Letter by Rajendram et al Regarding Article, "Clinical Characteristics and Outcomes of COVID-19 Patients With a History of Stroke in Wuhan, China".

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HomeStrokeVol. 51, No. 11Letter by Rajendram et al Regarding Article, “Clinical Characteristics and Outcomes of COVID-19 Patients With a History of Stroke in Wuhan, China” Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBLetter by Rajendram et al Regarding Article, “Clinical Characteristics and Outcomes of COVID-19 Patients With a History of Stroke in Wuhan, China” Rajkumar Rajendram, MBBS, Naveed Mahmood, MBBS and Ghulam Abbas Kharal, MD Rajkumar RajendramRajkumar Rajendram https://orcid.org/0000-0001-7790-4591 Department of Medicine, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia (R.R., N.M.). Search for more papers by this author , Naveed MahmoodNaveed Mahmood https://orcid.org/0000-0002-2276-5536 Department of Medicine, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia (R.R., N.M.). Search for more papers by this author and Ghulam Abbas KharalGhulam Abbas Kharal Division of Cerebrovascular Disorders, Cleveland Clinic Neurological Institute, Cleveland Clinic, OH (G.A.K.). Search for more papers by this author Originally published26 Oct 2020https://doi.org/10.1161/STROKEAHA.120.031173Stroke. 2020;51:e344–e345To the Editor:Qin et al1 highlight the adverse outcomes of patients with a history of stroke who develop coronavirus disease 2019 (COVID-19) in their article. The respiratory effects of COVID-19 are unusual; some patients are more hypoxic and have greater shunt than expected for the apparent lung injury.2 Shunt may be intrapulmonary or extrapulmonary.2 Patients with COVID-19 pneumonia will have intrapulmonary shunt.2 However, some patients may also have extrapulmonary shunt2—the most common anatomic substrate for which is an interatrial defect.2,3Patent foramen ovale (PFO) is present in 20% to 30% of the general population4 but is more common in patients with a history of stroke (50%).4 Although usually innocuous, an increase in right atrial pressure may trigger acute right-to-left interatrial shunt across a PFO.2–4 This can cause paradoxical embolization, platypnoea-orthodeoxia, and hypoxia.2–4 Thus, COVID-19 could be exacerbated by right-to-left interatrial shunt.2,3Yet, there are surprisingly few reports of COVID-19 in patients with interatrial defects.3 To date, only one case report has described the clinical course of a patient with a PFO who developed COVID-19.3,5 The notable absence of data on the interaction between PFO and COVID-19 suggests that these interatrial defects are not being diagnosed.3This may be particularly relevant in patients with a history of stroke. It is, therefore, important to determine the incidence of interatrial defects in the series of patients described by Qin et al.1 Subgroup analyses comparing blood gases, lung mechanics, imaging, and outcomes of patients with, and without, interatrial defects could contribute significantly to the understanding of COVID-19.Secondary prevention of PFO-related stroke and treatment of hypoxia due to right-to-left interatrial shunt are recognized indications for PFO closure.3,4 However, many centers are currently deferring this procedure.3 This may be counterproductive as the observations of Qin et al1 suggest that these patients are at high risk of complications from COVID-19.2,3,5 Furthermore, if echocardiography is being done, performing a bubble contrast study may yield clinically significant information in patients with COVID-19 if:stroke or systemic thromboembolism occursplatypnoea-orthodeoxia is detectedthe lung injury identified does not fully account for hypoxiasupplemental oxygen does not significantly improve hypoxia.The presence of an interatrial defect will influence respiratory management2,3 and may reduce the threshold for anticoagulation. Furthermore, PFO closure could prevent paradoxical embolization and improve hypoxia in select high-risk patients with COVID-19.2,3 We, therefore, propose that screening with bubble contrast echocardiography and closure of PFO should continue during the COVID-19 pandemic.2,3DisclosuresNone.FootnotesFor Disclosures, see page e344.