Surgical patent foramen ovale closure for prevention of paradoxical embolism-related cerebrovascular ischemic events

Joseph A. Dearani, Baran S. Ugurlu, Gordon K. Danielson, Richard C. Daly, Christopher G A McGregor, Charles J. Mullany, Francisco J. Puga, Thomas A. Orszulak, Betty J. Anderson, Robert D Jr. Brown, Hartzell V Schaff

Research output: Contribution to journalArticle

215 Citations (Scopus)

Abstract

Background - The role of surgical closure of patent foramen ovale (PFO) for cerebral infarction (CI) or transient ischemic attack (TIA) resulting from paradoxical embolism is unclear, and its effect on recurrence is unknown. Our objective was to determine the outcome of surgical closure of PFO in patients with a prior ischemic neurological event, define the rate of CI or TIA recurrence after PFO closure, and identify risk factors for these recurrences. Methods and Results - We retrospectively analyzed 91 patients (58 men, 33 women) with ≥1 previous cerebrovascular ischemic events who underwent surgical PFO closure between April 1982 and March 1998. The presence of a PFO with a right-to-left shunt was confirmed with transesophageal echocardiography. Mean age was 44.2±12.2 years. The index event was a CI in 59 and a TIA in 32; a Valsalva-like episode preceded the event in 15 patients. Deep venous thrombosis was documented in 9 patients, and a hypercoagulable state was identified in 10. Surgical closure was performed with extracorporeal circulation by either direct suture (n = 82) or patch closure (n=9). Limited incisions were used in 18.7% of patients. There was no operative mortality. Morbidity included transient atrial fibrillation (n=11), pericardial drainage for effusion (n=4), exploration for bleeding (n=3), and superficial wound infection (n= 1). Follow-up totaled 176.3 patient-years, and mean follow-up was 2.0 years. No one had a CI, and 8 had a TIA during follow-up, with l caused by temporal arteritis. Transesophageal echocardiography demonstrated all closures to be intact in these patients. The overall freedom from TIA recurrence during follow-up was 92.5±3.2% at 1 year and 83.4±6.0% at 4 years. Having multiple neurological events before PFO closure was the only significant risk factor for TIA or CI recurrence after closure by univariate analysis (P=0.05); the small number of post-PFO closure cerebral ischemic events precluded multivariate analysis. Conclusions - Surgical closure of PFO can be performed with minimal morbidity and mortality. PFO closure may decrease the risk of recurrent stroke or TIA and may avoid lifelong anticoagulation in the young adult if there is no other indication. Recurrent cerebrovascular ischemic events after surgery should prompt further evaluation to identify causes other than paradoxical embolism.

Original languageEnglish (US)
JournalCirculation
Volume100
Issue number19 SUPPL.
StatePublished - Nov 9 1999

Fingerprint

Paradoxical Embolism
Patent Foramen Ovale
Transient Ischemic Attack
Cerebral Infarction
Recurrence
Transesophageal Echocardiography
Morbidity
Giant Cell Arteritis
Extracorporeal Circulation
Pericardial Effusion
Mortality
Wound Infection
Venous Thrombosis
Atrial Fibrillation
Sutures
Drainage
Young Adult
Multivariate Analysis
Stroke
Hemorrhage

Keywords

  • Embolism
  • Heart septal defects
  • Stroke

ASJC Scopus subject areas

  • Physiology
  • Cardiology and Cardiovascular Medicine

Cite this

Dearani, J. A., Ugurlu, B. S., Danielson, G. K., Daly, R. C., McGregor, C. G. A., Mullany, C. J., ... Schaff, H. V. (1999). Surgical patent foramen ovale closure for prevention of paradoxical embolism-related cerebrovascular ischemic events. Circulation, 100(19 SUPPL.).

Surgical patent foramen ovale closure for prevention of paradoxical embolism-related cerebrovascular ischemic events. / Dearani, Joseph A.; Ugurlu, Baran S.; Danielson, Gordon K.; Daly, Richard C.; McGregor, Christopher G A; Mullany, Charles J.; Puga, Francisco J.; Orszulak, Thomas A.; Anderson, Betty J.; Brown, Robert D Jr.; Schaff, Hartzell V.

In: Circulation, Vol. 100, No. 19 SUPPL., 09.11.1999.

Research output: Contribution to journalArticle

Dearani, JA, Ugurlu, BS, Danielson, GK, Daly, RC, McGregor, CGA, Mullany, CJ, Puga, FJ, Orszulak, TA, Anderson, BJ, Brown, RDJ & Schaff, HV 1999, 'Surgical patent foramen ovale closure for prevention of paradoxical embolism-related cerebrovascular ischemic events', Circulation, vol. 100, no. 19 SUPPL..
Dearani JA, Ugurlu BS, Danielson GK, Daly RC, McGregor CGA, Mullany CJ et al. Surgical patent foramen ovale closure for prevention of paradoxical embolism-related cerebrovascular ischemic events. Circulation. 1999 Nov 9;100(19 SUPPL.).
Dearani, Joseph A. ; Ugurlu, Baran S. ; Danielson, Gordon K. ; Daly, Richard C. ; McGregor, Christopher G A ; Mullany, Charles J. ; Puga, Francisco J. ; Orszulak, Thomas A. ; Anderson, Betty J. ; Brown, Robert D Jr. ; Schaff, Hartzell V. / Surgical patent foramen ovale closure for prevention of paradoxical embolism-related cerebrovascular ischemic events. In: Circulation. 1999 ; Vol. 100, No. 19 SUPPL.
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abstract = "Background - The role of surgical closure of patent foramen ovale (PFO) for cerebral infarction (CI) or transient ischemic attack (TIA) resulting from paradoxical embolism is unclear, and its effect on recurrence is unknown. Our objective was to determine the outcome of surgical closure of PFO in patients with a prior ischemic neurological event, define the rate of CI or TIA recurrence after PFO closure, and identify risk factors for these recurrences. Methods and Results - We retrospectively analyzed 91 patients (58 men, 33 women) with ≥1 previous cerebrovascular ischemic events who underwent surgical PFO closure between April 1982 and March 1998. The presence of a PFO with a right-to-left shunt was confirmed with transesophageal echocardiography. Mean age was 44.2±12.2 years. The index event was a CI in 59 and a TIA in 32; a Valsalva-like episode preceded the event in 15 patients. Deep venous thrombosis was documented in 9 patients, and a hypercoagulable state was identified in 10. Surgical closure was performed with extracorporeal circulation by either direct suture (n = 82) or patch closure (n=9). Limited incisions were used in 18.7{\%} of patients. There was no operative mortality. Morbidity included transient atrial fibrillation (n=11), pericardial drainage for effusion (n=4), exploration for bleeding (n=3), and superficial wound infection (n= 1). Follow-up totaled 176.3 patient-years, and mean follow-up was 2.0 years. No one had a CI, and 8 had a TIA during follow-up, with l caused by temporal arteritis. Transesophageal echocardiography demonstrated all closures to be intact in these patients. The overall freedom from TIA recurrence during follow-up was 92.5±3.2{\%} at 1 year and 83.4±6.0{\%} at 4 years. Having multiple neurological events before PFO closure was the only significant risk factor for TIA or CI recurrence after closure by univariate analysis (P=0.05); the small number of post-PFO closure cerebral ischemic events precluded multivariate analysis. Conclusions - Surgical closure of PFO can be performed with minimal morbidity and mortality. PFO closure may decrease the risk of recurrent stroke or TIA and may avoid lifelong anticoagulation in the young adult if there is no other indication. Recurrent cerebrovascular ischemic events after surgery should prompt further evaluation to identify causes other than paradoxical embolism.",
keywords = "Embolism, Heart septal defects, Stroke",
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T1 - Surgical patent foramen ovale closure for prevention of paradoxical embolism-related cerebrovascular ischemic events

AU - Dearani, Joseph A.

AU - Ugurlu, Baran S.

AU - Danielson, Gordon K.

AU - Daly, Richard C.

AU - McGregor, Christopher G A

AU - Mullany, Charles J.

AU - Puga, Francisco J.

AU - Orszulak, Thomas A.

AU - Anderson, Betty J.

AU - Brown, Robert D Jr.

AU - Schaff, Hartzell V

PY - 1999/11/9

Y1 - 1999/11/9

N2 - Background - The role of surgical closure of patent foramen ovale (PFO) for cerebral infarction (CI) or transient ischemic attack (TIA) resulting from paradoxical embolism is unclear, and its effect on recurrence is unknown. Our objective was to determine the outcome of surgical closure of PFO in patients with a prior ischemic neurological event, define the rate of CI or TIA recurrence after PFO closure, and identify risk factors for these recurrences. Methods and Results - We retrospectively analyzed 91 patients (58 men, 33 women) with ≥1 previous cerebrovascular ischemic events who underwent surgical PFO closure between April 1982 and March 1998. The presence of a PFO with a right-to-left shunt was confirmed with transesophageal echocardiography. Mean age was 44.2±12.2 years. The index event was a CI in 59 and a TIA in 32; a Valsalva-like episode preceded the event in 15 patients. Deep venous thrombosis was documented in 9 patients, and a hypercoagulable state was identified in 10. Surgical closure was performed with extracorporeal circulation by either direct suture (n = 82) or patch closure (n=9). Limited incisions were used in 18.7% of patients. There was no operative mortality. Morbidity included transient atrial fibrillation (n=11), pericardial drainage for effusion (n=4), exploration for bleeding (n=3), and superficial wound infection (n= 1). Follow-up totaled 176.3 patient-years, and mean follow-up was 2.0 years. No one had a CI, and 8 had a TIA during follow-up, with l caused by temporal arteritis. Transesophageal echocardiography demonstrated all closures to be intact in these patients. The overall freedom from TIA recurrence during follow-up was 92.5±3.2% at 1 year and 83.4±6.0% at 4 years. Having multiple neurological events before PFO closure was the only significant risk factor for TIA or CI recurrence after closure by univariate analysis (P=0.05); the small number of post-PFO closure cerebral ischemic events precluded multivariate analysis. Conclusions - Surgical closure of PFO can be performed with minimal morbidity and mortality. PFO closure may decrease the risk of recurrent stroke or TIA and may avoid lifelong anticoagulation in the young adult if there is no other indication. Recurrent cerebrovascular ischemic events after surgery should prompt further evaluation to identify causes other than paradoxical embolism.

AB - Background - The role of surgical closure of patent foramen ovale (PFO) for cerebral infarction (CI) or transient ischemic attack (TIA) resulting from paradoxical embolism is unclear, and its effect on recurrence is unknown. Our objective was to determine the outcome of surgical closure of PFO in patients with a prior ischemic neurological event, define the rate of CI or TIA recurrence after PFO closure, and identify risk factors for these recurrences. Methods and Results - We retrospectively analyzed 91 patients (58 men, 33 women) with ≥1 previous cerebrovascular ischemic events who underwent surgical PFO closure between April 1982 and March 1998. The presence of a PFO with a right-to-left shunt was confirmed with transesophageal echocardiography. Mean age was 44.2±12.2 years. The index event was a CI in 59 and a TIA in 32; a Valsalva-like episode preceded the event in 15 patients. Deep venous thrombosis was documented in 9 patients, and a hypercoagulable state was identified in 10. Surgical closure was performed with extracorporeal circulation by either direct suture (n = 82) or patch closure (n=9). Limited incisions were used in 18.7% of patients. There was no operative mortality. Morbidity included transient atrial fibrillation (n=11), pericardial drainage for effusion (n=4), exploration for bleeding (n=3), and superficial wound infection (n= 1). Follow-up totaled 176.3 patient-years, and mean follow-up was 2.0 years. No one had a CI, and 8 had a TIA during follow-up, with l caused by temporal arteritis. Transesophageal echocardiography demonstrated all closures to be intact in these patients. The overall freedom from TIA recurrence during follow-up was 92.5±3.2% at 1 year and 83.4±6.0% at 4 years. Having multiple neurological events before PFO closure was the only significant risk factor for TIA or CI recurrence after closure by univariate analysis (P=0.05); the small number of post-PFO closure cerebral ischemic events precluded multivariate analysis. Conclusions - Surgical closure of PFO can be performed with minimal morbidity and mortality. PFO closure may decrease the risk of recurrent stroke or TIA and may avoid lifelong anticoagulation in the young adult if there is no other indication. Recurrent cerebrovascular ischemic events after surgery should prompt further evaluation to identify causes other than paradoxical embolism.

KW - Embolism

KW - Heart septal defects

KW - Stroke

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M3 - Article

C2 - 10567299

AN - SCOPUS:0345325569

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JO - Circulation

JF - Circulation

SN - 0009-7322

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