(upbeat music) <v Steven Messe>The title of this symposium is</v> "The Brain-Heart Team Approach: Secondary Prevention "After a Presumed PFO-Mediated Stroke." That's a mouth full, but we're gonna, we're gonna use it. All right, so here are the people who are gonna be speaking with you tonight. Megan Coylewright, you've heard about, myself, Megan Stevens, who's a neurologist, Molly Szerlip, who's a interventional cardiologist, David Thaler, another neurologist, and J. Volpi, a neurologist. And you'll hear different perspectives on this topic from different experts. I think that we'll have a lot of discussion amongst, between ourselves and we would love to have audience participation as well. At the end of this event we have planned for some time. Hopefully we'll have some time at the end to discuss cases. And if you all have interesting, difficult cases involving PFO and stroke, that'd be great. We can discuss those, but we brought some of our own also. Doing the overview right now. You're gonna hear about the state of evidence for PFO closure from Dave Thaler. You will hear current practice patterns from myself. The structuralist's view of the heart from Dr. Szerlip. And then, how to build a brain-heart team from Megan Stevens and Megan Coylewright. And then at the end again, hopefully we'll have time for some cases. All right, very briefly, setting the table for what we're gonna be talking about tonight History of PFO, this was originally described by Dr. Botallo, the structural finding in the heart. On a cadaver he noticed this communication between the atria in the heart, the right and left side. For a while it was named after him. It was called "Botallo's Foramen." Then, in 1877, Dr. Julius Cohnheim, who's a pathologist, a protege of Virchow, had a case of a young woman who died with both a DVT, and pulmonary embolism, and a stroke, and he noted that Botallo's Foramen was present and he posited that perhaps this was a conduit for a paradoxical embolization leading to cerebral ischemia. So, he was the first person to describe paradoxical embolization from a PFO. And then, we ignored that topic for the next 110 years or so. If you have not seen it before, this is what a PFO looks like on an echo. So, in the bottom left corner there is the right atrium, which is filled with agitated saline bubbles and above that is the left atrium. Of course, a PFO is a integral part of the fetal circulation and we all have this as we're developing in the womb. It's absolutely obligatory for us to get the oxygenated blood from the mother returning through the umbilical vein to the left side of the heart and out to the body. But, it slowly closes over time. And in autopsy, studies of adults ranges, incidences ranges from 17 to 29%. In the TEE en vivo testing from a population-based study, the largest one out of Mayo Clinic, showed that the rate was about a quarter of the patients, 25% had a PFO on TEE with agitated saline contrast. An atrial septal aneurysm, it's like a jump rope. So, if there's excessive length of the atrial wall there, you can see that it can really move quite a bit, excursion in and out and with breathing it gets even bigger. The actual definition of a septal aneurysm varies from one paper to another, anywhere between one and one and a half centimeters is considered a septal aneurysm. It is less common than a PFO, seen in about 2% of the population, and when you see it you frequently, more often than not, three quarters of the time, will see a PFO and it's associated with greater degrees of shunting. And this is now setting the stage for what we're gonna talk about tonight, that back in the late '80s there were these case control studies that suggested that you were more likely to have a PFO than the general population if you had a stroke, particularly if it was a stroke without another explanation, or a cryptogenic stroke. And this publication back in 2000 was a meta-analysis of a number of these case control studies. 2000 patients with stroke compared to 2000 patients without stroke, the odds of finding a PFO was over three fold if you were under 55 years of age. So, under 55, not likely to have atherosclerosis, much more likely to find a PFO. And from then on the story continues and we'll hear a lot more about it.

symposium

PFO-mediated stroke

brain-heart team

evidence

stroke risk