Prosthetic Valve Stenosis Research Articles

Early Prosthetic Valve Malfunction Leading to Cardiogenic Shock and Emergency Redo Mitral Valve Replacement

Early onset prosthetic valve stenosis is an uncommon complication after valve replacement surgery and is often caused by thrombus formation. Frequently it can be diagnosed by echocardiography and managed with optimizing anticoagulation and/or thrombolysis. We review a unique case of early bi-leaflet mechanical heart valve (BMHV) dysfunction where the patient rapidly progressed to cardiogenic shock requiring emergent re-do mitral valve surgery. Intraoperatively, the valve leaflets were found to be almost completely immobile secondary to thrombus formation directly on the hinges of the valve. This case demonstrates how the leaflet orientation of a BMHV affects transmitral flow and fluid dynamics. Furthermore, we also discuss left atrial vortex formation in the setting of atrial fibrillation, kinetic energy transfer through an anatomically implanted mechanical mitral valve, and their roles in contributing to early prosthetic valve thrombosis despite adequate anticoagulation.

Study Protocol for Transcatheter Aortic Valve Replacement for a Degenerated Aortic Bioprosthesis in a Japanese Cohort

Background: The valve-in-valve (VIV) procedure is being increasingly performed in high-risk patients with a degenerated bioprosthesis in an aortic position in Western countries. The early safety and efficacy of the VIV procedure, however, remain unclear in Japanese patients with a small aortic annulus. We present the protocol for a study designed to evaluate the early safety and efficacy of the VIV procedure in the aortic position in Japanese patients. Methods and Results: The prospective, single-center, non-comparative, clinical study of the VIV procedure for the aortic position (AORTIC VIV study) commenced in August 2016 and will end in March 2020. Patients will be monitored for ≥1 month after the VIV procedure. The targeted number of patients is 11. Eligible patients are those who have undergone transcatheter aortic valve replacement for a surgical valve (including stented or stentless bioprosthetic valves), or for a transcatheter heart valve. The VIV procedure is performed in high-operative-risk patients with substantial prosthetic valve stenosis, and regurgitation and heart failure resistant to medical treatment (unless the patient meets an exclusion criterion). The safety and efficacy of the VIV procedure will be evaluated in accordance with the Valve Academic Research Consortium-2 initiative. Conclusions: The AORTIC VIV study will clarify the early safety and efficacy of the VIV procedure in Japanese patients.

Stroke prevention strategies in patients with atrial fibrillation and heart valve abnormalities: perceptions of 'valvular' atrial fibrillation: results of the European Heart Rhythm Association Survey.

The purpose of this European Heart Rhythm Association (EHRA) Survey was to assess the perceptions of 'valvular' atrial fibrillation (AF) and management of AF patients with various heart valve abnormalities in daily clinical practice in European electrophysiology (EP) centres. Questionnaire survey was sent via the Internet to the EHRA-EP Research Network Centres. Of the 52 responding centres, 42 (80.8%) were university hospitals. Choosing the most comprehensive definition of valvular AF, a total of 49 centres (94.2%) encountered a mechanical prosthetic heart valve and significant rheumatic mitral stenosis, 35 centres (67.3%) also considered bioprosthetic valves, and 25 centres (48.1%) included any significant valvular heart disease, requiring surgical repair in the definition of valvular AF. Only three centres (5.8%) would define valvular AF as the presence of any (even mild) valvular abnormality. None of the centres would use non-vitamin K antagonist oral anticoagulants (NOACs) in AF patients with mechanical prosthetic valves, only 5 centres (9.8%) would use NOACs in patients with significant mitral stenosis, 17 centres (32.7%) would consider the use of NOACs in patients with bioprosthetic valves, and 21 centres (41.2%) would use NOACs in patients with a non-recent transcatheter valve replacement/implantation, while 13 centres (25.5%) would never consider the use of NOACs in AF patients with even mild native heart valve abnormality. Our survey showed marked heterogeneity in the definition of valvular AF and thromboprophylactic treatments, with the use of variable NOACs in patients with valvular heart disease other than prosthetic heart valves or significant mitral stenosis, indicating that this term may be misleading and should not be used.

Prosthesis-Patient Mismatch After Aortic Valve Replacement

Prosthesis-patient mismatch (PPM) occurs when the effective orifice area (EOA) of a normally functioning prosthesis is too small in relation to the patient's body size, resulting in abnormally high postoperative gradients. PPM is frequent following aortic valve replacement (AVR), and it is associated with increased risk of morbidity and mortality proportionally to its severity. Differential diagnosis between PPM and prosthetic valve stenosis is made by comparing the measured valve effective orifice area, by assessing the changes in valve area and gradient during follow-up and by evaluating leaflet morphology and mobility. Preventive strategies to avoid or minimize PPM should be implemented especially in the patients who are at high risk for severe PPM and in those who have vulnerability factors to PPM. Transcatheter AVR may be superior to surgical AVR for the prevention of PPM and associated adverse cardiac events, particularly in the subset of patients with a small (<21mm) aortic annulus. In this article, we discuss the most updated data regarding the diagnosis, clinical impact, and prevention of PPM after AVR.

Outcomes of Redo Transcatheter Aortic Valve Replacement for the Treatment of Postprocedural and Late Occurrence of Paravalvular Regurgitation and Transcatheter Valve Failure.

Transcatheter aortic valves can degenerate in a manner similar to surgical bioprostheses. Clinical and echocardiographic outcomes of patients who underwent redo transcatheter aortic valve replacement (TAVR) procedures >2 weeks post procedure were collected from 14 centers. Among 13 876 patients, 50 (0.4%) underwent redo TAVR procedure at participating centers. Indications for redo TAVR were moderate-severe prosthetic aortic valve stenosis (n=10, 21.7%), moderate-severe central prosthetic aortic valve regurgitation (n=13, 28.3%), and moderate-severe paraprosthetic aortic valve regurgitation (n=25, 50.0%). The index TAVR was most commonly a Medtronic CoreValve (N=38, 76.0%), followed by Edwards SAPIEN-type valves (n=12, 24.0%) and Portico (n=1, 2.0%). The redo TAVR device was most commonly a CoreValve/Evolut R (n=29, 58.0%), followed by a SAPIEN-type valve (n=20,40.0%) or a Boston Lotus valve (n=1, 2.0%). In 40 patients (80.0%), redo TAVR was performed using the identical device type or that of the succeeding generation. Valve performance was uniformly good after redo TAVR (mean transvalvular gradient post redo TAVR: 12.5±6.1 mm Hg). At hospital discharge, all patients remained alive, with 1 nondisabling stroke (2.0%) and 1 life-threatening bleed (2.0%). Permanent pacemaker implantation was required in 3 out of 35 patients without a prior pacemaker (8.6%). Late survival was 85.1% at a median follow-up of 1589 days (range: 31-3775) after index TAVR and 635 days (range: 8-2460) after redo TAVR. Redo TAVR for the treatment of postprocedural and late occurrence of paravalvular regurgitation and transcatheter aortic valve prosthesis failure seems to be safe, and it is associated with favorable acute and midterm clinical and echocardiographic outcomes.

Echocardiographic evaluation of prosthetic heart valves.

The specific flow pattern and imaging features of prosthetic heart valves poses major challenges for the Doppler echocardiographic assessment of prosthetic valve structure and function. A comprehensive approach that integrates several semi-quantitative and quantitative parameters obtained from multiple views is key to appropriately detect and quantitate prosthetic valve dysfunction and complications. In patients with prosthetic valves, and particularly in those with mitral prostheses, transesophageal echocardiography is often required to confirm and/or complement information obtained by transthoracic echocardiography. Three-dimensional echocardiography may provide incremental information for the identification of the underlying etiology of prosthetic valve stenosis or regurgitation. Transcatheter aortic valve implantation has rapidly expanded in the past 10 years and paravalvular regurgitation is frequent following this procedure. Given that paravalvular regurgitant jets are often multiple, irregular, and eccentric, the grading of this type of regurgitation is particularly challenging and requires an integrative multiwindow, multiplane, multiparametric approach.

Sometimes an ounce of extracorporeal membrane oxygenation prevention is worth a pound of extracorporeal membrane oxygenation cure

Emergency aortic valve replacement in the setting of severe aortic valve stenosis and cardiogenic shock carries increased risk of morbidity, including postcardiotomy cardiac failure. 1 Mechanical circulatory support with extracorporeal membrane oxygenation (ECMO) can be a lifesaving therapy for such patients. We report here the management of a patient with severe prosthetic aortic stenosis in cardiogenic shock whom we treated with ECMO therapy to achieve clinical stabilization before urgent aortic valve replacement. CLINICAL SUMMARY A 77-year old woman was admitted with a non–STsegment myocardial infarction, severe prosthetic aortic valve stenosis, and an ejection fraction of 37%. The patient had cardiogenic shock develop and underwent placement of an intra-aortic balloon pump. This resulted in stabilization of her systemic blood pressure; however, acute kidney injury developed, with low urinary output (67 mL over 6 hours) and elevated serum creatinine level (acute increase

Valvar replacement in infants and preschool children: a retrospective single-center study

Results Mean age at surgery was 11.7 ± 10.4 (min = 0.8, max = 32.9) months. Diagnoses were isolated congenital valvopathy (38%), atrioventricular septal defect (AVSD) (31%), common arterial trunk (19%) and tetralogy of Fallot (12%). Nine (50%) of the prostheses were located in mitral, 4 (22%) in aortic, 2 (11%) in pulmonary and 3 (17%) in truncal position. Five (31.3%) patients underwent reoperation during the follow-up period and the major indication was prosthetic valve stenosis. The mean time free of reoperation was 76.5 ± 18.8 months. Hospital mortality was 43.8% and the average survival time 58.4 ± 9.3 months. Statistically significant association was found between age at surgery and the occurrence of intra-hospital death, the younger the patient, the greater the risk of dying during the first month after the surgery (p = 0.026). There were differences between the intra-hospital mortality risks according to the underlying congenital heart disease, although this difference was not statistically significant (p = 0.084). Valvopathies due to other cardiac defects (AVSD, common arterial trunk and tetralogy of Fallot) had higher occurrence of intra-hospital death.

Subacute Transcatheter CoreValve Thrombotic Obstruction

An 86-year-old man with severe symptomatic aortic stenosis (additive Euroscore 7) underwent a transcatheter aortic valve implantation with a CoreValve bioprosthesis (26 mm, CoreValve Revalving Technology, Medtronic, Inc., Minneapolis, MN). The patient was discharged on aspirin and clopidogrel and advised to stop the clopidogrel after 3 months. This first 6-month follow-up was uneventful. Repeated echocardiograms obtained during this period revealed a slight increase in mean transprosthetic aortic pressure gradient without significant concomitant aortic regurgitation. At the last visit, 1 year later, the patient became symptomatic (New York Heart Association class II–III). He had no fever. Between the 6th and 12th month of follow-up, there was a documented increase in transprosthetic aortic peak velocity (4.11 m/s) and mean gradient (41 mm Hg) and a significant reduction in aortic effective orifice area (0.69 cm2), which indicated severe prosthetic valve stenosis. To evaluate the shape of the CoreValve, both transesophageal echocardiogram and cardiac computed tomography were performed. Although computed tomography revealed no change in prosthesis position (when compared with pre–transcatheter aortic valve implantation computed tomography) and the absence of significant deformation of the stent by any calcifications (Figure 1A–1D), transesophageal echocardiogram evidenced thickened …

Transapical Implantation of a Melody Valve in a Degenerated Low-Diameter Prosthetic Aortic Valve

78-year-old woman had undergone a biological aortic valve replacement (Mitroflow Pericardial, Sorin Inc, Burnaby, BC, Canada) and coronary artery bypass graft surgery 8 years previously. Acute exacerbation of her symptoms resulting from prosthetic aortic valve stenosis caused respiratory failure, necessitating resuscitation and mechanical ventilation. A transthoracic Doppler echocardiogram demonstrated peak and mean prosthetic aortic valve gradients of 70 and 51 mm Hg, respectively, and a calculated valve area of 0.5cm 2 (Figure 1). Coronary angiography demonstrated triple-vessel disease and 3 patent grafts to all coronary territories. Although the need for a tracheostomy and the seeming adherence of patent grafts to the sternal plate precluded conventional surgical intervention, the prosthetic valve size of 19 mm deemed the patient unsuitable for a conventional transcatheter aortic valve implantation. A Melody valve (Medtronic Inc, Santa Ana, CA), because of its suitability for annular diameters of 16 to 22 mm, was a possible solution. A surgical transapical approach was chosen because of the limitations of the Melody transvenous delivery system, poor vascular access, and the need for absolute control during the procedure. A pediatric cardiologist (E.B.) familiar with the Melody system was integrated into the team. The valve delivery system, Ensemble, is a balloon-in-balloon over-the-wire catheter onto which the valve is hand crimped. The level of expansion of the valve is determined by the size of the outer balloon used for inflation (range, 18–22 mm). The balloon and Melody valve are covered by a movable sleeve that is retracted before positioning and deployment with 22F profile that could easily be advanced through a 24F Ascendra-2 transapical sheath (Ascendra Inc, Reston, VA) originally designed for Edwards-XT transcatheter aortic valve implantation with its radiopaque markers and a reliable hemostatic seal. The femoral vessels were accessed for transvenous pacing and an aortic root marker pigtail catheter. The working angle was determined to be perpendicular to the Mitroflow ring (Figures 2 and 3). To avoid unequal valve expansion and to verify the true inner diameter of Mitroflow, we predilated the stenotic valve with a Nucleus 18-mm balloon (NuMed Inc, Hopkington, NY; Figure 4). After the valvuloplasty, the Melody delivery system was introduced via the Ascendra-2 sheath and positioned in a 50:50 position through the valve

An alternative procedure to valve replacement in prosthetic mitral valve stenosis

Pannus formation by the endothelial tissue overlapping the prosthetic mitral valve is a rare condition requiring surgical intervention in patients undergoing mitral valve replacement. In this article, we present a 54-year-old female patient admitted with the complaints of fatigue and dyspnea. Echocardiographic examination revealed prosthetic mitral valve stenosis, tricuspid valve stenosis and regurgitation and aortic valve stenosis following the previous mitral valve replacement. Transvalvular pannus resection with removal of prosthetic mitral valve stenosis, aortic valve replacement and tricuspid commissurotomy were performed. The patient was discharged on postoperative day 11 without any events.

Percutaneous balloon valvuloplasty for bioprosthetic mitral valve stenosis

Percutaneous transcatheter mitral valvuloplasty is the indicated treatment of choice for symptomatic native mitral valve stenosis, but there have been limited reports of successful procedures of balloon valvuloplasty for bioprosthetic mitral valve stenosis. We present the case of a 62-year-old woman suffering from progressive dyspnea due to bioprosthetic mitral valve stenosis. The measured mean pressure gradient across the mitral valve was 30 mmHg and the mitral valve area was 0.73 cm(2). Redoing mitral replacement was considered high risk and was refused by the patient. Percutaneous balloon valvuloplasty was performed with an Inoue balloon catheter inflated to 20 mm. The patient's symptoms immediately improved after the procedure, with no procedure-related complications. The mean pressure gradient across the valve decreased to 19 mmHg, and the mitral valve area increased to 1.21 cm(2) in postprocedural echocardiography. We conducted a literature search and identified 26 cases of balloon valvuloplasty for degenerated bioprosthetic valves. Of these, 14 cases were bioprosthetic mitral valves, and the results were favorable. However, more case reports are required to establish an evidence base for future expert recommendation of balloon valvuloplasty of prosthetic mitral valve. Meanwhile, balloon valvuloplasty will serve a niche role in highly selected patients with prosthetic mitral valve stenosis.

Severity of the Loss of High Molecular Weight Multimers Is Associated with Heyde Syndrome in Patients with Severe Aortic Stenosis.

AbstractAbstract 2230 Background:Heyde syndrome describes patients with severe aortic stenosis (AS) who have bleeding diathesis, especially gastrointestinal bleeding. Although acquired won Willebrand syndrome (AVWS) due to loss of the highest molecular weight multimers (HMWM) presents in most patients with severe AS, not all such patients develop Heyde syndrome. The goal of this study was to explore whether the severity of HMWM loss was significantly associated with Heyde syndrome. Methods:We first performed chart reviews on patients referred for double balloon enteroscopy (DBE) for GI bleeding or iron-deficiency anemia (GIB/FeDefic) in two time periods, from 2005–2008, and from 2009–2011. Next, patients who could have AVWS due to AS or other cardiovascular or hematologic disorders were identified. Laboratory tests including VWF antigen (VWF:Ag), VWF ristocetin cofactor activity or VWF latex immunoturgidic activity (VWF:Ltx) and/or VWF multimer analysis were performed as requested by physicians. From this population, patients with Heyde syndrome were identified. Their clinical and VWF laboratory testing results were compared to a separated group of patients with severe AS patients who had no clinically significant bleeding, but had matched gender and hemodynamic severity by echocardiogram (Matched AS Controls). These patients all had VWF:Ag, VWF:Ltx, and VWF multimers performed. In both Heyde syndrome patients and Matched AS controls, VWF multimer densitometry ratio of the HMWM (>15 mers) to low to intermediate multimers (2–15 mers) was assessed (VWF:multi ratio). Results:Overall, 437 patients underwent DBE for GIB/FeDef. Between 2005 and 2008, 1% of 318 patients had VWF testing. From 2009 to 2011, 23% of 119 patients were tested. Heyde syndrome was noted in 15 patients. Of the 437 patients, 134 patients (31%) likely had AVWS based on diagnoses of moderate-severe AS (30%), moderate to severe mitral regurgitation (25%), moderate to severe pulmonary hypertension (16%), prosthetic valve regurgitation or stenosis (13%), hypertrophic cardiomyopathy (10%), and hematologic disorders (4%). Among these 134 patients, 29 patients had VWF tests performed, and 22 had VWF multimer analysis. VWF antigen levels were similar in Heyde syndrome and Matched AS Controls (176±89% versus 155±77% respectively). Despite similar hemodynamic severity, more severe HMWM loss as indicated by lower VWF:Ltx/Ag and VWF:multi ratios was present in Heyde syndrome patients than matched AS controls (table, P<0.0007).Age, yearsMean gradient, mm HgVWF: Ltx/VWF:AgVWF:multi ratiosPFA-CADPHeyde (n=15)76±9†47±12†0.78±0.06*0.106±0.033*203±57†Matched AS Controls (n=25)78±1147±150.89±0.050.143±0.015174±121N=10 for VWF activity/antigen and PFA-CAPD in Heyde syndrome patients.*p<0.0007.†p=NS Conclusion:If AVWS is suspected in patients with GIB/FeDef, laboratory testing for VWF indices is important to confirm the diagnosis of AVWS. Despite similar hemodynamic severity, Heyde syndrome patients have more severe VWF HMWM loss indicated by significantly decreased VWF:Ltx/VWF:Ag and VWF:multi ratios. Conversely, though highly sensitive for AVWS, PFA-CADP does not predict bleeding tendency in patients with severe AS. Disclosures:No relevant conflicts of interest to declare.

High Transvalvular Gradients Across a Prosthetic Valve in the Mitral Position: Not Ignoring the Bigger Picture

High Transvalvular Gradients Across a Prosthetic Valve in the Mitral Position: Not Ignoring the Bigger Picture

Acute Cardioembolic Cerebral Infarction: Answers to Clinical Questions

Cardioembolic cerebral infarction (CI) is the most severe subtype of ischaemic stroke but some clinical aspects of this condition are still unclear. This article provides the reader with an overview and up-date of relevant aspects related to clinical features, specific cardiac disorders and prognosis of CI. CI accounts for 14−30% of ischemic strokes; patients with CI are prone to early and long-term stroke recurrence, although recurrences may be preventable by appropriate treatment during the acute phase and strict control at follow-up. Certain clinical features are suggestive of CI, including sudden onset to maximal deficit, decreased level of consciousness at onset, Wernicke’s aphasia or global aphasia without hemiparesis, a Valsalva manoeuvre at the time of stroke onset, and co-occurrence of cerebral and systemic emboli. Lacunar clinical presentations, a lacunar infarct and especially multiple lacunar infarcts, make cardioembolic origin unlikely. The most common disorders associated with a high risk of cardioembolism include atrial fibrillation, recent myocardial infarction, mechanical prosthetic valve, dilated myocardiopathy and mitral rheumatic stenosis. Patent foramen ovale and complex atheromatosis of the aortic arch are potentially emerging sources of cardioembolic infarction. Mitral annular calcification can be a marker of complex aortic atheroma in stroke patients of unkown etiology. Transthoracic and transesophageal echocardiogram can disclose structural heart diseases. Paroxysmal atrial dysrhyhtmia can be detected by Holter monitoring. Magnetic resonance imaging, transcranial Doppler, and electrophysiological studies are useful to document the source of cardioembolism. In-hospital mortality in cardioembolic stroke (27.3%, in our series) is the highest as compared with other subtypes of cerebral infarction. Secondary prevention with anticoagulants should be started immediately if possible in patients at high risk for recurrent cardioembolic stroke in which contraindications, such as falls, poor compliance, uncontrolled epilepsy or gastrointestinal bleeding are absent. Dabigatran has been shown to be non-inferior to warfarin in the prevention of stroke or systemic embolism. All significant structural defects, such as atrial septal defects, vegetations on valve or severe aortic disease should be treated. Aspirin is recommended in stroke patients with a patent foramen ovale and indications of closure should be individualized. CI is an important topic in the frontier between cardiology and vascular neurology, occurs frequently in daily practice, has a high impact for patients, and health care systems and merits an update review of current clinical issues, advances and controversies.

Extrinsic Mechanism Obstructing the Opening of a Prosthetic Mitral Valve: An Unusual Case of Suture Entrapment

Obstruction to a prosthetic cardiac valve is a well-recognized complication of cardiac valve replacement. Malfunction of the mobile component of a prosthetic valve to open or close correctly may occur in consequence of intrinsic or extrinsic causes (thrombus, vegetation, entrapment of left ventricular myocardium, suture entanglement, and pannus formation) that may result prosthetic valve stenosis and/or insufficiency. In the case we report a 48-year-old female with valve dysfunction occurred early after surgery, as one valve leaflet was only able to partially open due to suture entrapment.

Repeated successful balloon valvuloplasty of a bioprosthetic aortic valve in a nonagenerian

Calcific aortic stenosis remains a major cause of mortality and morbidity in the aging population. Surgical replacement remains the treatment of choice for this disease. Balloon aortic valvuloplasty was introduced as a palliative procedure for these patients, but was tempered by a high rate of recurrence, which has limited its usefulness. However, the introduction of smaller-profile balloons, rapid pacing, and closure devices have brought it back as an alternative treatment strategy in selected patients who are at too high risk for surgery with repeat valvuloplasty as needed for recurrences. We report a case of prosthetic aortic valve stenosis treated with valvuloplasty with intracardiac and fluoroscopic guidance with recurrence treated with repeat valvuloplasty with promising intermediate-term outcome and describe the growing valve in valve procedures.

43.3-Year Durability of a Smeloff-Cutter Ball-Caged Mitral Valve

Extended durability of mechanical heart valves has been documented for many years. We describe a case of a ball-caged mechanical valve implanted 43.3 years previous to developing valve dysfunction. The patient presented with both prosthetic valve stenosis and insufficiency. This Smeloff-Cutter valve (Cutter Laboratories, Berkeley, CA) in the mitral position was dysfunctional due to lipid absorption, which resulted in ball variance and concomitant pannus growth prevented optimal seating of the ball in its cage. This is the longest length of time in which a Smeloff-Cutter mechanical valve has been originally implanted.

Prosthetic Aortic Valve Stenosis in End-Stage Renal Failure

Although renal failure is one of the known comorbidities associated with rapid progression of aortic stenosis, it is unclear whether hemodialysis alters the progression of prosthetic aortic valve stenosis. We describe a 79-year-old female who underwent bioprosthetic aortic valve replacement 8 years ago with stable prosthetic valve area for the initial 6 years. In the last two years, coinciding with the initiation of maintenance hemodialysis, she developed progressive prosthetic valve stenosis to the point of clinical decompensation. She underwent a second prosthetic aortic valve replacement with symptom resolution. This case suggests that circulating milieu in end-stage renal failure and dialysis can accelerate the progression of prosthetic aortic valve stenosis. More frequent clinical followup and surveillance echocardiogram for dialysis patients with bioprosthetic aortic valve may facilitate timely management of valvular stenosis.

Cardioembolic Stroke: Clinical Features, Specific Cardiac Disorders and Prognosis

This article provides the reader with an overview and up-date of clinical features, specific cardiac disorders and prognosis of cardioembolic stroke. Cardioembolic stroke accounts for 14-30% of ischemic strokes and, in general, is a severe condition; patients with cardioembolic infarction are prone to early and long-term stroke recurrence, although recurrences may be preventable by appropriate treatment during the acute phase and strict control at follow-up. Certain clinical features are suggestive of cardioembolic infarction, including sudden onset to maximal deficit, decreased level of consciousness at onset, Wernicke’s aphasia or global aphasia without hemiparesis, a Valsalva manoeuvre at the time of stroke onset, and co-occurrence of cerebral and systemic emboli. Lacunar clinical presentations, a lacunar infarct and especially multiple lacunar infarcts, make cardioembolic origin unlikely. The more common high risk cardioembolic conditions are atrial fibrillation, recent myocardial infarction, mechanical prosthetic valve, dilated myocardiopathy, and mitral rheumatic stenosis. Transthoracic and transesophageal echocardiogram can disclose structural heart diseases. Paroxysmal atrial dysrhyhtmia can be detected by Holter monitoring. In-hospital mortality in cardioembolic stroke (27.3%, in our series) is the highest as compared with other subtypes of cerebral infarction. In our experience, in-hospital mortality in patients with early embolic recurrence (within the first 7 days) was 77%. Patients with alcohol abuse, hypertension, valvular heart disease, nausea and vomiting, and previous cerebral infarction are at increased risk of early recurrent systemic embolization. Secondary prevention with anticoagulants should be started immediately if possible in patients at high risk for recurrent cardioembolic stroke in which contraindications, such as falls, poor compliance, uncontrolled epilepsy or gastrointestinal bleeding are absent.