Cath Lab Digest - October 2007 - (Page 16)

16 CASE REPORT OCTOBER 2007 Table I. Prevalence of a PFO in patients with cryptogenic stroke Author Lechat4 Webster5 Di Tullio6 Year 1988 1988 1992 Study Type Case-control Case-control Cross-sectional with nested case-control Number of Subjects (N) 60 40 146 PFO Prevalence 40% vs. 10% 50% vs. 15% (p < 0.001) 48% vs. 4% < 55 yrs old (p 55 yrs old (p < 0.001) 40% vs. 18% < 55 yrs old (p < 0.001) 46% 39% Comparison Group 100 “normals” 40 age/sex matched Cryptogenic stroke vs. Identifiable origin of stroke Overell7 2000 Meta-analysis of case-control studies Prospective observational Prospective multicenter randomized controlled treatment trial 892 721 controls Mas8 Homma9 2001 2002 581 250 None None Table II. Prevalence of DVT in patients with a PFO and cryptogenic stroke Author Stollberger10 Lethen11 Cramer12 Year 1993 1997 2004 Study Type Cross-sectional observational Cross-sectional observational Cross-sectional observational Number of Subjects (N) 42 53 46 DVT Prevalence 57% 10% 20% Comparison Group Venography Venography MRI Venogram (MRV) Individuals with Eisenmenger’s syndrome initially have substantial leftto-right shunting — generally through an ASD or ventricular septal defect (VSD) — and, as a result, morphologic alterations occur in the small pulmonary arteries and arterioles leading to pulmonary hypertension and the resultant reversal of the intracardiac shunt, i.e., right-to-left. These individuals demonstrate central cyanosis and digital clubbing on exam, ECG shows right atrial and ventricular enlargement with right axis deviation, and echocardiography shows signs of chronic right ventricular volume and pressure overload with ventricular hypertrophy and enlargement. Our patient had none of these findings. Summary In summary, the evaluation of patients with cryptogenic stroke should include a search for the hidden PFO. And in the setting of a PFO, an increase in right-sided cardiac pressures — like that which occurs with an acute PE — can result in right-to-left shunting and pose a risk for a paradoxical embolism. ■ The authors can be contacted at harrisoa@uci.edu Note: This article underwent double-blind peer review by members of the Cath Lab Digest Editorial Board. Literature Review of PFO and DVT in Cryptogenic Stroke On review of the literature, there are six large studies that report a prevalence of PFO in cryptogenic stroke ranging from 38 to 50% as compared to controls (4 to 18%) (Table I).4-9 Furthermore, a few studies have assessed the prevalence of DVT in patients with a PFO and cryptogenic stroke and found 10 to 57% of patients to have demonstrable DVT (Table II).10-12 In the setting of a PFO, an increase in right-sided cardiac pressures — like that which occurs with an acute PE — can result in right-to-left shunting and pose a risk for a paradoxical embolism. 1. Benotti JR, Dalen JE. The natural history of pulmonary embolism. Clin Chest Med 1984;5:403-410. 2. Hara H, Virmani R, Ladich E, et al. Patent foramen ovale: current pathology, pathophysiology, and clinical status. J Am Coll Cardiol 2005; 46:1768-1776. 3. Hagen PT, Scholz DG, Edwards WD. Incidence and size of patent foramen ovale during the first 10 decades of life: an autopsy study of 965 normal hearts. Mayo Clin Proc 1984; 59:17-20. 4. Lechat P, Mas JL, Lascault G, et al. Prevalence of patent foramen ovale in patients with stroke. N Engl J Med 1988 May 5;318(18):1148-1152. References 5. Webster MW, Chancellor AM, Smith HJ, et al. Patent foramen ovale in young stroke patients. Lancet 1988 Jul 2;2(8601):11-12. 6. Di Tullio M, Sacco RL, Gopal A, et al. Patent foramen ovale as a risk factor for cryptogenic stroke. Ann Intern Med 1992 Sep 15;117(6):461-465. 7. Overell JR, Bone I, Lees KR. Interatrial septal abnormalities and stroke: a metaanalysis of case-control studies. Neurology 2000 Oct 24;55(8): 1172–1179. 8. Mas JL, Arquizan C, Lamy C, et al. Recurrent cerebrovascular events associated with patent foramen ovale, atrial septal aneurysm, or both. N Engl J Med 2001 Dec 13;345(24):1740-1746. 9. Homma S, Sacco RL, Di Tullio MR, et al. Effect of medical treatment in stroke patients with patent foramen ovale: patent foramen ovale in Cryptogenic Stroke Study. Circulation 2002 Jun 4;105(22):2625-2631. 10. Stollberger C, Slany J, Schuster I, et al. The prevalence of deep venous thrombosis in patients with suspected paradoxical embolism. Ann Intern Med 1993 Sep 15;119(6):461-465. 11. Lethen H, Flachskampf FA, Schneider R, et al. Frequency of deep vein thrombosis in patients with patent foramen ovale and ischemic stroke or transient ischemic attack. Am J Cardiol 1997 Oct 15;80(8):1066-1069. 12. Cramer SC, Rordorf G, Maki JH, et al. Increased pelvic vein thrombi in cryptogenic stroke: results of the Paradoxical Emboli from Large Veins in Ischemic Stroke (PELVIS) study. Stroke 2004 Jan;35(1):46-50. Epub 2003 Dec 4.

Table of Contents Feed for the Digital Edition of Cath Lab Digest - October 2007

Saints Medical Center Fibromuscular Dysplasia in Children and Adolescents Cerebral Vascular Accident Following a Pulmonary Embolism: Search for the Hidden Patent Foramen Ovale Contents Clinical Editor’s Corner Meetings Calendar CEU Education Center Radiation Tracking in the Cardiac Catheterization Lab Letter to the Editor Carotid Stenting: An update Release from Stent-jail: Beneficial Snow-Plowing? Patient Management Guidelines Searching for a Cardiovascular Position? Tips for Creating a ‘Stand-Out’ Resume Long-Term Implications of Short-Term Closure Decisions – The Evolution to Vascular Access Management and the Boomerang Catalyst System The Ten-Minute Interview with… Angie Bowles, RN, CCRN CMS Issues Final FY 2008 IPPS Rule ACVP• Membership Page Experience with a New Workhorse Guidewire Ask the Clinical Instructor: Q&A for Those New to Cath Lab A Glimpse of the Future of Clinical Education: Boston Scientific’s SimSuite Bus Visits Carnegie Institute 2007 Educational Fair Held at the Washington Hospital Center Research Update: Original Contribution Abstracts from The Journal of Invasive Cardiology What Do You Think? A Virtual Cath Lab Viewer (VCL): The Development of an Online 3D C-arm Simulator and Coronary Anatomy Viewer Clinical & Industry News Cost-Effectiveness of the Radial versus Femoral Artery Approach to Diagnostic Cardiac Catheterization

Cath Lab Digest - October 2007

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