Title: Letter to the Editor Regarding the Article by Holda et al., Patent Foramen Ovale Channel Morphometric Characteristics Associated with Cryptogenic Stroke: The MorPFO Score
Abstract: This letter is regarding the article entitled “Patent Foramen Ovale Channel Morphometric Characteristics Associated with Cryptogenic Stroke: The MorPFO Score” by Hołda et al.,1Hołda M.K. Krawczyk-Ożóg A. Koziej M. Kołodziejczyk J. Sorysz D. Szczepanek E. et al.Patent foramen ovale channel morphometric characteristics associated with cryptogenic stroke: the MorPFO score.J Am Soc Echocardiogr. 2021; 34: 1285-1293.e3Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar which we read with great interest. This article shows the usefulness of transesophageal echocardiography (TEE) for differentiation of pathogenic from incidental patent foramen ovale (PFO) channels based on the morphological characteristics and the suggested scores. The method suggested for PFO diagnosis was described as agitated contrast solution (0.9% saline solution or 5% glucose solution), which was injected at rest and during a Valsalva maneuver (VM).2Vitarelli A. Patent foramen ovale: pivotal role of transesophageal echocardiography in the indications for closure, assessment of varying anatomies and post-procedure follow-up.Ultrasound Med Biol. 2019; 45: 1882-1895Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar No further clarification has been provided in the article about the details of how the VM was performed, how its effectiveness was measured, or whether its equal performance among all patients has been standardized. As VM increases the right atrial–to–left atrial gradient during the release phase, its application during transthoracic echocardiography or TEE increases the diagnostic sensitivity of PFO2Vitarelli A. Patent foramen ovale: pivotal role of transesophageal echocardiography in the indications for closure, assessment of varying anatomies and post-procedure follow-up.Ultrasound Med Biol. 2019; 45: 1882-1895Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar; but from a practical point of view, performing VM during TEE is difficult and suboptimal VM reduces the diagnostic accuracy.3Rodrigues A.C. Picard M.H. Carbone A. Arruda A.L. Flores T. Klohn J. et al.Importance of adequately performed Valsalva maneuver to detect patent foramen ovale during transesophageal echocardiography.J Am Soc Echocardiogr. 2013; 26: 1337-1343Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar Therefore, different echocardiographic methods have been suggested for assessment of the adequacy and efficacy of VM during TEE, such as evaluating the presence of a leftward shift of the primary atrial septum with the release phase (indicating right atrial pressure > left atrial pressure)2Vitarelli A. Patent foramen ovale: pivotal role of transesophageal echocardiography in the indications for closure, assessment of varying anatomies and post-procedure follow-up.Ultrasound Med Biol. 2019; 45: 1882-1895Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar or a 20 cm/sec decrease in transmitral E velocity.3Rodrigues A.C. Picard M.H. Carbone A. Arruda A.L. Flores T. Klohn J. et al.Importance of adequately performed Valsalva maneuver to detect patent foramen ovale during transesophageal echocardiography.J Am Soc Echocardiogr. 2013; 26: 1337-1343Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar Sedation decreases the VM sufficiency as well, and Hołda and colleagues have acknowledged that the patients were not sedated during TEE,1Hołda M.K. Krawczyk-Ożóg A. Koziej M. Kołodziejczyk J. Sorysz D. Szczepanek E. et al.Patent foramen ovale channel morphometric characteristics associated with cryptogenic stroke: the MorPFO score.J Am Soc Echocardiogr. 2021; 34: 1285-1293.e3Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar which increases the chance of efficient VM. Nonetheless, they have not provided any details regarding the measurement of VM efficacy, the variation of which among participants can substantially influence the diagnostic accuracy of PFO. Another issue we want to address in this article regards the selection of participants for the control or “no stroke” group in both the derivation and validation (cohort) groups, who are considered patients without stroke or migraine and who were diagnosed with PFO during their TEE, which was performed for other reasons. We believe that this group cannot be considered as a “no stroke” group, and its use for the establishment of a scoring system and model for estimating the risk of cryptogenic stroke in the future is questionable, as we cannot guarantee that the patient with PFO will never have an embolic stroke in his/her lifetime. The exclusion criteria represented, including any type of cerebrovascular accident, diagnosed atrial septal defects, or any interventions within the interatrial septum, also cannot eliminate the risk of stroke in patients with PFO, and evidence suggests that the risk of paradoxical embolism of venous thrombi through the pathogenic PFO predisposes the patients to cryptogenic stroke.4Sun Y.-P. Homma S. Patent foramen ovale and stroke.Circ J. 2016; 80: 1665-1673Crossref PubMed Scopus (41) Google Scholar,5Miranda B. Fonseca A.C. Ferro J.M. Patent foramen ovale and stroke.J Neurol. 2018; 265: 1943-1949Crossref PubMed Scopus (37) Google Scholar Considering the short duration of follow-up in this study, a longer duration of follow-up may be helpful.
Publication Year: 2022
Publication Date: 2022-03-12
Language: en
Type: letter
Indexed In: ['crossref', 'pubmed']
Access and Citation
AI Researcher Chatbot
Get quick answers to your questions about the article from our AI researcher chatbot