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"apellidos" => "Margalho" ] 5 => array:2 [ "nombre" => "Lino" "apellidos" => "Goncalves" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "pt" => array:9 [ "pii" => "S0870255114003126" "doi" => "10.1016/j.repc.2014.08.009" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "pt" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255114003126?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204915000495?idApp=UINPBA00004E" "url" => "/21742049/0000003400000003/v2_201504010220/S2174204915000495/v2_201504010220/en/main.assets" ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial comment</span>" "titulo" => "Patent foramen ovale: Seeing through the mist" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "159" "paginaFinal" => "161" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Lídia de Sousa" "autores" => array:1 [ 0 => array:3 [ "nombre" => "Lídia" "apellidos" => "de Sousa" "email" => array:1 [ 0 => "lidiasousa@netcabo.pt" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Serviço de Cardiologia, Centro Hospitalar Lisboa Central, Lisboa, Portugal; Centro do Coração, Hospital Cuf, Lisboa, Portugal" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Foramen ovale patente: uma visão através da neblina" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In 1877 Connheim was the first to describe paradoxical embolism through a patent foramen ovale (PFO), a phenomenon that has since been documented in numerous autopsy and echocardiographic studies. Besides migration of thrombi through the septal defect, other mechanisms have been proposed that implicate PFO in cardioembolic phenomena, including increased vulnerability to atrial arrhythmias and local thrombus formation.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Various studies have demonstrated an association between PFO and cryptogenic stroke, but others have questioned the causal nature of this relationship.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">2–4</span></a> The figures show the importance of this link: around 25% of the general population have PFO, and around 40% of ischemic strokes are cryptogenic (of undetermined cause); PFO is a plausible mechanism that might explain many of them.</p><p id="par0015" class="elsevierStylePara elsevierViewall">But with such a common finding as PFO, how can its guilt or innocence be established, particularly regarding ischemic stroke? Distinguishing association from causality is always a challenge, but in this context is crucial.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The three randomized trials comparing percutaneous PFO closure with medical treatment<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">5–7</span></a> showed no benefit for either strategy, but they have significant limitations. The most important are low statistical power due to the small number of patients and events, crossover between study arms, variability in inclusion criteria, medical therapies and types of closure device, and the criteria used to define and assess events. It is striking that in two of these studies it took more than ten years to randomize even these small numbers of patients.</p><p id="par0025" class="elsevierStylePara elsevierViewall">However, subsequent analyses of these trials have helped to clarify certain points, such as the existence of alternative explanations for recurrent stroke in CLOSURE I<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">8</span></a> and evidence of long-term benefit in the closure arm of the RESPECT trial.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Meta-analyses have also shown contradictory results, although they generally favor percutaneous closure.<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">9,10</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The lack of solid evidence means that international medical societies do not recommend percutaneous PFO closure, although guidelines from national societies in some countries give indications for its use. In the American Heart Association/American Stroke Association guidelines for stroke prevention,<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">11</span></a> percutaneous closure may be considered in patients with PFO and deep vein thrombosis.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The article by Paiva et al.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">12</span></a> in this issue of the <span class="elsevierStyleItalic">Journal</span> describes the first prospective observational study in Portugal of patients undergoing percutaneous PFO closure following stroke. Some of the results merit particular attention. The population consisted of relatively young adults with few comorbidities, indicating that their referral for the technique was appropriate. The rate of serious device- or intervention-related complications was low, and the follow-up was long, which is essential to assess adverse effects in a condition like PFO. Some of the study limitations are pointed out by the authors, but there are other important points: it is difficult to estimate relative risk reductions in a study group by using historical data from a meta-analysis as a control; transesophageal echocardiography was not used for analysis of events in the study population, but transthoracic echocardiography has known limitations in assessing residual shunt and the presence of intracavitary or device-related thrombi; and concomitant medical therapy may had a significant impact on the results. The authors of observational studies must always seek alternative explanations for their findings, which in the present case was particularly difficult.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Three randomized trials are currently under way in this area: Patent Foramen Ovale Closure or Anticoagulants versus Antiplatelet Therapy to Prevent Stroke Recurrence (CLOSE), Device Closure versus Medical Therapy for Cryptogenic Stroke Patients with High-Risk Patent Foramen Ovale (DEFENSE-PFO), and GORE<span class="elsevierStyleSup">®</span> HELEX<span class="elsevierStyleSup">®</span> Septal Occluder/GORE<span class="elsevierStyleSup">®</span> Septal Occluder for Patent Foramen Ovale (PFO) Closure in Stroke Patients – The Gore REDUCE Clinical Study. However, the relatively small number of patients being randomized and the low rate of predicted events in this population mean that these trials are unlikely to resolve the question of the value of percutaneous PFO closure for secondary prevention of ischemic cerebrovascular events.</p><p id="par0050" class="elsevierStylePara elsevierViewall">While we await for further evidence to guide us, there are certain points to bear in mind when deciding on the appropriate therapeutic option.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Firstly, it is important to remember that a diagnosis of cryptogenic stroke should only be made after a thorough and extensive diagnostic workup to identify the cause, involving a multidisciplinary team in which specialists in neurology, internal medicine and imaging play central roles. Neuroradiological imaging is essential to identify patterns suggestive of a cardioembolic source, which cardiologists are not trained to assess.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">13</span></a> The anatomical characteristics of the PFO are another potential aid to decision-making; some studies have identified markers of increased risk, including the size of the PFO and of the shunt, spontaneous shunt at rest (without Valsalva maneuver), and the presence of atrial septal aneurysm.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">14</span></a> Finally, the RoPE study investigators<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">15</span></a> developed a 10-point index to identify patients most likely to benefit from percutaneous closure, assigning 1 point for each of the following: absence of four clinical variables (diabetes, hypertension, smoking, and prior stroke or transient ischemic attack); imaging evidence of the presence of cortical stroke; and age, with 1 point assigned for each decade under 70 years (5 points for those aged <30 years). The higher the score, the greater the likelihood of an ischemic event being related to the PFO. It is important to validate this index in further studies and analyses.</p><p id="par0060" class="elsevierStylePara elsevierViewall">To summarize, the selection of patients likely to benefit from percutaneous PFO closure for secondary prevention should be on an individual basis, following an extensive multidisciplinary diagnostic workup. Only in this way is it possible to ensure consistency in treatment, safety in outcomes and optimization of resources.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0065" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: de Sousa L. Foramen ovale patente: uma visão através da neblina. Rev Port Cardiol. 2015;34:159–161.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib0080" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Significant association of atrial vulnerability with atrial septal abnormalities in young patients with ischemic stroke of unknown cause" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "K. Berthet" 1 => "T. Lavergne" 2 => "A. 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Year/Month | Html | Total | |
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2024 November | 10 | 4 | 14 |
2024 October | 41 | 29 | 70 |
2024 September | 43 | 25 | 68 |
2024 August | 47 | 30 | 77 |
2024 July | 39 | 24 | 63 |
2024 June | 36 | 21 | 57 |
2024 May | 51 | 17 | 68 |
2024 April | 32 | 23 | 55 |
2024 March | 50 | 17 | 67 |
2024 February | 27 | 21 | 48 |
2024 January | 22 | 29 | 51 |
2023 December | 23 | 26 | 49 |
2023 November | 38 | 23 | 61 |
2023 October | 21 | 16 | 37 |
2023 September | 24 | 17 | 41 |
2023 August | 20 | 14 | 34 |
2023 July | 41 | 12 | 53 |
2023 June | 22 | 10 | 32 |
2023 May | 33 | 25 | 58 |
2023 April | 30 | 210 | 240 |
2023 March | 29 | 18 | 47 |
2023 February | 27 | 29 | 56 |
2023 January | 20 | 16 | 36 |
2022 December | 27 | 18 | 45 |
2022 November | 32 | 20 | 52 |
2022 October | 36 | 30 | 66 |
2022 September | 23 | 20 | 43 |
2022 August | 23 | 29 | 52 |
2022 July | 30 | 36 | 66 |
2022 June | 17 | 21 | 38 |
2022 May | 19 | 30 | 49 |
2022 April | 18 | 33 | 51 |
2022 March | 21 | 24 | 45 |
2022 February | 23 | 32 | 55 |
2022 January | 20 | 20 | 40 |
2021 December | 15 | 34 | 49 |
2021 November | 22 | 26 | 48 |
2021 October | 29 | 38 | 67 |
2021 September | 16 | 28 | 44 |
2021 August | 18 | 26 | 44 |
2021 July | 15 | 30 | 45 |
2021 June | 13 | 23 | 36 |
2021 May | 22 | 28 | 50 |
2021 April | 37 | 61 | 98 |
2021 March | 61 | 12 | 73 |
2021 February | 46 | 13 | 59 |
2021 January | 27 | 20 | 47 |
2020 December | 33 | 13 | 46 |
2020 November | 25 | 17 | 42 |
2020 October | 22 | 11 | 33 |
2020 September | 48 | 14 | 62 |
2020 August | 17 | 12 | 29 |
2020 July | 41 | 17 | 58 |
2020 June | 34 | 7 | 41 |
2020 May | 25 | 10 | 35 |
2020 April | 35 | 18 | 53 |
2020 March | 37 | 6 | 43 |
2020 February | 42 | 17 | 59 |
2020 January | 27 | 5 | 32 |
2019 December | 25 | 4 | 29 |
2019 November | 30 | 6 | 36 |
2019 October | 28 | 4 | 32 |
2019 September | 23 | 9 | 32 |
2019 August | 23 | 5 | 28 |
2019 July | 38 | 11 | 49 |
2019 June | 19 | 3 | 22 |
2019 May | 31 | 6 | 37 |
2019 April | 19 | 13 | 32 |
2019 March | 43 | 11 | 54 |
2019 February | 21 | 8 | 29 |
2019 January | 23 | 3 | 26 |
2018 December | 36 | 11 | 47 |
2018 November | 38 | 9 | 47 |
2018 October | 72 | 13 | 85 |
2018 September | 44 | 20 | 64 |
2018 August | 32 | 14 | 46 |
2018 July | 27 | 2 | 29 |
2018 June | 44 | 4 | 48 |
2018 May | 68 | 9 | 77 |
2018 April | 58 | 0 | 58 |
2018 March | 68 | 5 | 73 |
2018 February | 43 | 7 | 50 |
2018 January | 62 | 13 | 75 |
2017 December | 103 | 2 | 105 |
2017 November | 44 | 9 | 53 |
2017 October | 32 | 8 | 40 |
2017 September | 29 | 7 | 36 |
2017 August | 30 | 9 | 39 |
2017 July | 20 | 9 | 29 |
2017 June | 31 | 12 | 43 |
2017 May | 46 | 17 | 63 |
2017 April | 32 | 7 | 39 |
2017 March | 36 | 38 | 74 |
2017 February | 24 | 6 | 30 |
2017 January | 40 | 1 | 41 |
2016 December | 38 | 7 | 45 |
2016 November | 23 | 2 | 25 |
2016 October | 29 | 3 | 32 |
2016 September | 25 | 5 | 30 |
2016 August | 8 | 0 | 8 |
2016 July | 19 | 2 | 21 |
2016 June | 14 | 3 | 17 |
2016 May | 20 | 5 | 25 |
2016 April | 33 | 2 | 35 |
2016 March | 56 | 21 | 77 |
2016 February | 68 | 35 | 103 |
2016 January | 49 | 25 | 74 |
2015 December | 63 | 21 | 84 |
2015 November | 60 | 14 | 74 |
2015 October | 56 | 18 | 74 |
2015 September | 49 | 17 | 66 |
2015 August | 51 | 16 | 67 |
2015 July | 32 | 7 | 39 |
2015 June | 36 | 11 | 47 |
2015 May | 68 | 21 | 89 |
2015 April | 127 | 50 | 177 |