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Forame ovale pervio e ictus criptogenetico: indicazioni alla chiusura

This article discusses the management of patent foramen ovale (PFO) in cryptogenic stroke, including the diagnosis, evaluation, and treatment options. It provides an overview of various techniques and their effectiveness, as well as the predictors of stroke recurrence. The article also emphasizes the need for multidisciplinary evaluation and highlights the recommendations for percutaneous closure of PFO in carefully selected patients.

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Forame ovale pervio e ictus criptogenetico: indicazioni alla chiusura

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  1. Forame ovale pervio e ictus criptogenetico: indicazioni alla chiusura Dott. Giovanni Benedetti FTGM-Ospedale del Cuore, Massa Scuola Superiore Sant’Anna, Pisa

  2. Whatshould I do? EuropeanHeart Journal (2018) 00, 1–14

  3. Whatshould I do?

  4. Patentforamen ovale (PFO) • PFO is the consequence of failed closure, after birth, of the foramen ovale • Prevalence in 15% - 35% of the worldwide adult population

  5. PFO management: teamwork and systematic evaluation The decisionmakingshould be donetakinginto account an estimationof the individual: Probability of a causalroleof the PFO in the clinicalpicture Risk of recurrence

  6. PFO diagnosis • Combineduse of differenttechniquesiswarranted! • The techniquewith highestsensitivityshould be usedas a firstlineinvestigation Contrast-TEE Contrast-TCD Contrast-TTE EuropeanHeart Journal (2018) 00, 1–14

  7. C-TCD and C-TTE Meta-analysis of 29 studies, 2751 patients: c-TCD with c-TEE c-TCD had a sensitivity of 94% and a specificityof 92% EuropeanHeart Journal (2018) 00, 1–14

  8. Role of TEE in PFO evaluation • PFO morphology • Spatialrelationship of PFO and othercardiacstructures • Evaluation of atrialseptum • Eustachian valve/Chiari Network

  9. Diagnosisof PFO EuropeanHeart Journal (2018) 00, 1–14

  10. High probabilityof causal link betweencriptogeniticstroke and PFO Atrialseptalaneurysm Atrialseptalhypermobility Moderate/severe shunt SimultaneousPE or DVT

  11. Predictors of recurrence of cryptogeneticstrokein presence PFO EuropeanHeart Journal (2018) 00, 1–14: supplementaryappendix 4

  12. Stroke, RoPEscoreand PFO • High RoPe score • Youngerage • Corticallesion on imaging • No CV riskfactors Neurology. 2013 Aug 13; 81(7): 619–625

  13. Treatment algorithm EuropeanHeart Journal (2018) 00, 1–14

  14. Medicaltherapy:no RCTs! • Many medicaments has been used in secondary prevention for ischemic and criptogenitic stroke • In recentmeta-analysisof the RCTs, the incidence of recurrentstrokeon medicaltherapywas4.6% after 3.8 years of follow-up • A meta-analysis of observational trials showed the recurrence rate was5% per year JACC CardiovascInterv. 2012;5:777–89.

  15. OAC vs antiplateletfor cryptogenic solid systemic embolism

  16. Bleedingriskof OAC vs antiplatelettherapy in criptogeneticstroke

  17. 7213patientsin 31 countries From 2014 to 5 October 2017

  18. 36 patients • Double umbrellaimplantationwithoutcomplications • Norecurrence of eventsat 8,4 months FU CirculationVol 86, No 6 December1992

  19. 909 Pts with 18-60 years • 2 years of FU Randomization 1:1 STARFlex (NMT medical) Incidence of primaryendpoint 5,5% closuregroup vs 6,8% MT group (P=0,37) Percutaneousclosure of PFOdidnotoffer a greater benefit thanmedicaltherapy alone for the preventionof recurrentstroke or TIA N Engl J Med 2012;366:991-9.

  20. 414 Pts with < 60 years • 5years of FU Randomization 1:1 Amplatzer PFO occluder Incidence of primaryendpoint 3,4% closuregroup vs 5,4% MT group (P=0,34) Percutaneousclosure of PFO didnotresultin a significantreduction in the risk of recurrentemboliceventsor deathascompared with medicaltherapy N Engl J Med 2013;368:1083-91

  21. 980 pts: 499 closuregroup 944 pts: 471 closuregroup In the primaryintention-to-treatanalysis, therewasno significant benefit associated with closure of a patentforamen Percutaneousclosurewassuperior to medicaltherapyalone in the prespecified per-protocol and as-treatedanalyses N Engl J Med 2013;368:1092-100.

  22. 663 Pts with 16-60 years with atrialseptum/large shunt • Mean 5,3 years of FU Randomization 1:1:1 Amplatzer PFO:APT:AC Primaryendpoint 0% closuregroup vs 5,9% APT group (P=0,037) The rate of strokerecurrencewasloweramongthoseassigned to PFO closurecombined with antiplatelettherapythanamongthoseassignedto antiplatelettherapy alone. N Engl J Med 2017;377:1011-21.

  23. 664 Pts with moderate-large shunt • Mean 3,2 years of FU Randomization 2:1 HelexSeptalOccluder (GORE) Incidence of primaryendpoint 1,4% closuregroup vs 5,4% MT group (P=0,002) The risk of subsequentischemicstrokewasloweramongthoseassigned to PFO closurecombined with antiplatelettherapythanamongthoseassigned to antiplatelettherapyalone N Engl J Med 2017;377:1033-42.

  24. 120 Pts with high risk PFO • 2 years of FU Randomization1:1 Amplatzer PFO occluder Incidence of primaryendpoint 0% closuregroup vs 12,9 % MT group (P=0,013) PFO closure in patients with high-risk PFO characteristicsresulted in a lower rate of the primaryendpointaswellasstrokerecurrence JACC; 71; Issue 20, 2018; 2335-2342

  25. Complications of PFO closure

  26. Management afterpercutaneousclosure of PFO • DAPT for 1-6 monthsafter procedure • Single antiplatelet for atleast5 years EuropeanHeart Journal (2018) 00, 1–14

  27. Conclusion • Management of patients with cryptogenicstroke and PFO in manycasesiscontroversialand need of multidisciplinarevaluation • ESC raccomandationsis“to performpercutaneousclosure of a PFO in carefullyselectedpatientsaged from 18 to 65 years with a confirmedcryptogenicstroke/TIA and an high probability of a causalroleof the PFO asassessed by clinical, anatomical and imagingfeatures”

  28. Giovanni Benedetti, M.D giovannibenedetti@me.com

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