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PFO and Stroke PowerPoint Presentation

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Description : Check out this medical titled "PFO AND STROKE” by Dr sajad ahmad tak ( DNB scholar).

This medical is about PFO, or patent foramen ovale. PFO is a condition in which there is an opening in the heart between the two atrial chambers. This opening is present in all fetuses, but it usually closes shortly after birth. However, in some individuals, the opening remains open, which can lead to a variety of health issues, including strokes.

When a PFO is present, there is an increased risk of blood clots passing from the right atrium to the left atrium, where they can then travel to the brain and cause a stroke. However, not everyone with a PFO will experience a stroke, and it is often difficult to determine the exact cause of a stroke in any given individual.

The link between PFO and stroke is still not fully understood, but it is believed that in some cases, a PFO may increase the risk of stroke by allowing clots to pass from the right to the left side of the heart. This can occur when there is increased pressure on the right side of the heart, such as during physical exertion or when coughing, which can force blood through the PFO.

In some cases, people with PFO and a history of stroke may be recommended for a procedure called a PFO closure, which involves placing a device over the opening in the heart to prevent blood clots from passing through. However, the decision to undergo this procedure will depend on a variety of factors, including the individuals overall health and the severity of their condition.

Tags : PFO, STROKE, Cardiology, Cardiology

Published on : Jun 01, 2023 | Views : 713 | Downloads : 1

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PFO AND STROKE Dr sajad ahmad tak ( DNB scholar)
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Prevalence ; 25 to 30 % in normal population. patients with cryptogenic stroke increased prevalence. PFO-ASA study….around 45% pts had PFO.
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Pathophysiology Paradoxical emboli ( via right to left shunting) Right to left shunting : Rest Transient ( valsalva maneuver …..straining , coughing , lifting heavy objects)
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Diagnosis TEE…with agitated saline contrast ( bubble study) along with colour doppler . One TEE study of of 148 pts with PFO…Rt To Lt shunting ….57% at rest ….and 92% with straining or coughing. Other methods. TTE TCD
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PFO size : Grade 0,…. no microbubbles Grade 1 (small)….1 to 5 microbubbles. Grade 2 (moderate)….6 to 25 microbubbles Grade 3 ( large )….> 25.
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Is pFO the most likely mechanism of stroke History : what was pt. doing at time of stroke Any risk of DVT (..prolonged immobility, long haul air travelet etc). Is embolic stroke present : Multiple vascular territories Single wedge shaped infarct involving cortex and the underlying subcortical white matter.
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Evaluation for Venous thromboembolism: ( with in 2 to 3 days). Studies have shown low rates of proximal DVT ….10 to 22 %; Reasons include ; Incomplete evaluation Small emboli ( may go undetected by conventional doppler) Clot forms in the heart …leads, PFO tunnel Resolved DVT Clot may be lysed with thrombolytic therapy.
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PFO risk assessment ROPE SCORE …> 7… PASCAL classification system….probability of stroke is associated with PFO;
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ROPE SCORE
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PASCAL classification
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Management To prevent recurrent stroke Medical therapy ( antiplatlets or anticaugulation ) VS PFO closure
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6 Randomised Trials. Inclusion criteria 18 to 60 yr cryptogenic Stroke OR TIA . PFO primary outcome… recurrent ischemic stroke OR TIA.
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CLOSURE (2003 TO 2008) 909 PATIENTS . MULTICENTRE …USA AND CANADA PFO CLOSURE(447) AND MEDICAL G (462). 2YR F/UP . PRIMARY END POINT ( 5.5% VS 6.8% ) ( P= 0.37). CONCLUSION :NO SIGNIFICANT DIFFERENCE BETWEEN DEVICE CLOSURE AND MEDICAL THERAPY IN THE RATES OF PRIMARY ENDPOINT. PC (2000 TO 2009) 414 PATIENTS. EUROPE,BRAZIL, CANADA AND AUSTRALIA F/UP ..4YRS. 204 PFO CLOSURE VS 210 MEDICAL G. 3.4% VS 5.2% ( P=0.34) RESPECT(2003 TO2011) 980 PATIENTS. USA AND CANADA F/UP 2.6YRS 481 PFO CLOSURE VS 499 MEDICAL G 9PTS VS 16 PTS …( P=0.08) NOT SIGNIFICANT
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Extended RESPECT F/UP…..5.9yrs Recurrent stroke …. 18 vs 28 pts. (P=0.046). CONCLUSION ; significant difference between closure group v and medical group. Close (2008 to 2014) Three groups..1;1;1. France and Germany . 663 pts .with F/up ..53 months No stroke in pfo closure (238)vs 14 pts in antiplatlet group. (p<0.001). anticaugulant G ..3 (187) vs antiplatlet G 7 (174). REDUCE (2008 to 2015) 2:1 RATIO Canada, Finland ,UK and USA. 664 pTS . F/up 3.2 yrs 6 (441) ..vs 12 (223) developed recurrent stroke . (p=0.04). AF …6.6% pts in PFO group.
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DEFENCE-PRO TRIAL( May 2018) SEPTEMBER 2011 UPTO OCTOBER 2017. HIGH RISK PFO ( PFO WITH ASA , LARGE SIZE >2mm) 60 pts ..pfo closure vs medical group f/up…2yrs No stroke vs 5 ischemic strokes (medical G) P=0.023
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Discussion PFO CLOSURE SHOWED SIGNIFICANT REDUCTION IN RECURRENT STROKE AS COMPARED TO MEDICAL THERAPY. LARGE PFO DERIVED MORE BENEFIT. ATRIAL FIBRILLATION …MAIN ADVERSE OUTCOME IN PFO CLOSURE GROUP ( 60% PERIPRECEDURAL)
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LIMITATIONS Open Label increased the risk of Bias. NUMBER OF PRIMARY EVENTS WAS RELATIVELY LOW ( e.g; 52 in CLOSURE I trail, 18 in PC ,and 14 in CLOSE trail) Duration of Follow up…closure (2yrs) and RESPECT (2.6yrs) Safety and efficacy in patients older than 60 remains unclear.
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Recommendations Following characteristics in PFO pts favours PFO closure; Age < 60yrs Embolic stroke topography Exclusion of other sources of ischemic stroke A possible , probable or definite likelihood…as per PASCAL classification.
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Thank you