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

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

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

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.

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

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Michael Liu ◽  
Srikant Rangaraju ◽  
Alexander Duncan ◽  
Samir Belagaje ◽  
Trina Belair ◽  
...  
Keyword(s):  
Patent Foramen Ovale ◽  
Cryptogenic Stroke ◽  
Paradoxical Embolism ◽  
Embolic Stroke ◽  
Composite Outcome ◽  
Foramen Ovale ◽  
Primary Mechanism ◽  
Detailed Evaluation ◽  
D Dimer

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.

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

Stroke ◽  
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.

scholarly journals P916 RoPE score in causal association between patent foramen ovale and cryptogenic stoke, is it enough?

2020 ◽  
Vol 21 (Supplement_1) ◽  
Author(s):  
L Carnero Montoro ◽  
M Ruiz Ortiz ◽  
M Delgado Ortega ◽  
A M Rodriguez Almodovar ◽  
N Paredes Hurtado ◽  
...  
Keyword(s):  
Patent Foramen Ovale ◽  
Incidental Finding ◽  
Cryptogenic Stroke ◽  
Imaging Study ◽  
Interatrial Septum ◽  
Percutaneous Closure ◽  
Stroke Recurrence ◽  
Foramen Ovale ◽  
Complex Anatomy ◽  
History Of

Abstract Introduction The prevalence of patent foramen ovale (PFO) in the general population is high (25%). In patients with cryptogenic stroke (CS) and PFO, determining whether it is causally related to stroke or is an incidental finding is a controversial issue. The RoPE score was described in 2013 to predict the likelihood that the stroke was related to the PFO. The higher the score, the greater the risk of attributable causality, considering 6 as the cut-off point. This scale includes clinical variables, but does not consider the echocardiographic characteristics of PFO that were used as inclusion criteria in studies that have shown benefit with percutaneous closure, such as the complex anatomy of PFO (extensive passage of microbubbles across the PFO at rest and/or interatrial septum aneurysm). Purpose Our aim was to investigate the association of the RoPE score with recurrence of stroke in a series of patients with CS and percutaneously closed PFO in a period of time prior to the current recommendations, as well as to describe the presence of complex anatomy of PFO and its relationship with the value of that score. Methods A series of 172 consecutive patients with CS and percutaneous closure of PFO, included from January 2001 to November 2014 in a single center was analyzed, and the RoPE score was calculated retrospectively in each patient. The presence of complex anatomy of the PFO was estimated by echocardiography, and the rate of recurrence of stroke and the relationship of both variables with the value of the RoPE score was investigated. Results Of the 172 patients in the series, it was possible to calculate the RoPE score in 150 (87%) of them, which constitute the study sample. The mean age was 46 years (range 17-78), 60% were male, 21% were hypertense, 6% diabetic and 27% smokers. A history of previous stroke was present in 3% of patients and 11% had an imaging study with cortical infarction. RoPE score was ≥6 in 69% of the sample, and 66% of the patients presented complex anatomy of PFO, without significant differences between those with RoPE score ≥6 and &lt;6 (65% versus 70%, p = 0.62). Acute complications (mortality, cardiac tamponade, stroke, device embolism) related to closure of the PFO were not observed. After 17.5 years of maximum follow-up (mean 9.6 ± 3.7 years, no patients lost, with a total of 1441 patients-years of observation), 6 patients presented a stroke. The recurrence rate of stroke was very low in both groups of patients, either with RoPE score ≥6 or &lt;6 (0.4 versus 0.5 per 100 patients/year, p = 0.87). Conclusions In our center, before the current recommendations of PFO closure associated with CS, most of the patients had a RoPE score≥6. The majority of patients presented a complex anatomy of the PFO and the incidence of stroke recurrence was very low, independently of the value of the RoPE score.

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

2015 ◽  
Vol 114 (09) ◽  
pp. 614-622 ◽  
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.

scholarly journals Acute Myocardial Infarction Secondary to Paradoxical Embolism

2020 ◽  
Author(s):  
Abdullah R Alenezi ◽  
Muath Alanbaei ◽  
Islam Abouelenein
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Coronary Artery ◽  
Patent Foramen Ovale ◽  
Cryptogenic Stroke ◽  
Coronary Event ◽  
Paradoxical Embolism ◽  
Foramen Ovale ◽  
Artery Embolism ◽  
Coronary Artery Embolism

Patent foramen ovale is a risk factor for systemic embolic events such as cryptogenic stroke. Far less commonly, patent foramen ovale is associated with non-cerebral systemic embolic events. Paradoxical coronary artery embolism is a rare and underdiagnosed cause of acute myocardial infarction. It should be considered in patients presenting with myocardial infarction and an otherwise low-risk profile for atherosclerotic coronary artery disease. We describe a case of paradoxical coronary artery embolism causing ST elevation myocardial infarction. Echocardiography demonstrated patent foramen ovale with a significant shunt. In addition to the treatment of the acute coronary event, patent foramen ovale closure was performed to prevent recurrent paradoxical embolic events.

scholarly journals Patent Foramen Ovale and Cryptogenic Stroke: Challenges in Diagnosis and Management

2021 ◽  
Vol 42 (3) ◽  
Author(s):  
Dhanang Ali Yafi ◽  
Azmi Azmi
Keyword(s):  
Patent Foramen Ovale ◽  
Adult Population ◽  
Management Strategies ◽  
Cryptogenic Stroke ◽  
Paradoxical Embolism ◽  
Foramen Ovale ◽  
Arterial Circulation ◽  
Systemic Embolization ◽  
The Relationship ◽  
Pfo Closure

A patent foramen ovale (PFO) is a common disorder that affects between 20-34% of the adult population. This condition is a benign finding for most people. However, In some the PFO can open widely and enabling paradoxical embolism to transit from venous to arterial circulation, which is associated with stroke and systemic embolization. There are still unclear to date regarding the effectiveness of pharmacological anticoagulant therapy, defined as antithrombin or antiplatelet therapy, which has proven to be more beneficial for patients with PFO and cryptogenic stroke. In addition, surgical and transcutaneous PFO closure has been proposed for secondary prevention of stroke in patients with cryptogenic stroke with PFO. Both catheter-based and surgical modes of closure have been shown to reduce the incidence of subsequent embolism substantially. This review will discuss the evidence regarding the relationship between PFO and cryptogenic stroke and decision making for management strategies.

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