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Updated: Jul 1, 2025
Echocardiographic Evaluation of Atrial Communications before Transcatheter Closure
Published on: February 8, 2022
Comparison of atrial septal defect and patent foramen ovale in cryptogenic strokes
Constant Delabays1, Pamela Correia1, Eric Eeckhout2
1Stroke Center, Neurology Service, Department of Clinical Neurosciences, of the Lausanne University Hospital, Lausanne, Switzerland.
Insights
Atrial septal defect (ASD) is a rare cause of cryptogenic stroke (CS). Patients with ASD and CS share characteristics between high and low likelihood patent foramen ovale (PFO) strokes, warranting further investigation for stroke causes.
Area of Science:
- Cardiology
- Neurology
- Vascular Medicine
Background:
- Paradoxical embolism via right-to-left shunts, including atrial septal defects (ASD) and patent foramen ovale (PFO), is a recognized cause of cryptogenic strokes (CS).
- Understanding the specific role of ASD in CS pathogenesis is crucial for accurate diagnosis and treatment.
Purpose of the Study:
- To investigate the pathogenic role of ASD in cryptogenic strokes (CS).
- To compare characteristics of ASD patients with CS who have a high versus low likelihood of being related to PFO.
Main Methods:
- Prevalence of PFO and ASD in CS patients was determined using echocardiography.
- Patients with CS and PFO were stratified into high (HL-PFO) and low-likelihood (LL-PFO) groups based on the Risk of Paradoxical Embolism (RoPE) score.
- Epidemiological, clinical, and radiological variables of ASD patients were compared between the HL-PFO and LL-PFO groups.
Main Results:
- ASD and PFO were significantly associated with CS compared to non-CS patients (OR 5.2 and 2.8, respectively).
- ASD patients with CS exhibited characteristics intermediate between HL-PFO and LL-PFO groups, including age, sex, cardiovascular risk factors, and silent strokes.
- No significant differences were observed in clinical or radiological characteristics and clinical outcomes between the groups.
Conclusions:
- Atrial septal defect (ASD) is identified as a rare risk factor for cryptogenic strokes (CS).
- The clinical profile of ASD-related CS patients suggests a need for comprehensive evaluation for alternative stroke mechanisms.
- Individualized assessment of ASD's causative likelihood is recommended over routine closure procedures.
Objectives:
Paradoxical embolism from right-to-left shunt through atrial septal defect (ASD) and patent foramen ovale (PFO) is a well-accepted cause of "cryptogenic" strokes (CS). To better understand the pathogenic role of ASD, we compared ASD patients with CS having a high and low likelihood of being PFO-related.
Methods:
In the Acute Stroke Registry and Analysis of Lausanne, we calculated prevalence of PFO and ASD in CS patients undergoing echocardiography, and calculated odds ratios (OR) when compared to non-CS. Using the Risk of Paradoxical Embolism (RoPE) score, we divided CS PFO patients in high (HL-PFO, RoPE 8-10) and low-likelihood (LL-PFO, RoPE 0-4) PFO-related stroke. We then performed univariate comparison of epidemiological, clinical and radiological variables of ASD patients with both PFO groups.
Results:
Among all CS, prevalence of ASD and PFO were 1.3% and 36.8% respectively. When compared to non-CS, ASD and PFO were associated with CS (OR of 5.2, CI= 1.6-16.6, and 2.8, CI= 2.1-3.8). Compared with HL-PFO, ASD patients were older, more often female, had more cardiovascular risk factors and silent strokes. Compared with LL-PFO, ASD patients were younger, more often female, and had less risk factors. No differences were found for clinical and radiological characteristics and clinical outcome.
Conclusion:
ASD is a rare stroke risk factor for CS. Since characteristics of such patients lie in-between high and low-likelihood paradoxical PFO-strokes, a thorough work-up for other stroke mechanisms is warranted. Individual evaluation of the likelihood of the ASD being causative for stroke may be preferable over routine ASD closure.
