Prevention Of Recurrent Cryptogenic Stroke Research Articles

DVT, PULMONARY EMBOLISM, AND PARADOXICAL EMBOLISM THANKS TO A CARDIAC CONNECTION

SESSION TITLE: Medical Student/Resident Cardiovascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Concomitant venous and arterial thrombi are usually seen in hypercoagulable states, but we present an unusual case where a patient developed paradoxical embolism of deep venous thrombosis (DVT) and pulmonary embolism (PE) leading to acute limb ischemia due to the presence of a patent foramen ovale (PFO). CASE PRESENTATION: 70-year-old female with history of OSA, hypertension, diabetes on insulin presented to the hospital with sudden onset right lower extremity pain, numbness and weakness of few hours. Patient also complained of dyspnea on exertion that started about 3 weeks prior. At presentation, patient was hypoxic, and examination demonstrated a right lower extremity that was cold to touch and numb with faint dorsalis pedis and posterior tibialis pulses on the right compared to the left. CT chest, abdomen, pelvis with contrast showed an acute extensive pulmonary emboli with right heart strain, acute thrombus at the origin of the celiac trunk, superior and inferior mesenteric arteries, left lower pole renal artery, right common femoral artery, and left internal iliac artery with occlusion of the right common femoral, left internal iliac, and left lower pole renal arteries. Lower extremity venous doppler showed an acute deep venous thrombosis of the left popliteal vein and the femoral vein in the lower thigh. 2D echo with bubble study revealed D-shaped left ventricle due to septal flattening, consistent with elevated right ventricular pressure atrial septal aneurysm and a patent foramen ovale. Patient was started on heparin drip and emergently taken to the operating room for right lower extremity thrombo-embolectomy of right iliac, right femoral, right profunda, right superficial femoral artery, right popliteal artery and 4 compartment fasciotomies. Post-operatively, anticoagulation was changed to Rivaroxaban and was discharged to acute inpatient rehab in stable condition. DISCUSSION: The prevalence of PFO in the general population is more than 25% but most are asymptomatic, the prevalence of DVT was found to be as high as 41% in one study of patients with suspected paradoxical embolism and concomitant patent foramen ovale. Most of the data about PFO closure are for prevention of recurrent cryptogenic stroke with paucity of data on how to manage PFO and paradoxical embolism causing limb ischemia with associated DVT and PE. CONCLUSIONS: A high index of suspicion for PFO should be maintained when a patient with PE and/or DVT presents with concomitant evidence of arterial thromboembolism. Reference #1: 1.Stollberger C, Slany J, Schuster I, Leitner H, Winkler W, Karnik R. The Prevalence of Deep Venous Thrombosis in Patients with Suspected Paradoxical Embolism. Ann Intern Med. 1993;119:461–465. doi: 10.7326/0003-4819-119-6-199309150-00003 Reference #2: 2.Homma, S. and R. L. Sacco (2005). "Patent foramen ovale and stroke.” Circulation 112(7): 1063-1072. DISCLOSURES: No relevant relationships by Nellowe Candelario, source=Web Response No relevant relationships by Adegbola Oluwole, source=Web Response

The Role of Patent Foramen Ovale Closure in the Secondary Prevention of Cryptogenic Stroke: a Meta-Analysis Report

Background: Patent foramen ovale (PFO) closure has been compared to medical therapy for secondary prevention of recurrent cryptogenic stroke. Objectives: To produce an updated meta-analysis including only data from the primary analyses of clinical trials and to evaluate the role of PFO closure in the secondary prevention of recurrent stroke. Methods: Search in Medline (PubMed) and in ISI Web of Knowledge. Parameters under analysis and meta-analyses were: stroke, transient ischemic attack (TIA) and atrial fibrillation (AF). Comprehensive Meta-analysis Software V.2.0 [...]

Percutaneous Closure of Patent Foramen Ovale in Patients with Cryptogenic Stroke - An Updated Comprehensive Meta-Analysis.

The ideal treatment strategy for patients with cryptogenic stroke and patent foramen ovale (PFO) is not yet clear. Previous randomized controlled trials (RCTs) comparing transcatheter PFO closure with medical therapy in patients with cryptogenic stroke to prevent recurrent ischemic stroke showed mixed results. This meta-analysis aims to compare rates of recurrent stroke, transient ischemic attack (TIA) and all-cause mortality with PFO closure and medical therapy vs. medical therapy alone. PubMed and the Cochrane Center Register of Controlled Trials were searched for studies published through June 2018, comparing PFO closure plus medical therapy versus medical therapy alone. Six RCTs (n = 3750) comparing PFO closure with medical therapy were included in the analysis. End points were recurrent stroke, TIA and all-cause mortality. The odds ratios (OR) with 95% confidence interval (CI) were computed and p < 0.05 was considered as a level of significance. A total of 1889 patients were assigned to PFO closure plus medical therapy and 1861 patients were assigned to medical therapy only. Risk of recurrent stroke was significantly lower in the PFO closure plus medical therapy group compared to medical therapy alone. (OR 0.47, 95% CI 0.33-0.67, p < 0.0001). Rate of TIA was similar between the two groups (OR 0.76, 95% CI 0.52-1.14), p = 0.18). There was no difference in all-cause mortality between two groups (OR 0.73, CI 0.33-1.58, p = 0.42). Patients undergoing PFO closure were more likely to develop transient atrial fibrillation than medical therapy alone (OR: 5.85; CI: 3.06-11.18, p ≤0.0001) whereas the risk of bleeding was similar between the groups (OR: 0.93; CI: 0.55-1.57, p = 0.78). The results of this meta-analysis suggest that transcatheter closure of PFO plus medical therapy is superior to medical therapy alone for the prevention of recurrent cryptogenic stroke. However, PFO closure in these patients has not been shown to reduce the risk of recurrent TIA or all-cause mortality. There is a higher rate of transient atrial fibrillation post PFO closure device placement, the long-term effects of which have yet to be studied.

P715Patent foramen ovale closure versus medical therapy for prevention of recurrent cryptogenic stroke - a meta-analysis of randomized clinical trials

P715Patent foramen ovale closure versus medical therapy for prevention of recurrent cryptogenic stroke - a meta-analysis of randomized clinical trials

TCTAP A-076 Transcatheter Closure of Patent Foramen Ovale: Clinical Efficacy for Prevention of Recurrent Cryptogenic Stroke or Migraine Headache

Transcatheter closure of patent foramen ovale (PFO) for prevention of recurrent cryptogenic cerebrovascular events (CVE) has not been officially approved in Japan. However, previous studies suggested that >10000 patients/year are suffered from a cryptogenic stroke due to PFO in Japan. Additionally,

Prevention of recurrent cryptogenic stroke with percutaneous closure of patent foramen ovale; one year follow-up study with magnetic resonance imaging and Holter monitoring.

In this study, we aimed to evaluate the effect of percutaneous closure of patent foramen ovale (PFO) on the recurrence of stroke and new cardiac arrhythmia using magnetic resonance imaging (MRI) and Holter monitoring. Patients with PFO had >1 previous stroke or transient ischemic attack documented with MRI in the first event. PFO with right to left shunt was detected by transesophageal echocardiography (TEE) and transcranial Doppler ultrasound. MRI examinations were performed on patients before and one year after PFO closure was applied. A twenty-four hour Holter monitoring was performed in all patients within 1 month before and 6 months after the procedure. Percutaneous PFO closure was performed on 47 patients (25 female, mean age: 38.7 years) who had cerebral ischemic events detected by MRI. A year after the procedure, TEE showed that there was no residual interatrial right-to-left shunting. After a 14 month follow-up, no new cerebrovascular event and no new lesion on MRI were recorded. The incidence of arrhythmia did not increase significantly after the procedure on Holter monitoring (p=0.917). One-year clinical and MRI follow-up study of patients with cerebral ischemic events and percutaneous closure of PFO showed no recurrent event and no significant complication associated with the procedure. In addition, Holter monitorization demonstrated that the procedure did not increase the incidence of arrhythmias compared with pre-procedural monitoring.

Percutaneous closure of patent foramen ovale: “Closed” door after the last randomized trials?

Patent foramen ovale (PFO) percutaneous closure has previously been an accepted intervention for the prevention of recurrent cryptogenic stroke on the basis of observational studies. However, randomized trials have been lacking until now. Three recently published randomized trials (CLOSURE I, PC and RESPECT) do not demonstrate the superiority of this intervention versus optimal medical therapy, therefore making this practice questionable. Nonetheless, these trials have had certain pitfalls, mainly a lower than initially estimated number of patients recruited, therefore lacking sufficient statistical power. On the other hand, different closure devices were used in the three trials. In two of them (PC and RESPECT), the Amplatzer PFO Occluder was used and the STARflex device was used in the other one (CLOSURE I). Taken altogether, a meta-analysis of these three trials does not demonstrate a statistically significant benefit of percutaneous PFO closure (1.9% vs 2.9%; P = 0.11). However, if we analyze only the PC and RESPECT trials together, in which the Amplatzer PFO Occluder was used, a statistically significant benefit of percutaneous PFO closure is observed (1.4% vs 3.0%, P = 0.04). In conclusion, our interpretation of these trials is that the use of a dedicated, specifically designed Amplatzer PFO device could possibly reduce the risk of stroke in patients with PFO and cryptogenic stroke. This consideration equally applies to patients who have no contraindications for anticoagulant or antithrombotic therapy.

Prevention of recurrent cryptogenic stroke with percutaneous closure of patent foramen ovale; a follow-up study with magnetic resonance imaging

Prevention of recurrent cryptogenic stroke with percutaneous closure of patent foramen ovale; a follow-up study with magnetic resonance imaging

Migraine headache relief after transcatheter closure of patent foramen ovale

The purpose of this study was to determine the effects of transcatheter patent foramen ovale (PFO) closure on migraine frequency in patients with paradoxical cerebral embolism. The prevalence of migraine headache is higher in cryptogenic stroke patients with PFO than in the general population. Previous studies have suggested that closure of the PFO may reduce migrainous symptoms. Between April 2001 and December 2003, 162 consecutive patients with paradoxical cerebral embolism underwent transcatheter PFO closure for prevention of recurrent cryptogenic stroke or transient ischemic attack. A one-year retrospective analysis of migraine symptoms before and after PFO closure was performed. Active migraine was present in 35% (57 of 162) of patients, and 68% (39 of 57) experienced migrainous aura; 50 patients were available for analysis at one year. Complete resolution of migraine symptoms occurred in 56% (28 of 50) of patients, and 14% (7 of 50) of patients reported a significant (>or=50%) reduction in migraine frequency. Patients reported an 80% reduction in the mean number of migraine episodes per month after PFO closure (6.8 +/- 9.6 before closure vs. 1.4 +/- 3.4 after closure, p < 0.001). Results were independent of completeness of PFO closure at one year. In patients with paradoxical cerebral embolism, migraine headaches are more frequent than in the general population, and transcatheter closure of the PFO results in complete resolution or marked reduction in frequency of migraine headache.