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Abstract Background Metastasis of malignant tumors to the cardiac endocardium is rare and mainly involves the right side of the heart. It is extremely rare to involve the left cardiac endocardium, especially when there is neither pulmonary metastasis nor primary lung cancer, which we call “isolated” left cardiac endocardium metastasis in this paper. Few such cases previously reported in the literature were not screened for patent foramen ovale (PFO). Case presentation This article reports a case of a young woman with a history of surgery for cervical cancer, who was transferred to our hospital with a suspected diagnosis of PFO after recent recurrent multiple cerebral infarctions. On admission, transthoracic echocardiography revealed multiple stringy vegetations in the left ventricle, which were subsequently removed surgically, with intraoperative confirmation of a patent foramen ovale and closure of it simultaneously. According to her medical history and pathological results, she was diagnosed with left ventricular metastasis of cervical cancer, a rare case of isolated left heart endocardium metastasis without previous pulmonary metastasis, presumably through the patent foramen ovale. Conclusion PFO may play an important role in the process of isolated left heart endocardium metastasis in patients with distant malignancies and paradoxical embolism. Screening for PFO in high-risk patients may have significant clinical significance.

Objective: This study aims to evaluate the application value of contrast‐enhanced transthoracic echocardiography (cTEE) in the diagnosis of patent foramen ovale (PFO) under different states of stimulation, with the goal of enhancing the accuracy and efficiency of PFO diagnosis. Methods: This research consecutively enrolled patients suspected of having PFO from October 2022 to February 2024, presenting primary clinical symptoms such as unexplained syncope, headache, dizziness, and stroke. Patients underwent standard transthoracic echocardiography (TTE) and cTEE under three different states of stimulation (resting state, coughing, and Valsalva maneuver). Based on the presence of microbubbles in the left heart and their initial appearance time, patients were classified into PFO and control groups, with further diagnostic confirmation via transesophageal echocardiography (TEE) or foramen ovale closure procedures. Results: The study results revealed significant differences between the PFO and control groups regarding age (p = 0.034) and headache symptoms (p = 0.001). In the PFO group, TTE showed a higher positivity rate both at rest and during coughing, highlighting the association between PFO and specific clinical symptoms. The number of microbubbles observed during TTE increased significantly under various stimulation states, particularly during the Valsalva maneuver (p < 0.05). This increase became more pronounced as the duration of the maneuver was extended, underscoring the differential response of PFO patients under varied physiological testing conditions, especially during prolonged Valsalva maneuvers. Conclusion: The study confirms the significant value of cTEE in diagnosing PFO under different stimulation states, particularly emphasizing the application of the Valsalva maneuver to significantly improve the sensitivity and specificity of PFO detection. Thus, incorporating cTEE examinations under various stimulation states holds significant clinical importance for enhancing the accuracy and efficiency of PFO diagnosis. [ABSTRACT FROM AUTHOR]

Objective To investigate the clinical characteristics of female migraine patients with patent foramen ovale (PFO) and design a risk prediction model for PFO in female migraine patients (migraineur patients PFO risk prediction model, MPRPM). Methods Female migraine patients who visited Zhongshan Hospital, Fudan University from Jun 1, 2019 to Dec 31, 2022 were included. Preoperative information and follow-up results after discontinuation of medication were collected. Patients were divided into PFO-positive and PFO-negative groups based on transesophageal echocardiography results. A multivariate Logistic regression model and a random forest model were constructed, and the random forest model was validated multidimensionally. Key features were selected based on the mean decrease accuracy (MDA) to construct MPRPM. Results A total of 305 female patients were included in the study, with 204 patients in the PFO-positive group and 101 patients in the PFO-negative group. Multivariate Logistic regression analysis showed that age at migraine onset, attack frequency, severe impact on life during attacks, exercise-related headaches, menstruation-induced headaches, aura migraines, and a history of cryptogenic stroke were predictive factors for PFO positivity. The random forest model effectively predicted the incidence of PFO in female migraine patients, with an AUC of 0.895 (95%CI: 0.847-0.943). MPRPM demonstrated a sensitivity of 71.6% and specificity of 91.1% (AUC: 0.862, 95%CI: 0.818-0.906, P<0.001). The optimal cut-off value was 2.5 points. Patients correctly classified by the model showed a higher rate of symptom improvement compared to incorrectly classified patients (94.3% vs. 82.0%, P=0.023). Conclusion We identified predictive factors for PFO in migraine patients. MPRPM can provide guidance in the diagnostic process and therapeutic decision-making for female migraine patients, assist in patient triage, and reduce the healthcare burden. [ABSTRACT FROM AUTHOR]

BackgroundIntra-atrial shunts are associated with an elevated risk of embolic stroke of undetermined source (ESUS). Percutaneous occluder implantation is recommended as secondary prevention in younger patients. This study aims to compare the outcome after shunt occlusion between younger and older patients with a history of presumed paradox embolism and to evaluate the impact of high-volume shunting in an elderly population.MethodsWe conducted a single-center, retrospective, observational study, involving 187 patients who underwent interventional percutaneous PFO or ASD occlusion at our center between 2013 and 2023.ResultsThe mean age of participants was 51.8 ± 11.8 years, with 76 patients aged ≤50 years and 111 patients aged >50 years. Older patients presented more cardiovascular risk factors. The presence of atrial septum aneurysm or large shunting was evenly distributed (ASA 26.3% vs. 28.8%, p = 0.833, mean shunt defect size 6.67 vs. 7.23 mm, p = 0.151). There were no significant differences in procedural or intrahospital complications. The event rate during the 6-month follow-up was low. Recurrence of arterial embolism occurred in 1.6% of the younger and 3.8% of the older patients (p = 0.817). Comparison of high-volume shunts (defect size ≥10 mm or passage ≥20 bubbles during bubble study) with low-volume shunts in this elderly cohort with a mean age ≥50 years showed no significant difference in outcomes. There was a statistically non-significant trend toward a higher rate of residual shunt at the end of the procedure in the high-volume shunt group (2.9% vs. 9.8%, p = 0.0894). This difference was not observed at the 6-month follow-up anymore (14.5 vs. 12.1%, p = 0.628). Two unsuccessful implantation attempts were reported in the high-volume shunt group, while none were observed in the low-volume shunt group (p = 0.372). No intervention-related deaths occurred in this patient cohort during follow-up.ConclusionOcclusion of relevant, intra-atrial shunting is a safe and effective option for secondary prevention of cryptogenic embolism in patients over 50 years of age. The beneficial outcome was irrespective of a high-volume shunting before implantation.

Background: While cerebral infarction in children is rare, its prognosis is poor, and this condition can seriously burden society and families. A correlation between patent foramen ovale (PFO) and ischemic stroke has not been found in pediatric patients. Case presentation: We report a 7-year-old boy who suffered from multiple cerebral infarctions. Subsequently, the patient was diagnosed with an abnormal shunt of PFO. He underwent PFO closure and was followed up for 1 year. The patient did not experience any further cerebral infarction. Conclusions: With this case report, we want to illustrate that although the incidence rate of ischemic cerebral infarction in adolescents is very low, we should not neglect the role of PFO. Therefore, after exclusion other causes of cerebral infarction, PFO should be considered in adolescent and adult stroke patients with adult closure criteria in the same way. [ABSTRACT FROM AUTHOR]

Inner ear decompression sickness (IEDCS) is an uncommon diving-related injury affecting the vestibulocochlear system, with symptoms typically including vertigo, tinnitus, and hearing loss, either in isolation or combination. Classically associated with deep, mixed-gas diving, more recent case series have shown that IEDCS is indeed possible after seemingly innocuous recreational dives, and there has been one previous report of IEDCS following routine hyperbaric chamber operations. The presence of right-to-left shunt (RLS), dehydration, and increases in intrathoracic pressure have been identified as risk factors for IEDCS, and previous studies have shown a predominance of vestibular rather than cochlear symptoms, with a preference for lateralization to the right side. Most importantly, rapid identification and initiation of recompression treatment are critical to preventing long-term or permanent inner ear deficits. This case of a U.S. Navy (USN) diver with previously unidentified RLS reemphasizes the potential for IEDCS following uncomplicated diving and recompression chamber operations -- only the second reported instance of the latter. [ABSTRACT FROM AUTHOR]

Background: This single‐center observational study aimed to compare the echocardiographic and clinical features in patients diagnosed with migraine and embolic stroke of undetermined source (ESUS) who presented with a known patent foramen ovale (PFO). Methods: Two‐dimensional and color Doppler images were obtained using various transthoracic echocardiography views for both migraine and ESUS patients. Suspected PFO cases underwent further assessment through contrast echocardiography and transesophageal echocardiography (TEE). High‐risk PFO characteristics were evaluated using TEE, and the Risk of Paradoxical Embolism (RoPe) score was calculated. Results: The study included 310 participants (age range: 18–60, 73.2% female), with 43.5% diagnosed with migraine and 56.5% with ESUS. Common comorbidities included diabetes (26.1%). High‐velocity shunting through the interatrial septum was observed in 35.5% of patients. ESUS patients were older, with higher rates of diabetes and hypertension, while active smoking was more prevalent among migraine patients. Basic echocardiographic parameters were mostly similar, except for elevated pulmonary artery systolic pressure in ESUS. ESUS patients exhibited a greater occurrence of large microbubble passage through the interatrial septum and longer PFO lengths compared to migraine patients. However, the RoPe and High‐risk PFO scores were similar between the groups. Conclusions: ESUS patients, characterized by older age and higher rates of diabetes and hypertension, demonstrated increased pulmonary artery pressure, more significant microbubble crossings, and longer PFO lengths. Conversely, migraine patients had a higher prevalence of active smoking. Despite differing clinical profiles, the risk scores for PFO‐related embolic events were comparable between the groups. These findings underscore potential distinctions between ESUS and migraine patients with PFO and their implications for management strategies. [ABSTRACT FROM AUTHOR]

PurposeTo evaluate a noval bilateral asymmetric single-rivet occluder with reserved interatrial septal puncture area for treating patent foramen ovale (PFO).Materials and methodsThe study established a pig model of patent foramen ovale (PFO) by puncturing the oval fossa and then performing high-pressure balloon dilation. A specially designed bilateral asymmetric occluder for the reserved interatrial septal puncture area was then. used to close the PFO through catheter-based intervention. The pigs were kept for 3 months before undergoing a second catheter-based intervention, involving interatrial septal puncture using a newly developed occluder in the reserved interatrial septal puncture area. During 6 months, the experimental pigs underwent assessment using digital subtraction angiography (DSA), echocardiography, and histological evaluation.ResultsA patent foramen ovale (PFO) model was successfully established in 6 pigs using the puncture atrial septum high-pressure balloon dilation method. The diameter of the unclosed PFO was measured (3.56 ± 0.25 mm). Using the newly developed occluder device, all 6 pigs with unclosed PFO underwent successful catheter-based closure surgeries, with intraoperative and postoperative transesophageal echocardiography showing excellent device positioning and complete closure without residual shunting. After 3 months of implantation, the catheter-based interatrial septal puncture was performed through the reserved interatrial septal puncture area, and all procedures were successful. Immediately following euthanasia, a histological examination revealed intact and undamaged occluder devices with visible puncture holes in the reserved interatrial septal puncture area. No fracture of the nitinol wire was observed, and the surface of the occluder device showed coverage of endothelial and connective tissues. Utilizing a bilateral asymmetric single-rivet occluder device implanted through the reserved interatrial septal puncture area has proven effective in closing PFO. After implantation, the occluder device allows subsequent interatrial septal puncture procedures through the reserved area.ConclusionThe novel occluder device demonstrated excellent closure performance, biocompatibility, and puncturability in the experiment. This indicates the feasibility of conducting further catheter-based interventions on the interatrial septum.

Transesophageal echocardiography (TEE) with agitated saline contrast ("bubble study") is the gold standard for detection of patent foramen ovale (PFO). Standard provocative maneuvers help facilitate right‐to‐left shunting necessary for diagnosing PFO but may be difficult to implement during TEE. Hypovolemia related to preprocedural fasting may challenge detection of PFO in TEE, and additional optimization measures such as fluid replenishment with passive leg raise (PLR) can enhance PFO detection. We present a 57‐year‐old male with history of cryptogenic stroke and stubborn PFO which during TEE bubble study responded only to ample fluid replenishment with PLR following a period of prolonged preprocedural fasting. [ABSTRACT FROM AUTHOR]

Background: Platypnea-orthodeoxia syndrome (POS) is a relatively uncommon clinical syndrome characterized by dyspnea and deoxygenation accompanying postural changes, such as sitting or standing from a recumbent position. Case presentation: We describe the case of a 76-year-old woman who was hospitalized with dyspnea in the sitting position, which was relieved in the right lateral decubitus position. The patient was diagnosed with POS caused by a patent foramen ovale (PFO), dilation and elongation of the ascending aorta, and pectus excavatum. We performed PFO closure and replacement of the ascending aorta via median sternotomy. The patient's postoperative percutaneous oxygen saturation dramatically increased in the sitting position. Conclusions: Elongated and dilated ascending aorta and pectus excavatum with PFO may be risk factors for POS. In older patients, surgical intervention is an important treatment option for POS caused by cardiac and aortic comorbidities. [ABSTRACT FROM AUTHOR]

Background: Congenital heart defects, such as atrial septal defects (ASDs) and patent foramen ovale (PFO), may increase the risk of embolic events in total hip or knee arthroplasty (THA/TKA). The objective of this study was to determine the 90-day incidence of intraoperative and postoperative embolic events and all other complications in patients with a known ASD/PFO who underwent primary hip and knee arthroplasty. Methods: This is a retrospective review of 160 patients with ASD/PFO undergoing 196 primary arthroplasties (94 THAs, 102 TKAs) at a single institution. The mean age was 64 years (standard deviation [SD] 11.1), 40.6% were male, and average body mass index was 31 kg/m2 (SD 7.2). The mean follow-up period was 19 months (SD 16). Forty-three percent of patients were on anticoagulation preoperatively. All patients received postoperative thromboprophylaxis (48% aspirin, 31% direct oral anticoagulants, 18% warfarin, 3% enoxaparin). Results: There were no embolic events identified. Fourteen patients (7%) developed complications within 90 days. Three had bleeding complications, and 8 had other nonoperative complications, which were all managed conservatively and had uneventful recoveries. Additionally, 3 patients had complications requiring reoperations: 2 for periprosthetic fractures (1 THA, 1 TKA) and 1 for a periprosthetic infection (TKA). Conclusions: In this cohort of patients with a known ASD/PFO undergoing THAs and TKAs, there were no cases of embolic events. However, it would be advisable to have a thorough cardiology evaluation to assess potential risks and benefits of defect repair prior to total joint arthroplasty and to reduce the risk of paradoxical embolic events and the necessity of potent anticoagulation. Level of evidence: Prognostic Level IV.

Patent foramen ovale (PFO) is a common cardiac abnormality with a prevalence of 25% in the general population. PFO has been associated with the paradoxical embolism causing cryptogenic stroke and systemic embolization. Results from clinical trials, meta-analyses, and position papers support percutaneous PFO device closure (PPFOC), especially if interatrial septal aneurysms coexist and in the presence of large shunts in young patients. Remarkably, accurately evaluating patients to refer to the closure strategy is extremely important. However, the selection of patients for PFO closure is still not so clear. The aim of this review is to update and clarify which patients should be considered for closure treatment. [ABSTRACT FROM AUTHOR]

Objective To investigate the application value of intracardiac echocardiography (ICE) in transcatheter closure of latent patent foramen ovale (PFO). Methods This was a retrospective study of patients admitted to Zhongshan Hospital,Fudan University from Jun to Sep 2021 who showed atrium level shunt after valsalva maneuver by right heart contrast echocardiography and received transcatheter closure. They were divided into transthoracic echocardiography (TTE) group and ICE group according to using ICE or not. The general condition, ultrasound results, comorbidity, complications, operative and fluoroscopy time of two group were recored. Pearson correlation was used to analyze the correlation between diameter of foramen ovale measured by ICE during the operative and transesophageal echocardiography (TEE) before. Results Among 56 patients, there were 37 patients in TTE group and 19 patients in ICE group. Correlation analysis showed that the diameter of foramen ovale measured by ICE was positively associated with TEE (R=0.81,P<0.01). ICE could guide wire to pass through the foramen ovale during operation, which reduced the operation time and radiation exposure time. Conclusion ICE had significant value in transcatheter closure of latent PFO. It has not only a higher successful rate and safety, but also reduce the operation time and radiation exposure time compared to TTE. [ABSTRACT FROM AUTHOR]

Qian Cao,1,&ast; Yu Shen,1,2,&ast; Zhuo Hou,1 Defu Li,3 Boji Tang,1 Lijun Xu,1 Yanping Li4 1Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People’s Republic of China; 2Department of Neurology, The First Affiliated Hospital of Nanchang University, Nanchang, People’s Republic of China; 3Jiangxi Provincial Key Laboratory of Preventive Medicine, Nanchang University School of Public Health, Nanchang, Jiangxi, People’s Republic of China; 4Department of Neuroelectrophysiology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People’s Republic of China&ast;These authors contributed equally to this workCorrespondence: Lijun Xu, Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People’s Republic of China, Email xulijun20050901@sina.com Yanping Li, Department of Neuroelectrophysiology, The Second Affiliated Hospital of Nanchang University, No. 1, Minde Road, Nanchang, Jiangxi, People’s Republic of China, Email 359173628@qq.comIntroduction: Patent foramen ovale (PFO) is potentially associated with abnormal embolisms, and it results in mixing of arteriovenous blood when its right-to-left shunt (RLS) emerges. Present studies have found that PFO is a risk factor that can lead to many diseases. However, few studies have examined the relationship between PFO and dizziness.Methods: This study was a large single-center, prospective, controlled study. From March 2019 to March 2021, we recruited patients with dizziness were divided into two groups: “explained” and “unexplained”. All patients were submitted to contrast-enhanced transcranial Doppler ultrasound and screened for PFO. Transesophageal heart ultrasound or right heart catheterization was used to confirm PFO. Additionally, multiple factors were collected and statistical analysis was performed between the two groups.Results: Among the 244 patients included, 123 were in the “explained” group and 121 were in the “unexplained” group. The prevalence of PFO in the “explained” group was 34 (27.4%) compared to 79 (64.7%) in the “unexplained” group. In the “explained” group, 7 were RLS level IV, 6 were level III, 7 were level II, and 14 were level I. For the “unexplained” group, the numbers of patients with levels IV, III, II and I were 27, 26, 12 and 14, respectively. Univariate analysis revealed that PFO (χ2= 34.77, P < 0.001) and age (t = − 3.49, P < 0.001) seemed to be potential risk factor candidates for “unexplained” dizziness. In multiple regression analysis, age (OR = 0.97; 95% CI 0.95– 0.99) and the prevalence of PFO (OR = 4.37; 95% CI 2.50– 7.63) were statistically significant. Massively shunted PFO showed more pronounced risk factors (OR = 8.76; 95% CI 4.04– 19.03).Conclusion: There was a high prevalence of PFO and a greater RLS level in unexplained dizziness. PFO and age were independent risk factors for unexplained dizziness. When treating with unexplained dizziness, especially among young people, we must pay attention to the presence of PFO.Keywords: patent foramen ovale, PFO, right to left shunt, RLS, unexplained dizziness, contrast-enhanced transcranial Doppler ultrasound, cTCD

Background: About 30% of ischemic strokes do not have a clear cause, which is called cryptogenic stroke (CS). Increasing evidence suggests a potential link between CS and right-to-left shunt (RLS). RLS may lead to CS via paradoxical embolic mechanism. Hence, current study aims to explore the correlation between different RLS indexes and the occurrence of CS and its clinical diagnostic value in CS., Methods: A total of 117 patients diagnosed with CS from October 2020 to June 2024 were randomly collected, and 93 patients with only headache and dizziness were randomly collected as the control group. All patients underwent agitated saline contrast echocardiography (ASCE) and the semi-quantitative classification, type and duration of RLS were analyzed. Spearman correlation analysis was used to analyze the correlation between RLS grade and type and the occurrence of CS, and the correlation between RLS duration and RLS grade and type. The efficacy of different RLS grades, types and durations in the diagnosis of CS were analyzed by receiver operating characteristic (ROC) curve., Results: The included population ranged in age from 20-73 years, with 90 males and 120 females. There was no significant difference in basic data (e.g., gender, smoking history, drinking history, and the number of people with hypertension and diabetes) and serum biological indicators [triglyceride (TG), total cholesterol (TC), high-density lipoprotein (HDL) and low-density lipoprotein (LDL)] between the CS group and the control group (all P>0.05). The proportion of RLS (77.78%) in the CS group was significantly higher than that in the control group (35.48%) (P<0.001). Spearman correlation analysis showed that RLS grade (r=0.569) and type (r=0.346) were significantly correlated with the occurrence of CS (both P<0.001). In addition, RLS duration was significantly correlated with RLS type (r=0.902, P<0.001), but not with RLS size (P>0.05). ROC curve analysis showed that RLS grade had the highest area under the curve (AUC) in CS diagnosis, which was 0.807 [95% confidence interval (CI): 0.748-0.866], the diagnostic sensitivity was 68.4%, and the specificity was 87.1%. In addition, the diagnostic AUC of RLS type and RLS duration in CS were similar, at 0.700 (95% CI: 0.626-0.773) and 0.707 (95% CI: 0.634-0.780), respectively., Conclusions: RLS grade and RLS type are significantly correlated with the occurrence of CS. As an auxiliary means of CS diagnosis, RLS grade can effectively reduce the misdiagnosis rate of CS, which is of great clinical significance for early detection of CS risk., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://cdt.amegroups.com/article/view/10.21037/cdt-24-288/coif). The authors have no conflicts of interest to declare., (2024 AME Publishing Company. All rights reserved.)

Platypnea-orthodeoxia syndrome (POS) is a rare clinical condition characterized by dyspnea and hypoxemia during orthostatism, with relief in the supine position. The diagnosis of POS requires a high clinical suspicion, and its etiology stems from the admixture of venous blood, poor in oxygen, with arterial blood via a shunt. A patent foramen ovale (PFO) is the most commonly encountered anomaly at the root of POS.  Here, we present the case of a 67-year-old female patient where suspected POS led to the diagnosis of a PFO, which was the cause of an ischemic stroke., Competing Interests: Human subjects: Consent for treatment and open access publication was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Oliveira et al.)

A thrombus straddling a patent foramen ovale (TSPFO) is a rare condition that presents significant health risks, including stroke or myocardial infarction, and can be life-threatening if not promptly addressed. We report the case of a 42-year-old female with morbid obesity who presented with sudden shortness of breath due to a bilateral pulmonary embolism. Imaging revealed a thrombus extending from the right atrium to the left atrium through the patent foramen ovale (PFO). Further evaluation showed a new diagnosis of dilated cardiomyopathy, resulting in biventricular heart failure, confirmed by cardiac MRI. Given her relatively stable hemodynamics during her hospital stay, the patient was successfully treated with anticoagulation, leading to complete resolution of the clot, thus avoiding the need for thrombolysis or surgical intervention. In managing TSPFO, treatment decisions should be based on factors such as hemodynamic stability, coexisting conditions, the acute nature of the diagnosis, and the risk of embolism. While some literature reviews and case studies suggest that surgery may lower the risk of complications compared to thrombolysis or conservative medical management, the lack of level I and II evidence highlights the need for an individualized, evidence-informed approach to effective risk management., Competing Interests: Human subjects: Consent for treatment and open access publication was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Nama et al.)

Embolic strokes of undetermined source (ESUS) form a quarter of all ischemic strokes, with the majority of them being thromboembolic. Carotid free-floating thrombus (CFFT) is a rare cause of ischemic stroke. There are no current guidelines outlining the management of CFFT. Patent foramen ovale (PFO) is a common cardiac abnormality that is generally not considered to be an independent risk factor for stroke. But, in certain stroke cases involving younger patients (<55 years old), PFO may be a source of paradoxical embolism. However, ipsilateral atherosclerosis in carotids has a low prevalence in patients with clinically significant PFO. We present an unusual case of stroke with two possible etiologies, CFFT, and a large PFO, begging the question, which lesion was the culprit?, Competing Interests: Human subjects: Consent for treatment and open access publication was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Jog et al.)

BackgroundThe Cocoon patent foramen ovale (PFO) Occluder is a new generation nitinol alloy double-disk device coated with nanoplatinum, likely useful in patients with nickel hypersensitivity. Early results and mid-term outcomes of this device in percutaneous PFO closure are missing.AimsTo assess the preliminary efficacy and safety profile of PFO closure with Cocoon device in an Italian multi-center registry.MethodsThis is a prospective registry of 189 consecutive adult patients treated with the Cocoon PFO Occluder at 15 Italian centers from May 2017 till May 2020. Patients were followed up for 2 years.ResultsClosure of the PFO with Cocoon Occluder was carried out successfully in all patients, with complete closure without residual shunt in 94.7% of the patients and minimal shunt in 5.3%. Except from a case of paroxysmal supraventricular tachycardia and a major vascular bleeding, no procedural and in-hospital device-related complications occurred. No patient developed cardiac erosions, allergic reactions to nickel, or any other major complications during the follow-up. During the follow-up period, 2 cases of new-onset atrial fibrillation occurred within thirty-day.ConclusionsPercutaneous closure of PFO with Cocoon Occluder provided satisfactory procedural and mid-term clinical follow-up results in a real-world registry.

BackgroundWe present a case of a patient with a femoral neck fracture that shows neurological impairment and respiratory distress 1 day after trauma, caused by the Fat Embolism Syndrome with the presence of Cerebral Fat Embolisms.Case summaryA 75 year old female remained unresponsive after a hemi arthroplasty was performed because of a 1 day old femoral neck fracture. She rapidly developed respiratory insufficiency and an obstructive shock with right ventricle dilatation on transthoracic echocardiography. The diffusion-weighted MRI brain images showed the “Starfield” pattern, a radiologic phenomenon typical for FES. During 3 weeks of ICU admission the neurologic state slowly ameliorated.ConclusionThe rare FES is a clinical diagnosis with mainly respiratory, neurologic and dermatologic symptoms in the setting of a trauma patient. Fat embolisms are able to reach the brain without the presence of a patent foramen ovale to cause neurological symptoms. Diagnosing FES remains challenging but the distinctive “Starfield” pattern on MRI scans is promising.

Patent foramen ovale closure (PFO) is an underutilized therapy, and our study explored the challenges and feasibility of PFO closure in the Indian setting.Eighty patients with Embolic Stroke of Undetermined Source (ESUS) were screened by transcranial Doppler (TCD) for PFO. Twenty-nine patients underwent successful closure.High-risk features of a long tunnel, inter-atrial septal aneurysm, and large defect were present in 31%, 28%, and 59%. Transcranial Doppler had a sensitivity and specificity of 78% and 53% (p = 0.02) to detect PFO. Anticoagulation was withdrawn in 85% of patients post closure. Two patients had residual shunts at follow-up of 19 (9,34) months.

Percutaneous patent foramen ovale (PFO) closure by traditional, double disc occluder devices was shown to be safe for patients with PFO, and more effective than prolonged medical therapy in preventing recurrent thromboembolic events. The novel suture-mediated "deviceless" PFO closure system overcomes most of the risks and limitations associated with the traditional PFO occluders, appearing to be feasible in most interatrial septum anatomies, even if data about its long-term effectiveness and safety are still lacking. The aim of the present review was to provide to the reader the state of the art about the traditional and newer techniques of PFO closure, focusing both on the procedural aspects and on the pivotal role of transesophageal echocardiography (TEE) in patient's selection, peri-procedural guidance, and post-interventional follow-up. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Platypnea-orthodeoxia syndrome (POS) is a rare syndrome characterized by dyspnea and arterial oxyhemoglobin desaturation induced by moving to the upright position and relieved by recumbency. Different pathogenic processes can lead to POS including cardiopulmonary and hepatopulmonary disorders. CASE PRESENTATION: We here present an unusual case of POS triggered by a previous severe SARSCoV-2 pneumonia in a 66-year-old man admitted to our Emergency Department with worsening dyspnea and chest pain. CONCLUSIONS: SARS-CoV-2 pneumonia should be considered an emerging cause of POS because of its pulmonary and cardiac/intravascular pathological implications.

Objective To explore the efficacy and safety of transcatheter closure for patent foramen ovale (PFO) in elderly patients (≥60 years) to prevent recurrence of cerebrovascular events. Methods During Jan 2013 and Dec 2017, 218 consecutive PFO patients having underwent transcatheter closure were retrospectively collected in Zhongshan Hospital, Fudan University. All patients were divided into two groups according to age：non-elderly group (<60 years, n=180) and elderly group (≥60 years, n=38) . The clinical data including preoperative comorbidities, cardiac function, echocardiographic and right heart catheterization variables, PFO closure complications, and follow-up of recurrence rate of cerebral ischemia events were collected and analyzed. All survivals were reported by primary disease features using KaplanMeier methods and hazard ratios were derived from multivariate Cox models. Results All operations were completed under local anesthesia and guided by transthoracic echocardiography. The proportion of high risk PFO in the elderly group was higher than that in the non-elderly group (36. 8% vs. 20. 0%, P= 0. 025) . There were no statistically significant difference in the success rate of device implatation and surgery-related complications between two groups (both P=1. 000) . The median follow-up time was 13 months. There were no statistically significant difference in the incidence of recurrence of transient ischemic attack (TIA) and bradyarrhythmia between groups (P=0. 772 and 0. 593), but the rate of recurrence of stroke and new-onset atrial fibrillation (AF) were higher in the elderly group (P=0. 029 and 0. 007) . Log rank test showed that the main clinical event-free survival of the elderly group was lower than that of the non-elderly group (P=0. 019) . The stroke/TIA event-free survival of the elderly group was still lower than that of the non-elderly group (P=0. 004) . After adjusting the baseline data, Cox multivariate regression analysis showed that the age is a risk factor for recurrence of neurological ischemic events after PFO closure independent from hypertension and preoperative AF (HR=1. 237, 95%CI：1. 037-1. 477, P=0. 018) . Conclusion Compared with non-elderly patients, transcatheter closure is equally safe in elderly patients with PFO, but in terms of preventing the recurrence of cerebrovascular events, the clinical benefit is not as good as that of non-elderly patients. It is necessary to rigorously select suitable elderly PFO patients for closure treatment. [ABSTRACT FROM AUTHOR]

Patent foramen ovale (PFO) exists in 20-25% of the adult population, and about 40% of adults who present with cryptogenic stroke (CS) have a PFO. The benefit of intervention has been debated with regard to stroke prevention given the high risk of postoperative atrial fibrillation (AF). In light of this, clinical decision-making is guided by PFO-Associated Stroke Causal Likelihood (PASCAL) classification and Risk of Paradoxical Embolism (RoPE) score analysis. Contemporary studies have shown superlative benefits of PFO with device closure and antiplatelet therapy. In our case study, we describe a 52-year-old female with no comorbid conditions who initially presented with expressive aphasia. Upon further diagnostic workup, she was found to have a PFO on transesophageal echocardiogram (TEE). Cardiac monitoring revealed no underlying arrhythmias. The patient subsequently underwent successful PFO repair with device-assisted closure and intracardiac monitor placement. She was discharged with dual antiplatelet therapy. On postoperative follow-up, no detected arrhythmias were revealed, and she made a meaningful recovery with near-total resolution of her symptoms. Our case raises the question of the extent of comprehensive evaluation to rule out underlying etiologies including AF prior to considering device-assisted closure and suggests the need for further studies., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Hospital Corporation of America (HCA) Healthcare Graduate Medical Education (GME) issued approval MS#3934. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Bommarito et al.)

Introduction: Divers with a patent Foramen Ovale (PFO) have an increased risk for decompression sickness (DCS) when diving with compressed breathing gas. The relative risk increase, however, is difficult to establish as the PFO status of divers is usually only determined after a DCS occurrence.Methods: This prospective, single-blinded, observational study was designed to collect DCS data from volunteer divers after screening for right-to-left shunt (RLS) using a Carotid Doppler test. Divers were blinded to the result of the test, but all received a standardized briefing on current scientific knowledge of diving physiology and “low-bubble” diving techniques; they were then allowed to dive without restrictions. After a mean interval of 8 years, a questionnaire was sent collecting data on their dives and cases of DCS (if any occurred).Results: Data was collected on 148 divers totaling 66,859 dives. There was no significant difference in diving data between divers with or without RLS. Divers with RLS had a 3.02 times higher incidence of (confirmed) DCS than divers without RLS (p = 0.04). When all cases of (confirmed or possible DCS) were considered, the Relative Risk was 1.42 (p = 0.46). DCS occurred mainly in divers who did not dive according to “low-bubble” diving techniques, in both groups.Conclusion: This prospective study confirms that DCS is more frequent in divers with RLS (such as a PFO), with a Relative Risk of 1.42 (all DCS) to 3.02 (confirmed DCS). It appears this risk is linked to diving behavior, more specifically diving to the limits of the adopted decompression procedures.

Hemiplegic migraine (HM) is a rare subtype of migraine characterized by aura of motor weakness accompanied by visual, sensory, and/or speech symptoms. Aura symptoms usually resolve completely; permanent attack-related deficit and radiographic change were rare. Here, we reported a case presented with progressively aggravated hemiplegic migraine episodes refractory to medication. He experienced two prolonged hemiplegic migraine attacks that led to irreversible visual impairment and cortical necrosis on brain MRI. Multimodal MRI during attack showed persistent vasodilation and hyperperfusion in the affected hemisphere associated with deterioration of clinical symptoms and worsening of brain edema. Patent foramen ovale (PFO) was found on the patient. PFO closure resulted in a significant reduction of HM attacks. This case indicated that prolonged hemiplegic migraine attack could result in irreversible neurological deficit with radiographic changes manifested as cortical necrosis. Persistent hyperperfusion might be an important factor contributing to prolonged attack and persistent attack-related neurological deficit. We recommend screening for PFO in patients with prolonged or intractable hemiplegic migraine, for that closure of PFO might alleviate the attacks thus preventing the patient from disabling sequelae.

Introduction: Divers with a patent Foramen Ovale (PFO) have an increased risk for decompression sickness (DCS) when diving with compressed breathing gas. The relative risk increase, however, is difficult to establish as the PFO status of divers is usually only determined after a DCS occurrence. Methods: This prospective, single-blinded, observational study was designed to collect DCS data from volunteer divers after screening for right-to-left shunt (RLS) using a Carotid Doppler test. Divers were blinded to the result of the test, but all received a standardized briefing on current scientific knowledge of diving physiology and "low-bubble" diving techniques; they were then allowed to dive without restrictions. After a mean interval of 8 years, a questionnaire was sent collecting data on their dives and cases of DCS (if any occurred). Results: Data was collected on 148 divers totaling 66,859 dives. There was no significant difference in diving data between divers with or without RLS. Divers with RLS had a 3.02 times higher incidence of (confirmed) DCS than divers without RLS (p = 0.04). When all cases of (confirmed or possible DCS) were considered, the Relative Risk was 1.42 (p = 0.46). DCS occurred mainly in divers who did not dive according to "low-bubble" diving techniques, in both groups. Conclusion: This prospective study confirms that DCS is more frequent in divers with RLS (such as a PFO), with a Relative Risk of 1.42 (all DCS) to 3.02 (confirmed DCS). It appears this risk is linked to diving behavior, more specifically diving to the limits of the adopted decompression procedures. [ABSTRACT FROM AUTHOR]

Hemiplegic migraine (HM) is a rare subtype of migraine characterized by aura of motor weakness accompanied by visual, sensory, and/or speech symptoms. Aura symptoms usually resolve completely; permanent attack-related deficit and radiographic change were rare. Here, we reported a case presented with progressively aggravated hemiplegic migraine episodes refractory to medication. He experienced two prolonged hemiplegic migraine attacks that led to irreversible visual impairment and cortical necrosis on brain MRI. Multimodal MRI during attack showed persistent vasodilation and hyperperfusion in the affected hemisphere associated with deterioration of clinical symptoms and worsening of brain edema. Patent foramen ovale (PFO) was found on the patient. PFO closure resulted in a significant reduction of HM attacks. This case indicated that prolonged hemiplegic migraine attack could result in irreversible neurological deficit with radiographic changes manifested as cortical necrosis. Persistent hyperperfusion might be an important factor contributing to prolonged attack and persistent attack-related neurological deficit. We recommend screening for PFO in patients with prolonged or intractable hemiplegic migraine, for that closure of PFO might alleviate the attacks thus preventing the patient from disabling sequelae. [ABSTRACT FROM AUTHOR]

Background and Purpose: Right to left shunt (RLS), from patent foramen ovale (PFO) or elsewhere, is a recognized risk factor for stroke. Current standard of care for RLS diagnosis includes transthoracic echocardiography (TTE) which is insensitive, transesophageal echocardiography (TEE) which is invasive, and transcranial Doppler (TCD) which has excellent sensitivity and specificity for RLS but is heavily operator dependent and expertise is scarce. The purpose of this study was to evaluate the RLS detection rate of a novel robotic‐assisted TCD (ra‐TCD) to standard of care diagnostic techniques, including TTE, TEE, and TCD. Methods: This is a multicenter, prospective, single‐arm, nonsignificant risk device study of ra‐TCD versus TTE for RLS diagnosis in adult patients who present with neurological signs and symptoms that include embolic stroke or transient ischemic attack on the differential diagnosis. Up to 150 subjects will be enrolled at up to seven centers considering the prevalence of PFO, suboptimal transtemporal windows, and potential dropouts. Enrolled patients will undergo ra‐TCD supine and at 45° in a manner otherwise in line with standard of care TCD bubble technique. The enrolled patients will have undergone TTE, and optionally standard TCD and TEE, per usual care. Results: The primary efficacy endpoint is percent detection of RLS by ra‐TCD compared against TTE. The primary safety endpoint is the incidence of device‐related serious adverse events. Conclusions: This is the first multicenter, prospective study evaluating the accuracy, feasibility, and safety of novel ra‐TCD for the diagnosis of RLS as compared to standard of care diagnostics. [ABSTRACT FROM AUTHOR]

A patient presenting with acute ischemic stroke associated with patent foramen ovale (PFO) had concurrent deep vein thrombosis, pulmonary embolism, and new-onset atrial fibrillation. Upon initiation of anticoagulation therapy, the patient developed hemorrhagic transformation of the stroke. The patient's multiple potential sources of embolic stroke were treated with concomitant left atrial appendage occlusion and PFO closure through the PFO, made possible by using the Steerable Amulet Sheath under 3D-intracardiac echocardiography guidance., (© 2024 The Author(s). Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.)

Cryptogenic stroke refers to a type of ischemic stroke with no identifiable cause despite extensive diagnostic testing. Patent foramen ovale (PFO) treatment modality for the prevention of cryptogenic stroke has been controversial. We undertook this systematic review to compare the efficacy of PFO closure versus medical therapy in preventing recurrent cryptogenic stroke and to provide insight into the most effective treatment modality. Inclusion criteria included patients who had PFO, papers written in English language or had translation available, and papers focusing on medical therapy including drug and surgical treatment for PFO for the prevention of recurrent stroke. Exclusion criteria included articles in which full text could not be obtained and articles in which only one treatment modality was mentioned, either surgical closure or drug therapy. The databases used were PubMed, Cochrane, Embase, and ClinicalTrials.gov. We conducted a bias assessment through the modified Jadad scale for randomized controlled trials (RCTs) and AMSTAR.Ca for meta-analysis and systematic review. The literature search identified a total of 277 papers. After screening, 12 papers were selected for the review. Among these, five were RCTs, five were meta-analyses, one was a systematic review, and one was a systematic review with network meta-analysis. The RCTs included a total of 3,336 participants, while the meta-analyses included 21,813 participants. These finalized papers examined the outcomes of PFO closure compared to medical therapy in preventing recurrent strokes., Competing Interests: Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Mirza et al.)

Right ventricular failure (RVF) is a common complication that occurs after a left ventricular assist device (LVAD) is implanted. We report an interesting case of severe and refractory hypoxia during the early postoperative period after HeartMate3 (HM3) (Abbott Laboratories, Lake Forest, IL) implantation resulting in the unmasking of a right-to-left intracardiac shunt through a patent foramen ovale (PFO), triggered by early RVF. Importantly, the patient had a small left-to-right shunt after receiving a left-sided Impella 5.5 micro-axial pump (Abiomed, Danvers, MA, USA) pre-LVAD implantation. We observed improved hypoxia but worsening RVF after percutaneous PFO closure, necessitating right-sided mechanical circulatory support. We outline potential reasons for the significant PFO-related shunting seen after HM3 implantation, but not after Impella 5.5 placement. Uncertainty exists regarding the approach to a PFO in patients undergoing LVAD implantation. We propose an approach based on existing literature., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Pillai et al.)

Abstract Interventional patent foramen ovale (PFO) closure should be performed in patients aged 16 to 60 years (after extensive neurological and cardiological diagnostic work-up) with a history of cryptogenic ischaemic stroke and patent foramen ovale, with moderate or extensive right-to-left shunt. In patients with cryptogenic ischaemic stroke and patent foramen ovale, who reject a PFO closure, there is no evidence of superiority of oral anticoagulation over antiplatelet therapy. Therefore, secondary prevention should be performed with aspirin or clopidogrel. Atrial fibrillation, pericardial tamponade, and pulmonary embolism are reported complications during and after implantation of an occluder. However, these events are so rare that they should not influence the recommendation for implantation. This article is an abridged and translated version of the guideline published in Nervenarzt: Diener, HC., für die Deutsche Gesellschaft für Neurologie (DGN), Grau, A.J. et al. Nervenarzt (2018) 89: 1143. https://doi.org/10.1007/s00115-018-0609-y.

Herein, we report a pediatric case of acute paradoxical cerebral embolism complicated by serious acute pulmonary embolism that was caused by an extremely small patent foramen ovale (PFO). The patient had no medical history suggestive of any other reason.

During the recent years, paradoxical embolism and Patent Foramen Ovale (PFO) have drawn great attention because of their strong correlation with cryptogenic stroke in young patients. The coexistence of pulmonary and paradoxical embolism is even rarer. Awareness of this complication with prompt recognition and treatment could prevent significant disability and death. We presented a 51-year-old man with evidence of concomitant pulmonary embolism and overload due to Pulmonary Thromboembolism and stroke, which suggests the presence of Patent Foramen Ovale. He was successfully treated with anticoagulation and PTO closure was performed.

Background: Patent foramen ovale (PFO) has been associated with migraine, cryptogenic stroke (CS), and hypoxemia. However, which examination method is most reliable remains controversial. This study sought to investigate the diagnostic value of contrast-enhanced ultrasonography (cU), including contrast-enhanced transcranial Doppler (cTCD), contrast transthoracic echocardiography (cTTE), and contrast transesophageal echocardiography (cTEE), for PFO; and to determine the best diagnostic strategy., Methods: This retrospective observational study included a total of 147 consecutive patients suspected PFO at The First Hospital of Shanxi Medical University between October 2019 and January 2022. The patients also underwent cTCD, cTTE, and cTEE examinations. The standard for the diagnosis of PFO was confirmation of the presence of PFO by color Doppler flow signals or contrast microbubbles (MBs) passing through the foramen ovale., Results: A total of 123 patients were diagnosed with PFO and 24 patients without PFO during the study period. The detectable rates of cTCD, cTTE, and cTEE were 120 (97.56%), 110 (89.43%), and 121 (98.37%), respectively. The sensitivity between cTCD and cTEE for PFO were comparable [97.56%, 95% confidence interval (CI): 92.5% to 99.4% vs . 98.37%, 95% CI: 93.7% to 99.7%; P>0.99], and the sensitivity of both were higher than that of cTTE (89.43%, 95% CI: 82.3% to 94.0%; P=0.02 and P=0.001, respectively). In addition, the specificity of cTEE for PFO was significantly higher than that of cTCD (100%, 95% CI: 82.3% to 100.0% vs . 75.00%, 95% CI: 53.0% to 89.4%; P<0.001) and cTTE (100%, 95% CI: 82.3% to 100.0% vs . 75.00%, 95% CI: 53.0% to 89.4%; P<0.001). Further, the semi-quantitative classification ability of cTCD for PFO with right-to-left shunt (RLS) was significantly higher than that of cTTE and cTEE (P=0.02 and P<0.001, respectively), and that of cTTE was significantly higher than that of cTEE (P=0.01). The Spearman analysis showed that the degree of RLS was positively correlated with the inner diameter of the PFO (r=0.695, P<0.001)., Conclusions: The combination of cTCD and cTEE may provide a favorable strategy for the diagnosis of PFO., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-330/coif). The authors have no conflicts of interest to declare., (2024 Journal of Thoracic Disease. All rights reserved.)

Platypnea-orthodeoxia syndrome (POS) is a rare clinical condition characterized by positional dyspnea and/or hypoxia. We report two cases of patients with COVID-19 bronchopneumonia with a torpid evolution. Due to clinical suspicion of POS, a diagnostic workup was performed, including a bubble echocardiography, which revealed a patent foramen ovale (PFO) with early and massive passage of bubbles to the left cavities. Both patients underwent percutaneous PFO closure with a resolution of POS. Here, we present the second and third cases of POS associated with PFO successfully closed during the acute phase of COVID-19. This suggests that PFO closure could be a potential treatment option for this condition., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Jiménez-Segovia et al.)

Patent Foramen Ovale (PFO) is a remnant of fetal circulation that could be observed in the 25% of the population worldwide. PFO is associated to numerous clinical conditions as migraines, coronary embolization, transient ischemic attacks, and stroke. The main PFO concerns are related to its correlation to stroke, in particular in young adults. Despite the impact on morbidity that PFO could have, to date there is not clear evidence about its management and treatment. In this narrative review our aim is to summarize the more recent evidence in the literature dealing with PFO, in order to provide an updated overview on this topic., Competing Interests: Conflict of Interest The Authors declare that there is no conflict of interest.