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• W93587675 abstract "To the Editor:I read with interest the paper of Hussain and colleagues1 describing the transhepatic approach, in 2 patients, to closure of patent foramen ovale (PFO) with a 25-mm AMPLATZER occluder: in patient 1 because of recent cryptogenic stroke (CS) and in patient 2 because of presumed platypnea-orthodeoxia syndrome. In my judgment, the authors' indications for the procedure are questionable, and the benefit from the PFO closure in these 2 patients is therefore doubtful.First, let us consider the stroke patient. The prevalence of PFO in a healthy population is nearly 20% to 25%, and the frequency of PFO detection in stroke patients can be as high as 40% to 45%.2 Controversies still exist regarding paradoxical embolism as a stroke mechanism and the pathogenic relationship between PFO and cryptogenic stroke.2 The increasing diagnosis of PFO in patients with cryptogenic stroke—and the statistical association between the 2 conditions—do not automatically establish a cause-and-effect relationship.2 In a systematic review of patients with cryptogenic stroke, Alsheikh-Ali and colleagues3 found that approximately one third of the discovered PFOs were incidental and not likely to benefit from closure.Moreover, if paradoxical embolism is suspected to be the mechanism of thromboembolic events in a patient with PFO (as stated by Hussain and colleagues1 in their introduction), this implies the need to look for other conditions associated with paradoxical embolism, such as hypercoagulable disorder, recent deep venous thrombosis, and a right atrial pressure that is higher than the left.2 If any of these conditions was found in patient 1, the authors did not provide us with the details.Nor did Hussain and colleagues provide further echocardiographic data—such as the size of the PFO, the severity of shunting through the PFO, or the presence of a highly mobile interatrial septum or an atrial septal aneurysm—any of which might increase the risk for stroke or stroke recurrence in patients with PFO.2 Indeed their patient 1 appears to have a low risk profile for stroke recurrence. Because of the paucity of data in the literature to suggest clinical benefit from PFO closure in patients with a first-time stroke, PFO closure is currently not recommended in such cases.4 The PFO in Cryptogenic Stroke Study (PICSS) found that on medical therapy, either with warfarin or aspirin, the presence of PFO in stroke patients did not increase the chance of adverse events, regardless of PFO size or the presence of atrial septal aneurysm.5Now for the patient with presumptive platypnea-orthodeoxia syndrome. This clinical entity is extremely rare and poorly understood.6,7 Platypnea is a dyspnea induced by the sitting position and relieved by the prone position.6,7 Orthodeoxia is an accentuated arterial hypoxemia in the upright position, which is relieved or improved in the supine position.6,7 The terms platypnea and orthodeoxia were introduced (originally) to describe these phenomena in patients with pulmonary diseases, without the presence of intracardiac shunts.7 Platypnea-orthodeoxia syndrome has been increasingly reported in patients with underlying overt pulmonary diseases, with or without PFO.6,8–10The presumptive diagnosis of platypnea-orthodeoxia syndrome in patient 2 is not well grounded. The reported clinical symptomatology and objective findings—such as “severe intermittent dyspnea, sometimes manifest at rest,” PCO2 of 26 mmHg, PO2 of 60 mmHg, and an oxygen saturation of 91% on room air—are not surprising in a patient with a history of deep venous thrombosis and recurrent pulmonary embolism.Comparison of symptoms, oxygen saturation values, and severity of shunt, all in relation to upright and supine positions as done by others,6,8 might strengthen the authors' diagnosis of platypnea-orthodeoxia syndrome, but we have no evidence that this was done by Hussain and colleagues.1Medical therapy—aspirin in patient 1 and optimization of the anticoagulation therapy with warfarin in patient 2—would probably have been no less beneficial than PFO closure with an AMPLATZER occluder in these 2 patients.Giovanni Saeed, MDDepartment of Cardiac Surgery, Klinikum Bayreuth GmbH, Bayreuth, Germany" @default.
• W93587675 created "2016-06-24" @default.
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• W93587675 date "2011-01-01" @default.
• W93587675 modified "2023-09-23" @default.
• W93587675 title "Should patent foramen ovale be closed in patients with recent cryptogenic stroke or presumptive platypnea-orthodeoxia syndrome?" @default.
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