European Heart Journal Advance Access originally published online on May 4, 2005
European Heart Journal 2005 26(14):1446-1447; doi:10.1093/eurheartj/ehi316
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ASD closure for migraine: is there a scientific basis?: reply
Department of Cardiology
University Hospital Gasthuisberg
Herestraat 49 B
3000 Leuven
Belgium
Tel: +32 16 344235
Fax: +32 16 344240
E-mail address: werner.budts{at}uz.kuleuven.ac.be
We greatly appreciate the comments made by Gupta on our paper entitled ‘The influence of percutaneous atrial septal defect closure on the occurrence of migraine’.1 However, we have to warn the reader for over-interpreting our findings. With this study, we did not want to prove migraine prevention, but we were interested in the effect of percutaneous atrial septal defect (ASD) closure on migraine. Indeed, the reason for this study was our experience that migraine occurred in some patients and disappeared in others, almost immediately after the percutaneous procedure.
We do agree with Gupta that the haemodynamics of a patent foramen ovale and ASD differ substantially. However, right-to-left shunting in ASD patients is considerably underestimated. A right-to-left shunt can easily be documented by an intravenous contrast injection during a transoesophageal echocardiogram,2 even without a Valsalva manoeuvre. Contrast passage is more pronounced in larger (less restrictive) ASDs, which implicates lower pressure differences between left and right atria. In contrast, in smaller (restrictive) ASDs, the pressure differences between the atria are higher, which implicates less or even absent contrast passage. The smaller ASDs were not included in the study because they were not indicated to be closed. Therefore, we are not convinced that the right-heart haemodynamics of our study population might identify the degree of the potential right-to-left shunt. The explanation for the latter is probably much more complex. Finally, paradoxical embolism through an ASD leading to a cryptogenic stroke seems not to be so uncommon, which highlights the clinical relevance of a right-to-left shunt in these patients.3
The implication of atrial natriuretic peptide (ANP) in the pathogenesis of migraine remains controversial. Today, no clear relationship is documented between ANP and migraine. However, transient changes in ANP levels after ASD closure are reported.4 Future research will be necessary to determine its relationship with the occurrence of migraine.
On the basis of the data available in the literature and with regard to our study results, we do believe that micro-thrombi play an important role in the occurrence of migraine. The latter might explain the relationship between stroke and migraine and fits with our hypothesis of micro-thrombi on larger ASD devices resulting in the appearance of migraine. Indeed, even macro-thrombi seem not to be so uncommon after device closure.5 Nevertheless, we do agree that (paradoxical) micro-emboli are generally distributed randomly. However, regional differences in cerebral arterial reactivity might be present6 and explain why diffuse micro-emboli can cause repeated lateralized signs. In addition, it can be hypothesized that micro-emboli do not have to induce brain ischaemia to provoke a migraine attack, but only to modulate the neurovascular vaso-reactivity.
Finally, the appearance of migraine is strongly age dependent. Although it is purely hypothetical, it is possible that the interaction between trigger substances and the neurovascular excitability for these trigger substances changes over time. With device closure, we might influence this interaction. The fact that migraine appeared or disappeared almost immediately after ASD closure suggests a causative relationship. However, a larger study sample in a controlled prospective study design will be necessary to answer the remaining questions.
References
- Mortelmans K, Post M, Thijs V, Herroelen L, Budts W. The influence of percutaneous atrial septal defect closure on the occurrence of migraine. Eur Heart J 2005. doi:10.1093/eurheartj/ehi170. Published online ahead of print March 3, 2005.
- Kai H, Koyanagi S, Hirooka Y, Sugimachi J, Sadoshima J, Suzuki S, Takeshita A. Right-to-left shunt across atrial septal defect related to tricuspid regurgitation: assessment by transesophageal Doppler echocardiography. Am Heart J 1994;127:578–584.[CrossRef][ISI][Medline]
- Khositseth A, Cabalka AK, Sweeney JP, Fortuin FD, Reeder GS, Connolly HM, Hagler DJ. Transcatheter amplatzer device closure of atrial septal defect and patent foramen ovale in patients with presumed paradoxical embolism. Mayo Clin Proc 2004;79:35–41.[ISI][Medline]
- Muta H, Ishii M, Maeno Y, Akagi T, Kato H. Quantitative evaluation of the changes in plasma concentrations of cardiac natriuretic peptide before and after transcatheter closure of atrial septal defect. Acta Paediatr 2002;91:649–652.[CrossRef][ISI][Medline]
- Krumsdorf U, Ostermayer S, Billinger K, Trepels T, Zadan E, Horvath K, Sievert H. Incidence and clinical course of thrombus formation on atrial septal defect and patient foramen ovale closure devices in 1,000 consecutive patients. J Am Coll Cardiol 2004; 43:302–309.
[Abstract/Free Full Text] - Silvestrini M, Baruffaldi R, Bartolini M, Vernieri F, Lanciotti C, Matteis M, Troisi E, Provinciali L. Basilar and middle cerebral artery reactivity in patients with migraine. Headache 2004;44:29–34.[CrossRef][ISI][Medline]
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