AVOIDING TEE AND INVASIVE INTERVENTION IN LOW RISK PFO IN A CASE OF PARADOXICAL STROKE B BUNOL MD, K KINGSTON DM, O SAQQA MD, H SHI MD Department of Medicine, Tulane Health Sciences Center, New Orleans, LA BACKGROUND: Patent foramen ovales (PFO) can be incidentally found as part of a stroke work-up on a transthoracic echocardiogram (TTE) with bubble study. Transesophageal echocardiogram (TEE) is the standard for elucidating the size of the defect, however, is an invasive procedure with risk and cost. This case describes using PFO scoring systems and TTE to avoid overutilization. CASE: A 65-year-old man with hypertension initially presented after being found down at home. EKG showed sinus rhythm with premature atrial complexes. Magnetic resonance imaging (MRI) of the brain showed a new infarction in the superior left basal ganglia and posterior left hippocampus with old lacunar infarcts. A Transthoracic echocardiogram (TTE) showed an ejection fraction greater than 55%, with positive bubbles crossing the septal wall after 4-5 cycles concerning for a PFO. Venous doppler showed a left femoral and brachial thrombus. There was a concern for paradoxical embolus from the PFO and possible need for surgical closure. The Risk of Paradoxical Embolization (RoPE) score was calculated to be low at 3 (age, hypertension, previous stroke on imaging, subcortical infarcts). Although cryptogenic stroke was in two different territories, telemetry did not show any arrythmias, and the decision was made to treat with apixaban for deep venous thrombus’ and aspirin for secondary prevention. TEE was deferred. DISCUSSION: Although PFOs can be causally related to strokes, other processes such as atrial fibrillation, lacunar injury, hypercoagulable disease are more common. The RoPE score can be used to determine if TEE and repair can be beneficial. This scoring system was created due to the challenge of identifying which cryptogenic strokes bay be attributable to a PFO. This score can help give insight in how to separate from within a cryptogenic stroke population those PFO’s which are related to the stroke from those which are more likely incidental findings. The score will not directly predict who will or will not benefit from closure.
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