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How Well Does TEE Predict Recurrent Stroke?

And what are the implications for closure of patent foramen ovale using percutaneous intervention?

It is possible to close a patent foramen ovale (PFO) in stroke patients using a percutaneous device, which has led many physicians to recommend this procedure despite a lack of randomized data to document its benefit. Before assessing the value of intervention, we first must know how well we can predict risk for adverse events in medically treated patients with PFO. Toward that end, researchers studied transesophageal echocardiography (TEE) findings from 601 ischemic-stroke patients (mean age, 59) who had been enrolled in a double-blind study of aspirin versus warfarin for preventing stroke recurrence and death.

TEE findings included PFO (34%), atrial septal aneurysm (SA; 12%), prominent eustachian valve (EV; 35%), and right-atrial (RA) filamentous strands (19%). During 2-year follow-up, there were 71 recurrent ischemic strokes and 21 deaths (an overall event rate of 15%). Event rates did not differ significantly between patients with both PFO and SA and patients with neither feature, both in the overall study group and in the subgroup with cryptogenic stroke (roughly 40% of patients); patients with PFO/SA and prominent EV or RA filamentous strands had event rates similar to those of patients with none of those 4 features, both in the overall study group and in the cryptogenic-stroke subgroup. Among PFO/SA patients, event rates did not differ between warfarin and aspirin recipients.

Comment: These data fail to support the common conception that TEE findings can aid prediction of ischemic-stroke recurrence. Other studies have linked PFO/SA with risk for stroke recurrence (e.g., Journal Watch Cardiology Jan 18 2002), but patients in those studies were younger than patients in this one. It is possible that medical therapy equalizes the effect of anatomy on recurrence. However, given the high rate of adverse events (15% in this study), we clearly need a randomized trial of whether percutaneous-device closure is effective prevention.

— Howard C. Herrmann, MD

Published in Journal Watch Cardiology October 24, 2003

Citation(s):

Homma S et al. Atrial anatomy in non-cardioembolic stroke patients: Effect of medical therapy. J Am Coll Cardiol 2003 Sep 17; 42:1066-72.

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• Medline abstract (Free)

Castello R and Brott TG. Patent foramen ovale: Friend or foe? J Am Coll Cardiol 2003 Sep 17; 42:1073-5.

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• Medline abstract (Free)