(IV-6.O) 59-year-old female with patent foramen ovale (PFO) and persistent atrial fibrillation as a potential cause of recurrent cerebral ischemic events Komar M., Podolec J., Przewłocki T., Sobień B., Tomkiewicz-Pająk L., Motyl R., Kopeć G.
Experts: Przewłocki T., Małecka B., Kopeć G., Podolec P.

Background
Patent foramen ovale (PFO) occurs in 25% of healthy adults. Several pathologies are related to PFO including paradoxical embolism, migraine with aura and decompression illness in divers. Finding a PFO in patients suffering a stroke and/or TIA is common in daily practice. Therapeutic approach in such cases is complex and often controversial. Treatment options consist of antiplatelet therapy with aspirin, oral anticoagulation with VKA or percutaneous defect closure.
The authors present a case of patient suffering a TIA, with PFO and coexisting arterial embolism.

Case description
A 59-year-old Caucasian woman has been referred to our Centre by her GP with suspicion of atrial septal aneurysm visualized on echocardiographic examination and signs of probable cryptogenic cerebral thromboembolism. She is hemodynamically stable on admission. Her heart rate is 70 beats/minute and blood pressure 130/80 mmHg. Her major complaints are recurrent migraine headaches and palpitations without dizziness. No history of loss of consciousness. PFO was diagnosed in 2010 with the use of transesophageal echocardiography (TEE). CT study of the head performed in 2010 revealed middle cerebral artery aneurysm and a benign small size lesion in the frontal lobe. In 1995 she underwent varicose vein surgery. In 2006 her thyroid gland was removed surgically due to Hashimoto disease. She is euthyreotic at the time of admission. There is no family history of cardiovascular diseases or congenital defects. She has never smoked cigarettes. Her living conditions are considered to be good. Blood analysis reveals elevated lipid levels with no other abnormalities.
On transthoracic cardiac echo a thinning of interatrial septum is visualized with no signs of flow between the atria. Standard TEE procedure is then performed using a 5.0 MHz multiplane probe. The atrial septum is analyzed from the transverse mid-esophageal four- chamber view to the longitudinal biatrial- bicaval view. TEE shows a PFO of 6 mm length with rest separation of its walls to 1.5 mm. No thrombus is detected. Right- to-left shunt is evaluated on TEE by the presence of microbubbles traveling through the canal from the right atrium to the left atrium after Valsalva maneuver. The shunt was classified as small (<10 MBs). The effectiveness of Valsalva maneuver is verified by the use of TEE, which shows a reduction in right ventricular and atrial size and bulging of the atrial septum into the left atrium. Transcranial Doppler (TCD) at rest and during Vasalva maneuver is carried out onwards. 10 mL of air- mixed saline contrast is injected to the right antecubital vein and the Doppler signal is recorded during Valsalva maneuver, according to the standard protocol. The side of the cranium with the superior temporal window was chosen. The middle cerebral artery is identified with color Doppler and insonated bilaterally. TCD is deemed positive if at least one microembolic signal (MES) is recorded on TCD spectrum within the first three cardiac cycles following injection of the bubble contrast. The shunt is defined as small (1-10 MES). 24 hour ECG monitoring reveals a 6-second episode of atrial fibrillation. MR brain study shows numerous, small hypoechogenic lesions in the frontal lobe classified as probable cryptogenic thromboembolism. The diagnosis of middle cerebral artery aneurysm and a benign small brain tumor in the frontal lobe is confirmed. Due to the increased risk of stroke we discussed the case with an interventional neurologist, who decided to abstain from surgery, recommended observation and periodic MR study. Guidelines
According to the Guidelines for prevention of stroke in patients with ischemic stroke or transient attack updated by AHA/ASA in 2010 PFO closure may be considered in this case (class IIb levelC).

References
1. Meier B., Lock J.E.: Contemporary management of patent foramen ovale. Circulation 2003; 107: 5-9.
2. Manjila S, Masri T, Shams T et al.: Evidence-based review of primary and secondary ischemic stroke prevention in adults: a neurosurgical perspective. Neurosurg Focus. 2011 Jun;30(6):E1.
3. De Castro S, Cartoni D, Fiorelli M, et al. Morphological and functional characteristics of patent foramen ovale and their embolic implications. Stroke 2000;31:2407-13.

Experts’ comments:
1. Przewłocki T: PFO closure is recommended. Unless unsuitable morphology of the PFO, percutaneous approach would be the procedure of choice.
2. Małecka B: Paroxysmal AF (6-second insert in 24hr ECG monitoring) is a definite indication for VKA.
3. Kopeć G: Currently according to the American Stroke Society there are no enough data to straightforwardly recommend PFO closure. However, such treatment is possible as part of a clinical trial.
4. Podolec P: It is not known which therapy ASA or oral anticoagulation is superior to prevent thromboembolic events in PFO patients. However, taking into account the abnormal Holter ECG and the TIA history I would recommend oral anticoagulation in this patient.

Conclusions:
In the present case the PFO is only one of possible reasons for arterial embolism and atrial fibrillation. Percutaneous closure of the PFO does not eliminate the risk of atrial clot formation. VKA in this patient is the treatment of choice to reduce the risk of clot formation.

Authors:
Komar M.¹, Podolec J.², Przewłocki T.¹, Sobień B.¹, Tomkiewicz-Pająk L.¹, Motyl R.¹, Kopeć G.¹

Experts:
Przewłocki T.¹, Małecka B.³, Kopeć G.¹, Podolec P.¹

¹ Department of Cardiac and Vascular Diseases, Jagiellonian University College of Medicine, John Paul II Hospital, Krakow, Poland
² Department of Hemodynamics and Angiocardiography, John Paul II Hospital, Krakow, Poland
³ Department of Electrocardiology, Jagiellonian University College of Medicine, John Paul II Hospital, Krakow, Poland