<v Messe>We are open for questions</v> from the audience for sure. <v Audience Member>Just have a question.</v> What is the lifetime of the device? <v ->Yeah, so it lasts forever.</v> (panel members chuckling) When surgeons go back in to, like, if they have some other cardiac procedure done and surgeons go back in, it's actually quite interesting. Some of the PFO devices have endothelialized, others have not, so which brings to the point of maybe you should keep these people on aspirin, which is why I think I've sort of developed that to keep them on aspirin, because, and it's not, it's just based on the patient as to whether or not they endothelialize. So some of them say they can just pop it right out, and other times they have to like, dig for it. But they pretty much, once they're in, they're in. It's kinda like a stent. <v ->I mean, I think that makes sense.</v> I would just add other reasons are that if it was a paradoxical embolism, it was a venous clot to begin with, and these patients may be at higher risk for venous thromboembolism in the future, and aspirin actually does prevent that. And then there's also the small chance that the PFO was an innocent bystander and they did form a clot on their left side, and aspirin again is a good idea. So I'm in favor of it barring a bleeding contraindication or concern. David and Jay, you guys also recommend lifelong antiplatelets? <v ->Yeah, I do, and it's more for that second reason.</v> Remember, this is all probabilistic, right? And even in the high RoPE score patients, the PFO attributable fraction gets up to 90%, but not 100%. And that means 10% of those people that you're super confident had a PFO-associated stroke, didn't. And that means if you don't provide secondary stroke prevention guideline-directed to everybody, 10% of your patients you're gonna be under-treating. And then if the RoPE scores get lower and lower, then it turns into 40% you're not treating. So it's more of a statistical game that I think we need to continue to provide secondary prevention therapy, which includes anti-thrombotics of some sort. <v Audience Member>So thank you for the lecturers.</v> The last case, 65 years old, and even in my opinion is like, the closure of the PFO usually is a safe procedure, but in other patient can push and/or trigger hidden AF, or can be, change the architecture of the atrial cardiopathy, right? So why not closure the left atrial appendage in other patients at the same time that we close the PFO? Because in my opinion, this patient, in the next two years, you will find an atrial fibrillation if you perform a rhythm diagnosis and you follow up for sure. So my opinion would be I think, patient has atrial cardiopathy, I think if she will have, and this challenging cases, I was thinking doing the both procedures. I don't know, what do you think? <v ->Close everything.</v> (panel members chuckling) <v ->That's right after my own heart.</v> (laughing) <v ->Aw.</v> Yeah, we're just limited by, well, number one indication for sure, because you know, everything that we do does come with some risk, and then number two, payment. But I will suggest that the PFO is located in the anterior portion of the septum, and there's almost always enough room to go behind it for any left-sided intervention that you'd need to do in the future, so it's pretty rare that it closes off entry into the left side should you need to go for left atrial appendage closure later. <v ->Yeah, so basically when we do</v> any of those left-sided procedures, like MitraClip or LAAO, we always go either mid or inferior mid, posterior, so away from the PFO. Actually, we're never, even if there is a PFO, we never go through the PFO. That will never get you to where you're supposed to go. <v ->And I would just add I would never close</v> left atrial appendage prophylactically 'cause you think someone might get AFIB, but I would monitor them closely for AFIB. And for this patient, I would've considered suggesting a link. I'm not saying you shouldn't. But I do worry about AFIB, and I do know that in the older patients, you know, you're more likely to see it. <v ->She does have one.</v> <v ->Boom. (audience laughing)</v> So then I feel, and and I totally agreed with closing her, I think that was great, and you feel very comfortable that she has that, you know what's gonna happen. <v Volpi>Actually, Dr. Thaler,</v> can I ask you a question about that last case? What do you think of resetting that patient's RoPE score? Would it not be okay to simply evaluate her based on her index event age and keep that as her event? <v ->Yeah, that's a really good question.</v> So how long is a piece of rope is the question. (panel members chuckling) I saw a patient in their 60s who had their first stroke when they were in the Navy in the Gulf of Tonkin. <v Panel Members>Wow.</v> <v ->In the '60s, he was 19 or something.</v> And obviously, when I saw him, (chuckling) his RoPE score was much lower. But the RoPE score and the PASCAL Classification are guides, right, they're not the answer, and you have to be able to apply- Every single patient has something quirky about them, and you have to be able to apply some common sense to it. Can I make one comment about old people with PFOs and the notion that PFO-related stroke is a young stroke mechanism? I think that's wrong, and this is what I mean. The incidence of stroke in 30 year olds, and 40 year olds, and 50 year olds, is 20 per 100,000, or 30 per 100,000, something like that. It's really small. And amongst those stroke patients, PFO-related strokes are very common, let's say half of them. I don't know, that's probably too many. But 30%, whatever. So there's a bunch of PFO-related strokes in young stroke patients. The incidence of stroke in people who are in their 70s, and 80s, and 90s is not 30 per 100,000, it's like 3,000 per 100,000. And so the prevalence of PFOs amongst those old stroke patients, the prevalence of PFO-associated strokes amongst those old stroke patients could be much, much lower, but the incidence of PFO-related strokes amongst those older people might be getting higher. So, and we can go through the numbers, but there's all sorts of reasons that you pointed out, hypercoagulability, and cancer, and sitting around, and obesity, and sleep apnea that you might have more PFO-related strokes as people get older. So it's not unusual to have a PFO-associated stroke in older people, it's just much less prevalent amongst all the stroke patients that are so old. <v ->So I have a question-</v> <v ->I was just gonna say,</v> she actually does have severe obstructed sleep apnea, and a lot of the focus during those years where she was followed for conversion disorder were really just centered around treating her with CPAP, which was good on the one hand, but then she moved and she didn't take her machine. <v ->You know, how long do you-</v> So you're looking at these old people and you're looking for atrial fibrillation, and you get a 30-day event monitor, there's no AFIB because none of 'em will have AFIB in just 30 days, and so you put the ILR in, how long do you wait? Do you have to wait two years to be like, "Okay, you really don't have AFIB," because they could really have AFIB on year three, you know? So when- <v ->Yeah, but if it's at year three,</v> it probably didn't cause the stroke that got you to that point, most likely. <v ->I don't know, it's the same thing</v> with proximal AFIB. <v ->I think it's good</v> to know about AFIB. <v ->Stroke from proximal AFIB.</v> You know, there's people who had one episode of AFIB, and they're like, "Ah, you don't need to be on anticoagulants," and you know, you have AFIB and then you have your stroke, so I don't know what to say about that. <v ->If you look at the ILR data,</v> there's definitely an inflection point at about 60 days at which time the curve goes from pretty steep, at which you're probably detecting the actual, you know, cause of the stroke, versus then you just have kind of a different flatter line after that 60 days. So I mean, I would say 30 days is reasonable, 60 days is just as reasonable. Much beyond that, I don't know that you need to keep watching for, looking for the etiology. <v ->What was the original question?</v> We just like, took four tangents. (panel members and audience laughing) <v ->Right there.</v> All right, go ahead. <v ->Well, I will just-</v> I will just say, we have a couple hands up and it's past the time. <v ->We're having so much fun.</v> <v ->So perhaps-</v> I know, we're geeking out about it, as usual. We'll stick around. We'll also meet up I'm sure at the bar after to continue the discussion, but I just wanna thank the entire panel and everyone who joined us tonight for a fantastic discussion, and- (audience applauding) Let's keep preventing stroke. (light music)

device lifetime

aspirin

antiplatelet therapy

PFO closure

stroke prevention