Residual Shunt After Patent Foramen Ovale Closure and Long-Term Stroke Recurrence
Authors: Wenjun Deng, Shanye Yin, David McMullin, Ignacio Inglessis-Azuaje, Sammy Elmariah, Judy Hung, Eng H. Lo, Igor F. Palacios, Ferdinando S. Buonanno, MingMing Ning
Journal: Annals of Internal Medicine (2020)

Letters1 December 2020Residual Shunt After Patent Foramen Ovale Closure and Long-Term Stroke RecurrenceWenjun Deng, PhD, Shanye Yin, PhD, David McMullin, PhD, Ignacio Inglessis-Azuaje, MD, Sammy Elmariah, MD, MPH, Judy Hung, MD, Eng H. Lo, PhD, Igor F. Palacios, MD, Ferdinando S. Buonanno, MD, and MingMing Ning, MD, MMScWenjun Deng, PhDMassachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (W.D., S.Y., D.M., I.I., S.E., J.H., E.H.L., I.F.P., F.S.B., M.N.), Shanye Yin, PhDMassachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (W.D., S.Y., D.M., I.I., S.E., J.H., E.H.L., I.F.P., F.S.B., M.N.), David McMullin, PhDMassachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (W.D., S.Y., D.M., I.I., S.E., J.H., E.H.L., I.F.P., F.S.B., M.N.), Ignacio Inglessis-Azuaje, MDMassachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (W.D., S.Y., D.M., I.I., S.E., J.H., E.H.L., I.F.P., F.S.B., M.N.), Sammy Elmariah, MD, MPHMassachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (W.D., S.Y., D.M., I.I., S.E., J.H., E.H.L., I.F.P., F.S.B., M.N.), Judy Hung, MDMassachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (W.D., S.Y., D.M., I.I., S.E., J.H., E.H.L., I.F.P., F.S.B., M.N.), Eng H. Lo, PhDMassachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (W.D., S.Y., D.M., I.I., S.E., J.H., E.H.L., I.F.P., F.S.B., M.N.), Igor F. Palacios, MDMassachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (W.D., S.Y., D.M., I.I., S.E., J.H., E.H.L., I.F.P., F.S.B., M.N.), Ferdinando S. Buonanno, MDMassachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (W.D., S.Y., D.M., I.I., S.E., J.H., E.H.L., I.F.P., F.S.B., M.N.), and MingMing Ning, MD, MMScMassachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (W.D., S.Y., D.M., I.I., S.E., J.H., E.H.L., I.F.P., F.S.B., M.N.)Author, Article, and Disclosure Informationhttps://doi.org/10.7326/L20-1274 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail IN RESPONSE:We appreciate readers' interest in and insight on our recent report of the association between residual shunt after PFO closure and stroke recurrence. We agree with Dr. Kumar and colleagues' comment about the challenge of TIA diagnosis and the difficulty of precise PFO RLS quantification with current methods, especially in light of the connection between PFO and migraine (1). Transient ischemic attack has no footprint on diffusion-weighted magnetic resonance imaging; however, embolic TIA and migraine can be differentiated clinically in conjunction with collateral history, advanced perfusion imaging, and clinical expertise. We used a rigorous protocol of 2 vascular-trained ...References1. Tobis JM, Charles A, Silberstein SD, et al. Percutaneous closure of patent foramen ovale in patients with migraine: the PREMIUM trial. J Am Coll Cardiol. 2017;70:2766-74. [PMID: 29191325] doi:10.1016/j.jacc.2017.09.1105 CrossrefMedlineGoogle Scholar2. Silvestry FE, Cohen MS, Armsby LB, et al. Guidelines for the echocardiographic assessment of atrial septal defect and patent foramen ovale: from the American Society of Echocardiography and Society for Cardiac Angiography and Interventions. J Am Soc Echocardiogr. 2015;28:910-58. [PMID: 26239900] CrossrefMedlineGoogle Scholar3. Deng W, Beecher C, Burant C, et al. Metabolomic analysis of PFO-related stroke shows immediate and persistent decrease of homocysteine post PFO closure. Neurology. 2015;84 14 Suppl P2. Google Scholar4. Elmariah S, Furlan AJ, Reisman M, et al; CLOSURE I Investigators. Predictors of recurrent events in patients with cryptogenic stroke and patent foramen ovale within the CLOSURE I (Evaluation of the STARFlex septal closure system in patients with a stroke and/or transient ischemic attack due to presumed paradoxical embolism through a patent foramen ovale) trial. JACC Cardiovasc Interv. 2014;7:913-20. [PMID: 25147037] doi:10.1016/j.jcin.2014.01.170 CrossrefMedlineGoogle Scholar5. Liu K, Song B, Palacios IF, et al. Patent foramen ovale attributable cryptogenic embolism with thrombophilia has higher risk of recurrence and responds to closure. JACC Cardiovasc Interv. 2020. [Forthcoming]. CrossrefGoogle Scholar6. Martín F, Sánchez PL, Doherty E, et al. Percutaneous transcatheter closure of patent foramen ovale in patients with paradoxical embolism. Circulation. 2002;106:1121-6. [PMID: 12196339] CrossrefMedlineGoogle Scholar Author, Article, and Disclosure InformationAffiliations: Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (W.D., S.Y., D.M., I.I., S.E., J.H., E.H.L., I.F.P., F.S.B., M.N.)Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M19-3583. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoResidual Shunt After Patent Foramen Ovale Closure and Long-Term Stroke Recurrence Preetham Kumar , Mohammad K. Mojadidi , and Jonathan M. Tobis Residual Shunt After Patent Foramen Ovale Closure and Long-Term Stroke Recurrence Alexia Karagianni , Peter Eriksson , and Mikael Dellborg Residual Shunt After Patent Foramen Ovale Closure and Long-Term Stroke Recurrence Gaurav Aggarwal , Saurabh Aggarwal , and Marc Cohen Metrics Cited byCorrelation between percutaneous patent foramen ovale closure and recurrence of unexplained syncope2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association 1 December 2020Volume 173, Issue 11Page: 946-947KeywordsAtheromasConflicts of interestDiabetes mellitusDisclosureHazard ratioMagnetic resonance imagingMedical risk factorsMigraineStrokeTransient ischemic attacks ePublished: 1 December 2020 Issue Published: 1 December 2020 Copyright & PermissionsCopyright © 2020 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...