ECHO 2013 / Advanced TEE Clinical Decision Making in Cryptogenic Stroke and Atrial Fibrillation
.pdf
PFO and Risk of Stroke – Potential Cofactors
•Atrial septal aneurysm
•Morphologic variants (PFO size, Eustachian valve, Chiari network)
•Deep venous thrombosis
•Hypercoagulable states (factor V Leiden, G20210A mutation, etc.)
•Risk factors for thromboembolism (surgery, trauma, oral contraceptive use)
•Atrial irritability?
•Others???
Atrial Septal Aneurysm (ASA)
Atrial Septal Aneurysm (ASA)
•Associated with a PFO in 60-70% of cases
•Its independent embolic potential is unclear (is PFO the real culprit ?)
•Associated thrombi are rarely seen
Multicenter Study, Circulation, June 1995
• Possibly associated with atrial arrhythmias
Berthet K et al, Stroke 2000;31:398-403
Stroke Recurrence in Patients with PFO/ASA
(4-Year Event Rates; Patients <55 years of age; Aspirin 300mg/die)
16 |
|
15.2 |
|
|
|
% |
|
PFO+ASA |
14 |
|
|
|
(N=51) |
|
|
|
|
12 |
|
HR = 4.2 |
|
(95% CI 1.5 - 11.8) |
|
|
|
|
10 |
|
|
8 |
|
|
6 |
|
|
|
|
4.2 |
4 |
|
|
|
2.3 |
Neither |
2 |
|
(N=304) |
PFO |
|
|
|
|
|
|
(N=216) |
|
0 |
|
|
Mas et al, N Engl J Med 2001;345:1740-6
•In 48 patients with cryptogenic stroke, those with PFO+ASA had more often multiple acute brain lesions on MRI than patients with PFO alone (53% vs. 17%; p=0.01)
•The difference persisted after correction for PFO size, degree of R to L shunt and other vascular risk factors (p=0.04)
Bonati et al, Stroke 2006;37:2030-4
PFO size
PFO Size And Brain Imaging
-95 stroke patients undergoing TEE
-31/95 (33%) had a PFO
-Frequency of PFO higher in cryptogenic strokes
19/42 (45%) vs. 12/53 (23%) p=0.02
-Larger PFO (>2mm) more frequent in cryptogenic strokes
26% vs. 6% p=0.04
- Superficial infarcts more frequent with larger PFO 50% vs. 21% p=0.02
Steiner M et al, Stroke 1998;29:944-8
Eustachian Valve – Chiari network
Atrial Septal “Pouch”
Left Septal Pouch - Risk of Cryptogenic Stroke
(187 stroke patients, 157 control subjects)
Tugcu et al, JACC Img 2010, 3(12)1276-83
PFO Imaging - Advantages of TEE
•Greater sensitivity, especially for small PFOs (25% vs. 15% in the general population)
•Ability to “measure” the PFO opening (separation of septum primum and secundum)
•Better assessment of atrial septal aneurysm (ASA)
•Greater ability to distinguish between PFO and intrapulmonary shunts (direct visualization vs. “shunt timing” criteria)
•Better assessment of associated abnormalities certainly (thrombus) or possibly (Eustachian valve, Chiari network) related to the embolic potential
•Assessment of complications of therapeutic interventions (transcatheter PFO closure)