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Percutaneous patent foramen ovale (PFO) closure is becoming more and more common for the treatment or prevention of PFO-associated right-to-left shunt (RLS). This study aims to investigate the value of transesophageal echocardiography (TEE) in percutaneous PFO closure, and to explore a new method that can improve intraoperative diagnosis and surgical safety. Based on our inclusion and exclusion criteria, we enrolled 73 patients between 16 and 70 years old (average age 43.25 ± 14.87 years) who underwent percutaneous PFO closure at the Department of Cardiac Surgery, Zhongshan Hospital (Xiamen), Fudan University, from January 2022 to December 2023. Out of the 73 enrolled patients, there were 28 males (38.36%) and 45 females (61.64%), 29 migraine patients (39.73%), 14 patients (19.19%) with headache and dizziness, 14 patients (19.18%) with a history of cerebral infarction (CI), and 25 patients (34.25%) with CI, lacunar infarction or ischemic focus on magnetic resonance imaging (MRI). All patients received routine transthoracic echocardiography (TTE) and agitated saline contrast echocardiography (ASCE) before operations. Percutaneous closure of PFO was completed under the guidance of TEE. In 12 patients, the method of \"injection of heparinized sterile saline through the delivery sheath\" was used to observe their RLS, and the anatomical characteristics of the PFO according to the shunt path were monitored and evaluated. This method was also applied to some patients to guide the conveyor to pass through the foramen ovale (FO) channel safely and effectively, thereby improving the success rate of PFO closure. The application of TEE during the procedure of percutaneous PFO closure, including preoperative evaluation, intraoperative guidance, and postoperative reevaluation, can offer further details about the anatomical and shunt characteristics of PFO, improve the diagnosis rate, and confirm the safety of the surgical path. It ensures the safety and reliability of the whole operation, greatly improving the success rate and reducing postoperative complications. TEE guidance of percutaneous PFO closure has the advantages of minimal trauma, no radiation and real-time visualization, while injecting heparinized sterile saline through the delivery sheath is safer and more effective in improving the success rate and reducing postoperative complications.

In a randomized trial involving patients who had a first stroke from an embolus of unknown source, rivaroxaban at a daily dose of 15 mg did not result in a lower incidence of recurrent stroke than aspirin at a dose of 100 mg. Bleeding rates were higher with rivaroxaban.

IntroductionIschaemic stroke remains a leading cause of long-term disability and mortality worldwide. A large proportion of ischemic strokes remain aetiologically undifferentiated despite thorough investigation. These strokes are often termed cryptogenic (CS) and also include a subset which have an embolic pattern on brain imaging (embolic stroke of undetermined source, ESUS). Assessment of clinical and structural cardiac factors following stroke may aid in discrimination of cardioembolic stroke (CES) subtypes in this population. We sought to assess the strengths of association of clinical and structural cardiac factors with diagnosed CES in comparison with CS and ESUS populations.MethodsA systematic review of medical databases and grey literature was performed utilising the PRISMA statement (2000–2023; PROSPERO registration CRD42023426712) (figure 1). Various data points were individually extracted and meta-analysed using a random effects model, with values being assessed through odds ratio (OR) and standardised mean difference (SMD).ResultsWe analysed 80 studies involving a total of 15,669 patients (3,886 CES patients vs 11,783 CS / ESUS patients). CES patients tended to be older (ESUS; OR 0.409, 95% CI: 0.281 to 0.537; p<0.001) with higher rates of hypertension (CS; OR 1.455; 95% CI 1.213 to 1.744, p<0.001) (ESUS; OR 1.706; 95% CI: 1.236 to 2.356; p=0.001) and heart failure (CS; OR 2.289; 95% CI 1.329 to 3.940, p=0.003). Further, this population had an overall increase in left atrial (LA) size (CS; 0.667; 95% CI 0.513 to 0.820; p<0.001) (ESUS; SMD 0.810; 95% CI 0.562 to 1.058; p<0.001) and impairment of LA reservoir function (CS; SMD -1.190, 95% CI -1.461 to -0.919; p<0.001) when compared to patients with CS and ESUS. See table 1.ConclusionThese findings identify key clinical risk factors and structural cardiac changes which are associated with cardioembolic stroke mechanisms. Aggressive surveillance for subclinical atrial fibrillation in these patients may be warranted.Abstract 185 Table 1Parameters of cardioembolic strokes compared to cryptogenic strokes and embolic stroke of unknown source Outcomes Results 95% CI P-value Age 0.409*… 0.281 to 0.537 <0.001 Hypertension 1.706*… 1.236 to 2.356 0.001 1.455*å 1.213 to 1.744 <0.001 Heart failure 2.289*å 1.329 to 3.940 0.003 Left atrial diameter 0.901^… 0.413 to 1.389 <0.001 Left atrial reservoir strain -1.190^å -1.461 to -0.919 <0.001 Left atrial volume index 0.810^… 0.562 to 1.058 <0.001 0.667^å 0.513 to 0.820 <0.001 *Odds Ratio (OR); ^Standardised Mean Difference (SMD); …Embolic stroke of undetermined source (ESUS); åCryptogenic stroke (CS).Abstract 185 Figure 1PRIMSA flow diagramConflict of InterestNone

IntroductionGrowing evidence implicates atrial cardiopathy (AC) as a causative factor for embolic strokes of undetermined source (ESUS), a distinct subtype of cryptogenic stroke (CS). AC however is poorly defined, with several surrogate measures used in its characterisation. The aim of this systematic review and meta-analysis was to assess structural, and echocardiographic indices associated with adverse left atrial (LA) remodelling following CS or ESUS. Identification of such cardiac biomarkers may allow for prediction of incident AF following CS or ESUS.MethodologyFollowing PRISMA guidelines, a rigorous search of medical databases was conducted to identify literature investigating AF incidence after CS (PROSPERO registration CRD42023426712) (figure 1). Relevant studies analysing electrocardiographic and echocardiographic features of AC in this setting were included. Meta-analysis was performed on measures present in at least three studies meeting inclusion criteria. Effect sizes were displayed using standardised mean difference (SMD) or odds ratio (OR), employing a random effects model. 95% confidence intervals were generated and a p-value of <0.05 was considered significant.ResultsData from 49 included studies involving 8027 patients demonstrated that parameters of impaired LA function demonstrated the greatest strength of association with post-stroke AF. LA contractile (SMD: -1.279, 95% CI: -1.481 to -1.077, p<0.001) and LA reservoir strain (SMD: -0.913, 95% CI: -1.363 to -0.463, p<0.001) were the best echocardiographic predictors of incident AF following CS and ESUS. On electrocardiographic assessment, abnormal p-wave axis (OR 2.73; 95% CI: 1.43 to 5.22, p=0.002) and partial inter-atrial block (OR 2.10; 95% CI: 1.18 to 3.72, p=0.011) was also associated. Interestingly, abnormal electrocardiographic P-wave terminal force in lead V1 (PTFV1) was not associated with incident AF. See table 1.ConclusionsMarkers of atrial cardiopathy are predictive of AF occurrence following CS or ESUS strokes, with LA strain measurements displaying greatest association. Use of such markers may assist in identification of patients most benefitting from post-stroke prolonged ambulatory monitoring.Abstract 191 Table 1Markers of adverse LA remodelling and their association with incident AF post-CS or ESUS Outcomes Results 95% CI P-value LA Volume Index 0.709† 0.593 to 0.825 <0.001 LA Reservoir Strain -0.913† -1.363 to -0.463 <0.001 LA Contractile Strain -1.279† -1.481 to -1.077 <0.001 Abnormal PWA 2.727* 1.425 to 5.218 0.002 A-IAB 8.112* 1.120 to 58.761 0.038 P-IAB 2.102* 1.186 to 3.723 0.011 PR- Interval 0.345† 0.187 to 0.503 <0.001 P Wave Duration PTFV1 0.583† 0.372† 0.269 to 0.898-0.181 to 0.925 <0.001 0.187 NB: *Odds Ratio; †Standardized Mean DifferenceAbstract 191 Figure 1PRISMA flow diagramConflict of InterestN/A

Purpose of ReviewWe aim to evaluate the epidemiology, racial and gender disparity, etiology, and treatment of stroke in the younger population.Recent FindingsThe younger age group without vascular risk factors exhibits an increased prevalence of cardio-embolism in context of patent foramen ovale/atrial septal aneurysm strokes, from other determined etiology of non-atherosclerotic vasculopathy including dissection, inherited or acquired thrombophilia, and other unusual causes of stroke. Ethnic disparities also exist in certain populations.SummaryThe prevalence of stroke in the young is increasing due to several factors. Since stroke is often disabling, this trend poses an enormous threat to socioeconomic stability especially in developing countries. In young patients with an absence of conventional vascular risk factors and negative preliminary stroke work-up, clinicians must consider less common causes of stroke in this population. There is prime opportunity for future investigations as there is currently a lack of evidence-based management guidelines for these uncommon etiologies based on research completed to date.

IntroductionCurrent literature suggests that up to 30% of cryptogenic strokes (CS) have subsequent detection of atrial fibrillation (AF), dependent on duration of ambulatory cardiac monitoring. Several scoring systems have been developed to identify those patients at increased risk of incident AF, with variable sensitivity and specificity. We aimed to characterise clinical demographics and comorbidities associated with the development of AF in CS patients.MethodsFollowing PRISMA guidelines, a comprehensive search of medical databases and grey literature was conducted to identify pertinent studies analysing the incidence of AF following CS, from January 2000 to August 2023 (figure 1). Individual factors were extracted and subjected to meta-analysis. A random effects model was employed to establish an overall effect size through standardised mean difference (SMD) or odds ratio (OR).ResultsWe included data from 96 studies with a total of 29318 patients. Notable associations with AF development post-CS included CHA2DS2VASC ≥ 4 (OR 2.07; 95% CI 1.48 to 2.90, p<0.001), age ≥ 75 (OR 3.52; 95% CI, 2.78 to 4.47, p<0.001), left atrial enlargement (OR 2.09, 95% CI 1.58 to 2.75, p<0.001) and presence of valvular heart disease (OR 2.11, 95% CI, 1.04 to 4.26, p = 0.038). Of note, obesity, diabetes mellitus, and a history of heart failure were not associated with AF development. See table 1.ConclusionThis systematic review identifies clinical and echocardiographic factors associated with incident AF post-CS; use of such factors in predictive algorithms may be useful in identification of patients who may benefit from prolonged cardiac monitoring in this population.Abstract 106 Table 1Clinical and echocardiographic factors associated with incident AF post-CS Outcomes Results 95% CI P-value Age ≥ 75 3.517* 2.769 to 4.467 <0.001 Diabetes Mellitus 1.085* 0.950 to 1.195 0.280 Left atrial enlargement 2.088* 1.584 to 2.751 <0.001 Heart failure 1.531* 0.914 to 2.562 0.105 Left ventricular hypertrophy 1.449* 0.966 to 2.172 0.073 Hypertension 1.636* 1.417 to 1.888 <0.001 Obesity 1.941* 0.945 to 3.987 0.071 Valvular heart disease 2.107* 1.041 to 4.263 0.038 Peripheral vascular disease 1.418* 1.151 to 1.747 0.001 CHA2DS2VASC ≥ 4 2.073* 1.479 to 2.904 <0.001 NB: *Odds Ratio; †Standardized Mean Difference.Abstract 106 Figure 1PRISMA diagramConflict of InterestN/A

BackgroundThere is a high prevalence of PFO in patients with CS. Paradoxical embolisation (PE) may only be implicated in some of these patients. Careful assessment by an MDT is essential for the appropriate selection of patients for percutaneous PFO DC.MethodsConsecutive patients with CS and PFO, referred to a single tertiary cardiac centre between June 2005 and November 2019, were retrospectively studied. Clinical MDT work-up to ascertain cause for the clinical event and risk of recurrent events included clinical consultation, expert review of cardiac imaging (TOE/bubble contrast TTE), brain imaging (CT, CT angiography, DWI MRI), thrombophilia and arrhythmia investigations. PASCAL was classified retrospectively. MDT conclusions on final diagnosis and treatment recommendations were obtained from meeting minutes, electronic and paper records while clinical event follow up was assessed through routine electronic health records.Results168 patients (Mean age: 43.41 years, Female 50.6%) with a suspected PFO were referred with an index stroke (140 patients), TIA (23 patients) or peripheral emboli (5 patients). The median MDT meeting number per patient was 1 (IQR: 1–2). Cardiac imaging confirmed PFO presence in 87%, ASD in 5% and both in 4%: the intra-atrial septum was intact in 4%.Proximal source of thromboembolism was adjudged in 60.1% (101/168) of patients with atrial arrhythmia identified in 5 (table 1). Among the remaining 92 patients with possible PE, 64 were adjudged to be high risk of recurrence and PFO DC (closure group - CG) was recommended. In the remaining 28, PE was speculated, with a low risk of recurrence and DC was therefore not recommended (non-closure group – NCG). There was a higher proportion of cortical infarctions (79.4% vs 53.6%, p=0.024) in CG than NCG. High-risk TOE characteristics such as mobile septum (28.1% vs 17.9%, p=0.561), atrial septum aneurysms (28.1% vs 21.4%, p=0.759) and spontaneous shunt (53.1% vs 28.6%, p=0.084) were numerically higher in CG compared to NCG although not statistically significant. PASCAL classification showed higher proportions of \"probable\" causal associations (59.4% vs 10.7%, p<0.001) in CG compared to NCG.In a median follow-up of 6.37 years in all 168 patients, neurological events occurred in 1 patient in CG, 0 in NCG group and 2 in the group in whom PE was not considered likely. Arterial or venous thrombotic events (including DVTs, PEs and limb ischaemia) occurred in 1 patient in CG, 0 in the NCG and 2 in the non-PE group. Significant bleeding (defined as BARC3a and above) occurred in 1 patient in CG, 3 in NCG (HR 0.143, 95%CI 0.015–1.371, p=0.092) and 0 in non-PE group.ConclusionIn patients referred with CS and PFO, possible PE was implicated in only 54.8% and DC recommended in the minority (38.1%). Recurrent neurological or embolic event rates were low, and this corroborates the validity of the decision-making and importance of an MDT process in selecting patients for DC.Abstract 22 Table 1Of the 101 patients, paradoxical embolism through a PFO or ASD was deemed in 92 patients post MDT discussion. In the remaining 9 patients, the diagnosis was as follow: Diagnosis Frequency Atrial Fibrillation 5 LV cavity thrombus 1 Moderate aortic atheroma 1 LV trabeculation as a source of thrombus 1 Heart block leading to intermittent period of cerebral hypoperfusion 1 Conflict of InterestNil

A patent foramen ovale (PFO) is a highly prevalent finding in cryptogenic ischaemic stroke, particularly in young adults. A common challenge in clinical practice is to distinguish between incidental and pathogenic PFO. Some clinical features and tools such as the Risk of Paradoxical Embolism score may help determining the probability of a stroke-related PFO. Nonetheless, the best therapeutic option to reduce stroke recurrence after a cryptogenic stroke with PFO has been a matter of debate for a long time. We review the mechanisms of stroke-related PFO, together with its clinical features and diagnostic criteria. In addition, we focus on the methodological details and results from new studies in the field of secondary prevention. In contrast to prior evidence, the data from three recent clinical trials and an updated meta-analysis favour PFO closure over medical treatment after cryptogenic stroke/TIA for the prevention of stroke recurrence. The PFO closure device procedure is not associated with higher mortality or cardiovascular events, except for a small increase in the occurrence of transient atrial fibrillation. Furthermore, the benefit of PFO closure was higher among those with atrial septal aneurysm and PFO with large right-to-left shunt. Future studies should address pending issues such as the option for anticoagulants or antiplatelet in patients not undergoing closure, the duration of antiplatelet treatment after PFO closure and the role of PFO closure in patients older than 60.

Left atrial strain (LAS) has been widely studied as a predictor of atrial fibrillation (AF) after cryptogenic stroke (CS). However, the evidence about its prognostic role in terms of stroke recurrence and death in this setting remains scarce. A total of 92 consecutive patients with ischemic stroke or transient ischemic attack with ABCD2 scale ≥4 of unknown etiology were prospectively recruited. Echocardiography, including LAS was performed during admission. The primary outcome measure was the composite of stroke recurrence or death. The mean age was 77.5 ± 7.7, and 58% of patients were female. After a median follow up of 28 months, the primary outcome measure occurred in 15 patients (16%). The primary outcome was more frequent in patients with diabetes (53% vs 21%, p = 0.02), chronic kidney disease (33% vs 10%, p = 0.034), and a history of heart failure (13% vs 0%, p = 0.025). LAS reservoir (LASr) and LAS conduit (LAScd) were lower in patients developing the primary outcome (21% ± 7% vs 28.8% ± 11%, p = 0.017 and 7.7% ± 3.9% vs 13.7% ± 7%, p = 0.007, respectively). On multivariate analysis, LASr (hazard ratio 0.9, 95% confidence interval 0.85 to 0.99, p = 0.048) and diabetes (hazard ratio 3.3, 95% confidence interval 1.03 to 10.4, p = 0.045) were associated with stroke recurrence or all-cause death after CS. On the log-rank test (using the discriminatory cut-off value of LASr <23%), LASr (p = 0.009) was associated with higher risk of the primary outcome. In conclusion, lower values of the LAS reservoir were associated with a higher risk of stroke recurrence or death after CS. LAS may identify patients at higher risk of thromboembolism and stress conditions.

Background Cryptogenic strokes (CS) represent one third of admissions for stroke. Silent paroxysmal atrial fibrillation (PAF) is the underlying cause of a significant proportion of cases. The use of internal loop recorders (ILR) after CS has shown controversial results, remaining unclear in guidelines. Subtle ultrasound left atrium (LA) anomalies may help select patients more prone to suffer from silent PAF who can benefit from an ILR. Methods Randomized, controlled, parallel‐arm, open‐label trial of patients with CS. We evaluated the efficacy of early ILR for detection of silent PAF episodes compared to standard care. Clinical/ultrasound predictors of PAF were studied. The presence of subtle LA anomalies (any of: LA dilatation, maximum systolic global longitudinal strain < 21%, atrial contraction strain < 13%, atrial ejection fraction < 55%) was used in a pre‐specified subgroup analysis. Results Fifty‐nine CS patients were included (52.5% to ILR and 47.5% to standard care). There were no statistically significant differences among groups regarding baseline characteristics. Median follow‐up was 377 days. The diagnosis of silent PAF was made in 43.3% in the ILR group compared to 7.1% in the control group (HR 7.47, 95% CI 1.68–31.19, p = 0.008). Most PAF events were detected in the 100 days following ILR implantation. In patients with normal LA, PAF was observed in 23% versus 7%, while in patients with abnormal LA, PAF was diagnosed in 58.8% versus 7.7%. Conclusions An ILR implanted early after CS improves the detection of PAF compared to standard care. Individuals with abnormal LA features may benefit the most from ILR. Flowchart and inclusion/exclusion criteria for Criptofast Study. Patients were separated into two groups depending on the normal/abnormal left atrium, and all of them were early randomized to standard of care versus internal loop recorder implantation, searching for new onset atrial fibrillation at 12 months follow up. AF, atrial fibrillation; AFL, atrial flutter; ILR, implantable loop recorder; LA, left atrium; LAEF, left atrium ejection fraction; OAC, oral anticoagulation; PACS, peak atrial contraction strain; PALS, peak atrial longitudinal strain; SAT, supra‐aortic trunks; SHD, structural heart disease.