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Correspondence |

No Closure for Patent Foramen Ovale in Obstructive Sleep Apnea?Patent Foramen Ovale and Obstructive Sleep Apnea FREE TO VIEW

Stephen Paul Hoole, DM; Bushra Rana, MD; Leonard M. Shapiro, MD; Michael Davies, MD
Author and Funding Information

From Papworth Hospital NHS Foundation Trust.

Correspondence to: Stephen Paul Hoole, MBBCh, DM, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridge, CB233RE, England; e-mail: stephen.hoole@papworth.nhs.uk


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2013;143(2):581-582. doi:10.1378/chest.12-2216
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Published online
To the Editor:

We read with interest the report in a recent issue of CHEST (January 2013) by Shaikh et al1 regarding the association between patent foramen ovale (PFO) and obstructive sleep apnea (OSA). However, we believe that their conclusion stating the lack of benefit of PFO closure in OSA is unduly pessimistic and premature. They attempted closure of only six large PFOs with the BioSTAR device (NMT Medical Inc) and acknowledge their small sample size. However, at 12-month follow-up only three PFOs had sealed. Other studies of NMT PFO devices for migraine2 and stroke3 have also been neutral, possibly as a result of failure of NMT PFO devices to seal the PFO.4

The closure data are further weakened by performing PFO closure in individuals who were not oxygen desaturators; the oxygen desaturation index (ODI):apnea-hypopnea index (AHI) ratio was low, ranging from 0.34 to 0.87 at baseline. Patients with OSA and large right-to-left shunts who desaturate out of proportion to their apnea-hypopnea episodes would be more likely to benefit from PFO closure, in our opinion. Furthermore, we believe the treatment interaction between OSA and PFO is bidirectional. Existing case reports show that OSA symptoms may improve following closure of a PFO for other indications,5,6 but CPAP therapy for OSA can also suppress right-to-left shunting due to a PFO.7 The use of CPAP therapy in some, but not all, of the closure group may mask any observable benefit.

Taken together, this could explain why no discernible improvement in OSA was observed following BioSTAR implantation in this study. It remains to be seen if a device that truly seals the PFO can improve clinical outcome in a carefully selected group of patients with OSA.

References

Shaikh ZF, Jaye J, Ward N, et al. Patent foramen ovale in severe obstructive sleep apnea: clinical features and effects of closure. Chest. 2013;143(1):56-63.
 
Dowson A, Mullen MJ, Peatfield R, et al. Migraine Intervention With STARFlex Technology (MIST) trial: a prospective, multicenter, double-blind, sham-controlled trial to evaluate the effectiveness of patent foramen ovale closure with STARFlex septal repair implant to resolve refractory migraine headache. Circulation. 2008;117(11):1397-1404. [CrossRef] [PubMed]
 
Furlan AJ, Reisman M, Massaro J, et al CLOSURE I Investigators. Closure or medical therapy for cryptogenic stroke with patent foramen ovale. N Engl J Med. 2012;366(11):991-999. [CrossRef] [PubMed]
 
Van den Branden BJ, Post MC, Plokker HW, ten Berg JM, Suttorp MJ. Patent foramen ovale closure using a bioabsorbable closure device: safety and efficacy at 6-month follow-up. JACC Cardiovasc Interv. 2010;3(9):968-973. [CrossRef] [PubMed]
 
Silver B, Greenbaum A, McCarthy S. Improvement in sleep apnea associated with closure of a patent foramen ovale. J Clin Sleep Med. 2007;3(3):295-296. [PubMed]
 
Agnoletti G, Iserin L, Lafont A, Sidi D, Desnos M. Obstructive sleep apnoea and patent foramen ovale: successful treatment of symptoms by percutaneous foramen ovale closure. J Interv Cardiol. 2005;18(5):393-395. [CrossRef] [PubMed]
 
Pinet C, Orehek J. CPAP suppression of awake right-to-left shunting through patent foramen ovale in a patient with obstructive sleep apnoea. Thorax. 2005;60(10):880-881. [CrossRef] [PubMed]
 

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References

Shaikh ZF, Jaye J, Ward N, et al. Patent foramen ovale in severe obstructive sleep apnea: clinical features and effects of closure. Chest. 2013;143(1):56-63.
 
Dowson A, Mullen MJ, Peatfield R, et al. Migraine Intervention With STARFlex Technology (MIST) trial: a prospective, multicenter, double-blind, sham-controlled trial to evaluate the effectiveness of patent foramen ovale closure with STARFlex septal repair implant to resolve refractory migraine headache. Circulation. 2008;117(11):1397-1404. [CrossRef] [PubMed]
 
Furlan AJ, Reisman M, Massaro J, et al CLOSURE I Investigators. Closure or medical therapy for cryptogenic stroke with patent foramen ovale. N Engl J Med. 2012;366(11):991-999. [CrossRef] [PubMed]
 
Van den Branden BJ, Post MC, Plokker HW, ten Berg JM, Suttorp MJ. Patent foramen ovale closure using a bioabsorbable closure device: safety and efficacy at 6-month follow-up. JACC Cardiovasc Interv. 2010;3(9):968-973. [CrossRef] [PubMed]
 
Silver B, Greenbaum A, McCarthy S. Improvement in sleep apnea associated with closure of a patent foramen ovale. J Clin Sleep Med. 2007;3(3):295-296. [PubMed]
 
Agnoletti G, Iserin L, Lafont A, Sidi D, Desnos M. Obstructive sleep apnoea and patent foramen ovale: successful treatment of symptoms by percutaneous foramen ovale closure. J Interv Cardiol. 2005;18(5):393-395. [CrossRef] [PubMed]
 
Pinet C, Orehek J. CPAP suppression of awake right-to-left shunting through patent foramen ovale in a patient with obstructive sleep apnoea. Thorax. 2005;60(10):880-881. [CrossRef] [PubMed]
 
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