title: Persistent venous valves correlate with increased shunt and multiple preceding cryptogenic embolic events in patients with patent foramen ovale: an intracardiac echocardiographic study.
abstract: BACKGROUND
  It has been suggested that prominent Eustachian valve (EV) and Chiari's network (CN) predispose to paradoxical embolism but their presence in patients with presumed paradoxical stroke is not always easily detectable by transesophageal echocardiography (TEE). We sought to prospectively assess the frequency of EV/CN as assessed by intracardiac echocardiography (ICE) in patients submitted to patent foramen ovale (PFO) transcatheter closure in order to investigate their role in determining shunt severity and risk of multiple paradoxical embolisms.
  
  
  METHODS
  Over a 36-month period, we prospectively enrolled 98 consecutive patients (mean age 37 +/- 12.5 years, 68 females) with previous stroke referred to our center for PFO catheter-based closure. All patients underwent transcranial Doppler ultrasound (TC-D), TEE and ICE-guided transcatheter closure.
  
  
  RESULTS
  After ICE study and measurements, a prominent EV or CN were diagnosed on ICE in 72 patients (73.4%), whereas in 45 (45.9%, P < 0.01) on TEE. Patients with EV/CN had more frequently a curtain pattern on TC-D, a larger right-to-left shunt, and recurrent cerebral paradoxical embolisms before closure. EV/CN and medium-large shunt on TEE were the strongest predictors of recurrent paradoxical embolisms.
  
  
  CONCLUSIONS
  This study suggests that EV and CN have a deep impact on the pathophysiology of paradoxical embolism: EV and CN should be considered as adjunctive risk factors for paradoxical embolism in the decision-making process involving PFO patients.
authors.affiliation: Section of Adult Congenital and Adult Heart Disease, Cardiovascular Diagnosis and Endoluminal Interventions, Rovigo General Hospital, Rovigo, Italy. jackyheart@libero.it
authors.forename: Gianluca
authors.initials: G
authors.lastname: Rigatelli
authors.forename: Fabio
authors.initials: F
authors.lastname: Dell'avvocata
authors.forename: Gabriele
authors.initials: G
authors.lastname: Braggion
authors.forename: Massimo
authors.initials: M
authors.lastname: Giordan
authors.forename: Mauro
authors.initials: M
authors.lastname: Chinaglia
authors.forename: Paolo
authors.initials: P
authors.lastname: Cardaioli
mesh_terms: D000328:Adult; D006328:Cardiac Catheterization; D017548:Echocardiography, Transesophageal; D019320:Embolism, Paradoxical / Q000000981:diagnostic imaging / Q000209:etiology* / Q000628:therapy; D005260:Female; D054092:Foramen Ovale, Patent / Q000150:complications / Q000000981:diagnostic imaging* / Q000628:therapy; D006801:Humans; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D011446:Prospective Studies; D012008:Recurrence; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D020521:Stroke / Q000000981:diagnostic imaging / Q000209:etiology* / Q000628:therapy; D016896:Treatment Outcome; D017585:Ultrasonography, Doppler, Transcranial; D018084:Ultrasonography, Interventional; D055422:Venous Valves / Q000000981:diagnostic imaging*