Transesophageal echocardiography in cryptogenic stroke and patent foramen ovale: analysis of putative high-risk features from the risk of paradoxical embolism database.
BACKGROUND
Patent foramen ovale (PFO) is associated with cryptogenic stroke (CS), although the pathogenicity of a discovered PFO in the setting of CS is typically unclear. Transesophageal echocardiography features such as PFO size, associated hypermobile septum, and presence of a right-to-left shunt at rest have all been proposed as markers of risk. The association of these transesophageal echocardiography features with other markers of pathogenicity has not been examined.


RESULTS
We used a recently derived score based on clinical and neuroimaging features to stratify patients with PFO and CS by the probability that their stroke is PFO-attributable. We examined whether high-risk transesophageal echocardiography features are seen more frequently in patients more likely to have had a PFO-attributable stroke (n=637) compared with those less likely to have a PFO-attributable stroke (n=657). Large physiologic shunt size was not more frequently seen among those with probable PFO-attributable strokes (odds ratio [OR], 0.92; P=0.53). The presence of neither a hypermobile septum nor a right-to-left shunt at rest was detected more often in those with a probable PFO-attributable stroke (OR, 0.80; P=0.45; OR, 1.15; P=0.11, respectively).


CONCLUSIONS
We found no evidence that the proposed transesophageal echocardiography risk markers of large PFO size, hypermobile septum, and presence of right-to-left shunt at rest are associated with clinical features suggesting that a CS is PFO-attributable. Additional tools to describe PFOs may be useful in helping to determine whether an observed PFO is incidental or pathogenically related to CS.
Division of Cardiology, Tufts Medical Center, Boston, MA.
Benjamin S
BS
Wessler
David E
DE
Thaler
Robin
R
Ruthazer
Christian
C
Weimar
Marco R
MR
Di Tullio
Mitchell S V
MS
Elkind
Shunichi
S
Homma
Jennifer S
JS
Lutz
Jean-Louis
JL
Mas
Heinrich P
HP
Mattle
Bernhard
B
Meier
Krassen
K
Nedeltchev
Federica
F
Papetti
Emanuele
E
Di Angelantonio
Mark
M
Reisman
Joaquín
J
Serena
David M
DM
Kent
D000328:Adult; D000368:Aged; D016009:Chi-Square Distribution; D003326:Coronary Circulation; D016208:Databases, Factual; D017548:Echocardiography, Transesophageal; D019320:Embolism, Paradoxical / Q000000981:diagnostic imaging* / Q000453:epidemiology / Q000503:physiopathology; D005260:Female; D054092:Foramen Ovale, Patent / Q000000981:diagnostic imaging* / Q000453:epidemiology / Q000503:physiopathology; D006346:Heart Septum / Q000000981:diagnostic imaging; D006439:Hemodynamics; D006801:Humans; D016014:Linear Models; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D011237:Predictive Value of Tests; D015995:Prevalence; D018570:Risk Assessment; D012307:Risk Factors; D020521:Stroke / Q000000981:diagnostic imaging* / Q000453:epidemiology / Q000503:physiopathology; D017585:Ultrasonography, Doppler, Transcranial
cardiovascular imaging; cerebrovascular disease/stroke; congenital heart disease; echocardiography; foramen ovale, patent; risk factor