Multidisciplinary Approach to Patent Foramen Ovale Closure for Cryptogenic Stroke: Brain-Heart Board Experience.

IF 2.3 Q3 CLINICAL NEUROLOGY

Neurology. Clinical practice Pub Date : 2024-08-01 Epub Date: 2024-05-29 DOI:10.1212/CPJ.0000000000200319

Muhib Khan, Malgorzata Miller, Philip Mccarthy, Jenny P Tsai, William Merhi, Duane Berkompas, Nabil Wees, Nadeem I Khan, Asad Ahrar, Elizabeth Evans, Musa Dahu, Andre Gauri, Tarah Moelker, Nagib Chalfoun, Jiangyong Min

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引用次数: 0

Abstract

Background and objectives: Patent foramen ovale (PFO) is present in approximately 25% of adult population. The prevalence of PFO is high in patients with cryptogenic stroke suggesting paradoxical embolism. PFO closure in carefully selected patients is an effective secondary preventive strategy in these patients. We report predictors of management recommendations by the multidisciplinary Board and their impact on outcomes.

Methods: Brain-Heart Board comprises vascular and interventional neurology and cardiology subspecialties (structural, electrophysiology, and cardiac imaging). Adult patients referred to the Board for consideration of PFO closure between October 2017 to March 2021 were included in this retrospective cohort analysis. Demographics, comorbid conditions, risk of paradoxical embolism (RoPE) score, event frequencies (transient ischemic attack [TIA] or stroke, intracranial hemorrhage [ICH], post-PFO closure cardiac arrhythmias), and modified Rankin Scale (mRS) at 1 year were compared between the groups (PFO closure vs medical management). Multivariable logistic regression was used to identify factors associated with management recommendation and chi-square tests to test differences in outcomes for patients according to management.

Results: Two hundred seventy patients (229 stroke; 41 TIA) were discussed by the Board for PFO closure. 119 (44.0%) patients were recommended for PFO closure of which 117 (98.3%) had evidence of ischemic infarct on imaging. In univariate analysis, age was similar (50 ± 11.9 vs 52 ± 12.8, p = 0.17), but RoPE score was higher in closure as compared with the medical management group (6 [IQR 5-7] vs 5 [IQR 4-7], p < 0.05). In multivariable analysis, TIA as the index event was an independent predictor of Board recommendation against PFO closure (OR 0.05, 95% CI 0.01-0.19, p < 0.05). Event frequency was low in both cohorts (5.9% vs 4.8%, p > 0.05) and comprised cardiac arrhythmias (6 cases of atrial fibrillation and 1 ICH in closure group; 1 TIA and 1 recurrent stroke in medical management group). Excellent functional outcome (mRS 0-1) was similar in both cohorts (66.3% vs 70.7%, p > 0.05) at 1 year.

Discussion: Multidisciplinary Brain-Heart Board provides a clinical practice model of collaborative care to ensure proper patient selection for PFO closure. TIA as the index event is associated with recommendation of medical management by the multidisciplinary Brain-Heart Board.

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隐源性卒中闭孔术的多学科方法：脑-心委员会的经验。

背景和目的：约 25% 的成年人存在卵圆孔未闭（PFO）。在隐源性中风患者中，PFO 的发病率较高，提示存在矛盾性栓塞。在这些患者中，对精心挑选的患者进行 PFO 关闭是一种有效的二级预防策略。我们报告了多学科委员会管理建议的预测因素及其对结果的影响：脑-心委员会由血管和介入神经学以及心脏病学亚专业（结构、电生理学和心脏成像）组成。这项回顾性队列分析纳入了 2017 年 10 月至 2021 年 3 月期间转诊至该委员会考虑 PFO 关闭的成人患者。比较了两组患者（PFO 封闭组和药物治疗组）的人口统计学特征、合并症、矛盾性栓塞风险（RoPE）评分、事件频率（短暂性脑缺血发作 [TIA] 或中风、颅内出血 [ICH]、PFO 封闭后心律失常）以及 1 年后的改良 Rankin 评分表（mRS）。采用多变量逻辑回归来确定与治疗建议相关的因素，并采用卡方检验来检验不同治疗方法对患者预后的影响：委员会讨论了 270 例患者（229 例中风；41 例 TIA）的 PFO 关闭手术。119例（44.0%）患者被建议进行PFO关闭术，其中117例（98.3%）患者的影像学检查显示存在缺血性梗死。在单变量分析中，年龄相似（50 ± 11.9 vs 52 ± 12.8，P = 0.17），但与内科治疗组相比，关闭组的 RoPE 评分更高（6 [IQR 5-7] vs 5 [IQR 4-7]，P < 0.05）。在多变量分析中，TIA 作为指数事件是预测委员会建议是否关闭 PFO 的一个独立因素（OR 0.05，95% CI 0.01-0.19，p <0.05）。两组患者的事件发生率均较低（5.9% vs 4.8%，p > 0.05），其中包括心律失常（封堵组有 6 例房颤和 1 例 ICH；药物治疗组有 1 例 TIA 和 1 例复发性中风）。两组患者1年后的功能预后（mRS 0-1）相似（66.3% vs 70.7%，p > 0.05）：讨论：多学科脑-心委员会提供了一种合作治疗的临床实践模式，以确保为PFO闭合术选择合适的患者。以TIA为指标事件与多学科脑-心委员会建议的医疗管理有关。

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来源期刊

Neurology. Clinical practice CLINICAL NEUROLOGY-

CiteScore

4.00

自引率

0.00%

发文量

期刊介绍： Neurology® Genetics is an online open access journal publishing peer-reviewed reports in the field of neurogenetics. The journal publishes original articles in all areas of neurogenetics including rare and common genetic variations, genotype-phenotype correlations, outlier phenotypes as a result of mutations in known disease genes, and genetic variations with a putative link to diseases. Articles include studies reporting on genetic disease risk, pharmacogenomics, and results of gene-based clinical trials (viral, ASO, etc.). Genetically engineered model systems are not a primary focus of Neurology® Genetics, but studies using model systems for treatment trials, including well-powered studies reporting negative results, are welcome.