Summary
Background
No previous study has looked for an association between aortic dilatation and the clinical sequelae of patent foramen ovale (PFO), although a possible relationship has been identified in case reports.
Aim
To compare aortic dimensions in patients with symptomatic PFO and healthy controls.
Methods
Forty-seven patients were identified who presented with cryptogenic cerebrovascular accident (CVA) assessed as most likely secondary to PFO (confirmed by contrast study), were aged less than 50 years and underwent percutaneous PFO closure. Forty-seven age-, sex- and body surface area-matched healthy controls were also identified.
Results
Aortic root diameters were greater in PFO patients. The difference was more marked at the levels of the sinuses of Valsalva (34 ± 4 vs 31 ± 3 mm, P < 0.01) and the proximal ascending aorta (32 ± 4 vs 29 ± 3, P < 0.01) and more modest at the level of the aortic annulus (23 ± 3 vs 22 ± 2 mm, P = 0.20). In addition, patients with massive right-to-left shunting tended to have larger aortic diameters. In contrast, left ventricular end-systolic and end-diastolic diameters were not larger than in controls (30 ± 4 vs 32 ± 5 mm, P = 0.10 and 48 ± 5 vs 50 ± 4 mm, P = 0.04, respectively).
Conclusion
The present study shows that aortic diameter is increased in young patients with cryptogenic CVA and PFO compared with in healthy subjects. Our results suggest that aortic dilatation may potentiate the risk of CVA in PFO patients and support further research in this area.
Résumé
Contexte
Il n’existe pas d’étude ayant évalué la relation entre la taille de l’aorte ascendante et la présence d’un foramen ovale perméable (FOP) symptomatique, même si une telle association a été suggéré dans des cas cliniques.
Objectifs
Le but de cette étude était de comparer les dimensions de l’aorte chez des patients avec un FOP ayant présenté un accident vasculaire cérébral (AVC) et chez des sujets sains.
Méthodes
Nous avons inclus 47 patients ayant : 1 : présenté un AVC sans autre cause retrouvé qu’un FOP confirmé par épreuve de contraste ; 2 : agés de moins de 50 ans et ; 3 : ayant bénéficié d’une fermeture percutanée du FOP et 47 sujets sains comme contrôles appariés pour l’âge, le sexe et la surface corporelle.
Résultats
Les diamètres aortiques etaient significativement plus large chez les patients avec FOP que chez les contrôles. Les différences étaient surtout marquées au niveau des sinus de Valsalva (34 ± 4 vs 31 ± 3 mm, p < 0,01) et de l’aorte tubulaire (32 ± 4 vs 29 ± 3, p < 0,01) et moins au niveau de l’anneau (23 ± 3 vs 22 ± 2 mm, p = 0,20). Les patients avec un shunt important présentaient également des dimensions aortique plus importantes. À l’inverse, les dimensions ventriculaires n’étaient pas plus large chez les patients que chez les contrôles (30 ± 4 vs 32 ± 5, p = 0,10 et 48 ± 5 vs 50 ± 4 mm, p = 0,04, respectivement).
Conclusions
Cette étude montre que les dimensions aortiques sont plus importantes chez les patients avec FOP ayant présenté un AVC idiopathique que chez les sujets contrôles. Ces résultats suggèrent que la dilatation aortique pourrait être un facteur favorisant d’AVC chez les patients présentant un FOP et nécessite des études complémentaires.
Introduction
Patent foramen ovale (PFO) has been linked with an increased risk of cerebrovascular accident (CVA) in case-controlled studies , especially when associated with an atrial septal aneurysm (ASA) . However, PFO is a common finding in the general population (up to 25%) and factors that may potentiate the risk of stroke (in addition to the presence of a PFO) are of great interest . Case reports and one retrospective series have indicated a possible association between aortic root dilatation (particularly aneurysm formation) and right-to-left shunting. However, no previous study has looked for an association between aortic dilatation and the clinical sequelae of PFO. Thus, the aim of the present study was to compare aortic dimensions in patients with symptomatic PFO and in healthy controls hypothesizing that they would be larger in patients with PFO.
Methods
Population
Patients who have undergone PFO closure at our institution are enrolled into a database, which was reviewed to identify patients who presented with cryptogenic CVA as defined by the referring neurologist, had a PFO confirmed by a transthoracic echocardiography (TTE) contrast study, were aged less than 50 years and underwent percutaneous PFO closure. The database was reviewed for clinical variables including height, weight, body surface area (BSA), modifiable cardiovascular risk factors, history of migraine and the presence of ASA. Patients with PFO were matched for age, sex and BSA with healthy volunteers (nurses, medical students, physicians) with no previous medical history, who were not taking any medication and had no modifiable cardiovascular risk factors.
Echocardiographic analysis
TTE was performed using high-quality commercially available ultrasound systems (iE33 [Royal Philips Electronics, Amsterdam, The Netherlands] and Vivid 7 [GE Healthcare, Chalfont St. Giles, UK]). A PFO was considered present when a contrast test with agitated saline solution, at rest and during a Valsalva manoeuvre, showed an interatrial shunt with an early (within three cardiac cycles) opacification of the left atrium . ASA was defined as an interatrial septum (IAS) of abnormal mobility with protrusion of the septum into the left or right atrium by at least 10 mm beyond the baseline . Measurements of the aortic root and proximal ascending aorta were made retrospectively using the same methodology in controls and patients, from two-dimensional digitalized images and videos stored on the network, in the parasternal long-axis view, perpendicular to the long axis of the vessel, from leading edge to leading edge by one operator. Measurements were made at three levels: the aortic annulus, the sinuses of Valsalva and the proximal ascending aorta, 1 cm above the sinotubular junction. As is conventional, the aortic annulus diameter was measured at end systole, while the diameters at the sinuses of Valsalva and in the proximal ascending aorta were measured at end diastole . In addition, left ventricular end-diastolic and end-systolic diameters were measured in the parasternal long-axis view using M-mode.
Statistics and ethics
Continuous variables are expressed as mean ± standard deviation. Comparisons between PFO patients and controls were performed using the t test or the Khi 2 test, as appropriate. Variability in diameter measurements was calculated at each level (aortic annulus, sinuses of Valsalva and proximal ascending aorta) as the absolute difference between measurements performed weeks apart by the same operator (intraobserver variability) or different operators (interobserver variability). As this was a retrospective analytical study and the patients required no additional investigations, only verbal consent was obtained. Healthy controls are enrolled in an ongoing prospective study.
Results
Baseline characteristics
Between September 2006 and July 2009, 47 PFO patients with cryptogenic CVA and PFO met the enrolment criteria and were matched with 47 healthy controls. The characteristics of both populations are given in Table 1 . By design, there were no significant differences between populations in terms of age, sex, height, weight or BSA. No PFO patient was hypertensive. Nine (19%) PFO patients had a history of migraine, 35 (74%) met the diagnostic criteria for ASA and 23 (49%) had massive right-to-left shunting, as indicated by the passage of greater than 30 microbubbles spontaneously without a Valsalva manoeuvre during a TTE contrast study.
| Healthy volunteers ( n = 47) | Patients with patent foramen ovale ( n = 47) | P | |
|---|---|---|---|
| Age (years) | 35 ± 12 | 37 ± 7 | 0.3 |
| Men | 27 (57) | 28 (60) | 0.8 |
| Height (m) | 1.72 ± 0.09 | 1.72 ± 0.10 | 0.9 |
| Weight (kg) | 72 ± 11 | 74 ± 14 | 0.4 |
| Body surface area (kg/m 2 ) | 1.85 ± 0.16 | 1.88 ± 0.21 | 0.5 |
| End-diastolic left ventricular diameter | 50 ± 4 | 48 ± 5 | 0.10 |
| End-systolic left ventricular diameter | 32 ± 5 | 30 ± 4 | 0.04 |
| Aortic diameters | |||
| Aortic annulus | 22 ± 2 | 23 ± 3 | 0.2 |
| Sinuses of Valsalva | 31 ± 3 | 34 ± 4 | < 0.01 |
| Proximal ascending aorta | 29 ± 3 | 32 ± 4 | < 0.01 |
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