1	Cardiac Evaluation of Patients with Embolic Stroke ILAN HAY Cardiac Rehabilitation Institute Sheba Medical Center
2	Contents Definition of cardio-embolic stroke Definite and probable cardiac source of emboli Left atrial thrombus; MAC; Valve excrescences PFO and Atrial Septal Aneurysm Aortic Atheroma
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4	TOAST Classification of Ischemic stroke Large artery atherosclerosis Cardioembolism Small vessel occlusion Stroke of other determined etiology Stroke of undetermined etiology
5	SSS-TOAST Classification of Ischemic stroke Cardioaortic embolism Evident - The presence of a high-risk cardiac source of cerebral embolism Probable - Evidence of systemic embolism Presence of multiple acute infarctions Possible- The presence of a cardiac condition with low or uncertain primary risk of cerebral embolism Evidence for cardioaortic embolism in the absence of complete diagnostic investigation for other mechanisms
6	Cardiac sources- definite Left atrial thrombus Left ventricular thrombus Atrial fibrillation and paroxysmal atrial fibrillation Sustained atrial flutter Recent myocardial infarction (within 1 month) Rheumatic mitral or aortic valve disease
7	Cardiac sources- definite Bioprosthetic and mechanical heart valve Chronic myocardial infarction with ejection fraction <28 percent Symptomatic heart failure with ejection fraction <30 percent Dilated cardiomyopathy Bacterial endocarditis Non bacterial endocarditis Atrial myxoma
8	Cardiac sources- possible Mitral annular calcification Patent foramen ovale Atrial septal aneurysm Atrial septal aneurysm with patent foramen ovale Left ventricular aneurysm without thrombus
9	Cardiac sources- possible Left atrial swirling (no mitral stenosis or atrial fibrillation) Mitral valve strands
10	Cardiac evaluation
11	Low yield of transthoracic echocardiography for cardiac source of embolism 1,010 consecutive patients with cerebrovascular accidents The prevalence of a highly probable source of embolism was low in cases (< 3%) and no different from controls The prevalence of a possible cardiac source of embolism was also low (< 5%) and similar in cases and controls The presence of definite or possible thrombus on echocardiography resulted in alteration in therapy in only 2% of cases, of whom 77% had either heart failure, atrial fibrillation, or Q waves on the electrocardiogram
12	Selection of patients for transesophageal echocardiography after stroke and systemic embolic events. Role of transthoracic echocardiography. 824 patients after stroke and other suspected embolic events. Transesophageal echocardiography detected at least one potential source of embolism in 399 patients (49%): spontaneous contrast in 214 patients (26%), left atrial thrombus in 54 (7%), complex atheroma in 111 (13%), and interatrial septal anomalies in 126 (15%) Patient in sinus rhythm and normal TTE (n = 236), only 3 (1%) had spontaneous contrast, 11 (4.6%) had complex atheroma, and none had left atrial thrombus
13	Left atrial thrombi Associated with atrial fibrillation and mitral stenosis 45% percent of cardiogenetic thromboemboli 2894 patients , TEE for varios indication 94 (3%) left atrial thrombi; 83 were in AF 869 embolic stroke or TIA Left atrial thrombus only in 1% of patient with sinus rhythm and no mitral disease
14	Left atrial thrombi 43% of patients with AF and clinical thromboemoli Detailed visualization of the left atrial appendage 100% sensitivity 99% specificity with direct visualization at surgery TTE 39-65% sensitivity for left atrial thrombi
15	MAC
16	Mitral Annulus Calcification Most common TTE finding among elderly Associated with calcific atherosclerosis in Asc. & Thoracic Aorta but not coronary arteries Age dependence 8% (56y), 48% (81y) Associated with thromboembolism Associated with stroke, linear relation with severity RR for CVS death of 1.5
17	Valve strands
18	Valve Excrescences Thin elongated structure with hypermobility Occur on mitral, tricuspid, aortic valve Common on the left-sided heart valves of normal subjects and patients regardless of gender and age Persist unchanged over time and do not appear to be a primary source of cardioembolism.
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21	Patent Foramen Ovale Incidence
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23	PFO Anatomy Flap valve Narrow channal or large opening IVC flow directed towards PFO Shunt spontaneously or during Valsalva Size 1-19mm (mean 4.9 mm)
24	PFO Incidence 25% in autopsy series 25% in population based studies screened by TEE (SPARC-Olmsted County) 15% when examined by TTE (Northern Manhattan)
25	PFO
26	PFO
27	PFO
28	PFO
29	PFO
30	ASA
31	ASA
32	Atrial Septal Aneurysm Definition Diameter of base 15 mm or more Protrusion beyond IAS 15 mm or more Phasic excursion during respiration 15 mm or more Incidence: 2% in normal adults more frequent in subjects with PFO
33	PFO, Paradoxical Embolism and Cryptogenic Stroke During a short period of raised right atrial pressure, a venous thrombus arising from pelvic or leg veins passes through the PFO to the systemic circulation to cerebral vessels Illustrations have shown thrombi transversing the PFO (caught in the act)
34	PFO and Cryptogenic Stroke Numerous studies have reported a prevalence of 30-40% of PFO in young patients (<55y) with cryptogenic stroke Compared to 10% in pts with non-cryptogenic stroke, and 25% in the normal population
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37	Increased prevalence of PFO in cryptogenic stroke? SPARC – Olmsted County Study: Prospective (5.1years) population based study of 585 randomly sampled persons age 45+ yrs (67±13) with TEE: PFO 24.3%, ASA 1.9% PFO not a risk factor for stroke or TIA after adjustment for comorbidity HR 1.46 (0.74-2.88) ASA increases the risk * 4 p=0.07
38	Increased prevalence of PFO in Cryptogenic Stroke? NOMAS-study: Prospective study (6.5 yrs) of incidence, risk factors and clinical outcome of stroke in 1,100 individuals (68± 10yrs) without previous stroke, evaluated by TTE Stroke incidence 68pts (6.2%) Hazard Ratio 1.64 (CI 0.87-3.09)- PFO Hazard Ratio 1.25 (CI 0.17-9.24)- PFO + ASA
39	Is PFO a risk factor for stroke recurrence?
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41	Is PFO a Risk Factor for Stroke Recurrence? Sub study Warfarin-Aspirin Recurrent Stroke Study 630 stroke pts randomized to warfarin and aspirin 265 cryptogenic stroke 365 known stroke subtypes End point recurrent ischemic stroke or death PFO 33.8%
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45	Patent Foramen Ovale and Cryptogenic Stroke in Older Patients 503 stroke 227 cryptogenic 276 known cause 131 pts <55, 372 pts >55 TEE
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47	Atrial Septal Aneurysm (ASA) and Cryptogenic Stroke SPARC and NOMAS suggested an increased risk of stroke with ASA without PFO No increased risk with ASA + PFO In the PFO-aspirin trial stroke recurrence rate + death was significantly higher (15%/4yrs) in PFO + ASA (n=51), than in ASA without PFO (n=10) (0%) In the WARSS substudy stroke recurrence was independent of ASA
48	Therapeutic Options for PFO-related Stroke Low recurrence risk on aspirin Warfarin not more effective than aspirin Surgical Closure Endovascular closure devices
49	Antithrombotic Therapy for PFO-Associated Stroke Group Stroke or Death (2 yrs) Warfarin (N = 97) 16.5% Aspirin (N = 106) 13.2%
50	Should a PFO with Cryptogenic Stroke undergo Catheter Closure?
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52	Guidelines for Prevention of Stroke in Patients with Ischemic Stroke or TIA. A Statement for Healthcare Professionals from AHA, Am Stroke Ass Council on Stroke, Co-sponsored by Council of Cardiovasc Rad. and Interv. and affirmed by Am Ac of Neurol: Stroke 2006;37:577-617 ”Insufficient data exist to make a recommendation about PFO closure in patients with a first stroke and a PFO. PFO closure may be considered for patients with recurrent cryptogenic stroke despite optimal medical treatment (Class IIb, Level of Evidence C)”
53	Conclusions For patients with an ischemic stroke or TIA and a PFO antiplatelet therapy is reasonably to prevent a recurrent event Warfarin is reasonable for high-risk patients who have other indications for oral anticoagulation It is unknown whether patients benefit from catheter closure of PFO, which therefore can only be recommended in controlled clinical trials
54	AORTIC ATHEROMA
55	Aortic Atheroma
56	Aortic Atheroma
57	Aortic Atheroma
58	Aortic Atheroma
59	Aortic atheroma
60	Aortic Atheroma
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65	Atherosclerotic Disease of the Aortic Arch and the Risk of Ischemic Stroke Prospective case control study 250 consecutive patients admitted with ischemic stroke 250 control TEE Frequency and thickness of atherosclerotic plaques
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81	Risk Factors for Ischemic Stroke Age Hypertension Diabetes Mellitus Smoking Hyperlipidemia
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86	Therapy of Aortic Atheromas
87	Apical Thrombi
88	Apical Thrombi
89	Apical Thrombi
90	Atrial Thrombi
91	Atrial Thrombi
92	Atrial Thrombi
93	Endocarditis
94	Endocarditis
95	Endocarditis
96	Marantic Endocarditis
97	Marantic Endocarditis
98	Myxoma
99	Myxoma
100	Conclusions Cardioembolic Stroke 20% of Ischemic stroke Hx, Physical exam, ECG and TTE reveal most causes Specific therapy for PFO and Aortic Atheroma not established Consider TEE in recurrent strokes and pts<55