Persisting eustachian valve in adults: relation to patent foramen ovale and cerebrovascular events

doi:10.1016/j.echo.2003.12.003

Journal of the American Society of Echocardiography

Volume 17, Issue 3, March 2004, Pages 231-233

https://doi.org/10.1016/j.echo.2003.12.003 Get rights and content

Abstract

Background

The eustachian valve (EV) (valvula venae cavae inferioris) is a remnant of the embryonic right valve of the sinus venosus. Embryologically, the EV directs oxygenated blood from the inferior vena cava across the patent foramen ovale (PFO) into the systemic circulation. Transthoracic echocardiography shows the EV in the majority of newborns, but the prevalence of EV in adults studied with transesophageal echocardiography is unknown. We studied whether the presence of an EV is associated with PFO or with cryptogenic stroke.

Methods

The frequency and size of the EV was studied in 211 consecutive patients undergoing transesophageal echocardiography after a cryptogenic stroke and in 95 consecutive patients without cerebrovascular events. In all 306 patients, the presence of a PFO was studied with 2-dimensional transesophageal echocardiographic, color Doppler, and contrast echocardiographic studies.

Results

An EV was seen in 174 of 306 patients overall (57%). The mean size was 1.0 ± 0.4 cm (range: 0.5-2.0); 70% of patients with an EV had a PFO (Cohen's κ = 0.75; P < .001). This relationship was not significantly influenced by a cryptogenic stroke. The prevalence of PFO was 30% in the control group and 61% for those with presumed paradoxical embolism (P < .001). Thus, an EV was more common for patients with presumed paradoxical embolism than in control patients (143 of 211 68% vs 31 of 95 33%, respectively, P < .001). There was no significant difference in the size of the EV between the 2 groups (1.1 vs 1.0 cm; P = .24).

Conclusion

A persisting EV is a frequent finding in patients with a PFO. By directing the blood from the inferior cava to the interatrial septum, a persisting EV may prevent spontaneous closure of PFO after birth and may, therefore, indirectly predispose to paradoxical embolism.

Section snippets

Methods

We studied the prevalence and the size of the EV in 306 consecutive patients undergoing TEE. For 211 patients (125 men, 86 women; mean age 47.1 ± 12.6; range 17-70), TEE was performed to look for a cardiac source of embolism after a cryptogenic stroke; for 95 patients without cerebrovascular events (59 men, 36 women; mean age 48.5 ± 13.7; range 21-71), TEE was performed for other reasons. A TEE was performed because of the following indications: ruling out a PFO in the course of a diving

Results

Overall, an EV was seen in 174 (57%) and a PFO in 158 (52%) of 306 patients. An EV was more common among patients with presumed paradoxical embolism than in the control group (143 of 211 68% vs 31 of 95 33%, respectively; P < .001). A PFO was detected in 147 (48%) patients with an EV whereas 27 (8.8%) patients with an EV had no PFO. A total of 121 (39.5%) patients had neither an EV nor a PFO detectable whereas 11 (3.6%) patients had a PFO without an EV.

The mean size of the EVs seen was 1.0 ±

Discussion

Our study shows that TEE can frequently show an EV in adults. The prevalence of EV in our series is similar to that in an autopsy study.¹ We also found that EVs are more common in patients with a PFO, and consequently in patients with paradoxical embolism, than in patients without a PFO. We cannot prove a cause-effect relationship, but the anatomic and functional relationship between PFO and EV documented by TEE (Figure 2) supports the hypothesis of Douchette and Knoblich¹⁷ and Gombert¹⁸ that

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Percutaneous closure of a patent foramen ovale (PFO), a common variation of interatrial septum anatomy, is a commonly performed procedure in the catheterization laboratory to reduce the risk of recurrent stroke in selected patients and to treat other PFO-related syndromes. In the last twenty years, disc-based devices have represented the armamentarium of the interventional cardiologist; recently, suture-based devices have become an attractive alternative, despite limited data regarding their long-term performance. The present review gives an overview of the current evidence regarding suture-based PFO closure, the device's characteristics, the echocardiographic evaluation of the PFO anatomy, and recommendations for patient selection. A detailed procedural guide is then provided, and potential complications and future developments in the field are discussed.
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El tratamiento mediante cierre percutáneo está extendiendo su uso en el ictus asociado a foramen oval permeable (FOP). El objetivo del estudio es analizar la práctica clínica del cierre percutáneo de FOP y conocer las variables que determinan esta indicación.
Registro observacional prospectivo de casos de ictus isquémico/ataque isquémico transitorio criptogénico asociado a FOP diagnosticados en la red de hospitales NORDICTUS en el periodo 2018-2021. Se registraron datos clínicos, patrón radiológico, datos de ecocardiograma y factores vinculados al ictus asociado a FOP (enfermedad tromboembólica y criterios de embolia paradójica) Se analizó la indicación de cierre según edad (≤/ > 60 años) y de las características del FOP.
En el grupo ≤60 años (n = 488) se indicó cierre en 143 pacientes (29,3%). Las variables predictoras de esta indicación fueron: detección de un FOP de alto riesgo (OR 4,11; IC 2,6-6,5, p< 0,001), criterio de embolismo paradójico (OR 2,61; IC 1,28-5,28; p = 0,008) y el uso previo de antitrombóticos (OR 2,67; IC 1,38-5,18; p = 0,009). En el grupo de > 60 años (n = 124), el cierre se indicó en 24 casos (19%). Las variables relacionadas con esta opción fueron: antecedente de tromboembolismo pulmonar, predisposición a enfermedad tromboembólica, criterios de embolismo paradójico y FOP de alto riesgo.
En la indicación de cierre percutáneo, el factor principal es la detección de un FOP de alto riesgo (cortocircuito masivo, cortocircuito con aneurisma asociado). Otros factores de interés en la selección de pacientes son: antecedentes de enfermedad tromboembólica, criterios de embolismo paradójico o el uso previo de antitrombóticos.
There is an extending use of percutaneous closure of patent foramen ovale (PFO) as therapy for PFO-associated cryptogenic strokes. The aim of our study was to investigate the clinical practice of percutaneous closure of PFO and to analyse the variables for decision-making on the selection of patients for this procedure.
A prospective observational multicentric survey was conducted using all the cases of cryptogenic stroke/transient ischemic attack associated with PFO recorded in the NORDICTUS hospital registry during the period 2018-2021. Clinical data, radiological patterns, echocardiogram data and factors related to PFO-associated stroke (thromboembolic disease and paradoxical embolism criteria) were recorded. The indication for closure was analysed according to age (≤/ > 60 years) and the characteristics of the PFO.
In the group ≤60 years (n = 488), 143 patients (29.3%) underwent PFO closure. The most influential variables for this therapy were detection of a high-risk PFO (OR 4,11; IC 2,6-6,5, p< 0,001), criteria for paradoxical embolism (OR 2,61; IC 1,28-5,28; p = 0,008) and previous use of antithrombotics (OR 2,67; IC 1,38-5,18; p = 0,009). In the group >60 years old (n = 124), 24 patients had PFO closure (19%). The variables related to this option were history of pulmonary thromboembolism, predisposition to thromboembolic disease, paradoxical embolism criteria and high-risk PFO.
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Which is the case of 85% cases of paradoxical embolism [6] or other causes of pulmonary arterial hypertension; right atrial hyper pressure by tricuspid valve disease [12], right ventricular hyper pressure, right ventricular failure [12], positive pressure ventilation, positive end-expiratory pressure ventilation, right ventricular infarction, hypoxemia, extracorporeal circulation, pneumonectomy, chronic liver diseases, gas embolism [13]. FOP is frequently associated with various anatomical variations such as the Eustachian valve [15], Chiari malformation [16] or the aneurysm of the interatrial septum (ASA). The ASA is in 2% of clinical studies [17].
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We report the observation of a patient with a table associating an acute mesenteric ischemia and an acute ischemia of the upper limb; whose the etiological assessment revealed a deep venous thrombosis of the lower limbs complicated by pulmonary embolism.
These paradoxical embolisms occurred through a patent foramen ovale. The diagnosis of the patent foramen ovale in this patient was revealed by transthoracic echocardiography, with bubble test. The patient benefited from an embolectomy of the superior mesenteric artery and an embolectomy using fogarty catheter by approching humeral artery at the elbow crease with good postoperative evolution. The patient was put on long-term anticoagulation with Acenocoumarol (because of low socio-economic level of our patient). We didn't recommended the closure of the PFO because of the small size of the shunt and especially because the patient refuses that procedure.
Paradoxical embolism remains a pathology rarely mentioned by clinicians, although it can engage the functional and vital prognosis of the patient, hence the interest of a good cardiac evaluation in any patient with embolic ischemia.
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Given its association with PFO and cryptogenic stroke, further studies may be necessary to predict the anatomic features that risk-stratify patients for transcatheter interventions targeted at PFO and perhaps the EV itself. During fetal development, the right sinus venosus valve directs the flow of blood toward the interatrial septum and, subsequently, into the left atrium.1–5 Although this function is embryonic in nature, a remnant known as the EV can persist after birth and even into adulthood.
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Persisting eustachian valve in adults: relation to patent foramen ovale and cerebrovascular events

Abstract

Background

Methods

Results

Conclusion

Section snippets

Methods

Results

Discussion

Am Heart J

Am J Cardiol

J Am Soc Echocardiogr

J Am Soc Echocardiogr

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Variations and anomalies of the venous valves of the right atrium of the human heart

Arch Pathol

Echocardiographic appearance of Chiari networkdifferentiation from right heart heart pathology

Circulation

Eustachian valve endocarditis

Br Heart J