Patent foramen ovale in patients with cerebral infarction. A transesophageal echocardiographic study
G. W. Petty, B. K. Khandheria, C. P. Chu, J. D. Sicks and J. P. Whisnant
Division of Cerebrovascular Diseases, Mayo Clinic, Rochester, Minn., USA.
OBJECTIVES: To determine the frequency of patent foramen ovale (PFO) among
various subtypes of cerebral infarction. To determine whether any
historical or clinical characteristics predict the presence or absence of
PFO in these patients. DESIGN: Comorbidity and infarct subtype study.
SETTING: Referral-based study. PATIENTS: One hundred sixteen patients with
cerebral infarction consecutively referred for transesophageal
echocardiography during a 6-month period. MAIN OUTCOME MEASURES: Infarct
subtype classification was made using a clinical and radiographic
diagnostic rubric similar to that used by the Stroke Data Bank of the
National Institute of Neurological Diseases and Stroke. The frequency of
various risk factors and clinical characteristics in patients with and in
those without PFO and the frequency of PFO in patients with various infarct
subtypes were compared (chi 2 or Fisher exact tests). RESULTS: Patent
foramen ovale was detected in 37 patients (32%). Mean age was similar in
those with (60 years) and those without (64 years) PFO. Patent foramen
ovale was more frequent among men (39%) than women (20%, P = .03). Patients
with PFO had a lower frequency of atrial fibrillation, diabetes mellitus,
hypertension, and peripheral vascular disease compared with those without
PFO. There was no difference in frequency of the following characteristics
in patients with PFO compared with those without PFO: pulmonary embolus,
chronic obstructive pulmonary disease, pulmonary hypertension, peripheral
embolism, prior cerebral infarction, nosocomial cerebral infarction,
Valsalva maneuver at the same time of cerebral infarction, recent surgery,
or hemorrhagic transformation of cerebral infarction. Patent foramen ovale
was found in 22 (40%) of 55 patients with infarcts of uncertain cause and
in 15 (25%) of 61 with infarcts of known cause (cardioembolic, 21%; large
vessel atherostenosis, 25%; lacune, 40%) (P = .08). When the analysis was
restricted to patients who underwent Valsalva maneuver, PFO with right to
left or bidirectional shunt was found in 19 (50%) of 38 patients with
infarcts of uncertain cause and in 6 (20%) of 30 with infarcts of known
cause (P = .01). CONCLUSION: Although PFO was overrepresented in patients
with infarcts of uncertain in our and other studies, it has a high
frequency among patients with cerebral infarction of all types. The
relation between PFO and stroke requires further study.
