Patent Foramen Ovale Closure for Stroke Prevention and Other Disorders

Multidisciplinary Approach to Patent Foramen Ovale Closure for Cryptogenic Stroke: Brain-Heart Board Experience

Background and Objectives

Patent foramen ovale (PFO) is present in approximately 25% of adult population. The prevalence of PFO is high in patients with cryptogenic stroke suggesting paradoxical embolism. PFO closure in carefully selected patients is an effective secondary preventive strategy in these patients. We report predictors of management recommendations by the multidisciplinary Board and their impact on outcomes.

Methods

Brain-Heart Board comprises vascular and interventional neurology and cardiology subspecialties (structural, electrophysiology, and cardiac imaging). Adult patients referred to the Board for consideration of PFO closure between October 2017 to March 2021 were included in this retrospective cohort analysis. Demographics, comorbid conditions, risk of paradoxical embolism (RoPE) score, event frequencies (transient ischemic attack [TIA] or stroke, intracranial hemorrhage [ICH], post-PFO closure cardiac arrhythmias), and modified Rankin Scale (mRS) at 1 year were compared between the groups (PFO closure vs medical management). Multivariable logistic regression was used to identify factors associated with management recommendation and chi-square tests to test differences in outcomes for patients according to management.

Results

Two hundred seventy patients (229 stroke; 41 TIA) were discussed by the Board for PFO closure. 119 (44.0%) patients were recommended for PFO closure of which 117 (98.3%) had evidence of ischemic infarct on imaging. In univariate analysis, age was similar (50 ± 11.9 vs 52 ± 12.8, p = 0.17), but RoPE score was higher in closure as compared with the medical management group (6 [IQR 5-7] vs 5 [IQR 4-7], p < 0.05). In multivariable analysis, TIA as the index event was an independent predictor of Board recommendation against PFO closure (OR 0.05, 95% CI 0.01-0.19, p < 0.05). Event frequency was low in both cohorts (5.9% vs 4.8%, p > 0.05) and comprised cardiac arrhythmias (6 cases of atrial fibrillation and 1 ICH in closure group; 1 TIA and 1 recurrent stroke in medical management group). Excellent functional outcome (mRS 0-1) was similar in both cohorts (66.3% vs 70.7%, p > 0.05) at 1 year.

Discussion

Multidisciplinary Brain-Heart Board provides a clinical practice model of collaborative care to ensure proper patient selection for PFO closure. TIA as the index event is associated with recommendation of medical management by the multidisciplinary Brain-Heart Board.

Transoesophageal echocardiography beyond the Echo-Laboratory. An expert consensus paper of the working group of echocardiography of the Hellenic Society of Cardiology

Transoesophageal echocardiography (TOE) is a well-established and valid imaging modality, providing more accurate and of higher quality information than transthoracic echocardiography (TTE) for several specific diagnoses and recently a useful guide of an increasing number of catheter-based and surgical interventions. The present paper represents an effort by the Echocardiography Working Group (WG) of the Hellenic Society of Cardiology to state the essential steps of the TOE exam performed beyond the echo lab: a) in the operating rooms intraoperatively during either transcatheter interventions, or cardiothoracic surgery and b) in the intensive care unit for critically ill patients' monitoring. This paper includes information and tips and tricks about the pre-procedural evaluation, the procedural echocardiographic guidance and post - procedural evaluation of the result and potential complications.

Cryptogenic stroke in a 5-year-old girl with patent foramen ovale: A rare case

Stroke ranks among the prevalent factors contributing to child mortality. Cryptogenic stroke has been linked with patent foramen ovale (PFO), which has been suggested as a possible route for thrombus, gas bubble, or another particulate that comes through systemic venous circulation to the brain artery. Yet, the most effective approach for managing cryptogenic stroke involving a PFO remains uncertain. This case aims to report a PFO patient with complications of stroke. A 5-year-old girl was admitted to the emergency department at Dr. Zainoel Abidin Hospital, Banda Aceh, Indonesia, after experiencing numbness and weakness on her right side and a sudden onset of slurred speech three days before admission. Laboratory findings only showed leukocytosis, while coagulation tests were normal. Non-contrast brain CT revealed an occurrence of cerebral infarction in the left hemisphere. Transcranial Doppler showed no atherosclerosis in cerebral arteries, and carotid Doppler ultrasound results were reported normal. Transthoracic echocardiography showed a PFO with the right-to-left shunt. The patient was treated with an intravenous infusion of citicoline 250 mg twice daily, oral aspirin 80 mg daily, and oral mecobalamin 250 mg daily and was planned to undergo a PFO closure procedure. However, the patient's parents rejected the plan to perform a PFO closure procedure. PFO has the potential to be a contributing factor to cryptogenic stroke among children. PFO closure followed by antiplatelet therapy for a couple of months has been shown to outperform medical therapy alone. However, additional evaluation should be done to cautiously consider the PFO closure procedure in children.

Platypnea-orthodeoxia syndrome (POS) in a patient who had undergone partial liver resection

A South Asian male in his early 60s presented with acute-onset dyspnoea on postoperative day 4 after undergoing middle hepatic vein sacrificing partial liver resection for epithelioid angiomyolipoma. The patient's SpO2 on presentation was 65% in standing position which improved to 90% in left lateral decubitus. He was suspected of having platypnea-orthodeoxia syndrome (POS) which was confirmed on echocardiogram with microbubble contrast showing a large intracardiac right-to-left shunt. The patient was taken up for transcatheter closure of patent foramen ovale (PFO). A 30 mm Amplatzer PFO Occluder was deployed across the PFO which reduced the intracardiac shunt resulting in an improved arterial saturation as well as immediate relief of patient's symptoms. This case illustrates the importance of suspecting and recognising POS clinically as well as the efficacy of transcatheter closure of PFO in such cases leading to resolution of hypoxaemia in a short span of time.

Kidney Transplant Recipient With Cerebral Paradoxical Embolism Following Recurrent Idiopathic Deep Vein Thrombosis and Pulmonary Embolism: Case Report and Review of the Literature

Paradoxical embolism occurs when a thrombus crosses an intracardiac defect into the systemic circulation. Here, we present the case of a 35-yearold male kidney transplant recipient with a cerebral paradoxical embolism associated with a spontaneous venous thromboembolism. This patient had recurrent deep venous thrombosis and showering emboli to the lung and paradoxically to the brain through patent foramen ovale, and we treated him successfully. The role of bubble echocardiography was essential in diagnosis to avoid contrast-induced nephropathy. This is the first successfully managed case of a kidney transplant recipient with recurrent idiopathic deep vein thrombosis, pulmonary embolism, and cerebral paradoxical embolism. Bubble echocardiography was an excellent alternative to contrast angiography to avoid nephrotoxicity. Vitamin K antagonists are superior to direct oral anticoagulants, especially among nonadherent/noncompliant patients.

Atrial fibrillation and stroke: State-of-the-art and future directions

Atrial fibrillation (AF) and stroke remain a major cause of morbidity and mortality. The two conditions shared common co-morbidities and risk factors. AF-related strokes are associated with worse clinical outcomes and higher mortality compared to non-AF-related. Early detection of AF is vital for prevention. While various scores have been developed to predict AF in such a high-risk group, they are yet to incorporated into clinical guidelines. Novel markers and predictors of AF including coronary and intracranial arterial calcification have also been studied. There are also ongoing debates on the management of acute stroke in patients with AF, and those who experienced breakthrough stroke while on oral anticoagulants. We provided an overview of the complex interplay between AF and stroke, as well as the treatment and secondary prevention of stroke in AF. We also comprehensively discussed the current evidence and the ongoing conundrums, and highlighted the future directions on the topic.

Transcatheter closure of patent foramen ovale using the Cocoon occluder: A multicenter retrospective study

BACKGROUND

The Cocoon patent foramen ovale (PFO) occluder is a new device especially designed for transcatheter closure of PFO. This occluder has some distinctive structural modifications aimed at reducing the risk of major complications of transcatheter PFO closure. In this report we present our initial experience to evaluate the efficacy and safety of the Cocoon PFO occluder in 253 patients who underwent transcatheter PFO closure.

METHODS

The study cohort included 253 patients (median age 45 years) with embolic stroke of undetermined source who underwent attempted transcatheter closure of PFO for secondary prevention of paradoxical embolism. Patients were enrolled retrospectively from five sites in Greece and one in Romania between December 2016 and January 2021, and the median follow-up period was 28 months (range 12-48 months). Clinical and laboratory data from each participating center were sent to an electronic registry for evaluation and statistical analysis.

RESULTS

The Cocoon PFO occluder was permanently implanted in all patients. At 6 months, complete occlusion of PFO was observed in 251/253 (99.2%) patients. Three (1.2%) patients had a trivial residual shunt. Thrombus formation on the device, which was successfully treated with recombinant tissue plasminogen activator infusion, was observed in one (0.4%) patient. No other complications occurred. During a median follow-up period of 28 months, 3 (1.2%) patients, aged 64-67 years, developed new onset paroxysmal atrial fibrillation. No neurologic events, cardiac erosions, allergic reactions to nickel, or thrombus formation occurred.

CONCLUSION

The Cocoon PFO occluder is an effective and safe device that adds to our armamentarium for transcatheter closure of PFO.

Atrial fibrillation in embolic stroke of undetermined source: role of advanced imaging of left atrial function

AIMS

Atrial fibrillation (AF) is detected in over 30% of patients following an embolic stroke of undetermined source (ESUS) when monitored with an implantable loop recorder (ILR). Identifying AF in ESUS survivors has significant therapeutic implications, and AF risk is essential to guide screening with long-term monitoring. The present study aimed to establish the role of left atrial (LA) function in subsequent AF identification and develop a risk model for AF in ESUS.

METHODS AND RESULTS

We conducted a single-centre retrospective case-control study including all patients with ESUS referred to our institution for ILR implantation from December 2009 to September 2019. We recorded clinical variables at baseline and analysed transthoracic echocardiograms in sinus rhythm. Univariate and multivariable analyses were performed to inform variables associated with AF. Lasso regression analysis was used to develop a risk prediction model for AF. The risk model was internally validated using bootstrapping. Three hundred and twenty-three patients with ESUS underwent ILR implantation. In the ESUS population, 293 had a stroke, whereas 30 had suffered a transient ischaemic attack as adjudicated by a senior stroke physician. Atrial fibrillation of any duration was detected in 47.1%. The mean follow-up was 710 days. Following lasso regression with backwards elimination, we combined increasing lateral PA (the time interval from the beginning of the P wave on the surface electrocardiogram to the beginning of the A' wave on pulsed wave tissue Doppler of the lateral mitral annulus) [odds ratio (OR) 1.011], increasing Age (OR 1.035), higher Diastolic blood pressure (OR 1.027), and abnormal LA reservoir Strain (OR 0.973) into a new PADS score. The probability of identifying AF can be estimated using the formula. Model discrimination was good [area under the curve (AUC) 0.72]. The PADS score was internally validated using bootstrapping with 1000 samples of 150 patients showing consistent results with an AUC of 0.73.

CONCLUSION

The novel PADS score can identify the risk of AF on prolonged monitoring with ILR following ESUS and should be considered a dedicated risk stratification tool for decision-making regarding the screening strategy for AF in stroke.

Propensity-score matched analysis of patent foramen ovale closure in real-world study cohort with cryptogenic ischemic stroke

INTRODUCTION

Patent foramen ovale (PFO) occurs in 25% of the general population and in 40% of cryptogenic ischemic stroke patients. Recent trials support PFO closure in selected patients with cryptogenic stroke. We examined the outcomes of transcatheter PFO closure in a real-world study cohort with cryptogenic stroke.

METHODS

Consecutive ischemic stroke patients who were classified as cryptogenic on the TOAST aetiology and diagnosed with a PFO were included. All patients underwent either transcatheter PFO closure or medical therapy. A 2:1 propensity score matching by sex and Risk-of-Paradoxical-Embolism (RoPE) score was performed. Multivariable regression models adjusted for sex and RoPE score.

RESULTS

Our cohort comprised 232 patients with mean age 44.3 years (SD 10.8) and median follow-up 1486.5 days. 33.2% were female. PFO closure (n=84) and medical therapy (n=148) groups were well-matched with <10% mean-difference in sex and RoPE score. Two patients in the treated group (2.4%) and seven in the control group (4.7%) had a recurrent ischemic stroke event. Multivariable Cox regression demonstrated a hazard-ratio of 0.26 (95%CI 0.03-2.13, P=0.21) for PFO closure compared to control. The incidence of atrial fibrillation (AF) detected post-PFO closure was similar between the treated and control (1.19% vs 1.35%, multivariable logistic regression odds-ratio 0.90, 95%CI 0.04-9.81, P=0.94). There were no major periprocedural complications documented. The difference in restricted mean survival-time free from stroke at two years between treated and control was 26.2 days (95%CI 5.52-46.85, P=0.013).

CONCLUSIONS

In this Asian cohort, we report a low incidence of ischemic stroke recurrence and new-onset AF in patients who underwent PFO closure. When compared to the medical therapy group, there was no significant difference in the incidence of stroke recurrence and new-onset AF. Further studies involving larger real-world cohorts are warranted to identify patients who are more likely to benefit from PFO closure.

Heart Brain Clinic: An Integrated Approach to Stroke Care

Background and Objectives

Multidisciplinary clinics have been shown to improve care. Patients with patent foramen ovale (PFO)-associated stroke need evaluation by cardiology and neurology specialists. We report our experience creating a multidisciplinary Structural Heart Brain Clinic (HBC) with a focus on patients with PFO-associated stroke.

Methods

Demographic and clinical data were retrospectively collected for patients with PFO-associated ischemic stroke. Patients with PFO-associated stroke were divided into a standard care group and Heart Brain Clinic group for analysis. Outcome measures included time from stroke to PFO closure and number of clinic visits before decision regarding closure. Nonparametric analysis evaluated differences in median time to visit and clinical decision, while the chi square analysis compared differences in categorical variables between groups.

Results

From February 2017 to December 2021, 120 patients were evaluated for PFO-associated stroke. The Structural HBC began in 12/2018 with coordination between Departments of Neurology and Cardiology. For this analysis, 41 patients were considered in the standard care group and 79 patients in the HBC group. During data analysis, 107 patients had received recommendations about PFO closure. HBC patients required fewer clinic visits (p = 0.001) before decision about closure; however, among patients who underwent PFO closure, there was no significant difference in weeks from stroke to PFO closure. Clinicians were more likely to recommend against PFO closure among patients seen in HBC compared with those seen in standard care (p = 0.021).

Discussion

Our data demonstrate that a multidisciplinary, patient-centered approach to management of patients with PFO-associated ischemic stroke is feasible and may improve the quality of care in this younger patient population. The difference in recommendation to not pursue PFO closure between groups may reflect selection and referral bias. Additional work is needed to determine whether this approach improves other aspects of care and outcomes.

Comparative evaluation of intracardiac, transesophageal, and transthoracic echocardiography in the assessment of patent foramen ovale: A retrospective single-center study

INTRODUCTION

Certain patent foramen ovale (PFO) characteristics, such as a large right-to-left shunt (RLS) or atrial septal aneurysm, identify patients who may receive the highest clinical benefit from percutaneous PFO closure. This study aimed to compare intracardiac echocardiography (ICE) with standard echocardiographic imaging in the evaluation of high-risk PFO characteristics and RLS severity in patients with PFO-associated stroke.

METHODS

We conducted a retrospective review of all patients aged ≥18 years who underwent percutaneous PFO closure for PFO-associated stroke and received all three ultrasound-based cardiac imaging modalities and had interpretable results (N = 51). We then compared RLS severity, high-risk PFO characteristics, and the proportion of patients with a higher likelihood of PFO-associated stroke by ICE versus transthoracic echocardiogram (TTE) and transesophageal echocardiogram (TEE).

RESULTS

The final cohort had a mean (±SE) age of 48.4 (±1.8) years and was predominantly female (58.8%). ICE was more likely to identify a large RLS versus TTE/TEE combined (66.7% vs. 45.1%; p = 0.03). The use of ICE resulted in significantly more patients being reclassified as having a higher likelihood of PFO-associated stroke (TTE vs. TEE vs. ICE: 10.4% vs. 14.6% vs. 25%; p = 0.03). A high-quality bubble study was found to be the single most important factor associated with identifying a larger RLS across all modalities (ρ [p]; TTE: 0.49 [<0.001], TEE: 0.60 [<0.001], ICE: 0.32 [0.02]). The presence of a hypermobile septum was associated with significantly greater RLS on ICE (ρ [p]: 0.3 [0.03]), especially with poor quality bubble studies (ρ [p]: 0.49 [0.02]).

CONCLUSION

In this observational study of patients with PFO-associated stroke, ICE detected a large RLS more frequently than TTE and TEE; and reclassified some patients as having a higher likelihood of PFO-associated stroke.

Coronary air embolism during transcatheter patent foramen ovale closure for platypnea-orthodeoxia syndrome in a patient with severe respiratory disorder: a case report

Background

Coronary air embolism (CAE) is a rare and life-threatening complication of endovascular procedures, mostly due to procedure-related causes.

Case summary

A 70-year-old man with severe respiratory disorder presented with patent foramen ovale (PFO)-related platypnea-orthodeoxia syndrome (POS). Transcatheter PFO closure was performed under local anaesthesia and intracardiac echocardiographic guidance. After a 5-Fr catheter was passed through the PFO via a 7-Fr femoral vein sheath, the patient suddenly coughed and breathed deeply. Thereafter, intracardiac echocardiography showed massive microbubbles in all cardiac chambers and the ascending aorta, and an electrocardiogram showed ST-segment elevations in the anterior and inferior leads. Emergency coronary angiography confirmed occlusion of the mid-left anterior descending artery, suggesting CAE. As the intracoronary infusion of saline, nitroglycerine, and nicorandil was ineffective, we performed air aspiration using a thrombectomy device, achieving coronary blood flow improvement and ST-segment resolution. Thereafter, positive pressure support using manual bag-valve-mask ventilation under intravenous sedation supported successful transcatheter PFO closure without further air embolization.

Discussion

In this case with severe respiratory dysfunction, spontaneous deep breathing (spontaneous Valsalva manoeuvre) caused negative intrathoracic pressure and large drops in intravascular pressure. This phenomenon might have induced air contamination during device advancement, either by entrapping or leaving residual air in the gaps between the catheter and the sheath. Additionally, PFO with right-to-left shunts is more likely to cause paradoxical air embolization. Thus, the spontaneous Valsalva manoeuvre should be avoided with appropriate respiratory management to prevent paradoxical air embolization, including CAE, during transcatheter PFO closure under local anaesthesia in severe respiratory dysfunction patients.

Yield of Cardiac Investigations in Patients Presenting with Acute Ischaemic Stroke: A single tertiary centre experience

Objectives

Strokes are a major cause of morbidity and mortality. This study aimed to evaluate the effectiveness of routine cardiac investigations in identifying a cardioembolic aetiology for ischaemic strokes.

Methods

This retrospective study involved patients who presented with a stroke to the Sultan Qaboos University Hospital, Muscat, Oman, between January and December 2019.

Results

A total of 183 patients (mean age = 66.2 ± 13.5 years), the majority of which were male (n = 109, 59.6%), were included. The common risk factors included hypertension (74.9%), diabetes (61.7%) and hyperlipidaemia (54.6%). The middle cerebral artery was the most common artery affected, in 44 patients (24.0%). On admission, 14 (7.6%) patients were in atrial fibrillation (AF), while the rest were in sinus rhythm. The 24-hour electrocardiogram (ECG) Holter monitoring revealed no abnormalities in 135 patients. AF was observed in 15 (8.1%) patients (inclusive of the 14 who had AF on resting ECG). Furthermore, 32 (17.4%) patients had evidence of non-sustained atrial arrhythmia, and nine (4.9%) had non-sustained ventricular tachycardia. Frequent supraventricular ectopics (>30/hour) was noted on 30 patients (16.3%), while five (2.7%) patients had a high ventricular ectopic burden (>10% burden). No significant abnormalities were noted in the echocardiograms of the patients; however, 10 out of 132 (7.5%) patients presented a positive bubble echo. Enlarged left atria were found in 24 (13.1%) patients.

Conclusion

The overall diagnostic yield of the abnormalities from routine cardiac testing for patients with stroke appears to be low. Targeted screening of patients with cryptogenic stroke, as suggested by newer guidelines, is recommended.

Sclerotherapy of lower limb veins: Indications, contraindications and treatment strategies to prevent complications - A consensus document of the International Union of Phlebology-2023

BACKGROUND

Sclerotherapy is a non-invasive procedure commonly used to treat superficial venous disease, vascular malformations and other ectatic vascular lesions. While extremely rare, sclerotherapy may be complicated by serious adverse events.

OBJECTIVES

To categorise contraindications to sclerotherapy based on the available scientific evidence.

METHODS

An international, multi-disciplinary panel of phlebologists reviewed the available scientific evidence and developed consensus where evidence was lacking or limited.

RESULTS

Absolute Contraindications to sclerotherapy where the risk of harm would outweigh any benefits include known hypersensitivity to sclerosing agents; acute venous thromboembolism (VTE); severe neurological or cardiac adverse events complicating a previous sclerotherapy treatment; severe acute systemic illness or infection; and critical limb ischaemia. Relative Contraindications to sclerotherapy where the potential benefits of the proposed treatment would outweigh the risk of harm or the risks may be mitigated by other measures include pregnancy, postpartum and breastfeeding; hypercoagulable states with risk of VTE; risk of neurological adverse events; risk of cardiac adverse events and poorly controlled chronic systemic illness. Conditions and circumstances where Warnings and Precautions should be considered before proceeding with sclerotherapy include risk of cutaneous necrosis or cosmetic complications such as pigmentation and telangiectatic matting; intake of medications such as the oral contraceptive and other exogenous oestrogens, disulfiram and minocycline; and psychosocial factors and psychiatric comorbidities that may increase the risk of adverse events or compromise optimal treatment outcomes.

CONCLUSIONS

Sclerotherapy can achieve safe clinical outcomes provided that (1) patient-related risk factors and in particular all material risks are (1a) adequately identified and the risk benefit ratio is clearly and openly discussed with treatment candidates within a reasonable timeframe prior to the actual procedure; (1b) when an individual is not a suitable candidate for the proposed intervention, conservative treatment options including the option of 'no intervention as a treatment option' are discussed; (1c) complex cases are referred for treatment in controlled and standardised settings and by practitioners with more expertise in the field; (1d) only suitable individuals with no absolute contraindications or those with relative contraindications where the benefits outweigh the risks are offered intervention; (1e) if proceeding with intervention, appropriate prophylactic measures and other risk-mitigating strategies are adopted and appropriate follow-up is organised; and (2) procedure-related risk factors are minimised by ensuring the treating physicians (2a) have adequate training in general phlebology with additional training in duplex ultrasound, procedural phlebology and in particular sclerotherapy; (2b) maintain their knowledge and competency over time and (2c) review and optimise their treatment strategies and techniques on a regular basis to keep up with the ongoing progress in medical technology and contemporary scientific evidence.

Real world long-term outcomes among adults undergoing transcatheter patent foramen closure with amplatzer PFO occluder

BACKGROUND

Patent foramen ovale (PFO) is a congenital heart defect associated with an increased risk of cryptogenic stroke. We aimed to evaluate real-world outcomes of adult patients undergoing transcatheter PFO closure with the Amplatzer PFO Occluder.

METHODS

In this single centre, retrospective cohort study, we linked a detailed clinical registry with provincial administrative databases to obtain short and long-term outcomes. Validated algorithms were used to established baseline comorbidities and adverse outcomes.

RESULTS

Between 1999 and 2017, 479 patients had PFO closure with an Amplatzer PFO Occluder. The average age of the patients was 47.3 years (standard deviation (SD) = 12.4), and 54.7% were males. The procedural success was 100%, and 96% of patients were discharged on the same day. Any in-hospital complication was observed in 2.5% (n = 12) of patients. At 30 days post-discharge, 18% of patients had an ED visit and 5% a hospitalization. Over a mean follow-up of 9.1 (SD = 3.8) years, 4% experienced TIA, 1.5% stroke, and 7.6% atrial fibrillation. The composite outcome of stroke/TIA/death was observed in 10.9% of patients (1.22 events per 100 person-years). Patients >60 years old experienced higher rates of adverse events than younger patients.

CONCLUSIONS

In this large real-world cohort of patients with cryptogenic stroke, we observed excellent safety and effectiveness outcomes for PFO closure conducted with Amplatzer PFO Occluder, similar to randomized controlled trials or other long-term cohort studies. New onset atrial fibrillation was one of the most commonly adverse events. Future studies should investigate early post-discharge management of patients to prevent readmissions.

The feasibility and safety of combining atrial septal defect/patent foramen ovale and left atrial appendage closure: A systematic review and meta-analysis

Introduction

Atrial Septal Defect/Patent Foramen Ovale (ASD/PFO) occlusion is performed to prevent paradoxical embolism and reduce the risk of recurrent ischemic stroke. Left atrial appendage (LAA) closure is used as an alternative to medical therapy of non-valvular atrial fibrillation for prevention of stroke. Multiple studies have examined performing LAA and ASD/PFO occlusion. However, the feasibility and safety of combined occlusion of the left atrial appendage and ASD/PFO are not clear, furthermore, these studies are limited by their small sample sizes and retrospective analysis. In this study, we aimed to systematically review and meta-analyze the feasibility and safety of combining left atrial appendage and ASD/PFO closure.

Methods

PubMed, Web of Science, CNKI, Cochrane Library, Embase, and WanFang database were searched up to April 2022 to identify peer-reviewed human studies on assessing the feasibility, safety, and efficacy of combining left atrial appendage and ASD/PFO closure. The primary outcome was calculated: procedural feasibility outcome and procedural safety outcome.

Results

A total of 10 articles, including 340 patients from multiple countries, were included in the analysis. The principal findings of our study are: compared with single LAA closure, (i) combining PFO/ASD occlusion and LAA closure had similar procedural success proportion (98.43%, 95% CI: 96.67-100.00%), (ii) similar safety event incidences developed (1.67%, 95% CI: 0.24-3.92%), subgroup analyzed safety event incidences in death was 0.00 (95% CI: 0.00-0.33%), cardiac tamponade was 0.87% (95% CI: 0.00-2.77%), device embolization was 0.00 (95% CI: 0.00-0.60%), major bleeding was 0.00 (95% CI: 0.00-0.33%), stroke was 0.00 (95% CI: 0.00-0.02%).

Conclusion

Although this systematic review and meta-analysis demonstrate the technical feasibility and safety of combining closure of PFO/ASD and LAA, further studies of sufficient sample size, long-term follow-up, and rigor endpoint criteria are yet needed to fully evaluate this combination procedure for its role in clinical outcomes.

Potential Embolic Sources in Embolic Stroke of Undetermined Source Patients with Patent Foramen Ovale

INTRODUCTION

A patent foramen ovale (PFO) may coexist with other potential embolic sources (PESs) in patients with embolic stroke of undetermined source (ESUS), leading to difficulty in attributing the stroke to either the PFO or other PESs. We aimed to investigate the prevalence and predictors of concomitant PESs in ESUS patients with PFOs.

METHODS

A retrospective cohort study was conducted in a tertiary stroke centre. Consecutive patients with ESUS and a concomitant PFO admitted between 2012 and 2021 were included in the study. Baseline characteristics and investigations as a part of stroke workup including echocardiographic and neuroimaging data were collected. PESs were adjudicated by 2 independent neurologists after reviewing the relevant workup.

RESULTS

Out of 1,487 ESUS patients, a total of 309 patients who had a concomitant PFO with mean age of 48.8 ± 13.2 years were identified during the study period. The median Risk of Paradoxical Embolism (RoPE) score for the study cohort was 6 (IQR 5-7.5). Of the 309 patients, 154 (49.8%) only had PFO, 105 (34.0%) patients had 1 other PES, 34 (11.0%) had 2 PES, and 16 (5.2%) had 3 or more PES. The most common PESs were atrial cardiopathy (23.9%), left ventricular dysfunction (22.0%), and cardiac valve disease (12.9%). The presence of additional PESs was associated with age ≥60 years (p < 0.001), RoPE score ≤6 (p ≤0.001), and the presence of comorbidities including diabetes mellitus (p = 0.004), hypertension (p≤ 0.001), and ischaemic heart disease (p = 0.011).

CONCLUSION

A large proportion of ESUS patients with PFOs had concomitant PESs. The presence of concomitant PESs was associated with older age and a lower RoPE score. Further, large cohort studies are warranted to investigate the significance of the PES and their overlap with PFOs in ESUS.

Exertional desaturations after COVID-19: A case for PFO closure

We present a case of a woman with past medical history notable for mild COVID-19 infection who presented with dyspnea on exertion, then developed progressively worsening exertional desaturations and was found to have a patent foramen ovale (PFO). Extensive cardiopulmonary testing revealed no clear alternate etiology for her symptoms. After much discussion, she underwent successful closure of the PFO with complete resolution of her symptoms and significantly improved exertional desaturation.

Challenging Cases in Cerebrovascular Disease

Disorders involving the vascular system of the brain are numerous and sundry. Atherosclerotic thromboembolism of large vessels and lacunar infarctions of small vessel disease are well known. Brain infarction due to cardioembolism is common as well, and even more so when diligently sought. Rupture of intracranial blood vessels results in subarachnoid and intraparenchymal hemorrhage. We present four cases of stroke of uncommon cause and remind clinicians to be open minded to the many possible causes of stroke, in particular because early recognition and treatment is often critical. Case 1 discusses a patient with inflammatory cerebral amyloid angiopathy. The presentation, ability to recur, and current treatment considerations are reviewed. Case 2 discusses microangiopathic thrombotic angiopathy. Diagnosis and treatment are considered. An association with interferon therapy and the evolving terminology of this and related conditions are discussed. Case 3 discusses intracranial hemorrhage secondary to acute promyelocytic leukemia. Patients with acute leukemias require aggressive management of their coagulopathy, thrombocytopenia, and the disease itself. Finally, Case 4 discusses ischemic stroke due to a paradoxical embolism in the setting of a patent foramen ovale (PFO). Both medical and surgical management of a PFO for stroke prevention are considered.

Three-dimensional Transesophageal Echocardiography for Transcatheter Patent Foramen Ovale Closure: Standardizing Anatomic Nomenclature and Novel Sizing Concepts

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Terminology for PFO tunnel sizing remains unstandardized.

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Device size selection for transcatheter PFO closure is highly variable.

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Tunnel width measurements may be a better descriptor of PFO size.

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Wire sizing may be a useful technique for assessment of PFO dimensions.

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PFO sizing strategies based on tunnel width need to be better studied.

Biological Properties and Clinical Significance of Lipoprotein-Associated Phospholipase A2 in Ischemic Stroke

Ischemic stroke, which occurs following blockage of the blood supply to the brain, is a leading cause of death worldwide. Its main cause is atherosclerosis, a disease of the arteries characterized by the deposition of plaques of fatty material on the inner artery walls. Multiple proteins involved in the inflammation response have been identified as diagnosing biomarkers of ischemic stroke. One of these is lipoprotein-associated phospholipase A₂ (Lp-PLA₂), an enzyme that can hydrolyze circulating oxidized phospholipids, generating proinflammatory lysophosphatidylcholine and promoting the development of atherosclerosis. In the last two decades, a number of studies have revealed that both the concentration and the activity of Lp-PLA₂ are independent biomarkers of ischemic stroke. The US Food and Drug Administration (FDA) has approved two tests to determine Lp-PLA₂ mass and activity for predicting stroke. In this review, we summarize the biological properties of Lp-PLA₂, the detection sensitivity and limitations of Lp-PLA₂ measurement, the clinical significance and association of Lp-PLA₂ in ischemic stroke, and the prospects of therapeutic inhibition of Lp-PLA₂ as an intervention and treatment.

Patent foramen ovale: diagnostic evaluation and the role of device closure

Although seemingly benign, the presence of a patent foramen ovale (PFO) may play an important role in the pathophysiology of disease, specifically a paradoxical embolism leading to cryptogenic stroke. The European Society of Cardiology recently published guidelines detailing how PFOs are associated with paradoxical embolism and how they are diagnosed and managed. This review guides physicians in the diagnostic and referral process to a multidisciplinary team involved in PFO closure. It reviews the clinical trials comparing device closure with medical therapy and highlights the current NHS England commissioning process on PFO management. Finally, we give an overview of other conditions where PFO device closure may need to be considered.

Three‐dimensional and catheter‐based intracardiac echocardiographic characterization of the interatrial septum in 2 horses with suspicion of a patent foramen ovale

This case report describes the 2‐dimensional transthoracic (2D‐TTE), 3‐dimensional transthoracic (3D‐TTE) and intracardiac echocardiographic (ICE) characterization of the fossa ovalis region in 2 horses. The first case was presented for poor performance and showed an anechoic zone in the interatrial septum on 2D‐TTE. Based on 3D‐TTE a deepened fossa ovalis could be identified and using ICE the presence of an interatrial shunt could be excluded. The second case was referred for a cardiac murmur and the presence of turbulent flow in and around the interatrial septum on 2D‐TTE color flow Doppler. The complementary use of 2D‐TTE, 3D‐TTE, and ICE allowed detailed characterization of a patent foramen ovale, with evidence of a left‐to‐right shunt in a dorsocranial to ventrocaudal direction with limited hemodynamic implications. These 2 cases underline the feasibility of 3D‐TTE and ICE in horses and especially show the added value of ICE in a clinical setting.

Paradoxical embolisation in right-sided infective endocarditis and patent foramen ovale

Intravenous drug use (IVDU) is a growing public health crisis worldwide. A known complication of IVDU is right-sided infective endocarditis (RSIE) involving the tricuspid valve. As the tricuspid valve is burdened with infectious vegetations, it becomes a potential source of pulmonary and, very rarely, paradoxical systemic emboli. We report two patients with RSIE involving the tricuspid valve presenting with acute change in mental status. Subsequent imaging demonstrated embolisation to the brain in the setting of elevated right atrial pressures and the presence of a patent foramen ovale (PFO) with right-to-left shunting. We employed a strategy of percutaneous closure of PFO, to prevent further embolisation, as a successful bridge to definitive surgical management of RSIE. We emphasise that clinicians should evaluate for intracardiac shunting and pursue transesophageal echocardiography when encountering systemic emboli of unknown origin, particularly in patients with RSIE.

Current Challenges and Future Directions in Handling Stroke Patients With Patent Foramen Ovale—A Brief Review

The role of patent foramen ovale (PFO) in stroke was debated for decades. Randomized clinical trials (RCTs) have shown fewer recurrent events after PFO closure in patients with cryptogenic stroke (CS). However, in clinical practice, treating stroke patients with coexisting PFO raises some questions. This brief review summarizes current knowledge and challenges in handling stroke patients with PFO and identifies issues for future research. The rationale for PFO closure was initially based on the concept of paradoxical embolism from deep vein thrombosis (DVT). However, RCTs did not consider such details, limiting their impact from a pathophysiological perspective. Only a few studies explored the coexistence of PFO and DVT in CS with varying results. Consequently, the PFO itself might play a role as a prothrombotic structure. Transesophageal echocardiography thus appears most appropriate for PFO detection, while a large shunt size or an associated atrial septum aneurysm qualify for a high-risk PFO. For drug-based treatment alone, studies did not find a definite superiority of oral anticoagulation over antiplatelet therapy. Remarkably, drug-based treatment in addition to PFO closure was not standardized in RCTs. The available literature rarely considers patients with transient ischemic attack (TIA), over 60 years of age, and competing etiologies like atrial fibrillation. In summary, RCTs suggest efficacy for closure of high-risk PFO only in a small subgroup of stroke patients. However, research is also needed to reevaluate the pathophysiological concept of PFO-related stroke and establish strategies for older and TIA patients and those with competing risk factors or low-risk PFO.

Risk of Perioperative Stroke in Patients with Patent Foramen Ovale: A Systematic Review and Meta-Analysis

BACKGROUND

Patent foramen ovale (PFO) is a common congenital cardiac abnormality. Risk of stroke increases perioperatively; however, the association of PFO with perioperative stroke risk remains unclear. We conducted a systematic review to inform the risk of perioperative stroke in patients with PFO undergoing surgery.

METHODS

EMBASE, MEDLINE, and Cochrane databases were searched from inception to January 2020. We described methods used for establishing PFO and perioperative stroke diagnosis. We conducted meta-analyses to obtain pooled estimates for risk of stroke in patients with and without PFO in different surgical populations.

RESULTS

Ten articles with a total of 20,858,011 patients met the eligibility criteria. Prevalence of PFO ranged from 0.06-1.4% based on ICD code diagnosis and 10.4-40.4% based on echocardiography diagnosis. Perioperative stroke was observed in 0-25% of patients with PFO, and 0-16.7% without PFO. Studies that use echocardiography to diagnose PFO found no association between PFO and perioperative stroke. Studies that used ICD codes, found strong association but were highly heterogenous. PFO was not associated with a risk of perioperative stroke in cardiac and transplant surgeries. While the adjusted odds ratios for stroke were substantial for orthopedic, general, genitourinary, neuro, and thoracic surgeries (with PFO status established based on ICD codes), data heterogeneity and quality of data create significant uncertainty.

CONCLUSION

In conclusion, PFO is likely a risk factor for perioperative stroke in select types of surgeries. However, this is based on a very low-quality evidence. Rigorous, prospective studies are needed to further investigate this relationship.

Patent foramen ovale in children: Unique pediatric challenges and lessons learned from adult literature

A patent foramen ovale (PFO) is a frequent incidental finding during echocardiography in otherwise healthy children. In most healthy children with a diagnosis of isolated incidental PFO, no further follow-up or intervention is necessary. In some children, PFO is associated with certain clinical syndromes such as cryptogenic stroke, decompression sickness, migraine, and platypnea-orthodeoxia syndrome. This review discusses PFO anatomy, diagnostic imaging, PFO-associated clinical situations, management options, and the role of PFO in certain congenital heart disease. This review also highlights the current deficiency of pediatric data guiding management of these uncommon but important PFO-associated conditions. Future multicenter randomized controlled studies are necessary to guide the management of these unique and challenging PFO-associated conditions.

The Hype Surrounding Patent Foramen Ovale Closure and Cryptogenic Stroke: A Walk Through History

Cryptogenic stroke (CS) represents one-third of all ischaemic strokes. Studies have shown approximately that half of patients with CS have concomitant patent foramen ovale (PFO), with clear data supporting paradoxical embolization as an aetiology of CS. This article is the first of a multi-part review and will detail the history of PFO closure and the clinical trials that have evaluated the efficacy of PFO device closure. Data favour PFO closure in CS for reducing stroke in appropriate patients and should be considered as a treatment modality.

Unexplained arterial thrombosis: approach to diagnosis and treatment

Arterial thrombotic events in younger patients without a readily apparent etiology present significant diagnostic and management challenges. We present a structured approach to diagnosis with consideration of common causes, including atherosclerosis and embolism, as well as uncommon causes, including medications and substances, vascular and anatomic abnormalities, systemic disorders, and thrombophilias. We highlight areas of management that have evolved within the past 5 years, including the use of dual-pathway inhibition in atherosclerotic disease, antithrombotic therapy selection in embolic stroke of undetermined source and left ventricular thrombus, the role of closure of patent foramen ovale for secondary stroke prevention, and the thrombotic potential of coronavirus disease 2019 infection and vaccination. We conclude with a representative case to illustrate the application of the diagnostic framework and discuss the importance of consideration of bleeding risk and patient preference in determining the appropriate management plan.

Embolic Stroke of Undetermined Source: Approaches in Risk Stratification for Cardioembolism

Ischemic stroke is a leading cause of morbidity and mortality worldwide. Embolic stroke of undetermined source has been recently proposed to categorize nonlacunar ischemic strokes without confirmed etiology after adequate investigation with a likely embolic stroke mechanism. A strategy of empirical anticoagulation for embolic stroke of undetermined source patients is attractive but may only be beneficial in a select subset of patients. Strategies which would help identify the subset of embolic stroke of undetermined source patients most likely to have cardioembolic origin of stroke, and hence benefit from anticoagulation, are needed. This article will review current evidence which may be useful in the development of a risk stratification approach based on arrhythmia monitoring, cardiac imaging, and clinical risk stratification. This approach may be beneficial in clinical practice in improving patient outcomes and reducing stroke recurrence in this population; however, further work is required with active trials underway.

Concomitant AngioVac thrombectomy and patent foramen ovale closure in a patient with a large right atrial thrombus and recent paradoxical embolic stroke

A 59-year-old male with a history of gallbladder adenocarcinoma receiving chemotherapy and on therapeutic anticoagulation for portal vein thrombosis presented to the emergency department via ambulance after being found unresponsive and in cardiac arrest. Initial workup upon return of spontaneous circulation revealed a large right atrial mass, patent foramen ovale (PFO), and bilateral acute cortical infarctions. This constellation of findings were concerning for PFO-related paradoxical embolic strokes. Given the risk of recurrent paradoxical embolic events and the absolute contraindication to thrombolysis due to recent cerebral infarction, the decision was made to proceed with percutaneous vacuum-assisted thrombectomy using the AngioVac device. To prevent intraoperative thrombus propagation, PFO-closure was performed immediately prior to thrombectomy. Aspiration thrombectomy and PFO-closure were successful with complete thrombus removal and no intraoperative thrombus propagation. This case presents a minimally invasive and rapid treatment for a complex problem. An efficient and effective interdisciplinary team-based approach allowed the patient to resume cancer treatment relatively unabated.

Persistent pathology of the patent foramen ovale: a review of the literature

A patent foramen ovale (PFO) is an interatrial shunt, with a prevalence of 20-34% in the general population. While most people do not have secondary manifestations of a PFO, some reported sequelae include ischaemic stroke, migraine, platypnoea-orthodeoxia syndrome and decompression illness. Furthermore, in some cases, PFO closure should be considered for patients before neurosurgery and for patients with concomitant carcinoid syndrome. Recent trials support PFO closure for ischaemic stroke patients with high risk PFOs and absence of other identified stroke mechanisms. While PFOs can be associated with migraine with auras, with some patients reporting symptomatic improvement after closure, the evidence from randomised controlled trials is less clear in supporting the use of PFO closure for migraine treatment. PFO closure for other indications such as platypnoea-orthodeoxia syndrome, decompression illness and paradoxical embolism are based largely on case series with good clinical outcomes. PFO closure can be performed as a day surgical intervention with high procedural success and low risk of complications.

Concomitant acute myocardial infarction and acute pulmonary embolism caused by paradoxical embolism: a case report

Background

Due to its low incidence and diverse manifestations, paradoxical embolism (PDE) is still under-reported and is not routinely considered in differential diagnoses. Concomitant acute myocardial infarction (AMI) and acute pulmonary embolism (PE) caused by PDE has rarely been reported.

Case presentation

A 45-year-old woman presented with acute chest pain and difficulty with breathing. Multiple imaging modules including ECG, echocardiography, emergency cardioangiogram (CAG), and CT angiography of the pulmonary arteries showed acute occlusion of the posterolateral artery and acute PE. After coronary aspiration, no residual stenosis was observed. One month later, a bubble study showed inter-atrial communication via a patent foramen ovale (PFO). The AMI in this patient was finally attributed to PDE via the PFO. PFO closure was performed, and long-term anticoagulation was prescribed to prevent recurrent thromboembolic events.

Conclusions

PDE via PFO is a rare etiology of AMI, especially in patients with concomitant AMI and PE. Clinicians should be vigilant of this possibility and close the inter-atrial channel for secondary prevention.

Management dilemmas in acute ischemic stroke and concomitant acute pulmonary embolism: Case series and literature review

BACKGROUND

Pulmonary embolism (PE) and acute ischemic stroke (AIS) are common disorders with high morbidity and mortality, rarely presenting simultaneously. There is a paucity of data regarding the management of this uncommon presentation. The treatment of these two entities is complex in the acute phase due to the concomitant need for thrombolysis in AIS and anticoagulation for PE.

METHODS

We retrospectively reviewed confirmed ischemic stroke cases to identify patients presented with simultaneous PE from June 2018 to May 2019. Additionally, a literature review was performed. Two reviewers assessed the manuscripts' quality, and relevant data regarding clinical course and management was extracted.

RESULTS

We reviewed 439 patient charts, identifying two cases of concomitant AIS and PE. Additionally, twelve articles (n = 15 subjects) fulfilled our literature review criteria for a total of 17 cases, including ours. Intravenous anticoagulation (70.5%) was the most frequent intervention targeting both disorders. Therapies such as intravenous thrombolysis (23.53% (n = 4)) and mechanical thrombectomy (23.53% (n = 4)) were specific in AIS. Catheter-directed thrombolysis (5.88%) was used for PE. Clinical outcomes were favorable (asymptomatic or mild disable symptoms) in 47.05% (N = 8) of patients, while 41.17% had poor outcomes (severe disable symptoms or death).

CONCLUSIONS

AIS and PE stand for a challenge when they present simultaneously. The evaluation of risks and benefits of therapies such as intravenous thrombolysis, mechanical thrombectomy, and catheter-directed-thrombolysis in the clinical context is essential. According to our review, the ischemic stroke burden guides systemic anticoagulation decisions over interventional procedures when the hemodynamic status remains unaffected.

Cerebral paradoxical embolisation in a patient with cystic fibrosis with patent foramen ovale: a comparative review of literature

A 52-year-old woman with cystic fibrosis presented to the emergency department with expressive aphasia and right-sided hemiparesis. CT scan of the brain revealed a left middle cerebral artery territory infarct. A diagnosis of cerebral paradoxical embolisation associated with patent foramen ovale and a history of deep venous thrombosis was made. The patient underwent endovascular thrombectomy and percutaneous closure of patent foramen ovale. Current literature, including five published case reports, pertaining to the subject is discussed. The unique aspects of the case are highlighted, including the particular risk of cerebral paradoxical embolisation in patients with cystic fibrosis. The result of this case report, in context to previously reported literature, suggests that clinicians should be aware of paradoxical embolisation in patients with cystic fibrosis via an intracardiac shunt, particularly with implanted vascular access devices and a history of deep venous thrombosis.

Newly-found channels in the interatrial septum of the heart by dissection, histologic evaluation, and three-dimensional microcomputed tomography

A minute thrombus can pass through a small type of interatrial communication, which can result in a stroke or transient ischemic attack and several associated symptoms. This study sought to investigate a new type of interatrial communication. Thirty-one hearts from embalmed adult cadavers were investigated. Each interatrial channels (IACs) was classified as either an open or obstructed channel according to the connection of each hole on the right and left surfaces of the interatrial septum. Open channels were found in two specimens (6.5%). Both open and obstructed IACs followed tortuous courses through the interatrial septum. On the right surface of the interatrial septum, the hole was usually found adjacent to the left border of the interatrial septum between the opening of the superior vena cava into the right atrium and the superior margin of the fossa ovalis. Conversely, holes on the left surface of the interatrial septum were usually found in the upper and middle parts adjacent to the left border of the interatrial septum. This novel finding is expected to support our understanding of the onset of possible symptoms such as stroke in the absence of classical atrial septal defects.

[Patent foramen ovale. An update for primary care]

Patent foramen ovale (FOP) is the most prevalent cause of cryptogenic strokes in people under 60 years old. Although it is usually asymptomatic, it has a high risk of producing paradoxical embolism and, therefore, stroke with indeterminate outcomes. The study should be started based on clinical suspicion, and includes a multidisciplinary assessment and a determination of the type of treatment to be performed. The therapeutic possibilities range from conservative treatment (indefinite antithrombotic treatment), to its percutaneous closure (currently the most widely used). The first objective is to decrease the number of stroke recurrences. Conservative treatment should be reserved for those cases of low embolic risk. The risk assessment must be individualised, fundamentally based on the anatomical characteristics of the FOP and the patient clinic picture. The use of the RoPE risk scale (The Risk of Paradoxical Embolism) should be a tool to consider.

Antiplatelet and Antithrombotic Therapy After Patent Foramen Oval and Atrial Septal Defect Closure

Pathologies of the atrial septum include different interatrial communications varying from patent foramen ovale (PFO) to actual defects. Atrial septal defects (ASDs) may be localized within the fossa ovalis such as the secundum type ASD or outside the region of fossa ovalis, such as the ostium primum defect and sinus venosus defect. Over the last decades, the percutaneous closure of interatrial shunts has become a feasible and safe method. During these procedures, the delicate balance between thrombotic risk, device sealing process and bleeding risk is crucial. In this review, we sought to describe current available data on the antiplatelet and antithrombotic management of patients after percutaneous ASD or PFO closure.

Feasibility of using a handheld ultrasound device to detect and characterize shunt and deep vein thrombosis in patients with COVID-19: an observational study

BACKGROUND

Coronavirus disease 2019 (COVID-19) causes an atypical acute respiratory distress syndrome associated with thromboembolism and high shunt fraction. Shunt may be intrapulmonary, or extrapulmonary. Handheld devices are increasingly being used for point-of-care ultrasound, but their use to characterize shunt has not been reported.

OBJECTIVES

Determine the feasibility of using handheld ultrasound to detect and characterize anatomical substrates of hypoxia and deep vein thrombosis (DVT) in patients with COVID-19 suspected to have severe shunt.

METHODS

A handheld ultrasound device (iQ, Butterfly, USA) was used to perform lung ultrasound, vascular assessment for DVT, and limited transthoracic echocardiography (TTE) with color Doppler and saline microbubble contrast in patients with COVID-19 suspected to have severe shunt. Images were reassessed by an independent reviewer.

RESULTS

After screening 40 patients, six patients who fulfilled the inclusion criteria were identified. Two were excluded because palliation had been initiated. So, four patients were studied. Interpretable images were obtained in all cases. Interobserver agreement was good. All patients had abnormal lung ultrasound (lung ultrasound score range 17-22). Identified lung pathology included interstitial syndrome with light beams and small peripheral consolidation (4), lobar consolidation (1), and pleural effusion (1). Abnormal echocardiographic findings included interatrial shunt (2), intrapulmonary shunt (1), and dilated right ventricle with tricuspid valve regurgitation (1). Significant DVT was not detected.

CONCLUSION

Use of handheld ultrasound to perform combined lung ultrasound, DVT ultrasound, and limited TTE with color Doppler and saline microbubble contrast is feasible, and may be able to characterize shunt in critically hypoxic patients. Serial studies could be used to monitor changes in shunt. Further studies are required to determine whether this can guide treatment to improve the outcomes of patients with refractory hypoxia.

Atrial septal defect closure in a young patient presenting with recurrent cryptogenic stroke: a case report

Background

Having an inter-atrial shunt in the form of a patent foramen ovale or atrial septal defect increases the risk of developing cryptogenic stroke. Prompt action is required in order to prevent stroke recurrence. The source of embolization may not be clear on stroke workup.

Case presentation

A young female acutely presented with recurrent embolizations to the eye and brain. She was found to have an atrial septal defect. No clear intra-cardiac source of embolization was detected on workup including trans-esophageal echocardiography. Given the options between surgical versus device closure, the attending team opted for the surgical closure which yielded on direct left heart inspection small organized clots adherent to the tips of the mitral valve leaflets.

Conclusions

The case report illustrates the potential advantages of the direct surgical closure in detecting and extracting the embolization source in patients who present with recurrent cryptogenic stroke.

Patent Foramen Ovale in Cryptogenic Ischemic Stroke: Direct Cause, Risk Factor, or Incidental Finding?

Patent foramen ovale (PFO) has been associated with cryptogenic stroke. There is conflicting data and it remains uncertain whether PFO is the direct cause, a risk factor or an incidental finding. Potential stroke mechanisms include paradoxical embolism from a venous clot which traverses the PFO, in situ clot formation within the PFO, and atrial arrhythmias due to electrical signaling disruption. Main risk factors linked with PFO-attributable strokes are young age, PFO size, right-to-left shunt degree, PFO morphology, presence of atrial septal aneurysm, intrinsic coagulation-anticoagulation systems imbalance, and co-existence of other atrial abnormalities, such as right atrial septal pouch, Eustachian valve and Chiari's network. These may act independently or synergistically, multiplying the risk of embolic events. The RoPE score, a scale that includes factors such as young age, cortical infarct location and absence of traditional stroke risk factors, is associated with the probability of a PFO being pathogenic and stroke recurrence risk after the index stroke. Multiple investigators have attempted to correlate other PFO features with the risk of PFO-related stroke, but further investigation is needed before any robust conclusions are reached. PFO presence in young patients with cryptogenic stroke should be considered as etiologically suspect. Caution should be exercised in interpreting the relevance of other PFO features.

Cerebral paradoxical embolism associated with patent foramen ovale and idiopathic venous thromboembolism in a 31-year-old patient

Paradoxical embolism is the passage of venous thrombi into the arterial circulation through a pulmonary or intracardiac shunt. We report the management of a 31-year-old patient who initially presented with chest pain and right brachiofacial paresis. A diagnosis of paradoxical cerebral embolism associated with a spontaneous venous thromboembolism and a patent foramen ovale was made. The patient benefited from thrombolytic therapy and lifelong anticoagulation with good recovery. This case showed that percutaneous closure of a patent foramen ovale needs to be discussed individually.