Page 16 - Delaware Medical Journal - August, 2016
P. 16
A trans-jugular approach might be a feasible alternative for PFO closure when trans-femoral and trans-hepatic approaches are not possible or carry an increased risk.
ovale from the right internal jugular (RIJ) approach, the interventional radiologist was available for a trans-hepatic approach if necessary. Through the RIJ, an 8-French multi- purpose guiding catheter and an 8-French CLS guiding catheter allowed us to direct the tip of the guide towards the PFO and cross with a Terumo wire. However, when attempts were
made to advance the guiding catheter into the left atrium, the entire system prolapsed into the right ventricle. A Medtronic MedtronicVR, Minneapolis, USA] was used. However, it was
too rigid to advance into the left atrium. The patent foramen
ovale was successfully crossed using an 8-French Amplatzer torqueview delivery sheath. In order to give it the appropriate shape, the sheath was placed in hot saline and reshaped. A U-shaped curve was placed on the end of the sheath and the PFO was crossed with a guidewire (Figure 2 A-B). A 25-mm Multi- fenestrated ASD occluder was then deployed under TEE guidance (Figure 3 A-B). TEE revealed excellent position of the device (Figure 4). There were no complications related to the procedure and the patient recovered uneventfully.
DISCUSSION
Patients with PFO, paradoxical embolism, and either higher risk
aneurysm) or higher clinical characteristics (i.e. higher Risk of Paradoxical Embolism [ROPE] Score) are at increased risk of recurrent systemic embolization of 3.2-3.8 percent annually.7,8 The ROPE score was developed depending on a Risk of Paradoxical Embolism study that created a score depending on clinical variants to predict the risk of paradoxical embolism.8 Table 1 summarizes the components of the risk score. Strokes in patients with lower scores are more likely to result from non-paradoxical origin, while strokes in those with higher scores are more likely to be a paradoxical stroke.8 Optimal management of these patients is controversial. The randomized trials assessing PFO versus medical therapy in patients with cryptogenic stroke showed no difference between the two strategies in the primary intention- to-treat analysis.9 However, closure was superior to medical
TABLE 1: RoPE (Risk of Paradoxical Embolism) Score Calculator
CHARACTERISTIC
POINTS
SCORE
No history of hypertension
1
No history of diabetes
1
No history of stroke or TIA
1
Nonsmoker
1
Cortical infarct on imaging
1
Age
18–29
5
30–39
4
40–49
3
50–59
2
60–69
1
≥ 70
0
Total score (sum of individual points)
Maximum score (a patient < 30 y without vascular risk factors, no history of stroke/ TIA, or cortical infarct)
10
Minimum score (a patient ≥ 70 y with vascular risk factors, prior stroke, and no cortical infarct)
0
240
Del Med J | August 2016 | Vol. 88 | No. 8
