Embolic implications of combined risk factors in patients with patent foramen ovale (the CARPE criteria): consideration for primary prevention closure?
BACKGROUND
Large patent foramen ovale (PFO), spontaneous right-to-left shunt, large atrial septal aneurysm (ASA), coagulation abnormalities, and prominent eustachian valve (EV) have all been independently suggested as risk factors for recurrent stroke. We sought to retrospectively evaluate risk of stroke and impact of transcatheter PFO closure in patients with concurrent large PFO, spontaneous right-to-left shunt, large ASA, coagulation abnormalities, and prominent EV.


METHODS
Between March 2006 and October 2008, 36 (mean age 44 +/- 10.9 years, 28 females) out of 120 consecutive patients referred to our center for transcatheter PFO closure had concomitant diagnosis of (a) large PFO on transcranial Doppler (TCD) and transesophageal echocardiography (TEE), (b) spontaneous right-to-left shunt on TCD, (c) large ASA, (d) prominent EV, and (e) coagulation abnormalities. All patients fulfilled the standard current indications for transcatheter closure and underwent preoperative TEE and brain magnetic resonance imaging (MRI), with subsequent intracardiac echocardiographic-guided transcatheter PFO closure.


RESULTS
Compared to the remaining PFO population in the same period, patients with all five concomitant features had more ischemic brain lesions on MRI, previous history of recurrent stroke, more frequently a history of venous thromboembolism, and more severe migraine with aura. The concomitance of all the features confers the highest risk of recurrent stroke (OR 9.9, 3.0-18 [95% CI], P < 0.001).


CONCLUSIONS
Despite its small sample size and nonrandomized retrospective nature, this is the first study to suggest that patients with concurrence of all the investigated characteristics have potentially a higher risk of stroke compared to controls. We thus propose the CARP criteria as a basis for further larger, longitudinal studies to assess the potential benefits of transcatheter closure in this patient subset in the absence of clinical recurrent stroke.
Rigatelli
Gianluca
G
Section of Adult Congenital and Adult Heart Disease, Cardiovascular Diagnosis and Endoluminal Interventions, Rovigo General Hospital, Rovigo, Italy. jackyheart@libero.it
Dell'Avvocata
Fabio
F
Giordan
Massimo
M
Braggion
Gabriele
G
Aggio
Silvio
S
Chinaglia
Mauro
M
Roncon
Loris
L
Cardaioli
Paolo
P
Chen
Jack P
JP
D000328:Adult; D000704:Analysis of Variance; D017548:Echocardiography, Transesophageal; D019320:Embolism, Paradoxical / Q000209:etiology* / Q000517:prevention & control; D005260:Female; D054092:Foramen Ovale, Patent / Q000150:complications* / Q000000981:diagnostic imaging / Q000601:surgery; D006801:Humans; D016015:Logistic Models; D008297:Male; D020325:Migraine with Aura / Q000000981:diagnostic imaging / Q000209:etiology* / Q000517:prevention & control; D011322:Primary Prevention; D012189:Retrospective Studies; D012307:Risk Factors; D020521:Stroke / Q000000981:diagnostic imaging / Q000209:etiology* / Q000517:prevention & control; D018608:Ultrasonography, Doppler