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PFO

PFO. Dr Peter Wilmshurst Royal Shrewsbury Hospital Co-workers: Simon Nightingale, Lindsay Morrison, Matthew Pearson, Kevin Walsh, Phil Bryson, John Davis, J de Giovanni, Chris Byrne and MIST Trial investigators. NO CONFLICT OF INTEREST TO DECLARE.

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PFO

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  1. PFO Dr Peter Wilmshurst Royal Shrewsbury Hospital Co-workers: Simon Nightingale, Lindsay Morrison, Matthew Pearson, Kevin Walsh, Phil Bryson, John Davis, J de Giovanni, Chris Byrne and MIST Trial investigators

  2. NO CONFLICT OF INTEREST TO DECLARE

  3. Syndromes associated with right to left shunts • Paradoxical thromboembolism and stroke (atrial >>>>> pulmonary shunts)

  4. Syndromes associated with right to left shunts • Paradoxical thromboembolism and stroke (atrial >>>>> pulmonary shunts) • Paradoxical gas embolism and decompression illness (atrial >> pulmonary shunts)

  5. Syndromes associated with right to left shunts • Paradoxical thromboembolism and stroke (atrial >>>>> pulmonary shunts) • Paradoxical gas embolism and decompression illness (atrial >> pulmonary shunts) • Migraine with aura (atrial > pulmonary shunts)

  6. Syndromes associated with right to left shunts • Paradoxical thromboembolism and stroke (atrial >>>>> pulmonary shunts) • Paradoxical gas embolism and decompression illness (atrial >> pulmonary shunts) • Migraine with aura (atrial > pulmonary shunts) • Arterial hypoxaemia (pulmonary >>>>> atrial shunts)

  7. Prevalence of migraine with aura related to shunt size • 4% of general population • 4% of those with small right-to-left shunts • 25% of those with medium shunts at rest • 21% of those with large shunt with Valsalva • 53% of those with large shunt at rest • 53% of those with Hereditary Haemorrhagic Telangiectasia

  8. Determinants of size of the shunt through a PFO • Dimensions of the foramen • Size of the flap • Compliance of the flap • Pressure gradient* • Atrial flow characteristics* *variable

  9. Migraine with aura and increased incidence of cryptogenic stroke Large atrial shunts (PFO & ASD) are present in: • 7.3% - population controls • 38.1% - migraine with aura but no stroke • 84% - stroke and migraine with aura (Am J Card 2006;98:831-3)

  10. Migraine with aura and risk of decompression illness • People with migraine with aura have increased risk of neurological DCI (War Medicine 1944;5:304-14) • The increased risk is confined to migraineurs with a large PFO or other large right-to-left shunt (Clinical Science 2001;100:215-20).

  11. Recurrence of symptoms after PFO closure • Symptoms are not shunt-related and PFO is bystander.

  12. Recurrence of symptoms after PFO closure • Symptoms are not shunt-related and PFO is bystander. • PFO closure device responsible for recurrence (e.g. migraine triggering effect of device, stroke caused by thrombus on device or AF post implantation).

  13. Recurrence of symptoms after PFO closure • Symptoms are not shunt-related and PFO is bystander. • PFO closure device responsible for recurrence (e.g. migraine triggering effect of device, stroke caused by thrombus on device or AF post implantation). • Significant residual shunt through PFO, another atrial defect or a pulmonary shunt.

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