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Albart SA, Yusof Khan AHK, Wan Zaidi WA, Muthuppalaniappan AM, Kandavello G, Koh GT, Leong MC, Liew HB, Ong BH, Viswanathan S, Hoo FK, Looi I, Yap YG, Law WC. Management of patent foramen ovale in embolic stroke of undetermined source patients: Malaysian experts' consensus. Med J Malaysia 2023; 78:389-403. [PMID: 37271850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
INTRODUCTION About 20 to 40% of ischaemic stroke causes are cryptogenic. Embolic stroke of undetermined source (ESUS) is a subtype of cryptogenic stroke which is diagnosed based on specific criteria. Even though patent foramen ovale (PFO) is linked with the risk of stroke, it is found in about 25% of the general population, so it might be an innocent bystander. The best way to treat ESUS patients with PFO is still up for discussion. MATERIALS AND METHODS Therefore, based on current evidence and expert opinion, Malaysian expert panels from various disciplines have gathered to discuss the management of ESUS patients with PFO. This consensus sought to educate Malaysian healthcare professionals to diagnose and manage PFO in ESUS patients based on local resources and facilities. RESULTS Based on consensus, the Malaysian expert recommended PFO closure for embolic stroke patients who were younger than 60, had high RoPE scores and did not require long-term anticoagulation. However, the decision should be made after other mechanisms of stroke have been ruled out via thorough investigation and multidisciplinary evaluation. The PFO screening should be made using readily available imaging modalities, ideally contrasttransthoracic echocardiogram (c-TTE) or contrasttranscranial Doppler (c-TCD). The contrast-transesophageal echocardiogram (c-TEE) should be used for the confirmation of PFO diagnosis. The experts advised closing PFO as early as possible because there is limited evidence for late closure. For the post-closure follow-up management, dual antiplatelet therapy (DAPT) for one to three months, followed by single antiplatelet therapy (APT) for six months, is advised. Nonetheless, with joint care from a cardiologist and a neurologist, the multidisciplinary team will decide on the continuation of therapy.
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Affiliation(s)
- S A Albart
- Clinical Research Centre, Hospital Seberang Jaya, Ministry of Health Malaysia, Seberang Jaya, Pulau Pinang, Malaysia
| | - A H K Yusof Khan
- Universiti Putra Malaysia, Faculty of Medicine and Health Sciences, Department of Neurology, Serdang, Selangor, Malaysia.
| | - W A Wan Zaidi
- Hospital Canselor Tuanku Muhriz (HCTM), Department of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Wilayah Persekutuan Kuala Lumpur, Malaysia
| | | | - G Kandavello
- Institut Jantung Negara, Kuala Lumpur, Wilayah Persekutuan Kuala Lumpur, Malaysia
| | - G T Koh
- Hospital Serdang, Paediatric Cardiology Unit, Kajang, Selangor, Malaysia
| | - M C Leong
- Institut Jantung Negara, Kuala Lumpur, Wilayah Persekutuan Kuala Lumpur, Malaysia
| | - H B Liew
- Hospital Queen Elizabeth II, Department of Cardiology, Ministry of Health Malaysia, Kota Kinabalu, Sabah, Malaysia
| | - B H Ong
- Kedah Medical Centre, Alor Setar, Kedah, Malaysia
| | - S Viswanathan
- Hospital Kuala Lumpur, Department of Neurology, Ministry of Health Malaysia, Kuala Lumpur, Wilayah Persekutuan Kuala Lumpur, Malaysia
| | - F K Hoo
- Universiti Putra Malaysia, Faculty of Medicine and Health Sciences, Department of Neurology, Serdang, Selangor, Malaysia
| | - I Looi
- Clinical Research Centre, Hospital Seberang Jaya, Ministry of Health Malaysia, Seberang Jaya, Pulau Pinang, Malaysia
| | - Y G Yap
- Sunway Medical Centre, Petaling Jaya, Selangor, Malaysia
| | - W C Law
- Hospital Umum Sarawak, Department of Medicine, Ministry of Health Malaysia, Kuching, Sarawak, Malaysia
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Abstract
A 1.7 kg infant with obstructed supracardiac total anomalous pulmonary venous drainage (TAPVD) presented with severe pulmonary hypertension secondary to vertical vein obstruction. The child, in addition, had a large omphalocele that was being managed conservatively. The combination of low weight, unoperated omphalocele, and severe pulmonary hypertension made corrective cardiac surgery very high-risk. Therefore, transcatheter stenting of the stenotic vertical vein, as a bridge to corrective surgery was carried out. The procedure was carried out through the right internal jugular vein (RIJ). The stenotic segment of the vertical vein was stented using a coronary stent. After procedure, the child was discharged well to the referred hospital for weight gain and spontaneous epithelialization of the omphalocele. Stenting of the vertical vein through the internal jugular vein can be considered in very small neonates as a bridge to repair obstructed supracardiac total anomalous venous drainage.
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Affiliation(s)
- W K Lim
- Pediatric and Congenital Heart Center (PCHC), National Heart Institute, Kuala Lumpur, Malaysia
| | - M C Leong
- Pediatric and Congenital Heart Center (PCHC), National Heart Institute, Kuala Lumpur, Malaysia
| | - H Samion
- Pediatric and Congenital Heart Center (PCHC), National Heart Institute, Kuala Lumpur, Malaysia
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