Chiari Network and Eustachian Valves in PFO-related Stroke; Incidental or Pathogenic Finding?
Mohammed Qussay Ali Al-Sabbagh1, Prasanna Venkatesan Eswaradass2
1Department of neurology, University of Kansas Medical Center, 2Department of neurology, University of Kansas Health System
Objective:
Assess the prevalence of right atrial [Chiari network (CN) and Eustachian valves (EV)], and whether it is more common in stroke patients
Background:
Persistent cardiac venous valves like EV/CN, associated with Patent Foramen Ovale (PFO), are occasionally detected during stroke workup, but their clinical significance is uncertain with limited supporting literature.
Design/Methods:
A systematic literature search was performed on PubMed and Web of Science databases following PRISMA protocol for all cross-sectional studies, case-control studies, and case series reporting EV/CN in stroke patients. We retrieved a total of 68 articles initially, with only 6 articles fulfilling our inclusion criteria. Meta-analysis was conducted to determine the odds ratio (OR) of having EV/CN in patients with stroke-related PFO compared to asymptomatic PFO. We also assessed the pooled prevalence of EV/CN among stroke-related PFO patients.
Results:
We retrieved a total of six studies, comprising four case-control studies and two cross-sectional studies, involving 875 participants with a mean age of 44.6 years (±13.8). The combined prevalence of EV/CN among stroke-related PFO patients was 50% (95% CI: 31-68), with isolated prevalence rates of 43% (95% CI: 25-63) for EV and 18% (95% CI: 12-25) for CN. Patients with a history of stroke exhibited a higher prevalence of EV/CN compared to controls, with an OR of 2.45 (95% CI: 1.2-5, P < 0.01). All included studies uniformly defined EV/CN through either transesophageal echocardiography (TEE) or intracardiac cardiography (ICE). Intravascular PFO closure was the most commonly utilized approach.
Conclusions:
EV/CN are relatively common findings in stroke-related PFO. They are underrecognized and underreported despite being associated with higher stroke risk. EV/CN should be considered high risk PFO features. Nevertheless, there is scarcity in research emphasizing their impact on clinical decision-making, particularly of PFO closure and the selection of antithrombotic agents.