Interobserver and intraobserver variability in detection of patent foramen ovale and atrial septal aneurysm with transesophageal echocardiography

doi:10.1067/mje.2002.116718

Journal of the American Society of Echocardiography

Volume 15, Issue 5, May 2002, Pages 441-446

https://doi.org/10.1067/mje.2002.116718 Get rights and content

Abstract

Background: An accurate diagnosis of patent foramen ovale (PFO) and atrial septal aneurysm (ASA) may be of decisional importance in the management of patients with ischemic stroke. Very few studies have been devoted to observer agreement in the diagnosis of these atrial septum abnormalities using contrast transesophageal echocardiography, which is considered as the method of choice for the diagnosis. The aim of this study was to assess interobserver and intraobserver variability in the diagnosis of PFO and ASA with contrast echocardiography. Methods: Three sonographers independently reviewed 100 contrast studies stored on videotape on 2 occasions each. The interobserver and intraobserver variability was assessed by calculating κ statistics. Results: The overall interobserver and intraobserver κ values for the assessment of degree of shunting through a PFO were 0.77 (first and second reading) and 0.82, respectively. The best κ statistics were obtained when no and small shunts (less than 10 microbubbles) were pooled and compared with larger shunts. For the diagnosis of ASA, the overall interobserver κ value was 0.45 for the first reading and 0.71 for the second reading, whereas the overall intraobserver κ value was 0.74. Conclusion: Interobserver and intraobserver agreements for the diagnosis of PFO and ASA by transesophageal echocardiography are not perfect and need to be improved, particularly for ASA. This variability has to be taken into account when deciding on a potential risky treatment to prevent recurrent strokes. (J Am Soc Echocardiogr 2002;15:441-6.)

Section snippets

Methods

This study was part of a prospective multicentric study (the PFO-ASA study) designed (1) to assess the absolute and relative risks of recurrent stroke in patients with PFO or ASA or both abnormalities and an otherwise unexplained ischemic stroke and (2) to identify subgroups of patients with high risk of recurrence. Six hundred consecutive patients younger than 55 years with cryptogenic stroke were included in the PFO-ASA study between 1996 and 1998 and monitored up to December 2000. All

Results

Among the 100 patients, 3 were excluded because the 3 sonographers considered that the TEE examinations were of poor technical quality. The 97 remaining patients (mean age: 43.1 years; 53 males, 44 females) formed the basis of the study. TEE was performed using a multiplane transducer in 85 patients and a biplane transducer in 12.

Table 1 shows the prevalence of PFO and ASA reported by each sonographer (first reading).

. Prevalence of patent foramen ovale and atrial septal aneurysm reported by each

Discussion

To our knowledge, this is the first study to assess intraobserver and interobserver variability in the diagnosis of PFO and ASA with contrast TEE, in a large series of patients.

Cross et al⁶ reported interobserver and intraobserver variability in detection of PFO in 100 subjects without overt cardiac disease examined by contrast transthoracic echocardiography. Four observers blindly reviewed 100 examinations for the presence (any contrast in the left heart within 5 cardiac cycles after right

Conclusion

This study shows that interobserver and intraobserver agreements for the diagnosis of PFO and ASA are not perfect and need to be improved, particularly for ASA. Future TEE studies on these atrial septal disorders should include an assessment of the reliability of the diagnosis. From a practical point of view, confirmation of the diagnosis of PFO and ASA by 2 experienced sonographers is recommended, before deciding on a potential risky treatment.

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Selection of patients for percutaneous closure in nonlacunar cryptogenic stroke associated with patent foramen ovale. Data from the NORDICTUS cooperative registry
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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.
The detection of a high-risk PFO (large shunt, shunt with associated aneurysm) is the main criterion for a percutaneous closure-based therapy. Other conditions to consider in the eligibility of patients are the history of thromboembolic disease, paradoxical embolism criteria or the previous use of antithrombotics.
Air-embolism in the semi-sitting position for craniotomy: A narrative review with emphasis on a single centers experience
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Citation Excerpt :
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Albeit the semi-sitting position in neurosurgery has been in use for several decades, its application remains controversial in the neurosurgical and neuro-anaesthesia communities. The imminent and most feared risk of the sitting position is air entry into the vascular system due to the negative intravascular pressure leading to potentially life-threatening air embolism with its consequences. Recent advents in neurosurgical (improvement of the operating microscope, employment of intra-operative neurophysiological monitoring) and neuro-anaesthesia care (new anaesthetics, advanced monitoring modalities) have significantly impacted the approach to these surgeries. Vigilant intra-operative observation by an experienced team and peri-operative patient management guided by institutional protocols improves the safety profile of these surgeries. This review outlines the workflow and protocols used in our institution for all cases of semi-sitting position for skull base neurosurgery.
Cryptogenic stroke and patent foramen ovale
2020, Archives des Maladies du Coeur et des Vaisseaux - Pratique
Atrial Septal Aneurysm, Shunt Size, and Recurrent Stroke Risk in Patients With Patent Foramen Ovale
2020, Journal of the American College of Cardiology
In patients with patent foramen ovale (PFO)–associated stroke, the presence of large shunt or atrial septal aneurysm (ASA) has been suggested to convey a high risk of stroke recurrence.
The purpose of this study was to assess the respective influence of PFO size and ASA status on stroke recurrence under medical therapy in patients with recent PFO-associated stroke without alternative cause.
The authors pooled individual patient data from 2 prospective observational studies and the medical arms of 2 randomized trials, in which shunt size and ASA status was assessed by independent reading of echocardiographic images. Associations between PFO anatomical features and recurrent ischemic stroke were assessed by mixed effects Cox models.
Of 898 patients (mean age 45.3 years), 178 (19.8%) had ASA with large PFO, 71 (7.9%) ASA with nonlarge PFO, 397 (44.2%) large PFO without ASA, and 252 (28.1%) nonlarge PFO without ASA. Over a median follow-up of 3.8 years (interquartile range: 2.6 to 5.5 years), 47 (5.2%) patients experienced a recurrent stroke. There was a heterogeneity across studies for the association between PFO size and stroke recurrence (p_interaction = 0.01). In a model accounting for age, hypertension, antithrombotic therapy, and PFO anatomy, ASA was independently associated with recurrent stroke (adjusted hazard ratio: 3.27; 95% confidence interval: 1.82 to 5.86; p < 0.0001), whereas large PFO was not (average adjusted hazard ratio across studies: 1.43; 95% confidence interval: 0.50 to 4.03; p = 0.50).
In patients with PFO-associated stroke, ASA is a more important predictor of recurrent stroke than shunt size. These results can help to better identify those patients with a high risk of stroke recurrence under medical therapy who may derive the most benefit from PFO closure. (Patent Foramen Ovale Closure or Anticoagulants Versus Antiplatelet Therapy to Prevent Stroke Recurrence [CLOSE]; NCT00562289) (Device Closure versus Medical Therapy in Patients with Cryptogenic Stroke and High-Risk Patent Foramen Ovale [DEFENSE-PFO]; NCT01550588)
Transcatheter closure of patent foramen ovale in patients older than 60 years of age with cryptogenic embolism
2020, Revista Espanola de Cardiologia
Estudios aleatorizados han mostrado la eficacia del cierre percutáneo del foramen oval permeable (FOP) en pacientes de edad ≤ 60 años con ictus criptogénico. El objetivo de este estudio es determinar la seguridad y la eficacia a largo plazo del cierre percutáneo del FOP en pacientes mayores de 60 años con ictus criptogénico.
De 475 pacientes consecutivos con ictus criptogénico que se sometieron al cierre del FOP, 90 eran mayores de 60 años (media, 66 ± 5 años) y se los comparó con los 385 del grupo de edad ≤ 60 años (media, 44 ± 10 años).
Los pacientes mayores de 60 años tuvieron mayor prevalencia de factores de riesgo cardiovascular (FRCV) (hipertensión, dislipemia y diabetes; p < 0,01). No hubo diferencias en cuanto a complicaciones periprocedimiento. El seguimiento medio fue de 8 (4-12) años y hubo 17 muertes, todas de causa no cardiovascular (el 7,8% de los mayores de 60 años y el 2,6% de los de edad ≤ 60 años; HR = 4,12; IC95%, 1,56-10,89). Tuvieron un ictus recurrente 4 pacientes (el 2,2% de los mayores de 60 años frente al 0,5% de los de edad ≤ 60 años; HR = 5,08; IC95%, 0,71-36,2), y un accidente isquémico transitorio (AIT) 12 pacientes (el 3,3 frente al 2,3%; HR = 1,71; IC95%, 0,46-6,39). Hubo tendencia a una mayor incidencia de ictus/AIT en los mayores de 60 años (el 5,5 frente al 2,6%; HR = 2,62; IC95%, 0,89-7,75; p = 0,081), que no persistió tras ajustar por FRCV (HR = 1,97; IC95%, 0,59-6,56; p = 0,269).
El cierre percutáneo del FOP en pacientes mayores de 60 años con ictus criptogénico resultó seguro y se asoció con una baja incidencia de eventos isquémicos a largo plazo. Sin embargo, en los pacientes mayores de 60 años se observó una tendencia a mayor incidencia de ictus/AIT probablemente relacionada con mayor prevalencia de FRCV.
Randomized trials have shown the efficacy of transcatheter closure of patent foramen ovale (PFO) in patients aged ≤ 60 years with cryptogenic embolism. We aimed to assess the long-term safety and efficacy of PFO closure in patients aged > 60 years.
Of 475 consecutive patients with cryptogenic embolism who underwent PFO closure, 90 older patients aged > 60 years (mean, 66 ± 5 years) were compared with 385 younger patients aged ≤ 60 years (mean, 44 ± 10 years).
Older patients had a higher prevalence of cardiovascular risk factors (CVRF) (hypertension, dyslipidemia, diabetes; P < .01 for all vs younger patients). There were no differences in periprocedural complications between the 2 groups. During a median follow-up of 8 (4-12) years, there were a total of 17 deaths, all from noncardiovascular causes (7.8% and 2.6% in the older and younger patient groups, respectively; HR, 4.12; 95%CI, 1.56-10.89). Four patients had a recurrent stroke (2.2% and 0.5% in the older and younger patient groups, respectively; HR, 5.08; 95%CI, 0.71-36.2), and 12 patients had a transient ischemic attack (TIA) (3.3% and 2.3% in the older and younger patient groups, respectively; HR, 1.71; 95%CI, 0.46-6.39). There was a trend toward a higher rate of the composite of stroke/TIA in older patients (5.5% vs 2.6%; HR, 2.62; 95%CI, 0.89-7.75; P = .081), which did not persist after adjustment for CVRF (HR, 1.97; 95%CI, 0.59-6.56; P = .269).
In older patients with cryptogenic embolism, PFO closure was safe and associated with a low rate of ischemic events at long-term. However, older patients exhibited a tendency toward a higher incidence of recurrent stroke/TIA compared with younger patients, likely related to a higher burden of CVRF.

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^*: Supported by grants from the Programme Hospitalier de Recherche Clinique of the French Ministry of Health (AOM95059) and Sanofi-Synthelabo laboratories. The Assistance Publique-Hôpitaux de Paris had the legal responsibility of the study.

^**: Reprint requests: Pr Jean-Louis Mas, Service de Neurologie, Hôpital Sainte-Anne, 1 rue Cabanis, 75674 Paris Cedex 14, France (E-mail: [email protected]).

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Original ArticlesInterobserver and intraobserver variability in detection of patent foramen ovale and atrial septal aneurysm with transesophageal echocardiography*,**

Abstract

Section snippets

Methods

Results

Discussion

Conclusion

J Am Coll Cardiol

J Am Coll Cardiol

Am Heart J

J Am Coll Cardiol

Prevalence of patent foramen ovale in patients with stroke

N Engl J Med

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

Stroke

Diagnosis and management of paradoxical embolism and patent foramen ovale

Curr Opin Cardiol

Inter- and intra-observer variability in detection of patent foramen ovale with contrast echocardiography

Eur Heart J

Original Articles
Interobserver and intraobserver variability in detection of patent foramen ovale and atrial septal aneurysm with transesophageal echocardiography*,**