4. ETT in seconda armonica L’imaging in seconda armonica migliora significativamente la visualizzazione di bolle di gas
5. Modalità di esecuzione dell’ecocontrastografia Preparazione del paziente Ago cannula 18-gauge nella vena antecubitale destra Preparazione del MDC ed iniezione I a siringa da 10 ml riempita con 9 ml di soluzione salina o poligelatina. II a siringa con 1 ml di aria. Connettere le due siringhe con una valvola 3-vie a sua volta connessa con un corto flessibile all’agocannula. Far passare vigorosamente la soluzione aria/salina (o poligelatina) tra le 2 siringhe almeno 10 volte. Iniettare immediatamente in bolo. In caso di scarso o mancato passaggio di MDC ripetere con manovra di Valsalva. Manovra di Valsalva Far eseguire la manovra di Valsalva per almeno 5 sec ed iniettare il bolo appena inizia la fase di rilascio. Valutazione del risultati Esame positivo per comparsa di bolle in atrio sinistro entro 3 battiti dalla completa opacificazione dell’atrio destro.
6. Affidabilità dell’eco transtoracico con contrasto 83%*/nd nd PFO 100% °/ nd 82% °/ nd 68,4% °/ 88,9%° 93,2% °/ 98,8%° 90,5% °/ 89,7%° 96,5% °/ 94,6 %° Sensibilità e specificità di 2H ETT rispetto a ETE nella diagnosi di PFO Studio Anno Pazienti contrasto Sensibilità Tot / PFOampi Specificità Tot / PFOampi Tot Kuhl 34 1999 110 61 poligelatina 93%*/nd nd Van Camp 35 2000 109 24 salina Madala 36 1995 78 78 salina Clarke 37 2004 110 13 salina Daniëls C 21 2004 256 60 salina Maffè S 2009 75 62 salina 89% °/ nd 100% °/ %°
9. Shunt dx >sn: PFO ? Vena cava superiore sinistra persistente con sbocco in vena polmonare sup sin
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12. Associazione Stroke/PFO The unequivocal finding that both PFO and ASA are associated with ischemic stroke in the young is important. The implication for planned investigation is that PFO should be sought in young ( age <55) patients, and if found should not be regarded as incidental. Although less frequently detected, ASA is more strongly associated with ischemic and cryptogenic stroke than PFO
13. Associazione PFO/Stroke These prospective population-based data suggest that, after correction for age and comorbidity, PFO is not an independent risk factor for future cerebrovascular events in the general population. A larger study is required to test the putative stroke risk associated with ASA. Because of methodologic inconsistencies, detection rates of PFO in different populations vary widely, leading to potentially inaccurate conclusions regarding its association with stroke.
14. Recidiva in pazienti con ictus criptogenetico e PFO there is significant heterogeneity among studies in the estimated absolute rate of recurrent events for patients treated medically: for the composite of stroke or TIA, reported estimates range from 0,9 to over 10,11 events per 100 person-years, and for stroke alone estimates ranged from 0,9 to 5.113 events per 100 person-years.
15. Associazione PFO/recidiva di stroke In this systematic review and metaanalysis of observational studies, we found that among those with a cryptogenic stroke or TIA, the risk of recurrent cerebrovascular events is similar in those with vs without a PFO.
17. Conseguenze pratiche For patients who have had a cryptogenic stroke and have a PFO, the evidence indicates that the risk of subsequent stroke or death is no different from other cryptogenic stroke patients without PFO when treated medically with antiplatelet agents or anticoagulants. neurologists should communicate to patients and their families that presence of PFO does not confer an increased risk for subsequent stroke compared to other cryptogenic stroke patients without atrial abnormalities (Level A). in younger stroke patients, studies that can identify PFO or ASA may be considered for prognostic purposes (Level C). there is insufficient evidence to determine the superiority of aspirin or warfarin for prevention of recurrent stroke or death (Level U), but the risks of minor bleeding are possibly greater with warfarin (Level C). There is insufficient evidence regarding the effectiveness of either surgical or percutaneous closure of PFO (Level U).
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