Original Article
Recurrent Cerebrovascular Events Associated with Patent Foramen Ovale, Atrial Septal Aneurysm, or Both
N Engl J Med 2001; 345:1740-1746December 13, 2001
- Abstract
Background
Patent foramen ovale and atrial septal aneurysm have been identified as potential risk factors for stroke, but information about their effect on the risk of recurrent stroke is limited. We studied the risks of recurrent cerebrovascular events associated with these cardiac abnormalities.
Methods
A total of 581 patients (age, 18 to 55 years) who had had an ischemic stroke of unknown origin within the preceding three months were consecutively enrolled at 30 neurology departments. All patients received aspirin (300 mg per day) for secondary prevention.
Results
After four years, the risk of recurrent stroke was 2.3 percent (95 percent confidence interval, 0.3 to 4.3 percent) among the patients with patent foramen ovale alone, 15.2 percent (95 percent confidence interval, 1.8 to 28.6 percent) among the patients with both patent foramen ovale and atrial septal aneurysm, and 4.2 percent (95 percent confidence interval, 1.8 to 6.6 percent) among the patients with neither of these cardiac abnormalities. There were no recurrences among the patients with an atrial septal aneurysm alone. The presence of both cardiac abnormalities was a significant predictor of an increased risk of recurrent stroke (hazard ratio for the comparison with the absence of these abnormalities, 4.17; 95 percent confidence interval, 1.47 to 11.84), whereas isolated patent foramen ovale, whether small or large, was not.
Conclusions
Patients with both patent foramen ovale and atrial septal aneurysm who have had a stroke constitute a subgroup at substantial risk for recurrent stroke, and preventive strategies other than aspirin should be considered.
Media in This Article
Figure 1
Probability That Patients Will Remain Free from Recurrent Stroke or Transient Ischemic Attack (TIA), According to the Presence or Absence of Atrial Septal Abnormalities.Table 1
Base-Line Characteristics of the Patients, According to the Presence or Absence of Atrial Septal Abnormalities.Article Activity
- Article
During the past 15 years, the potential role of patent foramen ovale and atrial septal aneurysm in the genesis of ischemic stroke in young adults1-6 has been investigated. In addition to uncertainty about the mechanisms of stroke,7 therapeutic decisions are hindered by the lack of precise data on the risk of recurrent stroke. The few studies of this topic8-14 were retrospective, did not include a control group of patients with neither of these septal abnormalities, involved small numbers of patients, or used heterogeneous treatments for secondary prevention. In addition, the variability in the diagnosis of these septal abnormalities was usually not taken into account.
This follow-up study was designed to assess the absolute and relative risks of recurrent cerebrovascular events associated with these septal disorders in young patients with an otherwise unexplained ischemic stroke who were receiving aspirin and to identify subgroups of patients with a high risk of recurrent stroke.
Methods
Patients were consecutively enrolled at 30 neurology departments in Europe between May 1, 1996, and December 31, 1998, and were followed until December 31, 2000. Eligible patients were 18 to 55 years of age and had had an ischemic stroke (defined as a neurologic deficit that lasted more than 24 hours) within the preceding three months for which no definite cause had been identified after a standardized workup. Patients were excluded if the workup had been incomplete, if there was a contraindication to aspirin therapy, or if certain circumstances made follow-up impractical or compliance with treatment uncertain.
To assess the overall proportion of patients who were included in the study, 18 centers kept a registry of all patients 18 to 55 years of age with a recent (within three months) history of ischemic stroke who were seen during the enrollment period, with the reasons for exclusion from the study. The protocol conformed to the ethical guidelines of our institutions, and all participants gave written informed consent.
Data Collection
Risk factors for stroke, past vascular events, neurologic features, and the severity of stroke15 were systematically recorded. In addition to cerebral computed tomography (in 535 patients) or magnetic resonance imaging (in 428), all patients had a standardized workup to rule out definite causes of stroke. The workup comprised routine blood tests and a coagulation study (including tests for protein S, protein C, antithrombin III, and antiphospholipid antibodies), 12-lead electrocardiography and echocardiography, and at least one of the following vascular studies (within one month after the onset of stroke): catheter angiography (in 360 patients), magnetic resonance angiography (in 220), and cervical and transcranial ultrasonography (in 495). The decisions to perform additional investigations and to search for latent venous thrombosis were left to the discretion of the patients' physicians.
The following disorders were considered to be definite causes of stroke and led to exclusion16: large-artery atherosclerosis (defined by stenosis of at least 50 percent or occlusion of the corresponding vessel); lacunar stroke (defined by a small, deep infarct less than 15 mm in diameter in a patient with hypertension); cardioembolic causes, such as atrial fibrillation, recent (within four months before the stroke) myocardial infarction, dilated cardiomyopathy, rheumatic mitral stenosis, mitral or aortic vegetations or prostheses, left atrial or left ventricular thrombus or tumor, akinetic left ventricular segment, spontaneous echo contrast of the left atrium, and complex atheroma of the aortic arch; and other definite causes of stroke, such as nonatherosclerotic arteriopathies (e.g., dissection), coagulopathies, hematologic or systemic disorders (e.g., the antiphospholipid-antibody syndrome), or migrainous infarction.17
For each patient, the clinical, laboratory, and imaging data were reviewed by two neurologists and two neuroradiologists at the coordinating center who were unaware of the results of transesophageal echocardiography. Data on patients with a potential violation of the inclusion or exclusion criteria were reviewed by a validation committee.
Echocardiography
All patients underwent transthoracic and transesophageal echocardiography, performed by experienced sonographers according to a strictly predefined protocol.18 Patients were assessed for a patent foramen ovale and an atrial septal aneurysm at rest and during provocative maneuvers (Valsalva's maneuver and coughing), with the use of transesophageal echocardiography with contrast medium and 5-MHz multiplane transducers (in 86.4 percent of patients) or biplane transducers (in 13.6 percent). Examinations were recorded on videotape, and the videotapes were sent to the coordinating center for subsequent analysis.
To determine the degree of variability in the diagnosis of interatrial septal abnormalities, three sonographers independently reviewed, on two occasions each, videotapes from the first 100 patients.18 Given the substantial degree of disagreement among the three reviewers,18 all videotapes were reviewed independently by two sonographers who were unaware of patients' clinical data and outcomes.
A right-to-left shunt was diagnosed if at least three microbubbles appeared in the left atrium, either spontaneously or after provocative maneuvers, within three cardiac cycles after the complete opacification of the right atrium. The degree of shunting was defined as small if 3 to 9 microbubbles appeared, moderate if 10 to 30 microbubbles appeared, and large if more than 30 microbubbles appeared. An atrial septal aneurysm was diagnosed when the atrial septum extended at least 11 mm into the left or the right atrium, or both. The size of the aneurysm was classified as either 11 to 14 mm or 15 mm or more. The diagnosis of an atrial septal defect rested on the direct visualization of a septal defect on transesophageal echocardiography and on the recording of turbulent left-to-right flow across the defect on color-flow Doppler echocardiography.
The sonographers disagreed on the presence of patent foramen ovale in 13.9 percent of patients, the presence of atrial septal aneurysm in 6.6 percent, the degree of shunting in 26.6 percent, and the size of the aneurysm in 10.0 percent. In such cases, the videotapes were reviewed by the sonographers and a consensus was reached.
Treatment and Follow-up
After the index stroke but before enrollment, the use of antithrombotic therapy was governed by policy at each center. Secondary prevention with aspirin (300 mg daily) was started on the day of enrollment. In patients with deep venous thrombosis associated with stroke, aspirin was started after a three-to-six-month course of systemic anticoagulation. Vascular risk factors (including the use of hormonal contraception) were managed according to standard guidelines. Follow-up visits with the neurologists took place every six months. To assess a patient's compliance with aspirin therapy, the neurologist asked the patient at each visit whether he or she had temporarily stopped taking the drug since the last visit, and if so, for how long and for what reason.
The following outcome events were systematically recorded: stroke, defined by the acute occurrence of focal neurologic signs lasting for more than 24 hours in a different location from that of the previous stroke or worsening of an existing deficit that lasted for more than one week, or more than 24 hours if accompanied by a new lesion on neuroimaging; transient ischemic attack19; systemic embolism; myocardial infarction; and death. We assessed a patient's functional outcome after a recurrent stroke by comparing the Rankin scores recorded before and six months (plus or minus three months) after the event. In the case of a single transient ischemic attack, continuation of aspirin was recommended. In the case of multiple transient ischemic attacks, the decision whether to discontinue aspirin therapy was left to the patient's physician. All outcome events were documented and reviewed by the members of the validation committee, who were unaware of the results of echocardiography.
Statistical Analysis
Comparisons between groups were analyzed with use of the chi-square test, Fisher's exact test, t-test for unpaired data, or analysis of variance, as appropriate. Potential risk factors for recurrent cerebrovascular events that were independently associated with atrial septal abnormalities were identified by logistic-regression analysis.20
Kaplan–Meier survival analysis20 was used to assess the absolute risk of recurrent cerebrovascular events. The predictive value of each category of septal abnormality (no atrial septal abnormality, patent foramen ovale alone, atrial septal aneurysm alone, or both septal abnormalities) and of the degree of shunting with respect to recurrent cerebrovascular events was assessed with use of log-rank tests and Cox proportional-hazards models,20 to adjust for age, sex, and the number of traditional vascular risk factors (hypertension, diabetes, hypercholesterolemia, and smoking). The same analyses were performed in the 215 patients with no traditional risk factors for stroke. All tests were two-tailed.
On the basis of a preliminary study,9 we estimated that a total of 600 patients was required for the study to have the statistical power to detect at a level of 95 percent confidence a sampling error of no more than 1.5 percent, given a four-year rate of recurrent stroke of 4 percent.
Results
A total of 598 patients were enrolled in the study; 17 were subsequently excluded by the validation committee because they did not fulfill one or more of the inclusion criteria. Among 1340 consecutive young patients with stroke who were screened for possible inclusion in the study at 18 centers, 51.3 percent were not eligible because they had a definite cause of stroke, 21.9 percent had another reason for exclusion, and 26.8 percent were included in the study. Except for one patient who underwent surgical closure of the foramen, no patient was excluded because of the presence of a patent foramen ovale, an atrial septal aneurysm, or deep venous thrombosis.
Characteristics of the Patients
The base-line characteristics of the 304 patients without atrial septal abnormalities and the 277 patients with atrial septal abnormalities are shown in Table 1Table 1
Base-Line Characteristics of the Patients, According to the Presence or Absence of Atrial Septal Abnormalities.. There were no significant differences in these characteristics among the three groups with septal abnormalities — the 216 patients with patent foramen ovale alone, the 10 with atrial septal aneurysm alone, and the 51 with both abnormalities. In logistic-regression analysis, patients with septal abnormalities, as compared with those without such abnormalities, were younger, less likely to have hypertension (odds ratio, 0.52; 95 percent confidence interval, 0.31 to 0.88), less likely to have hypercholesterolemia (odds ratio, 0.60; 95 percent confidence interval, 0.37 to 0.98), less likely to be current smokers (odds ratio, 0.70; 95 percent confidence interval, 0.49 to 0.99), and more likely to have migraine (odds ratio, 1.96; 95 percent confidence interval, 1.24 to 3.12). The prevalence of atrial septal aneurysm was higher among patients with a patent foramen ovale than among those without it (19.1 percent vs. 3.2 percent, P<0.001) and increased with the degree of shunting (4.4 percent, 12.5 percent, and 25 percent in patients with small, moderate, and large shunts, respectively; P<0.001). No significant relation was found between the size of the aneurysm and the degree of shunting. Eleven patients had an atrial septal defect.Recurrent Events
Of the 581 patients, 2 were lost to follow-up. Neither had septal abnormalities. Table 2Table 2
Outcome According to the Presence or Absence of Atrial Septal Abnormalities. shows the outcome events during a mean (±SD) follow-up of 37.8±9.7 months. Of the 24 patients with a recurrent stroke, only 7 had a decrease in functional status, according to the Rankin score; 6 of the 7 had no septal abnormalities (P=0.07). None of the patients with an atrial septal defect had a recurrent cerebrovascular event.Aspirin therapy was initiated a mean of 25.1±20.7 days after the index stroke in the population as a whole, and the time of initiation did not differ significantly among the four groups of patients (P=0.1). Aspirin was discontinued in 20 patients because of an outcome event, in 21 at the request of the patient or his or her physician, in 16 because of a drug-induced adverse event, and in 16 for other reasons. Aspirin was replaced by another antiplatelet agent in 31 patients and by oral anticoagulants in 18 patients, whereas 24 patients received no further treatment. Overall, 92 percent of the patients received antiplatelet drugs for more than 90 percent of their follow-up period, with no significant difference in treatment rates among patients with no atrial septal abnormalities, those with both abnormalities, those with patent foramen ovale alone, and those with atrial septal aneurysm alone. All recurrent cerebrovascular events were in patients who were taking antiplatelet drugs.
The risk of recurrent cerebrovascular events according to the presence or absence of atrial septal abnormalities is shown in Table 3Table 3
Kaplan–Meier Estimates of the Risk of Recurrent Cerebrovascular Events within Four Years after the Index Stroke. and Figure 1Figure 1Probability That Patients Will Remain Free from Recurrent Stroke or Transient Ischemic Attack (TIA), According to the Presence or Absence of Atrial Septal Abnormalities.. The likelihood of survival free from stroke (P=0.03) or from stroke or transient ischemic attack (P=0.04) differed significantly between groups. In Cox analyses (Table 4Table 4
Cox Proportional-Hazard Models of the Predictors of Recurrent Cerebrovascular Events.), the presence of both atrial septal abnormalities was a significant predictor of an increased risk of recurrent cerebrovascular events, whereas the presence of a patent foramen ovale alone or an atrial septal aneurysm alone was not. The risk of recurrent stroke increased with age. The risk was higher in males than in females, but not significantly so, and it increased with the number of vascular risk factors, but not significantly so.The degree of shunting was not a significant predictor of the risk of recurrent cerebrovascular events (hazard ratio for small shunts, as compared with the absence of shunts, 1.01; 95 percent confidence interval, 0.23 to 4.52; hazard ratio for large shunts, 1.10; 95 percent confidence interval, 0.39 to 3.11; and hazard ratio for medium shunts, 1.60; 95 percent confidence interval, 0.57 to 4.51). The small number of patients with an atrial septal aneurysm precluded meaningful analysis of the role of the size of the aneurysm in the recurrence of stroke. The predictive value of the presence of both cardiac abnormalities remained significant in the subgroup of 215 patients with no traditional vascular risk factors (hazard ratio, 5.37; 95 percent confidence interval, 1.31 to 21.92).
Discussion
In this prospective, multicenter study, we used a standardized treatment to assess the relative and absolute risks of recurrent cerebrovascular events associated with the presence of a patent foramen ovale, an atrial septal aneurysm, or both abnormalities. We selected patients who were no older than 55 years of age because the higher prevalence of large-vessel atherosclerosis or small-artery disease in the elderly makes the diagnosis of cryptogenic stroke less frequent than in the young. In addition, the association of patent foramen ovale with cryptogenic stroke has been consistently reported in this age group, whereas the association in those older than 55 years remains uncertain.6 Reported rates of detection of atrial septal abnormalities in patients who have had a cryptogenic stroke range from 31 to 77 percent for patent foramen ovale and from 4 to 25 percent for atrial septal aneurysm.6 In the present study, an independent review of echocardiograms yielded results within these ranges.
An important finding of this study is that patients with both a patent foramen ovale and an atrial septal aneurysm who had had a cryptogenic stroke had a higher risk of recurrent stroke while taking aspirin than did patients with no septal abnormality or either septal abnormality alone. Indeed, the presence of both abnormalities was the only septal disorder significantly associated with an increased risk of recurrent stroke, and this finding remained significant when the analysis was restricted to patients who had no traditional vascular risk factors. This result is consistent with the results of our previous retrospective study,9 in which the combination of both septal abnormalities was also the only septal disorder predictive of an increased risk of recurrent stroke. Patients with both cardiac lesions in that study had an annual rate of recurrent stroke of 4.4 percent, which is very close to the rate we found in the present study. Case–control studies have also shown that the presence of both abnormalities is consistently more strongly associated with an increased risk of ischemic stroke than is the presence of either factor alone.5,6,8 Given the prognostic and potential therapeutic implications, young patients who have had an ischemic stroke should be examined for both septal disorders.
Another important finding of this study is that young patients with patent foramen ovale alone, whether small or large, who had had a cryptogenic stroke did not have a higher risk of recurrent stroke while taking aspirin than patients with no septal abnormalities. The low absolute risk of recurrent cerebrovascular events in these patients is consistent with rates reported in previous smaller, retrospective studies.8-14 This finding apparently contrasts with the results of case–control studies showing that patent foramen ovale is significantly associated with an increased risk of cryptogenic stroke, particularly in patients with a large degree of shunting.6,10,14,21-24 These studies, however, did not focus on the risk of recurrent stroke.
Potential mechanisms of stroke in patients with atrial septal abnormalities include paradoxical embolism from a venous source,7,25 direct embolization from thrombi formed within the aneurysm,26-28 and the formation of thrombus as a result of atrial arrhythmias.29 In patients with both septal abnormalities, the motion of the fossa ovalis membrane could be responsible. The motion of the fossa ovalis membrane may promote paradoxical shunting through mechanical action by enhancing the preferential orientation of the flow from the inferior vena cava toward the foramen ovale.14 The combination of both septal disorders may also indicate the presence of more severe disease of the atrial septum, which increases the likelihood of the local formation of thrombus, arrhythmias, or both. The patency of the foramen may allow a thrombus formed on the right atrial side of the aneurysm to reach the systemic circulation.
Secondary prevention for patients with a patent foramen ovale or an atrial septal aneurysm who have had a stroke is a subject of considerable debate. Accordingly, these patients have been treated empirically with antiplatelet drugs or anticoagulants, transcatheter closure of the foramen, or open-heart surgery.30,31 Our findings suggest that secondary prevention with aspirin is sufficient in young patients who have an isolated patent foramen ovale and who have had a single otherwise unexplained ischemic stroke. Together with previous evidence, our findings strongly suggest that patients with both a patent foramen ovale and an atrial septal aneurysm who have had a cryptogenic stroke constitute a subgroup with a higher risk of recurrent stroke. Whether these patients would benefit from more aggressive therapeutic strategies, such as a combination of antiplatelet drugs, long-term anticoagulation, or closure of the foramen ovale, needs to be assessed in randomized clinical trials.
Supported by grants from the Programme Hospitalier de Recherche Clinique of the French Ministry of Health (AOM95059) and Sanofi–Synthelabo Laboratories.
Source Information
From the Department of Neurology, Sainte-Anne Hospital, Paris V University, Paris (J.-L.M., C.A., C.L., M.Z.); the Departments of Cardiology (L.C.) and Biostatistics (J.C.), Cochin Hospital, Paris V University, Paris; and the Department of Cardiology, Charles Nicolle Hospital, Rouen University, Rouen, France (G.D.).
Address reprint requests to Dr. Mas at the Service de Neurologie, Hôpital Sainte-Anne, 1 rue Cabanis, 75674 Paris CEDEX 14, France, or at mas@chsa.broca.inserm.fr.
The members of the study group are listed in the Appendix.
Appendix
The members of the study group and the numbers of patients enrolled at each center (given in parentheses) were as follows: Coordinating center, Sainte-Anne Hospital, Paris — J.L. Mas, C. Arquizan, C. Lamy, M. Zuber, C. Gianesini, D. Trystram, J.F. Méder; Scientific committee — J.L. Mas (chair), Y. Bernard, B. Bertrand, J. Bogousslavsky, F. Chollet, L. Cabanes, A. Cohen, J.M. Ferro, H. Kwiecinski, J.P. Lesbre, D. Leys, T. Moulin, J.F. Pinel, R. Roudaut, D. Saudeau, F. Woimant; Transesophageal echocardiography committee — L. Cabanes, G. Derumeaux, X. Jeanrenaud, A. Cohen; Validation committee — P. Césaro, M. Giroud, F. Nicoli, S. Weber; Participating institutions and investigators — Centre Hospitalier Universitaire (CHU) Besançon, Besançon, France (62): T. Moulin, L. Tatu, A. Vuillemenot, D. Magnin, M.F. Seronde, F. Apffel, N. Meneveau, Y. Bernard; CHU Lariboisière and Saint-Antoine, Paris (61): F. Woimant, P. Amarenco, N. Kubis, K. Vahedi, I. Crassard, G. Ast, H. Chabriat, M. Sarazin, M. Haguenau, J.M. de Kermadec, A. N'Guyen Van Cao, S. Mazouz, B. Benhalima, C. Albo, A. Cohen, M. Khireddine, N. Lamisse; Sainte-Anne Hospital and CHU Cochin Port-Royal, Paris (52): L. Cabanes, I. Cornuejols, E. Lombard; CHU Nancy, Nancy, France (41): X. Ducrocq, J.C. Lacour, J.F. Bruntz, I. Magnin-Poull; CHU Tours, Tours, France (38): D. Saudeau, A. Sirinelli; CHU Rennes, Rennes, France (33): J.F. Pinel, C. de Place, M. Laurent, C. Bossee-Pilon; Medical University of Warsaw, Warsaw, Poland (27): H. Kwiecinski, B. Szyluk, A. Opuchlik, J. Mieszkowski, A. Torbicki, P. Pruszczyk, A. Kuch-Wocial; CHU Poitiers, Poitiers, France (21): J.P. Neau, C. Couderq, D. Coisne, G. Bacque, L. Christiaens, C. Couderq, P. Raud-Raynier; CHU Vaudois, Lausanne, Switzerland (21): P. Arnold, M. Altieri, J. Bogousslavsky, M. Nasratullah, N. Aebischer, X. Jeanrenaud; CHU Rouen, Rouen, France (20): E. Guégan-Massardier, B. Mihout, D. Thomas, G. Derumeaux, J.L. Gauthier; CHU Pitié-Salpêtrière, Paris (19): R. Manai, Y. Samson, G. Rancurel, E. Coignard, R. Isnard; CHU La Timone, Marseilles, France (18): L. Milandre, G. Habib; CHU Lille, Lille, France (16): D. Leys, C. Lucas, C. Savoye, L. Goullard, E. Chammas; Centre Hospitalier Général, Meaux, France (16): F. Chedru, A. Ameri, J.F. Lefort; CHU Saint-Etienne, Saint-Etienne, France (14): P. Garnier, D. Michel, C. Comtet, I. Cusey; Santa Maria Hospital, University of Lisbon, Lisbon, Portugal (14): T. Pinho e Melo, J.M. Ferro, P. Canhao, F. Falcao, F. Pais, I. Dionisio, M. Fiuza; CHU Bordeaux, Bordeaux, France (11): P. Gaïda, F. Rouanet, M. Marazanof, R. Roudaut, P. Laffort; CHU Grenoble, Grenoble, France (11): G. Besson, A. Jaillard, M. Hommel, B. Bertrand, J.P. Baguet; CHU Purpan, Toulouse, France (11): J.F. Albucher, M. Andrieu, N. Blot-Souletie, M. Elbaz, E. Maupas; Klinikum Grosshadern, Ludwig Maximilians University, Munich, Germany (11): T. Pfefferkorn, G. Hamann, W. von Scheidt; Dr. Schaffner Hospital, Lens, France (10): F. Mounier-Véhier, R. Deturck; CHU Rangueil, Toulouse, France (9): V. Larrue, P. Massabuau; CHU Nice, Nice, France (8): M.H. Mahagne, P. Gibelin; CHU Brest, Brest, France (8): Y. Mocquard, F. Rouhart, P. Diraison, Y. Jobic; CHU Angers, Angers, France (6): H. Brugeilles, C. Moreau, J. Laporte; Jolimont Hospital, Haine-Saint-Paul, Belgium (6): G. Devuyst, P. Bara, M. Vandooren, R. Luwaert; Tenon Hospital, CHU Saint-Antoine, Paris (5): S. Alamowitch, C. Roos, E. Garbarz, B. Cormier; E. Muller Hospital, Mulhouse, France (5): G. Rodier, S. Hass; Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium (5): S. Blecic, P. Unger; CHU Clermont-Ferrand, Clermont-Ferrand, France (2): A. Coustes-Durieux, P. Marcollet.
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Citing Articles
1
Kalpana Yeddula, Iftikhar Ahmad, Shafaath Husain Syed Mohammed, Sandeep Hedgire, Vikram Venkatesh, Suhny Abbara, Sanjeeva P. Kalva. (2012) Paradoxical air embolism following contrast material injection through power injectors in patients with a patent foramen ovale. The International Journal of Cardiovascular Imaging
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Roberta Esposito, Rosa Raia, Daniela De Palma, Ciro Santoro, Maurizio Galderisi. (2012) The role of echocardiography in the management of the sources of embolism. Future Cardiology 8:1, 101-114
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Niall G. Keenan, Éric Brochet, Jean-Michel Juliard, Mihaela Malanca, Pierre Aubry, Laurent Lepage, Caroline Cueff, Guillaume Jondeau, Bernard Iung, Alec Vahanian, David Messika-Zeitoun. (2012) Aortic root dilatation in young patients with cryptogenic stroke and patent foramen ovale. Archives of Cardiovascular Diseases
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F. Praz, S. Beney, A. Wahl, S. Windecker, B. Meier. (2012) Long-term follow-up after percutaneous closure of patent foramen ovale for secondary prevention of paradoxical embolism in elderly patients (≥70 years). European Geriatric Medicine
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Dieter Fischer, Ajmal Gardiwal, Jonas Haentjes, Gunnar Klein, Gerd-Peter Meyer, Helmut Drexler, Dirk Hausmann, Arnd Schaefer. (2011) Sustained risk of recurrent thromboembolic events in patients with patent foramen ovale and paradoxical embolism: long-term follow-up over more than 15 years. Clinical Research in Cardiology
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Takuya Fukuoka, Tomohisa Dembo, Harumitu Nagoya, Yuji Kato, Ohe Yasuko, Ichiro Deguchi, Hajime Maruyama, Yohsuke Horiuchi, Hidetaka Takeda, Norio Tanahashi. (2011) Factors related to recurrence of paradoxical cerebral embolism due to patent foramen ovale. Journal of Neurology
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Omar A. Jarral, Srdjan Saso, Joshua A. Vecht, Leanne Harling, Christopher Rao, Kamran Ahmed, Michael A. Gatzoulis, Iqbal S. Malik, Thanos Athanasiou. (2011) Does patent foramen ovale closure have an anti-arrhythmic effect? A meta-analysis. International Journal of Cardiology 153:1, 4-9
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Ehsan Yaghoubi, Reza Nemati, Kamran Aghasadeghi, Afshin Borhani Haghighi. (2011) The diagnostic efficiency of transesophageal compared to transthoracic echocardiographic findings from 405 patients with ischemic stroke. Journal of Clinical Neuroscience 18:11, 1486-1489
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PAOLO SCACCIATELLA, GIANFRANCO BUTERA, ILARIA MEYNET, MAURO GIORGI, MAURIZIO D’AMICO, MAURO PENNONE, GIANLUCA ALUNNI, VALERIA FRISENDA, ELISA PELLONI, SEBASTIANO MARRA. (2011) Percutaneous Closure of Patent Foramen Ovale in Patients with Anatomical and Clinical High-Risk Characteristics: Long-Term Efficacy and Safety. Journal of Interventional Cardiology 24:5, 477-484
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Jean Michel Yeguiayan, Isabelle Benatru, Boris Guiu, Jamal Abou Taam, Serge Albertini, Marc Freysz, Maurice Giroud. (2011) Recombinant tissue plasminogen activator for both pulmonary and cerebral embolism. The American Journal of Emergency Medicine 29:8, 961.e1-961.e4
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Dilek Kosehan, Kayihan Akin, Asli Koktener, Banu Cakir, Ayse Aktas, Mehmet Teksam. (2011) Interatrial shunt: diagnosis of patent foramen ovale and atrial septal defect with 64-row coronary computed tomography angiography. Japanese Journal of Radiology 29:8, 576-582
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Paul E. Cotter, Peter J. Martin, Mark Belham. (2011) Toward understanding the atrial septum in cryptogenic stroke. International Journal of Stroke 6:5, 445-453
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Antonio Arauz, Luis Murillo, Juan Manuel Márquez, Arturo Tamayo, Carlos Cantú, Francisco-Javier Roldan, Jesús Vargas-Barrón, Fernando Barinagarrementeria. (2011) Long-term risk of recurrent stroke in young cryptogenic stroke patients with and without patent foramen ovale. International Journal of Strokeno-no
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Yoshiaki Shimada, Asako Yoritaka, Yasutaka Tanaka, Nobukazu Miyamoto, Yuji Ueno, Nobutaka Hattori, Urabe Takao. (2011) Cerebral Infarction in a Young Man Using High-dose Anabolic Steroids. Journal of Stroke and Cerebrovascular Diseases
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B. Fuentes, J. Gallego, A. Gil-Nuñez, A. Morales, F. Purroy, J. Roquer, T. Segura, J. Tejada, A. Lago, E. Díez-Tejedor. (2011) Guía para el tratamiento preventivo del ictus isquémico y AIT (I). Actuación sobre los factores de riesgo y estilo de vida. Neurología
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Yasufumi Kijima, Teiji Akagi, Manabu Taniguchi, Koji Nakagawa, Kentaro Deguchi, Tomoko Tomii, Kengo Kusano, Shunji Sano, Hiroshi Ito. (2011) Catheter closure of atrial septal defect in patients with cryptogenic stroke: initial experience in Japan. Cardiovascular Intervention and Therapeutics
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Soh Hosoba, Tomoaki Suzuki, Tohru Asai, Noriyuki Takashima. (2011) Surgical Repair of a Giant Atrial Septal Aneurysm with Patent Foramen Ovale. The Heart Surgery Forum 14:4, E267-E268
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Emiliano De Marchis, Silvia Di Legge, Fabrizio Sallustio, Paolo Stanzione, Mauro Borzi, Francesco Romeo. (2011) Cryptogenic cerebral ischemia. Journal of Cardiovascular Medicine 12:8, 530-537
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Lisa Dark, Andre Loiselle, Rachael Hatton, Rohan Bhagwandeen, Nicholas Collins. (2011) Stroke during Pregnancy: Therapeutic Options and Role of Percutaneous Device Closure. Heart, Lung and Circulation 20:8, 538-542
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Jasmeet Singh, Daisuke Kobayashi, Michael Y. Chen, Evelyn Y. Anthony, Derek A. Williams. (2011) Neonatal Systemic Thromboembolism Secondary to Ductus Arteriosus Aneurysm and Patent Foramen Ovale. Congenital Heart Diseaseno-no
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SHERMAN G. SORENSEN, RANDALL SMOUT, SPOTSWOOD L. SPRUANCE. (2011) Transcranial Doppler Quantification of Residual Shunt After Percutaneous Patent Foramen Ovale Closure: Efficacy of the GORE® HELEX Septal Occluder. Journal of Interventional Cardiology 24:4, 366-372
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C. Bancal, F. Arnoult, L. Krapf, M. Bonay. (2011) Foramen ovale perméable et hypoxémie avec ou sans élévation des pressions droites. Revue des Maladies Respiratoires
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Wei Wu, James Yip, Yong-Dan Tang, Vincent Khoo, Jen Fong Kong, Duc Duong-Hong, Freddy Boey, Subbu S. Venkatraman. (2011) A Novel Biodegradable Septal Defect Occluder. Innovations: Technology and Techniques in Cardiothoracic and Vascular Surgery 6:4, 221-230
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William David Freeman, Maria I. Aguilar. (2011) Prevention of Cardioembolic Stroke. Neurotherapeutics 8:3, 488-502
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Enver Yerlioglu, Vijay Krishnamoorthy, Hoonbae Jeon, Allen Gustin, Ramona Nicolau-Raducu. (2011) Patent Foramen Ovale and Intracardiac Thrombus Identified by Transesophageal Echocardiography During Liver Transplantation. Journal of Cardiothoracic and Vascular Anesthesia
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Aurora Bakalli, Dardan Koçinaj, Ljubica Georgievska-Ismail, Tefik Bekteshi, Ejup Pllana, Basri Sejdiu. (2011) Right bundle branch block as a marker for interatrial septal abnormalities. Cardiology in the Young1-8
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Justin G. Luermans, Werner Budts, Jurriën M. Ten Berg, Herbert W. Plokker, Maarten J. Suttorp, Martijn C. Post. (2011) Comparison of outcome after patent foramen ovale closure in older versus younger patients. EuroIntervention 7:2, 209-215
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Catherine N. Dao, Jonathan M. Tobis. (2011) PFO and paradoxical embolism producing events other than stroke. Catheterization and Cardiovascular Interventions 77:6, 903-909
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Larry B. Goldstein, Nada El Husseini. (2011) Neurología y cardiología: puntos de contacto. Revista Española de Cardiología 64:4, 319-327
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Abdolhamid Shariat, Ehsan Yaghoubi, Reza Nemati, Ali Reza Moaref, Kamran Aghasadeghi, Afshin Borhani Haghighi. (2011) Microembolic Signals in Patients with Cryptogenic Stroke with or Without Patent Foramen Ovale. Journal of Stroke and Cerebrovascular Diseases
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Larry B. Goldstein, Nada El Husseini. (2011) Neurology and Cardiology: Points of Contact. Revista Española de Cardiología (English Edition)
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C. Hamilton-Craig, A. Sestito, L. Natale, A. Meduri, P. Santangeli, F. Infusino, F. Pilato, V. Di Lazzaro, F. Crea, G. A. Lanza. (2011) Contrast transoesophageal echocardiography remains superior to contrast-enhanced cardiac magnetic resonance imaging for the diagnosis of patent foramen ovale. European Journal of Echocardiography 12:3, 222-227
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Annabelle Lao, Cindy J. Fuller, Jill T. Jesurum. 2011. Transcranial Doppler in the Detection and Quantitation of Patent Foramen Ovale and Other Right-to-Left Circulatory Shunts. , 187-197.
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DIETER FISCHER, JONAS HAENTJES, GUNNAR KLEIN, BERNHARD SCHIEFFER, HELMUT DREXLER, GERD P. MEYER, ARND SCHAEFER. (2011) Transcatheter Closure of Patent Foramen Ovale (PFO) in Patients with Paradoxical Embolism: Procedural and Follow-Up Results after Implantation of the Amplatzer®-Occluder Device. Journal of Interventional Cardiology 24:1, 85-91
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J. O. Na, S. Y. Shin, H. E. Lim, C. U. Choi, S. H. Kim, J. W. Kim, E. J. Kim, E. M. Lee, S.-W. Rha, C. G. Park, H. S. Seo, D. J. Oh, Y.-H. Kim. (2011) Impaired transport function of the left atrium and left atrial appendage in cryptogenic stroke patients with atrial septal aneurysm and without patent foramen ovale. European Journal of Echocardiography 12:2, 140-147
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Vijay K Sharma. (2011) Patent foramen ovale morphology and stroke size. Interventional Cardiology 3:1, 23-27
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Ravikiran Korabathina, David E. Thaler, Carey Kimmelstiel. (2011) Stroke due to late device thrombosis following successful percutaneous patent foramen ovale closure. Catheterization and Cardiovascular Interventionsn/a-n/a
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Cao-jin Zhang, Yi-gao Huang, Xin-sheng Huang, Tao Huang, Wen-hui Huang, Jun-jun Shen. (2011) Transcatheter Closure of Patent Foramen Ovale in Chinese Patients With Paradoxical Embolism. Circulation Journal 75:8, 1867-1871
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Petros Tzimas, Georgios Papadopoulos. (2011) Huge Interatrial Septal Aneurysm: A Coincidental but Rather Fatal Finding. Case Reports in Medicine 2011, 1-3
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Bruce Irwin, Simon Ray. (2011) Patent Foramen Ovale-Assessment and Treatment. Cardiovascular Therapeuticsno-no
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T. A. Vale, J. D. Newton, E. Orchard, R. Bhindi, N. Wilson, O. J. Ormerod. (2011) Prominence of the Eustachian valve in paradoxical embolism. European Journal of Echocardiography 12:1, 33-36
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Ronak Rajani, Lorraine Lee, Manav Sohal, Muhammed Khawaja, David Hildick-Smith. (2011) Redo patent foramen ovale closure for persistent residual right-to-left shunting. EuroIntervention 6:6, 735-739
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David M Kent, David E Thaler, . (2011) The Risk of Paradoxical Embolism (RoPE) Study: Developing risk models for application to ongoing randomized trials of percutaneous patent foramen ovale closure for cryptogenic stroke. Trials 12:1, 185
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M. Àngels Font, Jerzy Krupinski, Adrià Arboix. (2011) Antithrombotic Medication for Cardioembolic Stroke Prevention. Stroke Research and Treatment 2011, 1-23
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Yuji Kato, Tomohisa Dembo, Hidetaka Takeda, Norio Tanahashi. (2011) Significance of Eustachian valve in paradoxical cerebral embolism. Nosotchu 33:5, 480-487
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Silvia Di Legge, Fabrizio Sallustio, Emiliano De Marchis, Costanza Rossi, Giacomo Koch, Marina Diomedi, Mauro Borzi, Francesco Romeo, Paolo Stanzione. (2011) Short-Term and Two-Year Rate of Recurrent Cerebrovascular Events in Patients with Acute Cerebral Ischemia of Undetermined Aetiology, with and without a Patent Foramen Ovale. ISRN Neurology 2011, 1-6
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David M. Greer, Shunichi Homma, Karen L. Furie. 2011. Cardiac Diseases. , 814-827.
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Maria I. Aguilar, Oscar R. Benavente. 2011. Secondary Prevention of Cardioembolic Stroke. , 1173-1191.
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K. K. Galougahi, T. Stewart, C. Y. P. Choong, C. E. Storey, M. Yates, G. H. Tofler. (2010) The utility of transoesophageal echocardiography to determine management in suspected embolic stroke. Internal Medicine Journal 40:12, 813-818
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B. S. Rana, L. M. Shapiro, K. P. McCarthy, S. Y. Ho. (2010) Three-dimensional imaging of the atrial septum and patent foramen ovale anatomy: defining the morphological phenotypes of patent foramen ovale. European Journal of Echocardiography 11:10, i19-i25
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R. Weber, B. Frank, H.-C. Diener. (2010) Antithrombotische und Antikoagulanzientherapie nach Schlaganfall und transitorisch ischämischer Attacke. Der Nervenarzt 81:12, 1509-1519
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Mouhammad A. Jumaa, Lawrence R. Wechsler. (2010) Management of Patent Foramen Ovale and Stroke. Current Treatment Options in Neurology 12:6, 483-491
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José M Ferro, Ayrton R Massaro, Jean-Louis Mas. (2010) Aetiological diagnosis of ischaemic stroke in young adults. The Lancet Neurology 9:11, 1085-1096
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P. E. Cotter, M. Belham, P. J. Martin. (2010) Stroke in younger patients: the heart of the matter. Journal of Neurology 257:11, 1777-1787
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Stefano De Castro, Federica Papetti, Emanuele Di Angelantonio, Biljana Razmovska, Giovanni Truscelli, Ursula Tuderti, Emanuele Puca, Agata Correnti, Marco Fiorelli, Massimiliano Prencipe, Danilo Toni. (2010) Feasibility and Clinical Utility of Transesophageal Echocardiography in the Acute Phase of Cerebral Ischemia. The American Journal of Cardiology 106:9, 1339-1344
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Hans-Christoph Diener, Christian Weimar, Ralph Weber. (2010) Antiplatelet therapy in secondary stroke prevention - state of the art. Journal of Cellular and Molecular Medicine 14:11, 2552-2560
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P. A. Ringleb, M.-G. Bousser, G. Ford, P. Bath, M. Brainin, V. Caso, Á. Cervera, A.l Chamorro, Charlotte Cordonnier, L. Csiba, A. Davalos, H.-C. Diener, J. Ferro, W. Hacke, M. Hennerici, M. Kaste, P. Langhorne, K. Lees, D. Leys, J. Lodder, H. S. Markus, J.-L. Mas, H. P. Mattle, K. Muir, B. Norrving, V. Obach, S. Paolucci, E. B. Ringelstein, P. D. Schellinger, J. Sivenius, V. Skvortsova, K. Stibrant Sunnerhagen, L. Thomassen, D. Toni, R.r von Kummer, N. Gunnar Wahlgren, M. F. Walker, J. Wardlaw. 2010. Ischaemic Stroke and Transient Ischaemic Attack. , 101-158.
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Ulrich Laufs, Uta C. Hoppe, Stephan Rosenkranz, Paulus Kirchhof, Michael Böhm, Hans-Christoph Diener, Matthias Endres, Martin Grond, Werner Hacke, Thomas Meinertz, E. Bernd Ringelstein, Joachim Röther, Martin Dichgans. (2010) Cardiological evaluation after cerebral ischaemia. Clinical Research in Cardiology 99:10, 609-625
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Lonneke M. L. De Lau, Frank W. G. Leebeek, Moniek P. M. De Maat, Peter J. Koudstaal, Diederik W. J. Dippel. (2010) Reviews: A review of hereditary and acquired coagulation disorders in the aetiology of ischaemic stroke. International Journal of Stroke 5:5, 385-394
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Nishant Gupta, Chris Lau, Anthony Al-Dehneh, Joseph Daoko, Aman Vazir, Rupen Parikh, Anuj Agarwal, Will Newton, Wishwdeep Dhillon, Isha Gupta, Dipak Pandya, Vincent A. DeBari, Aiman Hamdan, Fayez Shamoon, Mahesh Bikkina. (2010) Importance of Performing Transesophageal Echocardiography in Acute Stroke Patients older than Fifty. Echocardiography 27:9, 1086-1092
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Luis Afonso, Anupama Kottam, Ashutosh Niraj, Joya Ganguly, Pawan Hari, Mengistu Simegn, Rajeev Sudhakar, Sony Jacob, Seemant Chaturvedi, Greg J. Ensing, Theodore P. Abraham. (2010) Usefulness of Intravenously Administered Fluid Replenishment for Detection of Patent Foramen Ovale by Transesophageal Echocardiography. The American Journal of Cardiology 106:7, 1054-1058
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Rui Andre Providencia. (2010) Headache and cardiovascular disease: old symptoms, new proposals. Future Cardiology 6:5, 703-723
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Vinod Kumar Gupta. (2010) Patent foramen ovale closure and migraine: science and sensibility. Expert Review of Neurotherapeutics 10:9, 1409-1422
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Tasneem Z Naqvi, Reza Rafie, Samuel Daneshvar. (2010) ORIGINAL INVESTIGATIONS: Potential Faces of Patent Foramen Ovale (PFO PFO). Echocardiography 27:8, 897-907
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Armand Mekontso Dessap, Florence Boissier, Rusel Leon, Serge Carreira, Ferran Roche Campo, François Lemaire, Laurent Brochard. (2010) Prevalence and prognosis of shunting across patent foramen ovale during acute respiratory distress syndrome*. Critical Care Medicine 38:9, 1786-1792
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Ben Van den Branden, Justin Luermans, Martijn Post, Herbert Plokker, Jurriën ten Berg, Maarten Suttorp. (2010) The BioSTAR(r) device versus the CardioSEAL(r) device in patent foramen ovale closure: comparison of mid-term efficacy and safety. EuroIntervention 6:4, 498-504
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G. P. ANZOLA, L. GIUSTI DEL GIARDINO, M.P. PIRAS. (2010) Patent foramen ovale (PFO) and cryptogenic stroke. Journal of Thrombosis and Haemostasis 8:8, 1675-1677
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Y. Chandrashekhar. (2010) PFO and the Heart. JACC: Cardiovascular Imaging 3:8, 840-842
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Christian Spies, Qi-Ling Cao, Ziyad M Hijazi. (2010) Transcatheter patent foramen ovale closure: review and choice of devices. Interventional Cardiology 2:4, 601-614
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Sophie Rym Hamada, Jean Mantz. (2010) Patent Foramen Ovale, Bubble Test, and Major Spine Surgery. Anesthesiology 113:2, 463
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Jochen Wöhrle, Matthias Kochs, Vinzenz Hombach, Nico Merkle. (2010) Prevalence of Myocardial Scar in Patients With Cryptogenic Cerebral Ischemic Events and Patent Foramen Ovale. JACC: Cardiovascular Imaging 3:8, 833-839
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G. Fazio, G. Ferro, P. Carita, M. Lunetta, A. Gullotti, R. Trapani, A. Fabbiano, G. Novo, S. Novo. (2010) The PFO anatomy evaluation as possible tool to stratify the associated risks and the benefits arising from the closure. European Journal of Echocardiography 11:6, 488-491
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Jong-Young Lee, Jae-Kwan Song, Jong-Min Song, Duk-Hyun Kang, Sung-Cheol Yun, Dong-Wha Kang, Sun Uck Kwon, Jong Sung Kim. (2010) Association Between Anatomic Features of Atrial Septal Abnormalities Obtained by Omni-Plane Transesophageal Echocardiography and Stroke Recurrence in Cryptogenic Stroke Patients with Patent Foramen Ovale. The American Journal of Cardiology 106:1, 129-134
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Bushra S. Rana, Martyn R. Thomas, Patrick A. Calvert, Mark J. Monaghan, David Hildick-Smith. (2010) Echocardiographic Evaluation of Patent Foramen Ovale Prior to Device Closure. JACC: Cardiovascular Imaging 3:7, 749-760
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David A. Carpenter, Andria L. Ford, Jin-Moo Lee. (2010) Patent Foramen Ovale and Stroke: Should PFOs Be Closed in Otherwise Cryptogenic Stroke?. Current Atherosclerosis Reports 12:4, 251-258
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M. Pepi, A. Evangelista, P. Nihoyannopoulos, F. A. Flachskampf, G. Athanassopoulos, P. Colonna, G. Habib, E. B. Ringelstein, R. Sicari, J. L. Zamorano, , , M. Sitges, P. Caso. (2010) Recommendations for echocardiography use in the diagnosis and management of cardiac sources of embolism: European Association of Echocardiography (EAE) (a registered branch of the ESC). European Journal of Echocardiography 11:6, 461-476
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Alberta Cifarelli, Carmine Musto, Antonio Parma, Claudia Pandolfi, Edoardo Pucci, Rosario Fiorilli, Francesco De Felice, Marco Stefano Nazzaro, Roberto Violini. (2010) Long-term outcome of transcatheter patent foramen ovale closure in patients with paradoxical embolism. International Journal of Cardiology 141:3, 304-310
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Piergiorgio Lochner, Frediano Tezzon, Rafaelle Nardone, Christian Tanislav. (2010) Paradoxical brain embolism caused by an arterial−venous fistula: a diagnostic pitfall. Neurological Sciences 31:3, 341-343
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Omar Ahmad, Kate E. Ahmad, Keith B.G. Dear, Isabel Harvey, Andrew Hughes, Christian J. Lueck. (2010) Echocardiography in the detection of cardioembolism in a stroke population. Journal of Clinical Neuroscience 17:5, 561-565
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J.S. Shambrook, R. Chowdhury, I.W. Brown, C.R. Peebles, S.P. Harden. (2010) Cross-sectional imaging appearances of cardiac aneurysms. Clinical Radiology 65:5, 349-357
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Anastassios I. Mylonas, Christos A. Skouteris, Georgios Vretakos, Calliope Petraki. (2010) Cryptogenic Stroke and Parotid Tumor Surgery: A Case Report. Journal of Oral and Maxillofacial Surgery 68:5, 1205-1208
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M. R. Di Tullio. (2010) Patent foramen ovale and risk of stroke: is there more that we should know?. European Journal of Neurologyno-no
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U. Laufs, U.C. Hoppe, S. Rosenkranz, P. Kirchhof, M. Böhm, H.-C. Diener, M. Endres, M. Grond, W. Hacke, T. Meinertz, E.B. Ringelstein, J. Röther, M. Dichgans. (2010) Kardiologische Diagnostik nach zerebraler Ischämie. Der Nervenarzt 81:4, 444-462
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HoHai Van, Paul Poommipanit, Mostafa Shalaby, Rubine Gevorgyan, Chi-Hong Tseng, Jonathan Tobis. (2010) Sensitivity of Transcranial Doppler Versus Intracardiac Echocardiography in the Detection of Right-to-Left Shunt. JACC: Cardiovascular Imaging 3:4, 343-348
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R. Feurer, S. Sadikovic, D. Sepp, L. Esposito, M. Schleef, A. Bockelbrink, J. Schwarze, B. Hemmer, D. Sander, H. Poppert. (2010) Patent foramen ovale is not associated with an increased risk of stroke recurrence. European Journal of Neurology
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Gianluca Rigatelli, Fabio Dell'Avvocata, Federico Ronco, Paolo Cardaioli, Massimo Giordan, Gabriele Braggion, Silvio Aggio, Mauro Chinaglia, Giorgio Rigatelli, Jack P. Chen. (2010) Primary Transcatheter Patent Foramen Ovale Closure Is Effective in Improving Migraine in Patients With High-Risk Anatomic and Functional Characteristics for Paradoxical Embolism. JACC: Cardiovascular Interventions 3:3, 282-287
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Dolores Mesa, Martín Ruiz, Mónica Delgado, José Suárez de Lezo, Manuel Pan, Ignacio Tejero, Daniel García, Manuel Crespín, Carmen León, Francisco Toledano, Francisco Mazuelos, Juan J. Ochoa, Enrique Bescansa. (2010) Prevalencia de foramen oval permeable diagnosticado mediante ecocardiografía transesofágica en pacientes de edad igual o mayor que 55 años con ictus criptogénico. ¿Es diferente que en pacientes jóvenes?. Revista Española de Cardiología 63:3, 315-322
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Peter N Ruygrok. (2010) The Coherex FlatStent™: an advance in patent foramen ovale closure. Expert Review of Medical Devices 7:2, 193-199
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David E Thaler, David M Kent. (2010) Rethinking trial strategies for stroke and patent foramen ovale. Current Opinion in Neurology 23:1, 73-78
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Marco R. Di Tullio. (2010) Patent Foramen Ovale: Echocardiographic Detection and Clinical Relevance in Stroke. Journal of the American Society of Echocardiography 23:2, 144-155
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Ryan Ko, Nicola E Walker, Michael J Mullen. (2010) Different patent foramen ovale closure techniques in varying anatomies. Interventional Cardiology 2:1, 85-95
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Bernhard Meier. 2010. Patent Foramen Ovale Closure. , 81-92.
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2010. Synopsis of Adult Cardiac Surgical Disease. , 1-83.
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Leighton G. Kearney, Piyush M. Srivastava. (2010) Thrombus Entrapped in a Patent Foramen Ovale: A Potential Source of Pulmonary and Systemic Embolism. Heart, Lung and Circulation 19:1, 58-60
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Zeljko Zivanovic, Svetlana Ruzicka-Kaloci, Aleksandar Jesic, Biljana Radovanovic, Aleksandra Lucic-Prokin, Petar Slankamenac. (2010) Paradoxical emboli: Clinical importance of transcranial doppler for detection of patent foramen ovale. Medicinski pregled 63:7-8, 445-449
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MICHAEL BECKER, DOROTHEE FRINGS, JÃRG SCHRÃDER, CHRISTINA OCKLENBURG, EBERHARD MÃHLER, RAINER HOFFMANN, ANDREAS FRANKE, WOLFGANG LEPPER. (2009) Impact of Occluder Device Type on Success of Percutaneous Closure of Atrial Septal DefectsâA Medium-Term Follow-up Study. Journal of Interventional Cardiology 22:6, 503-510
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Daniel De Wolf. (2009) Complications of transcatheter atrial septal defect closure. Interventional Cardiology 1:2, 209-218
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Christian Spies, Melvin Wong. (2009) Patent foramen ovale and cryptogenic stroke: a complex neuro–cardio–vascular problem. Expert Review of Cardiovascular Therapy 7:11, 1455-1467
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Rajeev Garg, Azam Khaja, Richard Madsen, Martin A. Alpert, Lokesh Tejwani, Kul Aggarwal. (2009) Observer Variation in the Echocardiographic Measurement of Maximum Atrial Septal Excursion: A Comparison of M-Mode with Two-Dimensional or Transesophageal Echocardiography. Echocardiography 26:10, 1122-1126
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Christian Weimar, Ralph Weber, Hans-Christoph Diener. (2009) Antithrombotic medication for stroke prevention. Expert Review of Cardiovascular Therapy 7:10, 1245-1254
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R. Feurer, S. Sadikovic, L. Esposito, J. Schwarze, A. Bockelbrink, B. Hemmer, D. Sander, H. Poppert. (2009) Lesion patterns in patients with cryptogenic stroke with and without right-to-left-shunt. European Journal of Neurology 16:10, 1077-1082
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David R. Holmes, Howard A. Cohen, Carlos Ruiz. (2009) Patent Foramen Ovale, Systemic Embolization, and Closure. Current Problems in Cardiology 34:10, 483-530
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Gian Paolo Ussia, Valeria Cammalleri, Massimiliano Mulè, Marilena Scarabelli, Marco Barbanti, Francesco Scardaci, Sarah Mangiafico, Sebastiano Immè, Davide Capodanno, Corrado Tamburino. (2009) Percutaneous closure of patent foramen ovale with a bioabsorbable occluder device. Catheterization and Cardiovascular Interventions 74:4, 607-614
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