Cardiology>>>>>Adult Congenital Heart Disease and Pregnancy
Question 12#

One of the stroke physicians asks your advice regarding a 45-year-old man admitted with a stroke. The patient is overweight with known hypertension and raised lipids. He is a non-smoker. Carotid Doppler scans show no atheroma. The stroke physicians have performed a 24-hour tape which has shown clear runs of asymptomatic paroxysmal AF. They have also requested a bubble contrast echo which has demonstrated complete opacification of the left heart with Valsalva release. The heart is structurally normal apart from moderate LVH and a left atrial area of 30 cm2 . The patient is currently on antiplatelet therapy, but they are keen to know what the immediate strategy would be from the cardiac point of view.

A. There is a large PFO which represents a significant risk factor for recurrent stroke; once the patient has recovered, inpatient transcatheter PFO closure is indicated
B. There is clear evidence of paroxysmal AF: in the context of stroke and cardiovascular risk factors, we would recommend anticoagulation once beyond the acute risk of haemorrhagic transformation; no further treatment for the PFO is required whilst on anticoagulation
C. The patient is young and should have pulmonary vein isolation and a flutter ablation with transcatheter left atrial appendage closure and PFO closure
D. TOE is the next step to confirm the presence and anatomy of the shunt
E. Short episodes of AF can be seen in the context of an acute illness: the patient should have aggressive cardiovascular risk factor modification and BP control with ACE inhibitors; further ambulatory ECGs should be peformed when he has recovered as

Correct Answer is B

Comment:

This case describes a relatively young patient with a number of risk factors for stroke. Despite having risk factors for atherosclerosis, because of his age (and clear carotid Doppler scans) other foci for embolic stroke have been pursued. Two possibilities have been identified: left atrial thrombus as a result of AF or a paradoxical embolus via the PFO. The question asks for the immediate strategy. Anticoagulation protects against both sources of embolus and so is the immediate treatment of choice. PFO closure will not protect against LA thrombus due to PAF and anticoagulation would still be required. Complex ablation and device treatment may be a future option based on progress, but needs careful discussion. TOE is not required after a suggestive positive bubble test, which is the preferred modality to confirm a PFO. Periprocedural TOE is used to guide transcatheter closure. The AF is likely to be due to uncontrolled hypertension (LVH) and strict control with an ACE inhibitor can reduce the AF burden.