(IV-4D) Patient with PFO and thrombophilia after ischemic stroke and massive pulmonary thromboembo-lism Komar M. MD, PhD, Prof. Podolec P. MD, PhD, Prof. Przewłocki T. MD, PhD, Stępniewski J. MD

Keywords: PFO, thrombophilia, ischemic stroke, pulmonary thromboembo-lism

Background
Patent foramen ovale (PFO) is a congenital cardiac lesion that frequently persists into adulthood. Although most patients with a PFO are asymptomatic, a variety of clinical manifestations may be associated with PFO, most importantly cryptogenic stroke. The prevalence of PFO is higher in patients with cryptogenic stroke, particularly those under age 55 years in whom PFO is more likely to play a causal role. Approximately 40 percent of ischemic strokes in adults under 55 are cryptogenic. Although most individuals with a PFO are asymptomatic, a PFO can serve as a pathway for venous to arterial transit of emboli (paradoxical emboli) via right-to-left shunting when the pressure in the right atrium exceeds that in the left atrium, that occurs in normal individuals during early ventricular systole and with Valsalva maneuver.

Case description
We report a case of a 67-year-old Caucasian man referred to our Clinic for transcatheter closure of Patent Foramen Ovale (PFO) as a therapeutic option for stroke prevention. In May 2011 he was hospitalized due to sudden loss of consciousness accompanied by right side hemiparesis and aphasia. Accessory tests revealed elevation of ST segments in leads V1 to V6 and atrial fibrillation in ECG study and a thrombus passing through the PFO canal on cardiac echo study. CT brain scan showed an ischemic lesion located in the left parietal lobe. Coronary angiography showed a thrombus in LAD branch and thrombectomy was performed with positive effects. Angio-CT study of pulmonary arteries showed massive pulmonary thromboembolism. The patient was discharged from the hospital with the diagnosis of Transient Ischemic Attack, Acute Coronary Syndorme and massive Pulmonary Thrombembolism. Further investigation revealed thrombophilic condition of V Leiden mutation and the patient was put on VKA and ASA. Transesophageal echocardiography (TEE) together with Transcranial Doppler (TCD) performed prior to admission revealed hemodynamically significant PFO.
On current admission he was hemodynamically stable with persistent right upper limb dymetria and ataxia. Concomitant conditions included hypertension and Parkinson`s disease. He reported recurrent palpitations in the past few months. Holter ECG monitoring, ABPM and Tilt table test scheduled during hospitalization did not reveal any abnormalities.
Prevention of stroke in patients with atrial septal abnormalities include medical therapy with antiplatelet agents or anticoagulants and surgical or percutaneous closure of the defect according to ESO guidelines for the management of ischemic stroke. Considering the fact that the patient already receives anticoagulant therapy with VKA we refer to the experts for their recommendations before PFO closure is performed.

Current guidelines
Therapeutic options for prevention of recurrent stroke in patients with an atrial septal abnormality, include patent foramen ovale (PFO), ostium secundum atrial septal defect (ASD) and atrial septal aneurysm (ASA) are medical therapy with antiplatelet agents or anticoagulants, and surgical or percutaneous closure of the defect. The choice depends upon several factors, especially the type and the shape of abnormality.
Case reports and case control studies indicate an association between the presence of PFO and cryptogenic stroke in both younger and older patients. The population-based studies pointed in the same direction but did not confirm a significant association. In patients with PFO alone the overall risk of recurrence is low. However, when the PFO is combined with an atrial septal aneurysm, an Eustachian valve, a Chiari network, or in patients who have suffered more than one stroke the risk of recurrence can be substantial. Endovascular closure of PFO with or without septal aneurysm is feasible in such patients and may lower the risk of recurrent stroke compared to medical treatment however, RCTs are still lacking.
It is recommended that endovascular closure of PFO be considered in patients with cryptogenic stroke and high risk PFO (Class IV, GCP)

References
1. Guidelines for management of ischemic stroke and transient ischemic attack 2008 The European Stroke Organization (ESO) Executive Committee and the ESO Writing Committee

Expert’s conclusions:
Patient has been selected for oral anticoagulant therapy.
PFO closure has not been recommended by the experts.

Authors:
Komar M. MD, PhD¹, Prof. Podolec P. MD, PhD¹, Prof. Przewłocki T. MD, PhD¹, Stępniewski J. MD¹

Experts:
Prof. Biederman A.MD, PhD²

¹ Department of Cardiac and Vascular Diseases, Jagiellonian University College of Medicine, John Paul II Hospital, Krakow, Poland
² Department of Cardiac Surgery, Institute of Cardiology, Warsaw, Poland