Stroke, Vol 25, 782-786, Copyright © 1994 by American Heart Association
JP Hanna, JP Sun, AJ Furlan, WJ Stewart, CA Sila and M Tan
BACKGROUND AND PURPOSE: Paradoxical embolism through a patent foramen ovale
is a recognized cause of stroke, but clinical predictors, recurrence rate,
and prevention of brain infarcts in patients with patent foramen ovale have
not been determined. We reviewed transesophageal echocardiographic records
to ascertain echocardiographic predictors and optimal prophylaxis for
patent foramen ovale-related infarcts. METHODS: A patent foramen ovale was
identified in 74 patients during 615 transesophageal echocardiograms by
color Doppler or saline contrast during a 60-month period. On the basis of
final clinical situation, the patients were divided into the following
groups: group 1, infarct with patent foramen ovale a likely cause (n = 16);
group 2, infarct with patent foramen ovale an unlikely cause (n = 23); and
group 3, no infarct (n = 35). Transesophageal echocardiograms were reviewed
to assess patent foramen ovale characteristics and associated
cardio-embolic sources without knowledge of clinical details or group
assignment. Follow-up after a patent foramen ovale-related infarct was
obtained by telephone or written correspondence in 15 of 16 group 1
patients. RESULTS: Atrial septal aneurysms were more common in group 1
(38%) compared with group 2 (10%) and group 3 (8%) (P = .02). Contrast
right-to-left shunting occurred in 88% of group 1 (P = .06) and 86% of
group 2 (P = .07) compared with 60% of group 3. Prevention of recurrence in
subjects with presumed patent foramen ovale-related brain infarcts varied.
Aspirin was usually chosen after initial brain ischemia. Warfarin and
patent foramen ovale closure were usually reserved for subjects with
symptoms of brain ischemia while taking aspirin or those who required
warfarin or cardiac surgery for other indications. No recurrent infarcts
occurred in 15 patients during a mean follow-up period of 28 months.
CONCLUSIONS: Atrial septal aneurysm and right-to-left shunt may be
predictive of a patent foramen ovale that predisposes a patient to stroke.
Aspirin may provide sufficient infarct prophylaxis after initial ischemia.
Warfarin and surgical correction should likely be reserved for those in
whom aspirin is not effective or those who require warfarin or cardiac
surgery for other reasons until prospective studies are available.
ARTICLES
Patent foramen ovale and brain infarct. Echocardiographic predictors, recurrence, and prevention
Department of Neurology, Cleveland Clinic Foundation, Ohio 44195.
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