Paradoxical Embolism
2010; Lippincott Williams & Wilkins; Volume: 122; Issue: 19 Linguagem: Português
10.1161/circulationaha.110.961920
ISSN1524-4539
AutoresBradley A. Maron, Prem Shekar, Samuel Z. Goldhaber,
Tópico(s)Venous Thromboembolism Diagnosis and Management
ResumoHomeCirculationVol. 122, No. 19Paradoxical Embolism Free AccessCase ReportPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessCase ReportPDF/EPUBParadoxical Embolism Bradley A. Maron, Prem S. Shekar and Samuel Z. Goldhaber Bradley A. MaronBradley A. Maron From the Department of Internal Medicine, Division of Cardiovascular Medicine (B.A.M., S.Z.G.), and Department of Surgery, Division of Cardiothoracic Surgery (P.S.S.), Brigham and Women's Hospital and Harvard Medical School, Boston, Mass. , Prem S. ShekarPrem S. Shekar From the Department of Internal Medicine, Division of Cardiovascular Medicine (B.A.M., S.Z.G.), and Department of Surgery, Division of Cardiothoracic Surgery (P.S.S.), Brigham and Women's Hospital and Harvard Medical School, Boston, Mass. and Samuel Z. GoldhaberSamuel Z. Goldhaber From the Department of Internal Medicine, Division of Cardiovascular Medicine (B.A.M., S.Z.G.), and Department of Surgery, Division of Cardiothoracic Surgery (P.S.S.), Brigham and Women's Hospital and Harvard Medical School, Boston, Mass. Originally published9 Nov 2010https://doi.org/10.1161/CIRCULATIONAHA.110.961920Circulation. 2010;122:1968–1972Case presentation: A 69-year-old woman presented to the hospital with sudden-onset shortness of breath that occurred while standing from a sitting position. The patient was in moderate respiratory distress with a blood pressure of 109/78 mm Hg, heart rate of 109 bpm, and peripheral blood oxygen saturation level of 95% on 3 L of oxygen per nasal cannula. She had an accentuated pulmonary component of the second heart sound, sinus tachycardia on ECG, and an elevated troponin-I level. A large proximal pulmonary embolism was diagnosed by computed tomography. Transthoracic echocardiography demonstrated a right atrial (RA) mass. Transesophageal echocardiography revealed a 3.2-cm thrombus extending from the RA to the left atrium (LA) through a patent foramen ovale (PFO), consistent with impending paradoxical embolism (Figure and Figure I in the online-only Data Supplement).Download figureDownload PowerPointFigure. Impending paradoxical embolism. A 64-year-old woman admitted to the hospital with shortness of breath was referred for pulmonary embolectomy to treat a saddle pulmonary embolism. On intraoperative transesophageal echocardiography, a 3.2-cm thrombus (arrowheads) traversing the interatrial septum was observed. Mechanical removal of the clot by the cardiothoracic surgeon and surgical closure of the PFO occurred uneventfully, and the patient recovered without neurological complications. TV indicates tricuspid valve.OverviewCerebrovascular thromboembolism is responsible annually for ≈510 000 ischemic strokes and 139 000 deaths in the United States alone, with expenditure of ≈36 billion dollars.1 Ischemic stroke in the absence of conventional risk factors for cerebral vascular disease indicates that alternative mechanisms for stroke must exist.2 Indeed, a cause is unidentified or unproven in 40% of all strokes despite comprehensive diagnostic testing.3 These strokes are known as cryptogenic strokes.Less common causes of cryptogenic stroke include cardiac tumor, valvular strands (ie, Lambl's excrescences), aortic arch atherosclerotic plaque embolization, or intracardiac venous thromboembolism that is formed in association with structural heart disease.2,4,5 The most common cause of cryptogenic stroke is probably paradoxical embolism due to PFO.6,7Paradoxical embolism, or venous thromboembolism transit from right- to left-sided cardiac chambers, may occur via interventricular, interatrial, or pulmonary arteriovenous malformations. PFO rates are higher in cryptogenic stroke patients than in the general population. In a meta-analysis of 23 case-control studies, the odds ratio for a PFO in cryptogenic stroke patients compared with those with stroke from a known cause was 2.9 (95% confidence interval, 2.1 to 4.0).3,8 These findings are similar to those from Handke and colleagues,9 who prospectively evaluated 503 consecutive acute stroke patients and observed that compared with stroke from a determined cause, the PFO rate in cryptogenic stroke is significantly greater.Pathophysiology of Paradoxical EmbolismNormal fetal circulation is dependent on the foramen ovale, which provides a communication for oxygenated blood flow between the RA and LA during lung maturation.10,11 At birth, decreased pulmonary vascular resistance and increased LA pressure promote closure of the foramen ovale, although a probe-patent PFO is present in 27% of the general population at autopsy.11 An atrial septal aneurysm (ASA) is a bulging of the atrial septal membrane (eg, septum primum) in the region of the fossa ovalis and is present in ≈1% of PFO patients.12 The precise mechanism of stroke in PFO patients is unresolved but likely occurs due to (1) paradoxical embolism from venous thromboembolism transit through a PFO, (2) PFO- or ASA-induced thrombogenicity, or (3) LA clot formation from atrial arrhythmias that may occur in association with a PFO or ASA.Risk Stratification of PFO PatientsThe annual risk of cryptogenic and recurrent stroke in PFO populations is ≈0.1% and 1%, respectively.13,14 The influence of ASA on stroke risk in PFO patients remains unresolved. One analysis of patients with PFO plus ASA showed a 4-fold higher recurrent stroke rate over 4 years compared with patients with a PFO alone (19.2% versus 5.6%).14,15 A large PFO (≥4 mm determined by balloon dilation), prominent Chiari's network (ie, sinus venosus remnant), and PFO tunnel length >14 mm appear to increase the risk of cryptogenic stroke or transient ischemic attack (TIA).14,16 The magnitude of right-to-left shunting may positively correlate with the risk of cryptogenic stroke.17 In the Paradoxical Embolism From Large Veins in Ischemic Stroke (PELVIS) study, cryptogenic stroke was associated with a 5-fold greater probability of pelvic deep vein thrombosis than stroke of determined origin.18 Similarly, patients with impending paradoxical embolism often present with contemporaneous deep vein thrombosis or pulmonary embolism (Figure and Figure I in the online-only Data Supplement).19A genetic predisposition for cryptogenic stroke may exist. In 1 study, the factor V Leiden (G1691A) or prothrombin G20210A gene mutation conferred a 4-fold higher risk of stroke in young PFO patients compared with age-matched controls.20 However, larger epidemiological studies have not confirmed these findings. Therefore, there is insufficient evidence to implicate genetic forms of thrombophilia as independently conferring an increased risk of paradoxical embolism.Therapeutic Options to Prevent Stroke or TIA in PFO PatientsPrimary PreventionPrevention strategies for a first-time stroke do not differ in patients with respect to PFO status. Some have speculated that PFO closure for primary prevention of stroke may be appropriate in very-high-risk patients with a large PFO, ASA, spontaneous right-to-left shunt, prominent Chiari's network, and a primary coagulopathy.21 This hypothesis, however, requires further investigation.Secondary Prevention With Medical TherapyAntiplatelet pharmacotherapy with aspirin, aspirin plus extended-release dipyridamole, or clopidogrel is an American Heart Association/American Stroke Association class I indication for the secondary prevention of ischemic stroke. For cardioembolic stroke, warfarin is preferred in select patients.22 However, owing to inconsistent findings from the largest available clinical trials, optimal medical therapy for prevention of recurrent cryptogenic stroke remains unresolved. Mas and colleagues15 observed that in 277 consecutive cryptogenic stroke patients (mean age, 40 years) treated with aspirin (300 mg/d), PFO plus ASA but not PFO alone increased the rates of stroke or TIA compared with patients without either of these defects (hazard ratio=3.91; 95% confidence interval, 1.59 to 9.59; P<0.004). Their results suggested that aspirin monotherapy is adequate in PFO patients but provides insufficient protection for those with a complex interatrial defect such as ASA plus PFO.Homma and colleagues23 prospectively compared aspirin (325 mg/d) against warfarin (international normalized ratio, 1.8 to 2.4) in 265 cryptogenic stroke patients (mean age, 59 years) enrolled in the randomized, controlled Warfarin-Aspirin Recurrent Stroke Study (WARSS).24 Irrespective of ASA status (or PFO size), no significant difference in the 2-year rates of stroke or death among patients randomized to either treatment group was observed (aspirin, 14.3% versus warfarin, 12.7%).Rates of major bleeding from warfarin or aspirin therapy are ≈2% and 1%, respectively. Benefits and limitations of medical therapy are provided in Table 1.Table 1. Benefits and Limitations Associated With Medical and Percutaneous Device Closure Therapies for Preventing Recurrent Cryptogenic StrokeMedical TherapyPercutaneous Device ClosureBenefitsLimitationsBenefitsLimitationsNoninvasivePatient exposure to risks of minor (eg, mucosal) and major (eg, intracranial hemorrhage, blood transfusion requiring gastrointestinal hemorrhage) therapy-associated complicationsMinimally invasive procedure that is generally well toleratedUnpredictable postclosure delay in right-to-left shunt reductionWell-studied strategy for secondary prevention of stroke and venous thromboembolismDrug level monitoring required for warfarinPotential for permanent PFO defect closurePFO may close incompletelyMay be discontinued if necessaryPatient exposure to medication side effects (eg, aspirin-induced gastrointestinal intolerance, clopidogrel-induced thrombocytopenia)Reduction or elimination of right-to-left shuntElevated rates of postprocedural atrial arrhythmiasPotential for unfavorable drug-drug interactions and contribution to polypharmacyMay reduce migraine headache frequency or intensity in selected patientsPatient exposure to risk of major procedural complications including aortic regurgitation, device embolization, cardiac tamponade, device thrombus, atrioventricular block, among othersDoes not eliminate need for a short term (ie, 6 mo) of dual antiplatelet therapySecondary Prevention With Device TherapyThe Amplatzer Septal Occluder, Sideris buttoned device, Gore Helix Septal Occluder, and CardioSEAL Septal Occlusion System are commonly used devices approved by the US Food and Drug Administration for percutaneous closure of cardiac septal defects. Successful deployment results in secure device placement, complete defect occlusion, and elimination of clinically significant hemodynamic shunting. Reports suggesting that percutaneous PFO closure reduces the risk of a future stroke or TIA are primarily from case series and observational reports. In a meta-analysis of 1430 patients undergoing PFO occlusion, the rate of recurrent stroke was 0.19% (95% confidence interval, 0.05 to 0.49), which compares favorably against large medical therapy trials that report annual recurrent event rates of ≈1.4%.14 Sufficiently powered randomized trials comparing these treatment modalities have not yet been completed (Table 2), but evidence from retrospective analyses and registry data suggests that percutaneous PFO closure is a suitable option. Windecker and colleagues25 evaluated outcomes in a large cohort of cryptogenic stroke patients undergoing either percutaneous PFO closure (n=150) or medical therapy (n=158) and observed a substantial reduction in the 4-year rates of recurrent stroke or TIA in favor of device therapy (8.5% versus 24.3%; P=0.05).Table 2. Summary of Ongoing Randomized, Prospective Clinical Trial Comparing Medical Therapy and Percutaneous PFO Closure for the Prevention of Recurrent Cryptogenic StrokeStudyTrial Name/Goal Patient Enrollment/LocationTreatment GroupsMajor Inclusion CriteriaEnd PointPrimarySecondaryRandomized evaluation of recurrent stroke comparing PFO closure to established current standard of care treatmentRESPECT 710 USAmplatzer PFO OccluderAspirinClopidogrelAspirin plus dipyridamoleWarfarinAge 18–70 y Cryptogenic stroke within 270 days of enrollment To date, 86% show PFO shunting at rest, 35% have ASARecurrent nonfatal strokePostrandomization mortalityFatal ischemic strokeComplete closure of defect at 6 moAbsence of recurrent symptomatic cryptogenic nonfatal stroke or cardiovascular deathIncident TIAEvaluation of the STARFlex septal closure system in patients with a stroke or TIA due to the possible passage of a clot of unknown origin through a patent foramen ovale (PFO)CLOSURE-I 900 USAspirin 325 mg/d and/or warfarin (INR 2.5)STARFlex septal closure systemAge 18–60 y Ischemic stroke within 6 mo of enrollment PFO with evidence of either right-to-left shunt or associated ASATwo-year incidence of stroke or TIAAll-cause mortality at 30 d of follow-upNeurological mortality after 31 d of follow-upIncidence of primary end point, adverse events, primary end point, and adverse events by treatment groupPatent foramen ovale and cryptogenic embolismPC Trial 414 Australia, EuropeInvestigator's choice of warfarin (INR 2–3) or aspirin 100–325 mg/d or clopidogrel 75–150 mg/dAmplatzer PFO OccluderAge <60 y Prior stroke with sufficient time to recover activities of daily livingTime to death (fatal stroke, cardiovascular and noncardiovascular causes)Time to nonfatal strokeTime to peripheral embolismNew arrhythmiasMyocardial infarctionHospitalization related to PFO or its treatmentDevice complicationsBleeding complicationsPatent foramen ovale closure or anticoagulants vs antiplatelet therapy to prevent stroke recurrenceCLOSE 900 EuropeAspirinWarfarinPFO closure device of any ad hoc committee–approved typeAge 16–60 y PFO with evidence of either right-to-left shunt or ASAStroke within follow-up period (3–5 y)Disabling strokeIschemic strokeIntracranial hemorrhageIschemic stroke or TIA or systemic embolismAll-cause mortalityVascular deathGore HELEX septal occluder for patent foramen ovale (PFO) closure in stroke patientsGore REDUCE 664 US, EuropeAntiplatelet therapyAntiplatelet therapy plus device closure therapyAge 16–60 y Stroke or TIA within 180 d of enrollment PFO with evidence of right-to-left shuntFreedom from recurrent ischemic stroke or imaging-confirmed TIA through 24 mo after randomizationDevice-associated adverse eventsEvaluation of PFO closure by TTE/TEEINR indicates international normalized ratio; TTE, transthoracic echocardiogram; and TEE, transesophageal echocardiogram.Percutaneous closure also appears to be effective in patients with PFO plus ASA, particularly when associated with a substantial decrease in shunt severity. Major complication rates associated with device closure occur in ≈1.5% of patients, whereas the rate of minor complications such as femoral hematoma and new atrial arrhythmias is ≈8%.26 Additional limitations to device therapy include incomplete device occlusion and insufficient shunt reduction. Furthermore, to prevent clot formation on the surface of the septal occluder before device endothelialization, dual antiplatelet therapy is recommended for 6 months after device implantation (Table 1).Surgical PFO closure is comparable in efficacy to percutaneous approaches, with some estimates conferring an annual recurrent stroke rate of 0.34%.14 Surgical PFO closure as a single indication for sternotomy is uncommon but should be considered in high-risk cryptogenic stroke patients undergoing open heart surgery for other indications or in those for whom successful percutaneous closure is not possible.SummaryAnticoagulation with either daily aspirin or warfarin is recommended in PFO patients to prevent recurrent stroke. Percutaneous or surgical defect closure is a reasonable treatment choice in patients with a prior cryptogenic stroke and should be considered when the PFO is associated with high-risk features (American Heart Association class IIa indication, level of evidence C).27 Several ongoing randomized controlled clinical trials evaluating medical and percutaneous therapies for recurrent cryptogenic stroke prevention in PFO patients will provide additional data.Management of Presented CaseIn the case vignette, pulmonary embolectomy was recommended owing to the presence of a RA clot and the patient's high-risk clinical status. The impending paradoxical embolism discovered on intraoperative transesophageal echocardiography was excised, and the PFO was closed surgically. The patient had a full recovery without clinical evidence of stroke or TIA. She was discharged on lifelong warfarin therapy with target international normalized ratio of 2 to 3.DisclosuresNone.FootnotesThe online-only Data Supplement is available with this article at http://circ.ahajournals.org/cgi/content/full/122/19/1968/DC1.Correspondence to Bradley A. Maron, MD, Division of Cardiovascular Medicine, Brigham and Women's Hospital, PBB-1, 75 Francis St, Boston, MA 02115. E-mail [email protected]orgReferences1. O'Gara PT, Messe SR, Tuzcu EM, Catha G, Ring JC. Percutaneous device closure of patent foramen ovale for secondary stroke prevention. Circulation. 2009; 119:2743–2747.LinkGoogle Scholar2. Kizer JR, Devereux RB. Patent foramen ovale in young adults with unexplained stroke. N Engl J Med. 2005; 353:2361–2372.CrossrefMedlineGoogle Scholar3. Windecker S, Meier B. Is closure recommended for patent foramen ovale and cryptogenic stroke? Patent foramen ovale and cryptogenic stroke: to close or not to close? Closure: what else!Circulation. 2008; 118:1989–1998.LinkGoogle Scholar4. Maron BJ, Olivotto I, Bellone P, Conte MR, Cecchi F, Flygenring BP, Casey SA, Gohman TE, Bongioanni S, Spirito P. Clinical profile of stroke in 900 patients with hypertrophic cardiomyopathy. J Am Coll Cardiol. 2002; 39:301–307.CrossrefMedlineGoogle Scholar5. Di Tullio MR, Russo C, Jin Z, Sacco RL, Mohr JP, Homma SPatent Foramen Ovale in Cryptogenic Stroke Study Investigators. Aortic arch plaques and risk of recurrent stroke and death. Circulation.2009; 119:2376–2382.LinkGoogle Scholar6. Sastry S, Riding G, Morris J, Taberner D, Cherry N, Haegerty A, McCollum C. Young Adult Myocardial Infarction and Ischemic Stroke: the role of paradoxical embolism and thrombophilia (the YAMIS Study). J Am Coll Cardiol. 2006; 48:686–691.CrossrefMedlineGoogle Scholar7. Messé SR, Kasner SE. Patent foramen ovale in cryptogenic stroke: not to close. Circulation. 2008; 118:1999–2004.LinkGoogle Scholar8. Alsheikh-Ali AA, Thaler DE, Kent DM. Patent foramen ovale in cryptogenic stroke: incidental or pathogenic?Stroke. 2009; 40:2349–2355.LinkGoogle Scholar9. Handke M, Harloff A, Olschewski M, Hetzel A, Geibel A. Patent foramen ovale and cryptogenic stroke in older patients. N Engl J Med. 2007; 357:2262–2268.CrossrefMedlineGoogle Scholar10. Hara H, Vermani R, Ladich E, Mackey-Bojack S, Titus J, Reisman M, Gray W, Nakamura M, Mooney M, Poulose A, Schwartz RS. Patent foramen ovale: current pathology, pathophysiology, and clinical status. J Am Coll Cardiol. 2005; 46:1768–1776.CrossrefMedlineGoogle Scholar11. Hagen PT, Scholz DG, Edwards WD. Incidence and size of patent foramen ovale during the first 10 decades of life: an autopsy study of 965 normal hearts. Mayo Clin Proc. 1984; 59:17–20.CrossrefMedlineGoogle Scholar12. Silver MD, Dorsey JS. Aneurysms of the septum primum in adults. Arch Pathol Lab Med. 1978; 102:62–65.MedlineGoogle Scholar13. Lock JE. Patent foramen ovale is indicated, but the case hasn't gone to trial. Circulation. 2000; 101:838LinkGoogle Scholar14. Homma S, Sacco RL. Patent foramen ovale and stroke. Circulation. 2005; 112:1063–1072.LinkGoogle Scholar15. Mas J-L, Arquizan C, Lamy C, Zuber M, Cabanes L, Derumeaux G, Coste J. Recurrent cerebrovascular events associated with patent foramen ovale, atrial septal aneurysm, or both. N Engl J Med. 2001; 345:1740–1746.CrossrefMedlineGoogle Scholar16. Goel SS, Tuzcu EM, Shishehbor MH, de Oliveira EI, Borek PP, Krasuski RA, Rodriguez LL, Kapadia SR. Morphology of the patent foramen ovale in asymptomatic versus symptomatic (stroke or transient ischemic attack) patients. Am J Cardiol. 2009; 103:124–129.CrossrefMedlineGoogle Scholar17. Wahl A, Krumsdorf U, Meier B, Sievert H, Ostermayer S, Billinger K, Schwerzmann M, Becker U, Seiler C, Arnold M, Mattle HP, Windecker S. Transcatheter treatment of atrial septal aneurysm associated with patent foramen ovale for prevention of recurrent paradoxical embolism in high-risk patients. J Am Coll Cardiol. 2005; 45:377–380.CrossrefMedlineGoogle Scholar18. Cramer SC, Rordorf G, Maki JH, Kramer LA, Grotta JC, Burgin S, Hinchey JA, Benesch C, Furie KL, Lutsep HL, Kelly E, Longstreth WT. Increased pelvic vein thrombi in cryptogenic stroke: results of the Paradoxical Emboli From Large Veins in Ischemic Stroke (PELVIS) Study. Stroke. 2004; 35:46–50.LinkGoogle Scholar19. Myers PO, Bounamequx H, Panos A, Lerch R, Kalangos A. Impending paradoxical embolism: systematic review of prognostic factors and treatment. Chest. 2010; 137:164–170.CrossrefMedlineGoogle Scholar20. Botto N, Spadoni I, Giusti S, Ait-Ali L, Sicari R, Andreassi MG. Prothrombotic mutations as risk factors for cryptogenic ischemic cerebrovascular events in young subjects with patent foramen ovale. Stroke. 2007; 38:2070–2073.LinkGoogle Scholar21. Rigatelli G, Avvocata FD, Giordan M, Braggion G, Aggio S, Chinaglia M, Roncon L, Cardaioli P, Chen JP. Embolic implications of combined risk factors in patients with patient foramen ovale (the CARPE criteria): consideration for primary prevention closure?J Interven Cardiol. 2009; 22:398–403.CrossrefMedlineGoogle Scholar22. Adams RJ, Albers G, Alberts MJ, Benavente O, Furie K, Goldstein LB, Gorelick P, Halperin J, Harbaugh R, Johnston SC, Katzan I, Kelly-Hayes M, Kenton EJ, Marks M, Sacco RL, Schwamm LH. Updated to the AHA/ASA recommendations for the prevention of stroke in patients with stroke and transient ischemic attack. Stroke. 2008; 39:1647LinkGoogle Scholar23. Homma S, Sacco RL, Di Tullio MR, Sciacca RR, Mohr JPPFO in Cryptogenic Stroke Study (PICSS) Investigators. Effect of medical treatment in stroke patients with patent foramen ovale: Patent Foramen Ovale in Cryptogenic Stroke Study. Circulation.2002; 105:2625–2631.LinkGoogle Scholar24. Mohr JP, Thompson JLP, Lazar RM, Levin B, Sacco RL, Furie KL, Kistler JP, Albers GW, Pettigrew LC, Adams HP, Jackson CM, Pullicino P. A comparison of warfarin and aspirin for the prevention of recurrent ischemic stroke. N Engl J Med. 2001; 345:1444–1451.CrossrefMedlineGoogle Scholar25. Windecker S, Wahl A, Nedeltchev K, Arnold M, Schwerzmann M, Seiler C, Mattle HP, Meier B. Comparison of medical treatment with percutaneous closure of patent foramen ovale in patients with cryptogenic stroke. J Am Coll Cardiol. 2004; 44:750–758.CrossrefMedlineGoogle Scholar26. Bruch L, Parsi A, Grad MO, Rux S, Burmeister T, Krebs H, Kleber FX. Transcatheter closure of interatrial communications for secondary prevention of paradoxical embolism: single-center experience. Circulation. 2002; 105:2845–2848.LinkGoogle Scholar27. Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA, del Nido P, Fasules JW, Graham TP, Hijazi ZM, Hunt SA, King ME, Landzberg MJ, Miner PD, Radford MJ, Walsh EP, Webb GD. ACC/AHA 2008 guidelines for the management of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to develop guidelines on the management of adults with congenital heart disease). Circulation. 2008; 118:e714–e833.LinkGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Goh F, Leow A, Ho J, Ho A, Tan B, Yeo L, Li T, Galupo M, Chan M, Yeo T, Wong R, Chai P and Sia C (2022) Clinical characteristics, treatment and long-term outcomes of patients with right-sided cardiac thrombus, Hellenic Journal of Cardiology, 10.1016/j.hjc.2022.07.008, 68, (1-8), Online publication date: 1-Nov-2022. Huang J and Bhaskar S (2022) Clot Morphology in Acute Ischemic Stroke Decision Making, International Journal of Molecular Sciences, 10.3390/ijms232012373, 23:20, (12373) Shimfessel T, El-Dalati S, Sekela M and Ahmed T (2022) Paradoxical embolisation in right-sided infective endocarditis and patent foramen ovale, BMJ Case Reports, 10.1136/bcr-2022-250272, 15:5, (e250272), Online publication date: 1-May-2022. Sagar P, Sheriff E and Sivakumar K (2021) Extensive Pulmonary Thromboembolism and Serious Threat of Systemic Thromboembolism in a Suspected COVID Recovered Patient, Journal of The Indian Academy of Echocardiography & Cardiovascular Imaging, 10.4103/jiae.jiae_19_21, 5:2, (177), . Golemi I, Salazar Adum J, Tafur A and Caprini J (2019) Venous thromboembolism prophylaxis using the Caprini score, Disease-a-Month, 10.1016/j.disamonth.2018.12.005, 65:8, (249-298), Online publication date: 1-Aug-2019. Palazzo P, Ingrand P, Agius P, Belhadj Chaidi R and Neau J (2018) Transcranial Doppler to detect right-to-left shunt in cryptogenic acute ischemic stroke, Brain and Behavior, 10.1002/brb3.1091, 9:1, (e01091), Online publication date: 1-Jan-2019. Qiu B, Cai Y, Wang D, Lin J and Fan Y (2018) Closure versus Medical Therapy for Patent Foramen Ovale in Patients with Cryptogenic Stroke: An Updated Meta-Analysis of Randomized Controlled Trials, Journal of Stroke and Cerebrovascular Diseases, 10.1016/j.jstrokecerebrovasdis.2018.08.008, 27:12, (3463-3472), Online publication date: 1-Dec-2018. Xu H, Zhang H, Qin Y, Xue F, Xiong G, Yang L, Bai H and Wu J (2018) Patent foramen ovale closure versus medical therapy for cryptogenic stroke: An updated meta-analysis, Journal of the Neurological Sciences, 10.1016/j.jns.2018.04.029, 390, (139-149), Online publication date: 1-Jul-2018. Yang H, Nassif M, Khairy P, de Groot J, Roos Y, de Winter R, Mulder B and Bouma B (2018) Cardiac diagnostic work-up of ischaemic stroke, European Heart Journal, 10.1093/eurheartj/ehy043, 39:20, (1851-1860), Online publication date: 21-May-2018. Lattanzi S, Brigo F, Cagnetti C, Di Napoli M and Silvestrini M (2018) Patent Foramen Ovale and Cryptogenic Stroke or Transient Ischemic Attack: To Close or Not to Close? A Systematic Review and Meta-Analysis, Cerebrovascular Diseases, 10.1159/000488401, 45:5-6, (193-203), . Fu Q, Guo X, Mo D and Chen B (2017) Young Paradoxical Stroke Treated Successfully with Mechanical Thrombectomy Using Solitaire and Transcatheter Closure of Patent Foramen Oval, International Heart Journal, 10.1536/ihj.16-461, 58:5, (812-815), . Yamamoto S, Yokomizo Y, Akai T, Chiyoda T, Goto H and Masaki Y (2016) Acute aortic occlusion in a patient with chronic paralysis due to spinal cord injury: a case report, Surgical Case Reports, 10.1186/s40792-016-0251-5, 2:1, Online publication date: 1-Dec-2016. Li J, Liu J, Liu M, Zhang S, Hao Z, Zhang J and Zhang C (2015) Closure versus medical therapy for preventing recurrent stroke in patients with patent foramen ovale and a history of cryptogenic stroke or transient ischemic attack, Cochrane Database of Systematic Reviews, 10.1002/14651858.CD009938.pub2, 2015:9 Tang L, Fang Z and Zhou S (2013) Paradoxical embolism causing acute embolic events in a patient with hereditary thrombophiliaParadoxe Embolie als Ursache akuter embolischer Ereignisse bei einem Patienten mit hereditärer Thrombophilie, Herz, 10.1007/s00059-013-3994-9, 40:2, (314-317), Online publication date: 1-Apr-2015. Kwong J, Lam Y and Yu C (2013) Percutaneous closure of patent foramen ovale for cryptogenic stroke: A meta-analysis of randomized controlled trials, International Journal of Cardiology, 10.1016/j.ijcard.2013.07.077, 168:4, (4132-4138), Online publication date: 1-Oct-2013. Goldhaber S (2013) Deep Vein Thrombosis and Pulmonary Embolism Consultative Hemostasis and Thrombosis, 10.1016/B978-1-4557-2296-9.00016-6, (247-261), . Goldhaber S and Piazza G (2013) Pulmonary Embolism and Deep Vein Thrombosis Cardiovascular Therapeutics: A Companion to Braunwald's Heart Disease, 10.1016/B978-1-4557-0101-8.00038-2, (580-595), . Pirkl M, Myjavec A, Daněk T and Černý M (2012) A case of pulmonary thromboembolism with synchronous and metachronous paradoxical embolism through the patent foramen ovale - a case report, Cor et Vasa, 10.1016/j.crvasa.2012.08.001, 54:9-10, (e314-e322), Online publication date: 1-Sep-2012. Li J, Liu M, Zhang S, Hao Z, Zhang C, Zhang J and Liu M (2012) Closure versus medical therapy for preventing recurrent stroke in patients with patent foramen ovale and a history of cryptogenic stroke or transient ischemic attack Cochrane Database of Systematic Reviews, 10.1002/14651858.CD009938 Eagle S and Thompson A (2012) Congenital Heart Disease in the Adult Presenting for Noncardiac Surgery, ASA Refresher Courses in Anesthesiology, 10.1097/ASA.0b013e31825f5d02, 40:1, (18-25), . Ginsberg J (2012) Peripheral Venous Disease Goldman's Cecil Medicine, 10.1016/B978-1-4377-1604-7.00081-6, (499-506), . Katritsis D (2011) Transseptal puncture through atrial septal closure devices, Heart Rhythm, 10.1016/j.hrthm.2011.06.025, 8:11, (1676-1677), Online publication date: 1-Nov-2011. November 9, 2010Vol 122, Issue 19 Advertisement Article InformationMetrics © 2010 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.110.961920PMID: 21060086 Originally publishedNovember 9, 2010 PDF download Advertisement SubjectsAnticoagulantsCerebrovascular Disease/StrokeCerebrovascular ProceduresTreatment
Referência(s)