Cryptogenic Stroke Research Articles

Real-world utility of implantable loop recorders

Abstract Background Implantable loop recorders (ILRs) allow prolonged and continuous single-lead electrocardiogram recording and have significantly shortened time to electrocardiographic diagnosis and appropriate therapy of many bradyarrhythmias and tachyarrhythmias. Purpose The aim of this retrospective single center study was to evaluate ILR indications, diagnostic yield and ILR-guided interventions. Methods We retrospectively analyzed 388 patients (223 male / 165 female), who underwent Medtronic and Biotronik ILRs implantation at a heart center. Demographic and clinical data were obtained from the medical records. Remote monitoring was analyzed when no data of in-hospital follow up could be acquired. Results The mean age at ILR implantation was 63.4 ± 14.9 years with a mean follow-up of 20.7±17.6 months from ILR implantation. In total, 152 (39.2%) patients were followed by a remote monitoring system. Number of patients with ILR indication due to syncope (n=171; 44.1%) was significantly higher compared to patients with monitoring after ablation of atrial fibrillation or atrial flutter (n=108; 27.8%), cryptogenic stroke (n=50; 12.9%) and presyncope and dizziness (n=21; 5.4%) (p<0.05). After 12 months, arrhythmia was detected in 198 cases (79.2% out of 250 patients with detected arrhythmias). The most common type of arrhythmia was paroxysmal atrial fibrillation (31.7%) with a significantly higher prevalence compared to atrial tachycardias (16.5%) and supraventricular premature beats (9.8%) (p<0.05). Noteworthy, in 132 (52.8% out of 250) patients, ILR diagnosis corresponded to the suspected arrhythmia, whereas in 118 patients unexpected arrhythmias were detected. ILR diagnosis of arrhythmia lead in 147 (58.8%) patients to initiation of a new therapy or to a change of current medication. Changes of current medication occurred in 72 patients (28.8%), electrophysiology study/ablation in 66 patients (26.4%), pacemaker/ICD implantation in 46 (18.4%), electrical cardioversion in 6 patients (2.4%), and closure of the left atrial appendage in 1 patient. Conclusion Our study shows, that ILRs are an important diagnostic tool, providing clinical relevant data in about two thirds (65%) of the patients. About half (52.8%) of the detected arrhythmia correlated with the symptoms leading to ILR implantation (number needed to treat was around 2). Remote monitoring improves the diagnostic timing with a potential reduction of costs for health care. However, patient selection is critical and ILRs benefits needs to be proven in larger randomized trials.

Preliminary implantation experience in Europe with a novel insertable cardiac monitor

Abstract Background The LUX-Dx is a new insertable cardiac monitor (ICM) available in the European market since October 2022. Purpose To describe the initial experience of LUX-Dx implantation in Europe and report feedbacks from operators and patients. Methods The system includes an incision tool and a single-piece insertion tool that is pre-loaded with the small (1.2 cm3) ICM. The implantation procedure is straightforward and comprises the incision, the creation of the device pocket, the insertion of the ICM, the verification of sensing and the incision closure. Following implantation, patients are provided with a mobile device preloaded with the App which connects to their ICM and transmits data daily, or as needed, to the management system. We analyzed data and feedbacks collected at 20 European centers at the time of implantation and before patient discharge. Results A total of 175 implantation procedures were performed in 20 European centers. The most frequent indications for ICM implantation were syncope (n = 119, 68%) and cryptogenic stroke (n=15, 9%). Most procedures (157, 90%) were performed in electrophysiology laboratories by expert operators. The procedure was performed under local anesthesia in 169 (97%) patients, and systemic or local antibiotics were used before the procedure in 96 (55%) cases. A surface ECG mapping was performed before 65 (37%) insertions. All ICMs were implanted in the left parasternal region, with an orientation of 45° in 159 (91%) patients. Device repositioning was required after verification of sensing in 6 (3%) patients. The ICM was successfully implanted in all patients and no procedural complications were reported; the median time from skin incision to suture was 4 min (25th-75th percentiles 2-7). The mean R-wave amplitude was 0.38±0.34 mV at implantation and 0.42±0.38 mV before patient discharge (on average after 1 day). The P-wave visibility, i.e., the ratio between the number of clearly identifiable P-waves and the number of heart cycles during 10 sec ECG with a regular 1:1 conduction, was 92±21% at implantation and 93±18% before discharge. Survey questions on the overall operator experience with the implantation procedure are reported in Figure 1 and those on the patient experience are reported in Figure 2. Conclusions Implantation of the LUX-Dx seems fast and uncomplicated; operator and patient feedbacks are positive. Post-implantation sensing values, i.e. R-wave sensing and P-wave visibility, are good.Figure 1Figure 2

Effectiveness of a stepwise approach for screening of atrial fibrillation after stroke: insights from the SAFAS study

Abstract Background Detection of atrial fibrillation (AF) is critical after ischemic stroke, providing information regarding the mechanism of the event and leading to modification in the antithrombotic strategy. While most guidelines recommend screening patients for AF with 12-lead ECG, telemetry, long-duration Holter monitoring and implantable cardiac monitor (ICM), the optimal timing and combination of such screening tools remain unclear. Objective This study aimed at investigating the suitability of a sequential combination of screening techniques (12-lead ECG, telemetry, in hospital long-lasting Holter monitoring, and ICM in the detection of AF after stroke. Methods Patients without previously known AF admitted to the Dijon University Hospital stroke unit for acute ischemic stroke were prospectively enrolled. After a stepwise screening approach for AF based on admission ECG, telemetry monitoring during the stroke unit stay and long-duration Holter monitoring during hospital stay, cryptogenic stroke patients were implanted of an ICM. Primary endpoint was the presence of AF detected during the 3-year period after stroke based on this sequential screening approach. Results A total of 240 patients were included. Among them, 104 (43.3%) patients had a documented cause of stroke non-related to AF. Among the remaining 136 patients (53.7% male, 70.8±13.7 yo), AF was detected in 82 (60%) patients over the acute screening phase or the 3-year follow-up with ICM. AF was diagnosed using 12-lead ECG, in-hospital telemetry, and in hospital long-lasting Holter monitoring in 17 (13%), 25 (18%), and 18 (13%) patients, respectively. AF was detected after the first 24 hours on the long-lasting Holter monitoring in 66% of patients. Among the 76 (56%) patients classified as cryptogenic after the complete stroke work-up and implanted from an ICM, AF was detected in 22 (29%) patients. AF occurred during the first, second, and third years of implantable monitoring in 14 (18.4%), 5 (6.6%), and 3 (3.9%) patients, respectively (Figure 1). Mean time from ICM implantation to AF diagnosis was 308+/-279 days. Finally, among all AF detected, 72% (60/83) were found during the initial intensive in-hospital screening. Conclusion A stepwise approach for AF screening after ischemic stroke allows the early detection of AF in a substantial number of patients during hospital stay. Even with such proactive initial monitoring strategy, invasive monitoring remains complementary to non-invasive screening tools not to overlook more distant AF episodes. Studies focusing on the relative risk of ischemic stroke recurrence according to AF timing and burden are needed.Figure 1

Transcatheter PFO closure for cryptogenic stroke: current approaches and future considerations.

Patent Foramen Ovale (PFO) is a common congenital atrial septal defect present in 20%-35% of the general population. Although generally considered a benign anatomic variant, a PFO may facilitate passage of a thrombus from the venous to arterial circulation, thereby resulting in cryptogenic stroke or systemic embolization. A PFO is detected in nearly one half of patients presenting with cryptogenic stroke and often considered the most likely etiology when other causes have been excluded. In this review, we discuss the contemporary role of transcatheter closure of PFO in the treatment of cryptogenic stroke, including devices currently available for commercial use in the United States (Amplatzer PFOTM Occluder and GoreTM Cardioform Septal Occluder) and a novel suture-mediated device (NobleStitchTM EL) under clinical investigation. To provide the best care for cryptogenic stroke patients, practitioners should be familiar with the indications for PFO closure and corresponding treatment options.

REMOTE MONITORING IN CRYPTOGENIC STROKE

Abstract Introduction In the neurological field, one of the pathologies that receives the most attention due to its etiopathogenetic complexity is cryptogenic stroke. In the literature, a significant percentage of cryptogenic stroke is associated with Paroxysmal Atrial Fibrillation (FAP). With this study we wanted to compare our data with those of the literature and evaluate the incidence of remote control in promoting patient adherence to anticoagulant therapy, also analyzing the incidence of possible stroke recurrences in the monitored patients. Methodology All patients admitted to the Stroke Unit with cryptogenic stroke were evaluated with the ESUS SCORE. Patients who tested positive following the administration of the score underwent Loop Recorder (ILR) implantation for prolonged cardiac monitoring. Patients who showed episodes of FAP during monitoring were subsequently referred to the Stroke Unit to start anticoagulant therapy. A close telephone follow-up was subsequently carried out (every 15 days) to evaluate adherence to therapy and any stroke recurrences. Results 43 patients with cryptogenic stroke coming from the Stroke Unit and implanted by our center with Loop Recorder were evaluated. Among these 43 patients, 16 (37%) presented at least one episode of FAP, while 27 (63%) have not yet had any FAP event since the date of device implantation. In 60% of patients with FAP the duration of the event is greater than 5 hours. The time period between the stroke and the first FAP event in 6 out of 16 patients is approximately 1 month. Two patients presented the first episode within 7 days, while 8 patients within 10 months. In the telephone follow-up performed, 100% adherence to anticoagulant therapy was recorded, resulting in a recurrence of stroke in 0% of patients. Conclusions From the results obtained it was possible to conclude that the use of remote monitoring associated with close telephone follow-up allows the diagnosis of FAP and guarantees better patient adherence to anticoagulant therapy, significantly reducing stroke recurrences.

Implantation of a novel insertable cardiac monitor: preliminary multicenter experience in Europe.

The LUX-Dx™ is a novel insertable cardiac monitor (ICM) introduced into the European market since October 2022. The aim of this investigation was to provide a comprehensive description of the ICM implantation experience in Europe during its initial year of commercial use. The system comprises an incision tool and a single-piece insertion tool pre-loaded with the small ICM. The implantation procedure involves incision, creation of a device pocket, insertion of the ICM, verification of sensing, and incision closure. Patients receive a mobile device with a preloaded App, connecting to their ICM and transmitting data to the management system. Data collected at European centers were analyzed at the time of implantation and before patient discharge. A total of 368 implantation procedures were conducted across 23 centers. Syncope (235, 64%) and cryptogenic stroke (34, 9%) were the most frequent indications for ICM. Most procedures (338, 92%) were performed in electrophysiology laboratories. All ICMs were successfully implanted in the left parasternal region, oriented at 45° in 323 (88%) patients. Repositioning was necessary after sensing verification in 9 (2%) patients. No procedural complications were reported, with a median time from skin incision to suture of 4min (25th-75th percentiles 2-7). At implantation, the mean R-wave amplitude was 0.39 ± 0.30mV and the P-wave visibility was 91 ± 20%. Sensing parameters remained stable until pre-discharge and were not influenced by patient characteristics or indications. Procedural times were fast, exhibited consistency across patient groups, and improved after an initial experience with the system. Operator Operator feedback on the system was positive. Patients reported very good ease of use of the App and low levels of discomfort after implantation. LUX-Dx™ implantation appears efficient and straightforward, with favorable post-implantation sensing values and associated with positive feedback from operators and patients.

Cancer-associated ischemic stroke: current knowledge and future directions

Because cancer is a strong prothrombotic, there is an increased risk of thromboembolism, which includes ischemic stroke, especially in the first six to twelve months following a cancer diagnosis. The risk of ischemic stroke differs according to the location and stage of cancer. Given that the risk increases prior to a cancer diagnosis, stroke may be the initial sign of occult cancer. Although data on the risk, treatment, and outcomes of cancer-associated stroke are more limited than those on cancer-associated venous thromboembolism, the condition is still recognized as a thrombotic complication of cancer. Up to 10% of ischemic stroke patients also have a concurrent cancer diagnosis, and these patients seem to have higher short-term mortality and morbidity rates. With more people expected to survive longer after cancer treatment and an increasing number of cancer survivors, the burden of stroke among cancer patients is predicted to rise. This narrative review aims to provide an overview of the pathophysiologic mechanisms, treatment options, and epidemiology of ischemic stroke, including cancer screening for those who have cryptogenic (unexplained) stroke.

European Stroke Organisation (ESO) Guidelines on the diagnosis and management of patent foramen ovale (PFO) after stroke.

Patent foramen ovale (PFO) is frequently identified in young patients with cryptogenic ischaemic stroke. 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 signalling disruption. The purpose of this guideline is to provide recommendations for diagnosing, treating, and long-term managing patients with ischaemic stroke and PFO. Conversely, Transient Ischaemic Attack (TIA) was not considered an index event in this context because only one RCT involved TIA patients. However, this subgroup analysis showed no significant differences between TIA and stroke outcomes. The working group identified questions and outcomes, graded evidence, and developed recommendations following the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach and the European Stroke Organisation (ESO) standard operating procedure for guideline development. This document underwent peer-review by independent experts and members of the ESO Guideline Board and Executive Committee. The working group acknowledges the current evidentiary gap in delineating an unequivocal diagnostic algorithm for the detection of PFO. Although transoesophageal echocardiography is conventionally held as the most accurate diagnostic tool for PFO identification, its status as the 'gold standard' remains unsubstantiated by rigorously validated evidence. We found high-quality evidence to recommend PFO closure plus antiplatelet therapy in selected patients aged 18-60 years in whom no other evident cause of stroke is found but a PFO (i.e. PFO-associated stroke). The PASCAL classification system can be used to select such candidates for PFO closure. Patients with both a large right-to-left shunt and an atrial septal aneurysm benefit most from PFO closure. There is insufficient evidence to make an evidence-based recommendation on PFO closure in patients older than 60 and younger than 18 years. We found low quality evidence to suggest against PFO closure in patients with unlikely PFO-related stroke according to the PASCAL classification, except in specific scenarios (Expert Consensus). We suggest against long-term anticoagulation in patients with PFO-associated stroke unless anticoagulation is indicated for other medical reasons. Regarding the long-term AF monitoring after PFO closure, the working group concluded that there remains significant uncertainty regarding the risks and benefits associated with the use of long-term cardiac monitoring, such as implantable loop recorders. This document provides additional guidance, in the form of evidence-based recommendations or expert consensus statements, on diagnostic methods for PFO detection, and medical management after PFO closure.

PERCUTANEOUS CLOSURE OF PATENT FORAMEN OVALE AFTER A FAILED DEVICE–CLOSURE ATTEMPT: A HIGH–VOLUME SINGLE CENTRE EXPERIENCE

Abstract Introduction Persistence of patent foramen ovale (PFO) has been associated with cryptogenic stroke due to a paradoxical systemic embolism. In these cases, a percutaneous closure allows to decrease the risk of redo cerebral ischemic events. However, the presence of a complex anatomy might prevent a correct device–deployment with a high–risk o residual shunt and/or device embolization. We describe our experience about alternative technique after a failed device closure attempt. Methods We reviewed six cases wherein the device was not able to close effectively the PFO. In these cases, alternative techniques and skills were adopted to close the PFO. Results From 2021 to 2023, 194 PFO were closed in the congenital catheterization laboratory of Monaldi Hospital (Naples). In the most of cases (188/194 pts, 96.9%) an effective device closure was obtained. However, in 6 cases (3.1%) the device failed to have a PFO closure. In these 6 patients, the PFO anatomy was characterized by: a severe hypertrophy of the septum secundum (2 cases, 33%), an aneurysmatic interatrial septum (3 cases, 50%), a long stiff tunnel (6 cases, 100%). In three cases a deviceless suture–mediated system (NoblestichTM) was effective to achieve a complete PFO closure; whereas, in two cases a combined approach (suture–mediated system followed by a device deployment) allowed to achieve a complete PFO closure. In a patient with Ebstein anomaly and significant cyanosis due to right–to–left PFO shunt, a partial PFO closure (with mild residual right–to–left shunt) was obtained after NoblestichTM deployment. In this setting, the partial PFO closure was effective to achieve a significant improvement of the patient’s arterial saturation and the procedure stopped without to complete the PFO closure with a device. Conclusion Trans–catheter device closure is often effective to achieve a complete PFO closure. However, in some circumstances, the device was unable to have an appropriate PFO closure. A suture–mediated system or a combined approach (suture–mediated system with concomitant device deployment) are effective to achieve the PFO closure in these complex scenarios.

A whole-exome sequencing study of patent foramen ovale: investigating genetic variants and their association with cardiovascular disorders.

Patent foramen ovale (PFO) has a genetic predisposition and is closely associated with cryptogenic stroke (CS), migraine, decompression sickness, and hypoxemia. Identifying PFO-related mutant genes through whole-exome sequencing (WES) can help in the early recognition of cardiovascular genetic risk factors, guide timely clinical intervention, and reduce the occurrence of cardiovascular events. We analyzed mutant genes from ClinVar and OMIM databases. WES was performed on 25 PFO patients from Zhejiang Provincial Hospital of Chinese Medicine. Pathogenicity of variants was evaluated using American College of Medical Genetics and Genomics (ACMG) and Association for Molecular Pathology. (AMP) guidelines. In ClinVar (4 Feb 2023), 113 coding gene mutations were found, including 83 associated with PFO. From OMIM (18 Apr 2023), 184 gene mutations were analyzed, with 110 mutant coding genes. WES identified pathogenic mutations in two of 25 PFO patients (8%). LDLR, SDHC, and NKX2-5 genes were linked to PFO and primarily involved in myocardial tissue function. NKX2-5 may play a crucial role in PFO development, interacting with NOTCH1, GATA4, MYH6, SCN5A signaling pathways regulating cardiomyocyte characteristics. We identified pathogenic mutations in LDLR, SDHC, and NKX2-5 genes, implying their role in PFO development. Functional enrichment analysis revealed NKX2-5's interaction with signaling pathways regulating cardiomyocyte function. These findings enhance our understanding of PFO's genetic basis, suggesting potential therapeutic targets for future research.

Subjects with carotid webs demonstrate pro-thrombotic hemodynamics compared to subjects with carotid atherosclerosis

Carotid artery webs (CaW) are non-atherosclerotic projections into the vascular lumen and have been linked to up to one-third of cryptogenic strokes in younger patients. Determining how CaW affects local hemodynamics is essential for understanding clot formation and stroke risk. Computational fluid dynamics simulations were used to investigate patient-specific hemodynamics in carotid artery bifurcations with CaW, bifurcations with atherosclerotic lesions having a similar degree of lumen narrowing, and with healthy carotid bifurcations. Simulations were conducted using segmented computed tomography angiography geometries with inlet boundary conditions extracted from 2D phase contrast MRI scans. The study included carotid bifurcations with CaW (n = 13), mild atherosclerosis (n = 7), and healthy bifurcation geometries (n = 6). Hemodynamic parameters associated with vascular dysfunction and clot formation, including shear rate, oscillatory shear index (OSI), low velocity, and flow stasis were calculated and compared between the subject groups. Patients with CaW had significantly larger regions containing low shear rate, high OSI, low velocity, and flow stasis in comparison to subjects with mild atherosclerosis or normal bifurcations. These abnormal hemodynamic metrics in patients with CaW are associated with clot formation and vascular dysfunction and suggest that hemodynamic assessment may be a tool to assess stroke risk in these patients.

Effectiveness, utilisation and cost associated with implantable loop recorders versus external monitors after ischaemic or cryptogenic stroke

ObjectiveImplantable loop recorders (ILRs) are increasingly used for long-term rhythm monitoring after ischaemic and cryptogenic stroke, with the goal of detecting atrial fibrillation (AF) and subsequent initiation of oral anticoagulation...

Impact of an expanded reimbursement policy on utilization of implantable loop recorders in patients with cryptogenic stroke in Korea.

The reimbursement policy for cryptogenic stroke (CS) was expanded in November 2018 from recurrent strokes to the first stroke episode. No reports have demonstrated whether this policy change has affected trends in implantable loop recorder (ILR) utilization. We identified patients who received an ILR implant using the Korea Health Insurance Review and Assessment Service database between July 2016 and October 2021. Patients meeting all the following criteria were considered to have CS indication: 1) prior stroke history, 2) no previous history of atrial fibrillation or flutter (AF/AFL), and 3) no maintenance of oral anticoagulant for ≥4 weeks within a year before ILR implant. AF/AFL diagnosed within 3 years after ILR implant or before ILR removal was considered ILR-driven. Among 3,056 patients, 1,001 (32.8%) had CS indications. The total ILR implant number gradually increased for both CS and non-CS indications and the number of CS indication significantly increased after implementing the expanded reimbursement policy. The detection rate for AF/AFL was 26.3% in CS patients over 3 years, which was significantly higher in patients implanted with an ILR within 2 months after stroke than those implanted later. The expanded coverage policy for CS had a significant impact on the number of ILR implantation for CS indication. The diagnostic yield of ILR for AF/AFL detection seems better when ILR is implanted within 2 months than later. Further investigation is needed to demonstrate other clinical benefits and the optimal ILR implantation timing.

Diagnostic yield of implantable loop recorders: results from the hellenic registry

ObjectiveImplantable loop recorders (ILRs) are increasingly being used for long-term cardiac monitoring in different clinical settings. The aim of this study was to investigate the real-world performance of ILRs—including the time to diagnosis—in unselected patients with different ILR indications. Methods and ResultsIn this multicenter, observational study, 871 patients with an indication of pre-syncope/syncope (61.9%), unexplained palpitations (10.4%), and atrial fibrillation (AF) detection with a history of cryptogenic stroke (CS) (27.7%) underwent ILR implantation. The median follow-up was 28.8 ± 12.9 months. In the presyncope/syncope group, 167 (31%) received a diagnosis established by the device. Kaplan-Meier estimates indicated that 16.9% of patients had a diagnosis at 6 months, and the proportion increased to 22.5% at 1 year. Of 91 patients with palpitations, 20 (22%) received a diagnosis based on the device. The diagnosis was established in 12.2% of patients at 6 months, and the proportion increased to 13.3% at 1 year. Among 241 patients with CS, 47 (19.5%) were diagnosed with AF. The diagnostic yield of the device was 10.4% at 6 months and 12.4% at 1 year. In all cases, oral anticoagulation was initiated. Overall, ILR diagnosis altered the therapeutic strategy in 26.1% of the presyncope/syncope group, 2.2% of the palpitations group, and 3.7% of the CS group in addition to oral anticoagulation initiation. ConclusionIn this real-world patient population, ILR determines diagnosis and initiates new therapeutic management for nearly one-fourth of patients. ILR implantation is valuable in the evaluation of patients with unexplained presyncope/syncope, CS, and palpitations.

Management of patent foramen ovale in non-cardiac surgery

Patent foramen ovale (PFO) is a remnant of normal fetal anatomy which may persist into adulthood, mostly asymptomatic. In some adults, PFO may result in a potential for shunting venous thromboembolism to the arterial circulation; less frequently it can cause interatrial, right-to-left shunting of deoxygenated blood. The pathogenesis of several medical conditions is related to the presence of PFO. Some randomized clinical trials have shown evidence of benefit for device closure as compared with medical therapy in patients with cryptogenic stroke. The literature reported several cases of carbon dioxide embolism during general laparoscopic surgery and sometimes stroke after laparoscopic or neurosurgery but there are neither prospective studies addressing these issues, nor randomized clinical trials assessing the effectiveness of pharmacotherapy or interventional procedures at decreasing risk. The European position paper suggests routine monitoring in non-cardiac surgery of patients with a PFO and no actual indications for closure. This article aims to further stratify the risk of periprocedural stroke and paradoxical embolism in this category of patients.

Percutaneous Patent Foramen Ovale Closure: Stroke and Beyond.

Over 750,000 individuals suffer from stroke annually in the United States, with 87% of these strokes being ischemic in nature. Roughly 40% of ischemic strokes occur in individuals 60 years of age or under. A quarter of all ischemic strokes have no identifiable cause despite extensive workup and are deemed cryptogenic in nature. Patent Foramen Ovales (PFO) has been postulated in stroke causation by either paradoxical embolization or platelet activation in the tunnel of the defect. The incidence of PFO is reported to be 15-25% in the general population but rises to 40% in patients with cryptogenic stroke. While the initial trials evaluating PFO closures were non-revealing, subsequent long-term follow-ups, as well as recent trials evaluating PFO closures in cryptogenic stroke patients 60 years of age or under, demonstrated the superiority of percutaneous closure compared to medical therapy alone, leading to FDA approval of PFO closure devices. In this review, we review the diagnosis of PFO, postulated stroke mechanisms, literature supporting PFO closure, patient selection for percutaneous closure, procedural considerations, and associated procedural complications.

Co-occurrence of patent foramen ovale and Chiari network in a diabetic patient.

The coexistence of congenital cardiovascular anomalies provides valuable insights into the intricate nature of human cardiac anatomy and its potential interactions with underlying health conditions. This case report presents an autopsy analysis of a diabetic patient manifesting both a patent foramen ovale and a Chiari network. A 26-year-old male with a history of type 2 diabetes mellitus was admitted with post cardiac arrest. He died despite resuscitative efforts. Autopsy revealed notable findings including a patent foramen ovale and a Chiari network. Post-mortem biochemical markers indicated elevated HbA1c level and hyperglycaemia. The absence of cryptogenic strokes or paradoxical embolism prompted exploration into potential relationships between these anomalies and metabolic disturbances, and prompts a discussion about whether the observed anatomical variations could potentially serve as risk factors contributing to the patient's death due to complications of diabetes. The co-occurrence of a patent foramen ovale and a Chiari network within a diabetic patient, accompanied by elevated HbA1c level and hyperglycaemia, offers a unique perspective on the convergence of congenital cardiovascular variation and metabolic health. The juxtaposition of these anomalies with biochemical markers underscores the intricate interplay between cardiac morphology and metabolic conditions.

Periodontitis, Dental Procedures, and Young-Onset Cryptogenic Stroke

Periodontitis is associated with an increased risk of ischemic stroke, and the risk may be particularly high among young people with unexplained stroke etiology. Thus, we investigated in a case-control study whether periodontitis or recent invasive dental treatments are associated with young-onset cryptogenic ischemic stroke (CIS). We enrolled participants from a multicenter case-control SECRETO study including adults aged 18 to 49 y presenting with an imaging-positive first-ever CIS and stroke-free age- and sex-matched controls. Thorough clinical and radiographic oral examination was performed. Furthermore, we measured serum lipopolysaccharide (LPS) and lipotechoic acid (LTA) levels. Multivariate conditional regression models were adjusted for stroke risk factors, regular dentist visits, and patent foramen ovale (PFO) status. We enrolled 146 case-control pairs (median age 41.9 y; 58.2% males). Periodontitis was diagnosed in 27.5% of CIS patients and 20.1% of controls (P < 0.001). In the fully adjusted models, CIS was associated with high periodontal inflammation burden (odds ratio [OR], 95% confidence interval) with an OR of 10.48 (3.18–34.5) and severe periodontitis with an OR of 7.48 (1.24–44.9). Stroke severity increased with the severity of periodontitis, having an OR of 6.43 (1.87–23.0) in stage III to IV, grade C. Invasive dental treatments performed within 3 mo prestroke were associated with CIS, with an OR of 2.54 (1.01–6.39). Association between CIS and invasive dental treatments was especially strong among those with PFO showing an OR of 6.26 (1.72–40.2). LPS/LTA did not differ between CIS patients and controls but displayed an increasing trend with periodontitis severity. Periodontitis and recent invasive dental procedures were associated with CIS after controlling for multiple confounders. However, the role of bacteremia as a mediator of this risk was not confirmed.

Patent Foramen Ovale (PFO) in Patients of Cryptogenic Stroke AND Transient Ischemic Attack (TIA): A Real World Experience

Background: Stroke, a leading cause of brain tissue damage, presents a significant health concern globally. Cryptogenic stroke (CS), with an unclear origin, poses diagnostic challenges, with the patent foramen ovale (PFO) implicated in some cases. This study aims to investigate PFO prevalence in North India among patients with cryptogenic stroke, addressing current research gaps.&#x0D; Objective: To assess PFO occurrence in patients with cryptogenic stroke and Transient Ischemic Attack (TIA) using Echocardiography.&#x0D; Methods &amp; Results: This preliminary study analyzed PFO prevalence in patients with CS and TIA from February 2020 to November 2021, involving 25 participants. Descriptive statistics and the Chi-square test were employed. Key findings include a mean age of 44.80±9.13 years, 64% men, and 36% women. Ischemic stroke accounted for 72% of cases, while TIA represented 28%. PFO prevalence was 44%, with no significant gender-PFO association. No correlations were found between stroke type and PFO presence, nor were comorbidities like hypertension and diabetes observed.&#x0D; Conclusion: The study highlights a clinically significant distribution of PFO presence but no notable association between stroke type and PFO presence. These findings contribute to understanding PFO's role in cryptogenic stroke and have implications for clinical practice.

Incidental and anticipated arrhythmic diagnoses in patients with an implantable cardiac monitor.

In this study, we investigated a cohort of unselected patients with various indications for an implantable cardiac monitor (ICM). Our main objectives were to determine the incidence of arrhythmic diagnoses, both anticipated and incidental in relation to the ICM indication, and to assess their clinical relevance. We examined remote monitoring transmissions from patients with an ICM at four Italian sites to identify occurrences of cardiac arrhythmias. Concurrently, we collected data on medical actions taken in response to arrhythmic findings. The study included 119 patients, with a median follow-up period of 371 days. ICM indications were syncope/presyncope (46.2%), atrial fibrillation management (31.1%), and cryptogenic stroke (22.7%). In the atrial fibrillation management group, atrial fibrillation was the most common finding, with an incidence of 36% [95% confidence interval (CI) 22-55%] at 18 months. Rates of atrial fibrillation were not significantly different between patients with cryptogenic stroke and syncope/presyncope [17% (95% CI 7-40%) vs. 8% (95% CI 3-19%), P = 0.229].For patients with cryptogenic stroke, the incidence of asystole and bradyarrhythmias at 18 months was 23% (95% CI 11-45%) and 42% (95% CI 24-65%), respectively, similar to estimates obtained for patients implanted for syncope/presyncope ( P = 0.277 vs. P = 0.836).Overall, 30 patients (25.2%) required medical intervention following ICM-detected arrhythmias, predominantly involving atrial fibrillation ablation (10.9%) and medication therapy changes (10.1%). In a real-life population with heterogeneous insertion indications, approximately 25% of patients received ICM-guided medical interventions within a short timeframe, including treatments for incidental findings. Common incidental arrhythmic diagnoses were bradyarrhythmias in patients with cryptogenic stroke and atrial fibrillation in patients with unexplained syncope.