Abstract WP264: Frequency of Hypercoagulability in Patients With Embolic Stroke of Undetermined Source and Patent Foramen Ovale

Introduction: Patent foramen ovale (PFO) is more commonly found in patients with cryptogenic stroke and paradoxical embolism is commonly assumed to be the primary mechanism. Our objective was to determine the frequency of hypercoagulability in cryptogenic stroke patients and PFO. Methods: Consecutive patients with embolic stroke of undetermined source (ESUS) seen at the Emory Clinic from January 1, 2017 to June 30, 2019 who underwent echocardiogram with bubble study and markers of coagulation and hemostatic activation (MOCHA) testing (serum d-dimer, prothrombin fragment 1.2, thrombin-antithrombin complex, fibrin monomer) were included; abnormal MOCHA was defined as ≥ 2 elevated markers. Venous thromboembolism, malignancy, other defined hypercoagulable state, and the composite outcome were assessed at routine follow-up and compared across groups based on PFO status. Results: Of 172 patients (mean age 63 ± 16 years, 60% female), 40 (23%) had a PFO. Compared to the PFO- group, the PFO+ group was younger (p=<0.001), less likely to have hypertension (p<0.001) and diabetes (p=0.011), and had a higher ROPE score (p=0.007) (Table 1). There was no difference in the frequency of abnormal MOCHA between groups and the composite outcome was less frequent in PFO+ versus PFO- patients (p=0.017). In the subgroup of patients <60 years old, there was no difference in the frequency of abnormal MOCHA and the composite outcome. Conclusion: Hypercoagulability as measured by MOCHA was not associated with the presence of PFO in ESUS patients. Based on our results, ESUS patients should undergo a detailed evaluation for alternative causes of stroke other than paradoxical embolism.

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Patent Foramen Ovale, the Role of Antiplatelet Therapy Alone or Anticoagulant Therapy Alone Versus Device Closure for Cryptogenic Stroke: A Review of the Literature and Current Recommendations

Cardiovascular & Hematological Agents in Medicinal Chemistry ◽

10.2174/1871525718666200203111641 ◽

2020 ◽

Vol 18 (2) ◽

pp. 135-150

Author(s):

Harsha S. Nagarajarao ◽

Chandra P. Ojha ◽

Archana Kedar ◽

Debabrata Mukherjee

Keyword(s):

Patent Foramen Ovale ◽

Cryptogenic Stroke ◽

Narrow Channel ◽

Paradoxical Embolism ◽

Current Evidence ◽

Foramen Ovale ◽

The Right ◽

The Relationship ◽

Current Guidelines

: Cryptogenic stroke and its relation to the Patent Foramen Ovale (PFO) is a long-debated topic. Recent clinical trials have unequivocally established the relationship between cryptogenic strokes and paradoxical embolism across the PFO. This slit-like communication exists in everyone before birth, but most often closes shortly after birth. PFO may persist as a narrow channel of communication between the right and left atria in approximately 25-27% of adults. : In this review, we examine the clinical relevance of the PFO with analysis of the latest trials evaluating catheter-based closure of PFO’s for cryptogenic stroke. We also review the current evidence examining the use of antiplatelet medications versus anticoagulants for stroke prevention in those patients with PFO who do not qualify for closure per current guidelines.

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Long-term follow-up after percutaneous closure of patent foramen ovale for secondary prevention of paradoxical embolism in elderly patients (≥70 years)

European Geriatric Medicine ◽

10.1016/j.eurger.2011.12.008 ◽

2012 ◽

Vol 3 (1) ◽

pp. 23-27

Author(s):

F. Praz ◽

S. Beney ◽

A. Wahl ◽

S. Windecker ◽

B. Meier

Keyword(s):

Secondary Prevention ◽

Elderly Patients ◽

Patent Foramen Ovale ◽

Paradoxical Embolism ◽

Percutaneous Closure ◽

Foramen Ovale ◽

Long Term Follow Up

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Patent Foramen Ovale Device Closure in a 27 Years Old Young Lady with Cryptogenic Ischaemic Stroke - First Case Report from Bangladesh

Cardiovascular Journal ◽

10.3329/cardio.v13i2.52978 ◽

2021 ◽

Vol 13 (2) ◽

pp. 227-234

Author(s):

AQM Reza ◽

Aparajita Karim ◽

Mahmood Hasan Khan ◽

Kazi Atiqur Rahman ◽

Md Aliuzzaman Joarder ◽

...

Keyword(s):

Ischaemic Stroke ◽

Patent Foramen Ovale ◽

Incidental Finding ◽

Cryptogenic Stroke ◽

Paradoxical Embolism ◽

Foramen Ovale ◽

Coagulation Therapy ◽

First Case ◽

Treatment Paradigm ◽

Meta Analyses

A patent foramen ovale (PFO) is highly prevalent in patients with strokes of unknown cause or cryptogenic strokes (CSs). It has been remained an unsolved question as to whether a PFO should be closed or not to prevent recurrent strokes in patients diagnosed with cryptogenic stroke (CS). A paradoxical embolism through a PFO is pointed as a leading cause of CS, especially in younger patients with low risk factors for stroke. It also remains an unsolved matter on type of anti-coagulation therapy, which would be better for patients with CS and a PFO. In addition, surgical and transcutaneous closure of a PFO has been proposed for the secondary prevention of stroke in patients with CS with PFO. Several randomized controlled trials have been conducted in recent years to test whether a PFO closure gives a significant benefit in the management of CS. Many investigators believed that a PFO was an incidental finding in patients with CS. However, meta-analyses and more recent specific trials have eliminated several confounding factors and possible biases and have also emphasized the use of a shunt closure over medical therapy in patients with CS. Therefore, these latest studies can possibly change the treatment paradigm in the near future. We are reporting a case of cryptogenic ischaemic stroke in middle cerebral artery territory due to paradoxical embolism through a PFO which was successfully closed with a device solely by a Bangladeshi Consultant & his team first time in Bangladesh. Cardiovasc. j. 2021; 13(2): 227-234

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Abstract TMP13: Baseline DWMRI Characteristics In Patients With Cryptogenic Stroke And Patent Foramen Ovale: Results From The Closure I Trial

Stroke ◽

10.1161/str.44.suppl_1.atmp13 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Richard Jung ◽

Benny Kim ◽

Joseph Massaro ◽

Anthony J Furlan

Keyword(s):

Patent Foramen Ovale ◽

Cox Regression ◽

Recurrent Stroke ◽

Cryptogenic Stroke ◽

Patient Characteristics ◽

Paradoxical Embolism ◽

Foramen Ovale ◽

Anterior Circulation ◽

Significant Difference ◽

Multivariate Proportional Hazard

Background: Cryptogenic stroke may have several etiologies including paradoxical embolism through a patent foramen ovale (PFO). A cardiac source of embolism may be suggested by multiple infarcts, sometimes hemorrhagic, in different vascular distributions or a cortical wedge shaped infarct. We report the baseline diffusion weighted MRI (DWMRI) characteristics in patients with cryptogenic stroke and a patent foramen ovale (PFO) from the CLOSURE I trial. Methods: CLOSURE I compared device closure versus medical therapy for secondary prevention in patients with cryptogenic TIA or stroke and a PFO. Of 909 patients randomized, 562 patients demonstrated acute infarcts on baseline DWMRI and are included in this analysis. Multivariate proportional hazard Cox regression compared imaging subgroups with remaining randomized patients Results: Single infarcts were found in 62% of patients. Of these, 61% were anterior circulation, 30% posterior, and 8.5% were of uncertain territory. Of the anterior circulation infarcts, 40% were cortical, 36% subcortical, and 24% affected both the cortical and subcortical regions. Of the posterior circulation infarcts, 45% were thalamic or cerebellar. Of 562 patients, 18.5% had a single subcortical lesion <1.5cm in diameter and met the radiological definition of an acute lacunar infarct. Multiple infarcts were found in 38%. Infarcts in a single vascular territory were found in 23%, often in the anterior circulation (66%). Infarcts in multiple vascular territories were found in 15%. Hemorrhagic infarction was present in 9%. Adjusting for patient characteristics, no significant difference in 2 year rate of TIA, stroke or death was found compared to remaining randomized patients. Discussion: The specificity of infarct patterns for embolism in patients with cryptogenic stroke and a PFO is uncertain. We found no significant relationship between lacunar or subcortical infarction and the risk of recurrent TIA or stroke. Baseline infarct patterns on DWMRI in patients with cryptogenic stroke and PFO may not be useful in predicting recurrent stroke risk or determining best prevention therapy.

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Patent foramen ovale closure by using transesophageal echocardiography for cryptogenic stroke: single center experience in 132 consecutive patients

Journal of Cardiothoracic Surgery ◽

10.1186/s13019-020-1042-4 ◽

2020 ◽

Vol 15 (1) ◽

Cited By ~ 1

Author(s):

Yangyang Han ◽

Xiquan Zhang ◽

Fengwei Zhang

Keyword(s):

Body Weight ◽

Contrast Agents ◽

Transesophageal Echocardiography ◽

Patent Foramen Ovale ◽

Cryptogenic Stroke ◽

Percutaneous Closure ◽

X Rays ◽

Foramen Ovale ◽

Pfo Closure

Abstract Background Percutaneous closure of patent foramen ovale (PFO) is routinely performed using plain fluoroscopy in the catheter room. This method results in inevitable radiation damage, adverse effects of contrast agents on kidneys, and high cost. We performed PFO closure with a simplified and economical transesophageal echocardiography (TEE)-only guided approach in the operating room. This study aimed to investigate the feasibility, safety, and effectiveness of the percutaneous closure of PFO by only using TEE. Methods We reviewed the medical records of patients who underwent percutaneous PFO closure at our center from December 2013 to December 2017. A total of 132 patients with PFO and cryptogenic strokes underwent PFO closure by using cardi-O-fix PFO device under TEE guidance. The participants comprised 64 and 68 male and female patients, respectively. The mean age and body weight of the patients were 39.40 ± 13.22 years old (12–68 years old) and 65.42 ± 9.70 kg (40–95 kg), respectively. All patients only received aspirin (3–5 mg/kg body weight, oral administration) for 6 months. Contrast-enhanced transthoracic echocardiography (c-TTE) with Valsalva maneuver was performed during follow-up, and questionnaire surveys were obtained at 3, 6, and 12 months after the procedure. Results All (100%) patients were successfully closed. Follow-ups were conducted for 13 months to 48 months, with an average of 27 months. No severe complications were found during the follow-up period. Paroxysmal atrial fibrillation occurred in 4 patients within 3 months after the procedure. No recurrent stroke or death occurred in all patients during the follow-up period. Transient ischemic attack occurred in one patient 6 months after the procedure. Ten (7.6%) patients had a right-to-left shunt, as demonstrated by c-TTE at 12 months of follow-up. Among the 57 patients suffering from migraine, significant relief or resolution was reported by 42 (73.7%) patients. Conclusion TEE-only guided PFO closure was a safe, feasible, and effective method that did not require the use of X-rays and contrast agents.

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Transcatheter Closure of Patent Foramen Ovale in Patients with Paradoxical Embolism. Procedural and Follow-up Results after Implantation of the Starflex®Occluder Device with Conjunctive Intensified Anticoagulation Regimen

Journal of Interventional Cardiology ◽

10.1111/j.1540-8183.2008.00345.x ◽

2008 ◽

Vol 21 (2) ◽

pp. 183-189 ◽

Cited By ~ 14

Author(s):

DIETER FISCHER ◽

MARTIN FUCHS ◽

ARND SCHAEFER ◽

BERNHARD SCHIEFFER ◽

SMITA JATEGAONKAR ◽

...

Keyword(s):

Patent Foramen Ovale ◽

Transcatheter Closure ◽

Paradoxical Embolism ◽

Foramen Ovale ◽

Occluder Device

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D-dimer for prediction of long-term outcome in cryptogenic stroke patients with patent foramen ovale

Thrombosis and Haemostasis ◽

10.1160/th14-12-1040 ◽

2015 ◽

Vol 114 (09) ◽

pp. 614-622 ◽

Cited By ~ 5

Author(s):

Young Dae Kim ◽

Dongbeom Song ◽

Hyo Suk Nam ◽

Kijeong Lee ◽

Joonsang Yoo ◽

...

Keyword(s):

Ischaemic Stroke ◽

Patent Foramen Ovale ◽

Pulmonary Thromboembolism ◽

Cryptogenic Stroke ◽

Foramen Ovale ◽

Stroke Patients ◽

Term Outcome ◽

Long Term Outcome ◽

D Dimer

SummaryPatent foramen ovale (PFO) is a potential cause of cryptogenic stroke, given the possibility of paradoxical embolism from venous to systemic circulation. D-dimer level is used to screen venous thrombosis. We investigated the risk of embolism and mortality according to the presence of PFO and D-dimer levels in cryptogenic stroke patients. A total of 570 first-ever cryptogenic stroke patients who underwent transesophageal echocardiography were included in this study. D-dimer was assessed using latex agglutination assay during admission. The association of long-term outcomes with the presence of PFO and D-dimer levels was investigated. PFO was detected in 241 patients (42.3 %). During a mean 34.0 ± 22.8 months of follow-up, all-cause death occurred in 58 (10.2 %) patients, ischaemic stroke in 33 (5.8 %), and pulmonary thromboembolism in 6 (1.1 %). Multivariate Cox regression analysis showed that a D-dimer level of > 1,000 ng/ml was an independent predictor for recurrent ischaemic stroke in patients with PFO (hazard ratio 5.341, 95 % confidence interval 1.648–17.309, p=0.005), but not in those without PFO. However, in patients without PFO, a D-dimer level of > 1,000 ng/ml was independently related with all-cause mortality. The risk of pulmonary thromboembolism tended to be high in patients with high D-dimer levels, regardless of PFO. Elevated D-dimer levels in cryptogenic stroke were predictive of the long-term outcome, which differed according to the presence of PFO. The coexistence of PFO and a high D-dimer level increased the risk of recurrent ischaemic stroke. The D-dimer test in cryptogenic stroke patients may be useful for predicting outcomes and deciding treatment strategy.

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