{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,1,20]],"date-time":"2026-01-20T13:44:03Z","timestamp":1768916643809,"version":"3.49.0"},"reference-count":26,"publisher":"Texas Heart Institute Journal","issue":"4","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2020,8]]},"abstract":"<jats:p>Percutaneous closure of patent foramen ovale (PFO) is widely performed to prevent recurrent stroke or transient ischemic attack in patients with cryptogenic stroke. However, the influence of different degrees of right-to-left shunting (RLS) has rarely been reported.<\/jats:p>\n        <jats:p>We retrospectively evaluated the cases of 268 patients with cryptogenic stroke who underwent PFO closure at our hospital from April 2012 through April 2015. In accordance with RLS severity, we divided the patients into 2 groups: persistent RLS during normal breathing and the Valsalva maneuver (n=112) and RLS only during the Valsalva maneuver (n=156). Baseline characteristics, morphologic features, and procedural and follow-up data were reviewed. The primary endpoint was stroke or transient ischemic attack.<\/jats:p>\n        <jats:p>More patients in the persistent group had multiple or bilateral ischemic lesions, as well as a larger median PFO diameter (2.5 mm [range, 1.8\u20133.9 mm]) than did patients in the Valsalva maneuver group (1.3 mm [range, 0.9\u20131.9 mm]) (<jats:italic>P<\/jats:italic> &lt;0.001). Atrial septal aneurysm was more frequent in the persistent group: 25 patients (22.3%) compared with 18 (11.5%) (<jats:italic>P<\/jats:italic>=0.018). Three patients in the persistent group had residual shunting. The annual risk of recurrent ischemic stroke was similar between groups: 0.298% (persistent) and 0.214% (Valsalva maneuver).<\/jats:p>\n        <jats:p>Our findings suggest that patients with persistent RLS have more numerous severe ischemic lesions, larger PFOs, and a higher incidence of atrial septal aneurysm than do those without. Although our persistent group had a greater risk of residual shunting after PFO closure, recurrence of ischemic events did not differ significantly from that in the Valsalva maneuver group.<\/jats:p>","DOI":"10.14503\/thij-17-6582","type":"journal-article","created":{"date-parts":[[2021,1,20]],"date-time":"2021-01-20T23:20:24Z","timestamp":1611184824000},"page":"244-249","source":"Crossref","is-referenced-by-count":9,"title":["Importance of Persistent Right-to-Left Shunt After Patent Foramen Ovale Closure in Cryptogenic Stroke Patients"],"prefix":"10.14503","volume":"47","author":[{"given":"Lu","family":"He","sequence":"first","affiliation":[{"name":"Department of Structural Heart Disease, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710068, People's Republic of China"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Gesheng","family":"Cheng","sequence":"additional","affiliation":[{"name":"Department of Structural Heart Disease, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710068, People's Republic of China"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Yajuan","family":"Du","sequence":"additional","affiliation":[{"name":"Department of Structural Heart Disease, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710068, People's Republic of China"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Yushun","family":"Zhang","sequence":"additional","affiliation":[{"name":"Department of Structural Heart Disease, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710068, People's Republic of China"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"5628","reference":[{"issue":"1","key":"i1526-6702-47-4-244-b1","series-title":"Mayo Clin Proc","first-page":"17","article-title":"Incidence and size of patent foramen ovale during the first 10 decades of life: an autopsy study of 965 normal hearts","volume":"59","year":"1984","unstructured":"Hagen\n              PT,\n            \n            \n              Scholz\n              DG,\n            \n            \n              Edwards\n              WD.\n            \n          \n          Incidence and size of patent foramen ovale during the first 10 decades of life: an autopsy study of 965 normal hearts.\n\t\t\t\t\tMayo Clin Proc1984;59(1):17\u201320."},{"issue":"1","key":"i1526-6702-47-4-244-b2","series-title":"Interv Cardiol Clin","first-page":"51","article-title":"Influence of PFO anatomy on successful transcatheter closure","volume":"2","year":"2013","unstructured":"Onorato\n              E,\n            \n            \n              Casilli\n              F.\n            \n          \n          Influence of PFO anatomy on successful transcatheter closure.\n\t\t\t\t\tInterv Cardiol Clin2013;2(1):51\u201384."},{"issue":"6","key":"i1526-6702-47-4-244-b3","series-title":"Catheter Cardiovasc Interv","first-page":"821","article-title":"Anatomy of the patent foramen ovale for the interventionalist","volume":"73","year":"2009","unstructured":"McKenzie\n              JA,\n            \n            \n              Edwards\n              WD,\n            \n            \n              Hagler\n              DJ.\n            \n          \n          Anatomy of the patent foramen ovale for the interventionalist.\n\t\t\t\t\tCatheter Cardiovasc Interv2009;73(6):821\u20136."},{"issue":"11","key":"i1526-6702-47-4-244-b4","series-title":"N Engl J Med","first-page":"991","article-title":"Closure or medical therapy for cryptogenic stroke with patent foramen ovale","volume":"366","year":"2012","unstructured":"Furlan\n              AJ,\n            \n            \n              Reisman\n              M,\n            \n            \n              Massaro\n              J,\n            \n            \n              Mauri\n              L,\n            \n            \n              Adams\n              H,\n            \n            \n              Albers\n              GW,\n            \n          \n          .\n\t\t\t\t\tClosure or medical therapy for cryptogenic stroke with patent foramen ovale.\n\t\t\t\t\tN Engl J Med2012;366(11):991\u20139."},{"issue":"12","key":"i1526-6702-47-4-244-b5","series-title":"N Engl J Med","first-page":"1092","article-title":"Closure of patent foramen ovale versus medical therapy after cryptogenic stroke","volume":"368","year":"2013","unstructured":"Carroll\n              JD,\n            \n            \n              Saver\n              JL,\n            \n            \n              Thaler\n              DE,\n            \n            \n              Smalling\n              RW,\n            \n            \n              Berry\n              S,\n            \n            \n              MacDonald\n              LA,\n            \n          \n          .\n\t\t\t\t\tClosure of patent foramen ovale versus medical therapy after cryptogenic stroke.\n\t\t\t\t\tN Engl J Med2013;368(12):1092\u2013100."},{"issue":"12","key":"i1526-6702-47-4-244-b6","series-title":"N Engl J Med","first-page":"1083","article-title":"Percutaneous closure of patent foramen ovale in cryptogenic embolism","volume":"368","year":"2013","unstructured":"Meier\n              B,\n            \n            \n              Kalesan\n              B,\n            \n            \n              Mattle\n              HP,\n            \n            \n              Khattab\n              AA,\n            \n            \n              Hildick-Smith\n              D,\n            \n            \n              Dudek\n              D,\n            \n          \n          .\n\t\t\t\t\tPercutaneous closure of patent foramen ovale in cryptogenic embolism.\n\t\t\t\t\tN Engl J Med2013;368(12):1083\u201391."},{"issue":"4","key":"i1526-6702-47-4-244-b7","series-title":"Heart","first-page":"444","article-title":"Closure of patent foramen ovale: technique, pitfalls, complications, and follow up","volume":"91","year":"2005","unstructured":"Meier\n              B.\n            \n          \n          Closure of patent foramen ovale: technique, pitfalls, complications, and follow up.\n\t\t\t\t\tHeart2005;91(4):444\u20138."},{"issue":"1","key":"i1526-6702-47-4-244-b8","series-title":"J Interv Cardiol","first-page":"33","article-title":"Morphological features pertinent to interventional closure of patent oval foramen","volume":"16","year":"2003","unstructured":"Ho\n              SY,\n            \n            \n              McCarthy\n              KP,\n            \n            \n              Rigby\n              ML.\n            \n          \n          Morphological features pertinent to interventional closure of patent oval foramen.\n\t\t\t\t\tJ Interv Cardiol2003;16(1):33\u20138."},{"issue":"5","key":"i1526-6702-47-4-244-b9","series-title":"Neurology","first-page":"765","article-title":"Different degrees of right-to-left shunting predict migraine and stroke: data from 420 patients","volume":"66","year":"2006","unstructured":"Anzola\n              GP,\n            \n            \n              Morandi\n              E,\n            \n            \n              Casilli\n              F,\n            \n            \n              Onorato\n              E.\n            \n          \n          Different degrees of right-to-left shunting predict migraine and stroke: data from 420 patients.\n\t\t\t\t\tNeurology2006;66(5):765\u20137."},{"issue":"3","key":"i1526-6702-47-4-244-b10","series-title":"Int J Cardiol","first-page":"357","article-title":"Spontaneous large right-to-left shunt and migraine headaches with aura are risk factors for recurrent stroke in patients with a patent foramen ovale","volume":"120","year":"2007","unstructured":"Giardini\n              A,\n            \n            \n              Donti\n              A,\n            \n            \n              Formigari\n              R,\n            \n            \n              Salomone\n              L,\n            \n            \n              Palareti\n              G,\n            \n            \n              Guidetti\n              D,\n            \n            \n              Picchio\n              FM.\n            \n          \n          Spontaneous large right-to-left shunt and migraine headaches with aura are risk factors for recurrent stroke in patients with a patent foramen ovale.\n\t\t\t\t\tInt J Cardiol2007;120(3):357\u201362."},{"issue":"21","key":"i1526-6702-47-4-244-b11","series-title":"J Am Coll Cardiol","first-page":"2257","article-title":"Permanent right-to-left shunt is the key factor in managing patent foramen ovale","volume":"58","year":"2011","unstructured":"Rigatelli\n              G,\n            \n            \n              Dell'Avvocata\n              F,\n            \n            \n              Cardaioli\n              P,\n            \n            \n              Giordan\n              M,\n            \n            \n              Braggion\n              G,\n            \n            \n              Aggio\n              S,\n            \n          \n          .\n\t\t\t\t\tPermanent right-to-left shunt is the key factor in managing patent foramen ovale.\n\t\t\t\t\tJ Am Coll Cardiol2011;58(21):2257\u201361."},{"issue":"1","key":"i1526-6702-47-4-244-b12","series-title":"Neurol Sci","first-page":"5","article-title":"The Italian Guidelines for stroke prevention. The Stroke Prevention and Educational Awareness Diffusion (SPREAD) Collaboration","volume":"21","year":"2000","unstructured":"Inzitari\n              D.\n            \n          \n          The Italian Guidelines for stroke prevention. The Stroke Prevention and Educational Awareness Diffusion (SPREAD) Collaboration.\n\t\t\t\t\tNeurol Sci2000;21(1):5\u201312."},{"issue":"5","key":"i1526-6702-47-4-244-b13","series-title":"Stroke","first-page":"564","article-title":"A classification and outline of cerebrovascular diseases. II","volume":"6","year":"1975","unstructured":"A classification and outline of cerebrovascular diseases. II.\n\t\t\t\t\tStroke1975;6(5):564\u2013616."},{"issue":"15","key":"i1526-6702-47-4-244-b14","series-title":"Circulation","first-page":"1942","article-title":"Frequency of atrial septal aneurysms in patients with cerebral ischemic events","volume":"99","year":"1999","unstructured":"Agmon\n              Y,\n            \n            \n              Khanderia\n              BK,\n            \n            \n              Meissner\n              I,\n            \n            \n              Gentile\n              F,\n            \n            \n              Whisnant\n              JP,\n            \n            \n              Sicks\n              JD,\n            \n          \n          .\n\t\t\t\t\tFrequency of atrial septal aneurysms in patients with cerebral ischemic events.\n\t\t\t\t\tCirculation1999;99(15):1942\u20134."},{"issue":"10","key":"i1526-6702-47-4-244-b15","series-title":"JACC Cardiovasc Imaging","first-page":"1062","article-title":"The eustachian ridge: not an innocent bystander","volume":"7","year":"2014","unstructured":"Kydd\n              AC,\n            \n            \n              McNab\n              D,\n            \n            \n              Calvert\n              PA,\n            \n            \n              Hoole\n              SP,\n            \n            \n              Rekhraj\n              S,\n            \n            \n              Sievert\n              H,\n            \n          \n          .\n\t\t\t\t\tThe eustachian ridge: not an innocent bystander.\n\t\t\t\t\tJACC Cardiovasc Imaging2014;7(10):1062\u20133."},{"issue":"3","key":"i1526-6702-47-4-244-b16","series-title":"J Am Soc Echocardiogr","first-page":"231","article-title":"Persisting eustachian valve in adults: relation to patent foramen ovale and cerebrovascular events","volume":"17","year":"2004","unstructured":"Schuchlenz\n              HW,\n            \n            \n              Saurer\n              G,\n            \n            \n              Weihs\n              W,\n            \n            \n              Rehak\n              P.\n            \n          \n          Persisting eustachian valve in adults: relation to patent foramen ovale and cerebrovascular events.\n\t\t\t\t\tJ Am Soc Echocardiogr2004;17(3):231\u20133."},{"issue":"1","key":"i1526-6702-47-4-244-b17","series-title":"J Am Coll Cardiol","first-page":"203","article-title":"Chiari's network: normal anatomic variant or risk factor for arterial embolic events?","volume":"26","year":"1995","unstructured":"Schneider\n              B,\n            \n            \n              Hofmann\n              T,\n            \n            \n              Justen\n              MH,\n            \n            \n              Meinertz\n              T.\n            \n          \n          Chiari's network: normal anatomic variant or risk factor for arterial embolic events?\n          \n            J Am Coll Cardiol\n          \n          1995;26(1):203\u201310."},{"issue":"43","key":"i1526-6702-47-4-244-b18","series-title":"Medicine (Baltimore)","first-page":"e1937","article-title":"A comparison of transthoracic echocardiography and transcranial Doppler with contrast agent for detection of patent foramen ovale with or without the Valsalva maneuver","volume":"94","year":"2015","unstructured":"Zhao\n              E,\n            \n            \n              Wei\n              Y,\n            \n            \n              Zhang\n              Y,\n            \n            \n              Zhai\n              N,\n            \n            \n              Zhao\n              P,\n            \n            \n              Liu\n              B.\n            \n          \n          A comparison of transthoracic echocardiography and transcranial Doppler with contrast agent for detection of patent foramen ovale with or without the Valsalva maneuver.\n\t\t\t\t\tMedicine (Baltimore)2015;94(43):e1937."},{"issue":"5","key":"i1526-6702-47-4-244-b19","series-title":"Stroke","first-page":"944","article-title":"Patent foramen ovale size and embolic brain imaging findings among patients with ischemic stroke","volume":"29","year":"1998","unstructured":"Steiner\n              MM,\n            \n            \n              Di Tullio\n              MR,\n            \n            \n              Rundek\n              T,\n            \n            \n              Gan\n              R,\n            \n            \n              Chen\n              X,\n            \n            \n              Liguori\n              C,\n            \n          \n          .\n\t\t\t\t\tPatent foramen ovale size and embolic brain imaging findings among patients with ischemic stroke.\n\t\t\t\t\tStroke1998;29(5):944\u20138."},{"issue":"7","key":"i1526-6702-47-4-244-b20","series-title":"Stroke","first-page":"1322","article-title":"The need to quantify right-to-left shunt in acute ischemic stroke: a case-control study","volume":"29","year":"1998","unstructured":"Serena\n              J,\n            \n            \n              Segura\n              T,\n            \n            \n              Perez-Ayuso\n              MJ,\n            \n            \n              Bassaganyas\n              J,\n            \n            \n              Molins\n              A,\n            \n            \n              Davalos\n              A.\n            \n          \n          The need to quantify right-to-left shunt in acute ischemic stroke: a case-control study.\n\t\t\t\t\tStroke1998;29(7):1322\u20138."},{"issue":"7","key":"i1526-6702-47-4-244-b21","series-title":"Am J Cardiol","first-page":"596","article-title":"Relation between patent foramen ovale and unexplained stroke","volume":"71","year":"1993","unstructured":"Van Camp\n              G,\n            \n            \n              Schulze\n              D,\n            \n            \n              Cosyns\n              B,\n            \n            \n              Vandenbossche\n              JL.\n            \n          \n          Relation between patent foramen ovale and unexplained stroke.\n\t\t\t\t\tAm J Cardiol1993;71(7):596\u20138."},{"issue":"1","key":"i1526-6702-47-4-244-b22","series-title":"Am Heart J","first-page":"158","article-title":"Patent foramen ovale: association between the degree of shunt by contrast transesophageal echocardiography and the risk of future ischemic neurologic events","volume":"131","year":"1996","unstructured":"Stone\n              DA,\n            \n            \n              Godard\n              J,\n            \n            \n              Corretti\n              MC,\n            \n            \n              Kittner\n              SJ,\n            \n            \n              Sample\n              C,\n            \n            \n              Price\n              TR,\n            \n            \n              Plotnick\n              GD.\n            \n          \n          Patent foramen ovale: association between the degree of shunt by contrast transesophageal echocardiography and the risk of future ischemic neurologic events.\n\t\t\t\t\tAm Heart J1996;131(1):158\u201361."},{"issue":"1","key":"i1526-6702-47-4-244-b23","series-title":"Stroke","first-page":"31","article-title":"Patent foramen ovale: is stroke due to paradoxical embolism?","volume":"24","year":"1993","unstructured":"Ranoux\n              D,\n            \n            \n              Cohen\n              A,\n            \n            \n              Cabanes\n              L,\n            \n            \n              Amarenco\n              P,\n            \n            \n              Bousser\n              MG,\n            \n            \n              Mas\n              JL.\n            \n          \n          Patent foramen ovale: is stroke due to paradoxical embolism?\n          \n            Stroke\n          \n          1993;24(1):31\u20134."},{"issue":"6","key":"i1526-6702-47-4-244-b24","series-title":"Am J Med","first-page":"456","article-title":"The association between the diameter of a patent foramen ovale and the risk of embolic cerebrovascular events","volume":"109","year":"2000","unstructured":"Schuchlenz\n              HW,\n            \n            \n              Weihs\n              W,\n            \n            \n              Horner\n              S,\n            \n            \n              Quehenberger\n              F.\n            \n          \n          The association between the diameter of a patent foramen ovale and the risk of embolic cerebrovascular events.\n\t\t\t\t\tAm J Med2000;109(6):456\u201362."},{"issue":"7","key":"i1526-6702-47-4-244-b25","series-title":"J Am Coll Cardiol","first-page":"1598","article-title":"Transesophageal echocardiography and carotid ultrasound in patients with cerebral ischemia: prevalence of findings and recurrent stroke risk","volume":"23","year":"1994","unstructured":"Comess\n              KA,\n            \n            \n              DeRook\n              FA,\n            \n            \n              Beach\n              KW,\n            \n            \n              Lytle\n              NJ,\n            \n            \n              Golby\n              AJ,\n            \n            \n              Albers\n              GW.\n            \n          \n          Transesophageal echocardiography and carotid ultrasound in patients with cerebral ischemia: prevalence of findings and recurrent stroke risk.\n\t\t\t\t\tJ Am Coll Cardiol1994;23(7):1598\u2013603."},{"issue":"12","key":"i1526-6702-47-4-244-b26","series-title":"Stroke","first-page":"1865","article-title":"Atrial septal aneurysm and patent foramen ovale as risk factors for cryptogenic stroke in patients less than 55 years of age. A study using transesophageal echocardiography","volume":"24","year":"1993","unstructured":"Cabanes\n              L,\n            \n            \n              Mas\n              JL,\n            \n            \n              Cohen\n              A,\n            \n            \n              Amarenco\n              P,\n            \n            \n              Cabanes\n              PA,\n            \n            \n              Oubary\n              P,\n            \n          \n          .\n\t\t\t\t\tAtrial septal aneurysm and patent foramen ovale as risk factors for cryptogenic stroke in patients less than 55 years of age. A study using transesophageal echocardiography.\n\t\t\t\t\tStroke1993;24(12):1865\u201373."}],"container-title":["Texas Heart Institute Journal"],"original-title":[],"link":[{"URL":"https:\/\/thij.kglmeridian.com\/view\/journals\/thij\/47\/4\/article-p244.xml","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"http:\/\/meridian.allenpress.com\/thij\/article-pdf\/47\/4\/244\/2778502\/i1526-6702-47-4-244.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/thij.kglmeridian.com\/downloadpdf\/journals\/thij\/47\/4\/article-p244.xml","content-type":"text\/html","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/thij.kglmeridian.com\/downloadpdf\/journals\/thij\/47\/4\/article-p244.xml","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2024,11,7]],"date-time":"2024-11-07T15:36:42Z","timestamp":1730993802000},"score":1,"resource":{"primary":{"URL":"https:\/\/thij.kglmeridian.com\/view\/journals\/thij\/47\/4\/article-p244.xml"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2020,8]]},"references-count":26,"journal-issue":{"issue":"4"},"URL":"https:\/\/doi.org\/10.14503\/thij-17-6582","relation":{},"ISSN":["0730-2347","1526-6702"],"issn-type":[{"value":"0730-2347","type":"print"},{"value":"1526-6702","type":"electronic"}],"subject":[],"published":{"date-parts":[[2020,8]]}}}