SESSION TITLE: Cardiothoracic Interventions 2SESSION TYPE: Rapid Fire Case ReportsPRESENTED ON: 10/18/2022 10:15 am - 11:10 amINTRODUCTION: We present a case of a systemic thromboembolic phenomenon with multiple strokes, DVT, PE, splenic and kidney infarcts in the setting of patent foramen ovale (PFO), mitral valve vegetation, and active malignancy.CASE PRESENTATION: A 64-year-old female with a past medical history of urothelial adenocarcinoma in remission for two years presented with complaints of nausea. She was found to be having segmental and sub-segmental emboli in bilateral lung fields and also small pulmonary infarcts in the lower lobes bilaterally. CT abdomen showed right-sided hydronephrosis, newly developed spleen and kidney infarcts, right iliac thrombus, and worsening intra-abdominal lymphadenopathy concerning recurrence. Urine culture grew Enterococcus, but serial blood cultures were negative. Ultrasound showed right posterior tibial and peroneal non-occlusive thrombi, and she was started on anticoagulation. On day 2, she was found to have a new onset facial drop. CT head and MRI brain showed multifocal bilateral supratentorial and left cerebellar acute/early subacute infarcts, raising concern of cardioembolic origin. Anticoagulation was continued with close neurovascular monitoring. TTE was unrevealing for cardiac emboli; hence TEE was pursued, which showed a patent foramen ovale demonstrating right to left shunt by agitated saline and a small 0.6x0.3 cm mobile echo density on the anterior mitral leaflet with leaflet perforation. She was treated for possible enterococcal endocarditis and tentatively planned for PFO closure after finishing the antibiotic course.DISCUSSION: The most likely explanation for systemic thromboembolism is a malignancy-induced hypercoagulable state and an underlying infectious process. She will likely need indefinite anticoagulation for VTE. Based on a large study on neuroimaging findings in cryptogenic stroke in patients with and without patent foramen ovale; Strokes that were large, radiologically apparent, superficially located, or unassociated with prior radiological infarcts were more likely to be PFO-associated than were smaller, deep strokes, or accompanied by chronic infarcts[1]. It is likely that PFO might be contributing to the stroke. That being said, it is hard to dismiss the newly seen echo density on her mitral valve. A 2018 meta-analysis showed that in patients with a PFO and cryptogenic stroke, transcatheter device closure decreases the risk for recurrent stroke compared with medical therapy alone.[2] However, there is not enough evidence about PFO closure in non-cryptogenic stroke with indications for long-term anticoagulation, such as in our case.CONCLUSIONS: The benefit of PFO device closure is uncertain for patients with an indication for long-term anticoagulation. We need further studies and an individualized approach with shared decision-making considering risks and benefits.Reference #1: Thaler DE, Ruthazer R, Di Angelantonio E, Di Tullio MR, Donovan JS, Elkind MS, Griffith J, Homma S, Jaigobin C, Mas JL, Mattle HP, Michel P, Mono ML, Nedeltchev K, Papetti F, Serena J, Weimar C, Kent DM. Neuroimaging findings in cryptogenic stroke patients with and without patent foramen ovale. Stroke. 2013 Mar;44(3):675-80. doi: 10.1161/STROKEAHA.112.677039. Epub 2013 Jan 22. PMID: 23339957; PMCID: PMC3595100.Reference #2: Shah R, Nayyar M, Jovin IS, Rashid A, Bondy BR, Fan TM, Flaherty MP, Rao SV. Device Closure Versus Medical Therapy Alone for Patent Foramen Ovale in Patients With Cryptogenic Stroke: A Systematic Review and Meta-analysis. Ann Intern Med. 2018 Mar 6;168(5):335-342. doi: 10.7326/M17-2679. Epub 2018 Jan 9. Erratum in: Ann Intern Med. 2018 Sep 18;169(6):428. PMID: 29310136.DISCLOSURES: No relevant relationships by Aja JanyavulaNo relevant relationships by Harshitha Mergey DevenderNo relevant relationships by Sushrutha SridharNo relevant relationships by Abira UsmanNo relevant relationships by Vishruth Vyata SESSION TITLE: Cardiothoracic Interventions 2 SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: We present a case of a systemic thromboembolic phenomenon with multiple strokes, DVT, PE, splenic and kidney infarcts in the setting of patent foramen ovale (PFO), mitral valve vegetation, and active malignancy. CASE PRESENTATION: A 64-year-old female with a past medical history of urothelial adenocarcinoma in remission for two years presented with complaints of nausea. She was found to be having segmental and sub-segmental emboli in bilateral lung fields and also small pulmonary infarcts in the lower lobes bilaterally. CT abdomen showed right-sided hydronephrosis, newly developed spleen and kidney infarcts, right iliac thrombus, and worsening intra-abdominal lymphadenopathy concerning recurrence. Urine culture grew Enterococcus, but serial blood cultures were negative. Ultrasound showed right posterior tibial and peroneal non-occlusive thrombi, and she was started on anticoagulation. On day 2, she was found to have a new onset facial drop. CT head and MRI brain showed multifocal bilateral supratentorial and left cerebellar acute/early subacute infarcts, raising concern of cardioembolic origin. Anticoagulation was continued with close neurovascular monitoring. TTE was unrevealing for cardiac emboli; hence TEE was pursued, which showed a patent foramen ovale demonstrating right to left shunt by agitated saline and a small 0.6x0.3 cm mobile echo density on the anterior mitral leaflet with leaflet perforation. She was treated for possible enterococcal endocarditis and tentatively planned for PFO closure after finishing the antibiotic course. DISCUSSION: The most likely explanation for systemic thromboembolism is a malignancy-induced hypercoagulable state and an underlying infectious process. She will likely need indefinite anticoagulation for VTE. Based on a large study on neuroimaging findings in cryptogenic stroke in patients with and without patent foramen ovale; Strokes that were large, radiologically apparent, superficially located, or unassociated with prior radiological infarcts were more likely to be PFO-associated than were smaller, deep strokes, or accompanied by chronic infarcts[1]. It is likely that PFO might be contributing to the stroke. That being said, it is hard to dismiss the newly seen echo density on her mitral valve. A 2018 meta-analysis showed that in patients with a PFO and cryptogenic stroke, transcatheter device closure decreases the risk for recurrent stroke compared with medical therapy alone.[2] However, there is not enough evidence about PFO closure in non-cryptogenic stroke with indications for long-term anticoagulation, such as in our case. CONCLUSIONS: The benefit of PFO device closure is uncertain for patients with an indication for long-term anticoagulation. We need further studies and an individualized approach with shared decision-making considering risks and benefits. Reference #1: Thaler DE, Ruthazer R, Di Angelantonio E, Di Tullio MR, Donovan JS, Elkind MS, Griffith J, Homma S, Jaigobin C, Mas JL, Mattle HP, Michel P, Mono ML, Nedeltchev K, Papetti F, Serena J, Weimar C, Kent DM. Neuroimaging findings in cryptogenic stroke patients with and without patent foramen ovale. Stroke. 2013 Mar;44(3):675-80. doi: 10.1161/STROKEAHA.112.677039. Epub 2013 Jan 22. PMID: 23339957; PMCID: PMC3595100. Reference #2: Shah R, Nayyar M, Jovin IS, Rashid A, Bondy BR, Fan TM, Flaherty MP, Rao SV. Device Closure Versus Medical Therapy Alone for Patent Foramen Ovale in Patients With Cryptogenic Stroke: A Systematic Review and Meta-analysis. Ann Intern Med. 2018 Mar 6;168(5):335-342. doi: 10.7326/M17-2679. Epub 2018 Jan 9. Erratum in: Ann Intern Med. 2018 Sep 18;169(6):428. PMID: 29310136. DISCLOSURES: No relevant relationships by Aja Janyavula No relevant relationships by Harshitha Mergey Devender No relevant relationships by Sushrutha Sridhar No relevant relationships by Abira Usman No relevant relationships by Vishruth Vyata