Tips and tricks in management of cryptogenic stroke and PFO
1-This topic is considered of the controversial topics
2-To be able to select the appropriate patient who will benefit from PFO closure, we should go through 2 parallel tracks:
-Neurologist track
-Cardiologist track
I-Neurologist track:
1-Every effort should be made to confirm that this stroke is really cryptogenic stroke(so all work up should be done to exclude other types of stroke either large vessel or Small vessel or embolic or other determined etiology)
2- History : ask about valsalva or straining or cough or prolonged travel or DVT before the event
3-Assessment of ROPE score(risk of paradoxical embolization):
-In general, if the patient is young with cortical Infarction and no CV risk factors then It is mostly cryptogenic
-If patient presenting with multiple cortical or subcortical infarction mostly it is embolic
4-Recuritment window: PFO device closure is done within 180 days from the onset of stroke
5-Recruitment age: 18-60 years
II-Cardiologist track:
1-Every effort should be made to exclude hidden AF or embolic source
2-It is recommended to ask for rhythm monitoring(External loop) for 4 weeks to exclude silent or paroxysmal AF.
-This duration can be reduced to 1-2 weeks if patient below age of 40, no Risk factors for AF (such as Valvular heart disease or hypertension, hyperthyroidism or alchol intake).
3-Predictors of paroxysmal AF such as CHADS-VASc score and in ECG predictors such as frequent PACs, P wave dispertion.
4-Echo assessment should include assessment of LA size( including LA volumes), LA function (including emptying fraction) as well as LAA function and emptying velocity
5- Full Assessment of PFO including the bubble study(appearance of bubbles in the LA within 3 cardiac cycles). To be candidate for PFO closure, right to Left shunt must be demonstrated with or without valsalva.
6-Presence of Interatrial septal aneurysm increases the risk and the possibility that this PFO is incriminated in the cryptogenic stroke
7-Patients maintained on long term oral anticoagulant are not candidate for device closure of PFO
8-After device closure of PFO, patients are maintained on aspirin, then if there is recurrent cryptogenic stroke on top of device and antiplatelet , shifting to oral anticoagulant instead of aspirin may be considered
8-Trials that showed that PFO closure device is superior to antithrombotic include :
CLOSE
REDUCE
RESPECT trials
From tips and tricks in cardiology book & Practical Handbook of Advanced Interventional Cardiology