embolic-appearing stroke deemed cryptogenic after thorough evaluation. […] The opportunity for risk stratification and secondary stroke prevention in this cohort cryptogenic stroke with PFO underscored a number of randomised controlled trials (RCT) leading to a Food and Drug Administration (FDA) approval of the Amplatzer PFO Occluder in October 2016. […] However the stroke recurrence rate in patients with cryptogenic stroke with PFO is low, estimated at 12 strokes per 100 patient-years, and it is difficult to determine if those recurrent strokes are causally related to PFO.
#6 Patent foramen ovale and cryptogenic stroke: diagnosis and updates in secondary stroke prevention | Stroke and Vascular Neurology
https://svn.bmj.com/content/3/2/84
The patent foramen ovale (PFO), given its high prevalence in the general population and especially in patients with cryptogenic stroke, has long generated investigation and debate on its propensity for stroke by paradoxical embolism and its management for stroke prevention. […] The opportunity for risk stratification and secondary stroke prevention in this cohortcryptogenic stroke with PFOunderscored a number of randomised controlled trials (RCT) leading to a Food and Drug Administration (FDA) approval of the Amplatzer PFO Occluder in October 2016. […] The stroke recurrence rate in patients with cryptogenic stroke with PFO is low, estimated at 12 strokes per 100 patient-years, and it is difficult to determine if those recurrent strokes are causally related to PFO. […] A PFO is postulated to serve as a conduit for paradoxical embolism to the brain from deep vein thrombosis (DVT) with pulmonary embolism (PE).
#7 Patent foramen ovale and cryptogenic stroke: diagnosis and updates in secondary stroke prevention
https://pmc.ncbi.nlm.nih.gov/articles/PMC6047340/
The patent foramen ovale (PFO), given its high prevalence in the general population and especially in patients with cryptogenic stroke, has long generated investigation and debate on its propensity for stroke by paradoxical embolism and its management for stroke prevention. […] The benefit from PFO closure relies on careful patient selection: those under the age of 60 years with few to no vascular risk factors and embolic-appearing stroke deemed cryptogenic after thorough evaluation. […] The opportunity for risk stratification and secondary stroke prevention in this cohort cryptogenic stroke with PFO underscored a number of randomised controlled trials (RCT) leading to a Food and Drug Administration (FDA) approval of the Amplatzer PFO Occluder in October 2016. […] However the stroke recurrence rate in patients with cryptogenic stroke with PFO is low, estimated at 12 strokes per 100 patient-years, and it is difficult to determine if those recurrent strokes are causally related to PFO.
#8 Comparison of outcome after patent foramen ovale closure in older versus younger patients | EuroIntervention
https://eurointervention.pcronline.com/article/comparison-of-outcome-after-patent-foramen-ovale-closure-in-older-versus-younger-patients
Percutaneous PFO closure appears to be effective for secondary prevention of cryptogenic stroke in younger patients but seems to be related with less beneficial outcome in elderly. […] The recurrence of TIA did not differ significantly between the two groups (log rank test, P=0.14). […] In multivariable analysis, age 55 years remained a predictor of the primary endpoint (HR 3.2; 95% CI 1.1-9.1; p=0.03). […] The annual recurrence rate of stroke or TIA after medical treatment in elderly with a cryptogenic stroke and a documented PFO is 10%. We found an annual recurrence rate of stroke or TIA of 2.4% in elderly who underwent a PFO closure for a cryptogenic embolic event. Hence, the transcatheter PFO closure might have beneficial effects in both younger and older patients with cryptogenic thromboembolism, but the higher recurrence rate of stroke or TIA in older patients compared to younger patients might be attributable to other factors.
#9 Comparison of outcome after patent foramen ovale closure in older versus younger patients | EuroIntervention
https://eurointervention.pcronline.com/article/comparison-of-outcome-after-patent-foramen-ovale-closure-in-older-versus-younger-patients
Percutaneous PFO closure appears to be effective for secondary prevention of cryptogenic stroke in younger patients but seems to be related with less beneficial outcome in elderly. […] The recurrence of TIA did not differ significantly between the two groups (log rank test, P=0.14). […] In multivariable analysis, age 55 years remained a predictor of the primary endpoint (HR 3.2; 95% CI 1.1-9.1; p=0.03). […] The annual recurrence rate of stroke or TIA after medical treatment in elderly with a cryptogenic stroke and a documented PFO is 10%. We found an annual recurrence rate of stroke or TIA of 2.4% in elderly who underwent a PFO closure for a cryptogenic embolic event. Hence, the transcatheter PFO closure might have beneficial effects in both younger and older patients with cryptogenic thromboembolism, but the higher recurrence rate of stroke or TIA in older patients compared to younger patients might be attributable to other factors.
#10 Comparison of outcome after patent foramen ovale closure in older versus younger patients | EuroIntervention
https://eurointervention.pcronline.com/article/comparison-of-outcome-after-patent-foramen-ovale-closure-in-older-versus-younger-patients
Our findings confirm that percutaneous PFO closure in patients with a history of paradoxical embolism appears to be effective for prevention of recurrent stroke and TIA in patients younger than 55 years. Recurrence was significantly higher in the older patients group, suggesting that either percutaneous PFO closure may be less beneficial in elderly or that they constitute a high risk population.
#11 Determinants of adverse outcomes following patent foramen ovale closure in elderly patients | EuroIntervention
https://eurointervention.pcronline.com/article/determinants-of-adverse-outcomes-following-patent-foramen-ovale-closure-in-elderly-patients
BACKGROUND: Limited data are available on transcatheter patent foramen ovale (PFO) closure outcomes in the elderly. […] AIMS: Through this study, we aimed to determine the incidence and predictors of adverse events (recurrent cerebrovascular events [CVE] and atrial fibrillation [AF]) post-PFO closure in older patients with cryptogenic events. […] RESULTS: A total of 689 patients were included (median age 65 years, 41.2% female, mean Risk of Paradoxical Embolism [RoPE] score 4.5). […] After a median follow-up of 2 (interquartile range 1-5) years, 66 patients (9.6%) had died. […] CVE and stroke rates were 1.21 and 0.55 per 100 patient-years, respectively. […] New-onset AF occurred at a rate of 3.30 per 100 patient-years, with 51.3% within one month post-procedure. […] Older patients undergoing PFO closure had a relatively low rate of CVE and new-onset AF after a median follow-up of 2 years. […] The presence of diabetes, ASA, and a more advanced age determined an increased risk of adverse clinical events. […] These factors may be considered in the clinical decision-making process regarding PFO closure in this challenging population.
#12 Determinants of adverse outcomes following patent foramen ovale closure in elderly patients | EuroIntervention
https://eurointervention.pcronline.com/article/determinants-of-adverse-outcomes-following-patent-foramen-ovale-closure-in-elderly-patients
BACKGROUND: Limited data are available on transcatheter patent foramen ovale (PFO) closure outcomes in the elderly. […] AIMS: Through this study, we aimed to determine the incidence and predictors of adverse events (recurrent cerebrovascular events [CVE] and atrial fibrillation [AF]) post-PFO closure in older patients with cryptogenic events. […] RESULTS: A total of 689 patients were included (median age 65 years, 41.2% female, mean Risk of Paradoxical Embolism [RoPE] score 4.5). […] After a median follow-up of 2 (interquartile range 1-5) years, 66 patients (9.6%) had died. […] CVE and stroke rates were 1.21 and 0.55 per 100 patient-years, respectively. […] New-onset AF occurred at a rate of 3.30 per 100 patient-years, with 51.3% within one month post-procedure. […] Older patients undergoing PFO closure had a relatively low rate of CVE and new-onset AF after a median follow-up of 2 years. […] The presence of diabetes, ASA, and a more advanced age determined an increased risk of adverse clinical events. […] These factors may be considered in the clinical decision-making process regarding PFO closure in this challenging population.
#13 Determinants of adverse outcomes following patent foramen ovale closure in elderly patients | EuroIntervention
https://eurointervention.pcronline.com/article/determinants-of-adverse-outcomes-following-patent-foramen-ovale-closure-in-elderly-patients
BACKGROUND: Limited data are available on transcatheter patent foramen ovale (PFO) closure outcomes in the elderly. […] AIMS: Through this study, we aimed to determine the incidence and predictors of adverse events (recurrent cerebrovascular events [CVE] and atrial fibrillation [AF]) post-PFO closure in older patients with cryptogenic events. […] RESULTS: A total of 689 patients were included (median age 65 years, 41.2% female, mean Risk of Paradoxical Embolism [RoPE] score 4.5). […] After a median follow-up of 2 (interquartile range 1-5) years, 66 patients (9.6%) had died. […] CVE and stroke rates were 1.21 and 0.55 per 100 patient-years, respectively. […] New-onset AF occurred at a rate of 3.30 per 100 patient-years, with 51.3% within one month post-procedure. […] Older patients undergoing PFO closure had a relatively low rate of CVE and new-onset AF after a median follow-up of 2 years. […] The presence of diabetes, ASA, and a more advanced age determined an increased risk of adverse clinical events. […] These factors may be considered in the clinical decision-making process regarding PFO closure in this challenging population.
#14 Patent foramen ovale and cryptogenic stroke: diagnosis and updates in secondary stroke prevention
https://pmc.ncbi.nlm.nih.gov/articles/PMC6047340/
A PFO is postulated to serve as a conduit for paradoxical embolism to the brain from deep vein thrombosis (DVT) with pulmonary embolism (PE). […] The data on shunt size and risk of stroke have been nebulous: while some studies suggest larger shunt increases the risk of stroke, others note no difference based on shunt size. […] A meta-analysis by Almekhlafi et al found that recurrent stroke or TIA rates of cryptogenic stroke with PFO did not increase compared with cryptogenic stroke without PFO (relative risk (RR)=1.1, 95%CI 0.8 to 1.5). […] The difficulty with attributing PFO as the actual cause of stroke has led to the development of the Risk of Paradoxical Embolism (RoPE) score in cryptogenic stroke, drawing from a database of 3023 patients with cryptogenic stroke who had PFO studied by TEE or TCD.
#15 Patent foramen ovale and cryptogenic stroke: diagnosis and updates in secondary stroke prevention | Stroke and Vascular Neurology
https://svn.bmj.com/content/3/2/84
A number of studies have examined the clinical clues that predict PFOs propensity for paradoxical embolism. […] The data on shunt size and risk of stroke have been nebulous: while some studies suggest larger shunt increases the risk of stroke, others note no difference based on shunt size. […] A meta-analysis by Almekhlafi et al found that recurrent stroke or TIA rates of cryptogenic stroke with PFO did not increase compared with cryptogenic stroke without PFO (relative risk (RR)=1.1, 95%CI 0.8 to 1.5). […] The difficulty with attributing PFO as the actual cause of stroke has led to the development of the Risk of Paradoxical Embolism (RoPE) score in cryptogenic stroke, drawing from a database of 3023 patients with cryptogenic stroke who had PFO studied by TEE or TCD. […] PFO-attributable fraction of cryptogenic stroke is 60% in those with RoPE score of 6 or higher, with scores 910 reaching almost 90%.
#16 Patent foramen ovale and cryptogenic stroke: diagnosis and updates in secondary stroke prevention
https://pmc.ncbi.nlm.nih.gov/articles/PMC6047340/
PFO-attributable fraction of cryptogenic stroke is 60% in those with RoPE score of 6 or higher, with scores 910 reaching almost 90%. […] The heterogeneity and inconsistent data collection across the component databases prevented the RoPE model from including some predictive variables cited in previous studies, such as obesity index, stroke severity, DVT or PE history, hypercoagulable states, prolonged travel/forced immobility, migraine, sleep apnoea, Valsalva at stroke onset and wake up stroke/TIA. […] For patients 1860 years old with cryptogenic stroke, few vascular risk factors, and high-risk PFO characteristics such as large shunt and ASA, percutaneous PFO closure will reduce recurrent stroke risk, provided that the institutional procedural complication rate is low and minor risk of AF is understood.
#17 Patent foramen ovale and cryptogenic stroke: diagnosis and updates in secondary stroke prevention | Stroke and Vascular Neurology
https://svn.bmj.com/content/3/2/84
A number of studies have examined the clinical clues that predict PFOs propensity for paradoxical embolism. […] The data on shunt size and risk of stroke have been nebulous: while some studies suggest larger shunt increases the risk of stroke, others note no difference based on shunt size. […] A meta-analysis by Almekhlafi et al found that recurrent stroke or TIA rates of cryptogenic stroke with PFO did not increase compared with cryptogenic stroke without PFO (relative risk (RR)=1.1, 95%CI 0.8 to 1.5). […] The difficulty with attributing PFO as the actual cause of stroke has led to the development of the Risk of Paradoxical Embolism (RoPE) score in cryptogenic stroke, drawing from a database of 3023 patients with cryptogenic stroke who had PFO studied by TEE or TCD. […] PFO-attributable fraction of cryptogenic stroke is 60% in those with RoPE score of 6 or higher, with scores 910 reaching almost 90%.
#18 Patent foramen ovale and cryptogenic stroke: diagnosis and updates in secondary stroke prevention
https://pmc.ncbi.nlm.nih.gov/articles/PMC6047340/
PFO-attributable fraction of cryptogenic stroke is 60% in those with RoPE score of 6 or higher, with scores 910 reaching almost 90%. […] The heterogeneity and inconsistent data collection across the component databases prevented the RoPE model from including some predictive variables cited in previous studies, such as obesity index, stroke severity, DVT or PE history, hypercoagulable states, prolonged travel/forced immobility, migraine, sleep apnoea, Valsalva at stroke onset and wake up stroke/TIA. […] For patients 1860 years old with cryptogenic stroke, few vascular risk factors, and high-risk PFO characteristics such as large shunt and ASA, percutaneous PFO closure will reduce recurrent stroke risk, provided that the institutional procedural complication rate is low and minor risk of AF is understood.
#19 Patent foramen ovale and cryptogenic stroke: diagnosis and updates in secondary stroke prevention | Stroke and Vascular Neurology
https://svn.bmj.com/content/3/2/84
The heterogeneity and inconsistent data collection across the component databases prevented the RoPE model from including some predictive variables cited in previous studies, such as obesity index, stroke severity, DVT or PE history, hypercoagulable states, prolonged travel/forced immobility, migraine, sleep apnoea, Valsalva at stroke onset and wake up stroke/TIA. […] Percutaneous PFO closure is beneficial and relatively safe for secondary stroke prevention among adults 60 years, with few conventional vascular risk factors, who have undergone a thorough work-up of their stroke aetiology and are deemed cryptogenic except for the presence of PFO, and who may have large shunts or associated ASA. […] Future studies examining AC (including DOACs) versus PFO closure in subjects with cryptogenic stroke and the clinical significance of transient AF post procedure would be of great value.
#20 Prognostic significance of patent foramen ovale in anticoagulated patients with atrial fibrillation | Open Heart
https://openheart.bmj.com/content/7/1/e001229
The presence of concurrent PFO in this largely anticoagulated group of patients with AF was not associated with increased risk of ischaemic stroke. […] The presence of a concurrent PFO does not increase the risk of ischaemic stroke in patients with AF, mainly due to shunt flow at baseline (unprovoked) being directed from left-to-right in the majority of patients with AF. […] The presence of PFO in patients with AF was not associated with embolic risk beyond those with right-to-left shunt and other established risk factors in this predominantly anticoagulated AF population.
#21 Prognostic significance of patent foramen ovale in anticoagulated patients with atrial fibrillation | Open Heart
https://openheart.bmj.com/content/7/1/e001229
The presence of concurrent PFO in this largely anticoagulated group of patients with AF was not associated with increased risk of ischaemic stroke. […] The presence of a concurrent PFO does not increase the risk of ischaemic stroke in patients with AF, mainly due to shunt flow at baseline (unprovoked) being directed from left-to-right in the majority of patients with AF. […] The presence of PFO in patients with AF was not associated with embolic risk beyond those with right-to-left shunt and other established risk factors in this predominantly anticoagulated AF population.
#22 Patent foramen ovale and cryptogenic stroke: diagnosis and updates in secondary stroke prevention
https://pmc.ncbi.nlm.nih.gov/articles/PMC6047340/
PFO-attributable fraction of cryptogenic stroke is 60% in those with RoPE score of 6 or higher, with scores 910 reaching almost 90%. […] The heterogeneity and inconsistent data collection across the component databases prevented the RoPE model from including some predictive variables cited in previous studies, such as obesity index, stroke severity, DVT or PE history, hypercoagulable states, prolonged travel/forced immobility, migraine, sleep apnoea, Valsalva at stroke onset and wake up stroke/TIA. […] For patients 1860 years old with cryptogenic stroke, few vascular risk factors, and high-risk PFO characteristics such as large shunt and ASA, percutaneous PFO closure will reduce recurrent stroke risk, provided that the institutional procedural complication rate is low and minor risk of AF is understood.
#23 Patent foramen ovale and cryptogenic stroke: diagnosis and updates in secondary stroke prevention | Stroke and Vascular Neurology
https://svn.bmj.com/content/3/2/84
The heterogeneity and inconsistent data collection across the component databases prevented the RoPE model from including some predictive variables cited in previous studies, such as obesity index, stroke severity, DVT or PE history, hypercoagulable states, prolonged travel/forced immobility, migraine, sleep apnoea, Valsalva at stroke onset and wake up stroke/TIA. […] Percutaneous PFO closure is beneficial and relatively safe for secondary stroke prevention among adults 60 years, with few conventional vascular risk factors, who have undergone a thorough work-up of their stroke aetiology and are deemed cryptogenic except for the presence of PFO, and who may have large shunts or associated ASA. […] Future studies examining AC (including DOACs) versus PFO closure in subjects with cryptogenic stroke and the clinical significance of transient AF post procedure would be of great value.
#24 Patent foramen ovale and cryptogenic stroke: diagnosis and updates in secondary stroke prevention | Stroke and Vascular Neurology
https://svn.bmj.com/content/3/2/84
The heterogeneity and inconsistent data collection across the component databases prevented the RoPE model from including some predictive variables cited in previous studies, such as obesity index, stroke severity, DVT or PE history, hypercoagulable states, prolonged travel/forced immobility, migraine, sleep apnoea, Valsalva at stroke onset and wake up stroke/TIA. […] Percutaneous PFO closure is beneficial and relatively safe for secondary stroke prevention among adults 60 years, with few conventional vascular risk factors, who have undergone a thorough work-up of their stroke aetiology and are deemed cryptogenic except for the presence of PFO, and who may have large shunts or associated ASA. […] Future studies examining AC (including DOACs) versus PFO closure in subjects with cryptogenic stroke and the clinical significance of transient AF post procedure would be of great value.
#25 Patent Foramen Ovale (PFO): Symptoms, Causes & Treatment
https://my.clevelandclinic.org/health/diseases/17326-patent-foramen-ovale-pfo
Patent foramen ovale affects about 25% of people worldwide. PFO impacts about 30% to 40% of people whove had an unexplained stroke. This does not mean that everyone who has PFO will experience a stroke or mini-stroke. […] Recent research suggests that PFO closure may help prevent future strokes in people with PFO whove had an unexplained stroke. […] Many children with PFO find the flap seals completely on its own during their first three years. Many people who still have PFO as adults lead long, full lives. […] Patent foramen ovale (PFO) is a small communication between the upper right and left chambers of your heart. PFO affects about 25% of people. PFO often doesnt cause any symptoms and may not require treatment. But it can sometimes indicate stroke or mini-stroke. If you have a history of stroke or blood clots, your provider may suggest treatment. Treatments include medications, catheterization and surgery. Most people with patent foramen ovale can lead full lives.
#26 Patent Foramen Ovale (PFO): Symptoms, Causes & Treatment
https://my.clevelandclinic.org/health/diseases/17326-patent-foramen-ovale-pfo
Patent foramen ovale affects about 25% of people worldwide. PFO impacts about 30% to 40% of people whove had an unexplained stroke. This does not mean that everyone who has PFO will experience a stroke or mini-stroke. […] Recent research suggests that PFO closure may help prevent future strokes in people with PFO whove had an unexplained stroke. […] Many children with PFO find the flap seals completely on its own during their first three years. Many people who still have PFO as adults lead long, full lives. […] Patent foramen ovale (PFO) is a small communication between the upper right and left chambers of your heart. PFO affects about 25% of people. PFO often doesnt cause any symptoms and may not require treatment. But it can sometimes indicate stroke or mini-stroke. If you have a history of stroke or blood clots, your provider may suggest treatment. Treatments include medications, catheterization and surgery. Most people with patent foramen ovale can lead full lives.
#27 Comparison of outcome after patent foramen ovale closure in older versus younger patients | EuroIntervention
https://eurointervention.pcronline.com/article/comparison-of-outcome-after-patent-foramen-ovale-closure-in-older-versus-younger-patients
Percutaneous PFO closure appears to be effective for secondary prevention of cryptogenic stroke in younger patients but seems to be related with less beneficial outcome in elderly. […] The recurrence of TIA did not differ significantly between the two groups (log rank test, P=0.14). […] In multivariable analysis, age 55 years remained a predictor of the primary endpoint (HR 3.2; 95% CI 1.1-9.1; p=0.03). […] The annual recurrence rate of stroke or TIA after medical treatment in elderly with a cryptogenic stroke and a documented PFO is 10%. We found an annual recurrence rate of stroke or TIA of 2.4% in elderly who underwent a PFO closure for a cryptogenic embolic event. Hence, the transcatheter PFO closure might have beneficial effects in both younger and older patients with cryptogenic thromboembolism, but the higher recurrence rate of stroke or TIA in older patients compared to younger patients might be attributable to other factors.
#28 Patent foramen ovale and cryptogenic stroke: diagnosis and updates in secondary stroke prevention | Stroke and Vascular Neurology
https://svn.bmj.com/content/3/2/84
The heterogeneity and inconsistent data collection across the component databases prevented the RoPE model from including some predictive variables cited in previous studies, such as obesity index, stroke severity, DVT or PE history, hypercoagulable states, prolonged travel/forced immobility, migraine, sleep apnoea, Valsalva at stroke onset and wake up stroke/TIA. […] Percutaneous PFO closure is beneficial and relatively safe for secondary stroke prevention among adults 60 years, with few conventional vascular risk factors, who have undergone a thorough work-up of their stroke aetiology and are deemed cryptogenic except for the presence of PFO, and who may have large shunts or associated ASA. […] Future studies examining AC (including DOACs) versus PFO closure in subjects with cryptogenic stroke and the clinical significance of transient AF post procedure would be of great value.