A short description of the background that led to the research (current results and conclusions should not be included). Individuals directly involved in the creation of the manuscript, but not associated with the authorship, may be credited.
Summary
For the detailed procedure, refer to the above information on how to perform a bubble contrast test. TTE visualizes a positive bubble contrast test with a large right-left shunt in the 1st patient (fig 9a.), and the negative.
Using echocardiography, we can identify the presence of PFO and estimate the risky morphology of PFO.
Patent Foramen Ovale (PFO) Implying Paradoxical Embolism as a New Insight in Cryptogenic Stroke
Introduction
Although the rate of atrial fibrillation was higher in the PFO closure group than in the antiplatelet only group. For youth and middle-aged people with cryptogenic stroke associated with high-risk PFO, there is now only randomized trial supporting the conclusion of PFO, namely the Gore REDUCE trial. These patients were randomly assigned in a 2:1 ratio to undergo PFO closure with antiplatelet or antiplatelet alone, respectively.
Of the 664 patients, 441 patients were randomized to the PFO closure group and 223 patients were assigned to the antiplatelet alone group. This randomized trial provides evidence regarding the effectiveness of PFO closure in recurrent stroke reduction in patients under 60 years of age with moderate to large interatrial shunts and cryptogenic stroke.16-17.
Conclusion
The researchers found that patients who underwent PFO closure with antiplatelet agents had a significantly lower incidence of clinical ischemic stroke (1.4%) and of re-infarction (5.7%), compared to those receiving antiplatelet therapy alone. which had an incidence of 5.4% and 11.3%. clinical ischemic stroke and silent cerebral infarction, respectively. Identification of high-risk patent foramen ovale associated with cryptogenic stroke: development of a scoring system. RoPE score as a predictor of recurrent ischemic events after percutaneous patent foramen ovale closure. Int Heart J.
Recurrent Stroke Reduction with Patent Foramen Ovale Color Versus Medical Therapy Based on Patent Foramen Ovale Features: A Meta-Analysis of Randomized Controlled Trials. Paten Foramen Oval Closure for Secondary Prevention of Cryptogenic Stroke: Updated Meta-Analysis of Randomized Clinical Trials.
Patent Foramen Ovale Closure Procedure
In real-world clinical practice, it is not so simple to prove PFO-related cryptogenic shock and then make decisions about PFO closure. The RoPE score helps us calculate the possibility of cryptogenic stroke caused by PFO, it can also be used to predict the risk of recurrent stroke and the risk of mortality after the PFO closure procedure. RoPE score of ≤ 6 indicates a high risk of recurrent paradoxical embolism and mortality after PFO closure.9.
PFO closure is recommended in patients with cryptogenic stroke who have been well systematically studied and have high-risk PFO morphology. Percutaneous PFO closure can be performed in a standard catheterization laboratory under fluoroscopy and transesophageal echocardiography (TEE) guidance.
Cryptogenic Stroke: Cardiac Rhythm Monitoring as An Indispensable Screening Modality
Introdution
The current screening paradigm for AF has shifted to only high-risk or CS patients to avoid serious complications. A multicenter, open-label, randomized trial by Koh et al.18 demonstrated that 30-day smartphone electrocardiogram monitoring significantly improves the detection rate of AF in patients with cryptogenic stroke. From 2017 to 2020, the trial looked at the diagnostic yield of smartphone ECG recording in cryptogenic stroke patients aged 55 years or older with no prior history of AF.
Participants were subjects without prior history of AF or not currently using oral anticoagulation. Finally, the use of digital health tools has revolutionized the screening of AF, but this can generate false-positive rhythms, so verification is needed to confirm the rhythm.
Conflict of interest
The field of digital health has evolved rapidly, bringing about transformation in the management of atrial fibrillation. Digital health tools have revolutionized health screening as information can be collected more frequently, increasing reliability, validity and the ability to detect changes over time. Currently, there are several types of digital health monitoring tools available, which can be divided into ECG tracking technologies and non-ECG tracking technologies.
In terms of screening the general population, the ECG generated by digital health tools is still considered pre-diagnostic. However, the integration of digital health technologies and healthcare professionals can lead to greater value and better care.
Sources of funding
In addition, traditional monitors may be ineffective in some cases, as the duration and time of wear may be inconsistent with symptoms.16 Thus, digital health tools will help with more ad hoc monitoring. However, the weaknesses of these tools are false-positive episodes of AF due to significant electrical or motion artifact, misclassified rhythms, and the unavailability of another arrhythmia classification.17. Therefore, verification by the attending physician is necessary to prevent overtreatment. 17 The Apple Heart study is a good example showing that the probability of reporting an irregular heartbeat was low in the general population. 19 From 2017 to 2018, the trial observed identification of AF via the app for smart watch during normal use.
Pulse palpation and 12-lead ECG were recommended for AF screening in the high-risk population. A higher detection rate of AF can be achieved with longer durations of monitoring, such as implantable cardiac monitoring and 7- or 21-day Holter monitoring.
Ethical Clearance
Cryptogenic Stroke
A Challenge in Diagnosis and Management
Introduction and Definition
Patent foramen ovale (PFO) is a congenital cardiac abnormality associated with cryptogenic stroke. It is also thought to be an important risk factor for cryptogenic stroke, especially in the younger population.17 The prevalence of PFO in patients with cryptogenic stroke is around 40%. In a study that used magnetic resonance imaging (MRI) to assess the structure of the atria, they found that atrial fibrosis was more common in a group of patients with cryptogenic stroke.
Given that cryptogenic stroke is associated with an embolic mechanism, the use of anticoagulants may be beneficial. In a study by Gupta et al., it was shown that 22% of patients with cryptogenic stroke had evidence of intraplaque hemorrhage, which became the underlying mechanism of cryptogenic stroke.
Treatment
No patients reached the primary endpoint in the PFO closure group compared with the medical treatment group.
Discussion
Conflict of Interest
Phenotypic ASCO characterization of young patients with ischemic stroke in the prospective multicenter observational sifap1 study. Analysis of 1008 consecutive patients aged 15 to 49 years with the first ever ischemic stroke: the Helsinki Young Stroke Registry. Transcranial Doppler is complementary to echocardiography for detection and risk stratification of Patent Foramen Ovale.
Guidelines for stroke prevention in patients with stroke and TIA: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. The atrial cardiopathy and antithrombotic drugs for prevention after cryptogenic stroke, randomized trial: rationale and methods.
Patent Foramen Ovale and Cryptogenic Stroke : Challenges in Diagnosis and Management
Patients with PFO and ASA who have had a stroke have a higher risk of recurrent strokes.9. ASA stroke prevention in patients with stroke or TIA guidelines recommend the following; There is. Clinical and imaging findings in cryptogenic stroke patients with and without patent foramen ovale: the PFO-ASA study.
Early recurrent ischemic lesions in patients with cryptogenic stroke and patent foramen ovale: an observational study. Effect of Medical Treatment in Stroke Patients with Patent Foramen Oval: Patent Foramen Oval in Cryptogenic Stroke Study.
Case Series Coexistence of PFO with Other Conditions: WWho’s The Culprit?
Background
Case Illustrations
He hypothesized that the PFO served as a pathway for an arterial embolism that paradoxically began in the venous circulation. Treatment modalities include antiplatelet/anticoagulant and/or PFO occlusion.9 The relationship between CS and PFO is mainly found in people under 55 years of age. This hypercoagulable state is believed to be the main cause in the creation of paradoxical emboli in this patient.
Ischemic stroke can occur in the setting of deep vein thrombosis and subsequent paradoxical embolism via a PFO. The presence of a PFO is associated with an increased risk of CS, especially in the young.
Acknowledgements
The stroke is believed to be cardioembolic, with PFO and occult AF a risk factor for CS. The presence of concomitant PFO in this largely anticoagulant group of patients with AF was not associated with an increased risk of ischemic stroke. A systematic review by Hviid et al. suggests that the presence of acquired or hereditary thrombophilia in patients with CS and PFO increases the risk of recurrence, even after closure of the PFO.
Clinical presentation, PFO morphology, and RoPE score can be used to determine PFO pathogenicity and risk of stroke recurrence. The goal of management of patients with PFO and CS includes prevention of stroke recurrence and disability.
Financial support and sponsorship
MRI revealed multiple infarct sites in the cortical region and lesions in multiple vascular regions. The presence of PFO in patients with AF was not associated with embolic risk except in patients with a right-to-left shunt and other established risk factors in this predominantly anticoagulated AF population.13. Therefore, CS patients with patent foramen ovale should also be evaluated for deep vein thrombosis in the legs and pelvic veins.1415.
However, there is only limited evidence regarding the impact of thrombophilia and the risk of recurrent CS with PFO. PFO closure can reduce the risk of stroke recurrence, but additional antithrombotic therapy is still necessary to provide maximum protection against its recurrence.14, 16 Therefore, PFO closure can be considered in this case, but it may not be completely not be necessary.
Conflicts of interest
Closure of the PFO is the best solution for preventing recurrence of paradoxical embolism through the PFO. In case 2, the patient had a history of hypertension and dyslipidemia, known risk factors for stroke. However, as the patient had experienced recurrent strokes, further TEE and holter evaluation was done.
However, it is noted that the presence of thrombophilia predisposes a patient more frequently to venous rather than arterial thrombosis. Ischemic stroke due to thrombophilic disorders can involve any arterial territory and often affects several arterial territories at the same time.
