Section of Adult Congenital and Adult Heart Disease, Cardiovascular Diagnosis and Endoluminal Interventions, Rovigo General Hospital, Viale Tre Martiri, Rovigo, Italy.
J Am Coll Cardiol. 2011 Nov 15;58(21):2257-61. doi: 10.1016/j.jacc.2011.06.064.
We sought to prospectively evaluate risk of stroke and impact of transcatheter patent foramen ovale (PFO) closure in patients with permanent right-to left shunt compared with those with Valsalva maneuver-induced right-to-left shunt.
Pathophysiology and properly management of PFO still remain far from being fully clarified: in particular, the contribution of permanent right-to-left shunt remains unknown.
Between March 2006 and October 2010, we enrolled 180 (mean age 44 ± 10.9 years, 98 women) of 320 consecutive patients referred to our center for transcatheter PFO closure, who had spontaneous permanent right-to-left shunt on transcranial Doppler and transthoracic/transesophageal echocardiography. All patients fulfilled the standard current indications for transcatheter closure and underwent preoperative transesophageal echocardiography and brain magnetic resonance imaging, with subsequent intracardiac echocardiographic-guided transcatheter PFO closure. We compared the clinical echocardiographic characteristics of these patients (Permanent Group) with the rest of 140 patients with right-to-left shunt only during Valsalva maneuver (Valsalva Group).
Compared with the Valsalva Group patients, patients of the Permanent Group had increased frequency of multiple ischemic brain lesions on magnetic resonance imaging, previous recurrent stroke, previous peripheral arteries embolism, migraine with aura, and-more frequently-atrial septal aneurysm and prominent Eustachian valve. The presence of permanent shunt confers the highest risk of recurrent stroke (odds ratio: 5.9, 95% confidence interval: 2.0 to 12, p < 0.001). No differences were recorded between the 2 groups with regard to recurrence of ischemic events after the closure procedure.
Despite its small-sample nature, our study suggests that patients with permanent right-to-left shunt have potentially a higher risk of paradoxical embolism compared with those without.
我们旨在前瞻性评估与瓦尔萨尔瓦动作诱发右向左分流相比，永存性右向左分流患者经导管卵圆孔未闭（PFO）封堵术的中风风险和影响。
PFO 的病理生理学和适当管理仍远未完全阐明：特别是，永存性右向左分流的贡献仍不清楚。
2006 年 3 月至 2010 年 10 月，我们纳入了 320 例连续患者中的 180 例（平均年龄 44 ± 10.9 岁，98 例女性），这些患者经颅多普勒超声和经胸/经食管超声心动图检查均有自发性永存性右向左分流。所有患者均符合经导管 PFO 封堵术的标准适应证，并接受了术前经食管超声心动图和脑磁共振成像检查，随后进行了心内超声引导下的经导管 PFO 封堵术。我们比较了这些患者（永久性分流组）与仅在瓦尔萨尔瓦动作时存在右向左分流的其余 140 例患者（瓦尔萨尔瓦分流组）的临床超声心动图特征。
与瓦尔萨尔瓦分流组患者相比，永久性分流组患者的磁共振成像上多发性缺血性脑病变、复发性中风、外周动脉栓塞、有先兆偏头痛和更常见的房间隔瘤及明显的耳咽管瓣的发生率更高。永久性分流的存在赋予了复发性中风的最高风险（优势比：5.9，95%置信区间：2.0 至 12，p < 0.001）。在封堵术后缺血性事件的复发方面，两组之间没有差异。
尽管样本量较小，但我们的研究表明，与没有永久性右向左分流的患者相比，永存性右向左分流患者发生矛盾性栓塞的潜在风险更高。
