title: Permanent right-to-left shunt is the key factor in managing patent foramen ovale.
abstract: OBJECTIVE
  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.
  
  
  BACKGROUND
  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.
  
  
  METHODS
  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).
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Section of Adult Congenital and Adult Heart Disease, Cardiovascular Diagnosis and Endoluminal Interventions, Rovigo General Hospital, Viale Tre Martiri, 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: Paolo
authors.initials: P
authors.lastname: Cardaioli
authors.forename: Massimo
authors.initials: M
authors.lastname: Giordan
authors.forename: Gabriele
authors.initials: G
authors.lastname: Braggion
authors.forename: Silvio
authors.initials: S
authors.lastname: Aggio
authors.forename: Mauro
authors.initials: M
authors.lastname: Chinaglia
authors.forename: Sangeeta
authors.initials: S
authors.lastname: Mandapaka
authors.forename: John
authors.initials: J
authors.lastname: Kuruvilla
authors.forename: Jack P
authors.initials: JP
authors.lastname: Chen
authors.forename: Aravinda
authors.initials: A
authors.lastname: Nanjundappa
mesh_terms: D006328:Cardiac Catheterization; D006348:Cardiac Surgical Procedures / Q000379:methods*; D017548:Echocardiography, Transesophageal; D005260:Female; D005500:Follow-Up Studies; D054092:Foramen Ovale, Patent / Q000000981:diagnostic imaging / Q000601:surgery*; D006801:Humans; D015994:Incidence; D007558:Italy / Q000453:epidemiology; D008297:Male; D011379:Prognosis; D011446:Prospective Studies; D011655:Pulmonary Embolism / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control*; D020521:Stroke / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control*