Updates on Prevention of Cardioembolic Strokes

Abstract

Cardiac embolism continues to be a leading etiology of ischemic strokes worldwide. Although pathologies that result in cardioembolism have not changed over the past decade, there have been significant advances in the treatment and stroke prevention methods for these conditions. Atrial fibrillation remains the prototypical cause of cardioembolic strokes. The availability of new long-term monitoring devices for atrial fibrillation detection such as insertable cardiac monitors has allowed accurate detection of this leading cause of cardioembolism. The non-vitamin K antagonist oral anticoagulants have improved our ability to prevent strokes for many patients with non-valvular atrial fibrillation (NVAF). Advances in left atrial appendage closure and the U.S. Food and Drug Administration approval of the WATCHMAN (Boston Scientific) device for stroke prevention in NVAF patients who have an appropriate rationale for a nonpharmacological alternative, have revolutionized the field and provided a viable option for patients at higher hemorrhagic risk. The role of patent foramen ovale closure for secondary prevention in selected patients experiencing cryptogenic ischemic strokes at a relatively young age has become clearer thanks to the very recent publication of long-term outcomes from three major studies. Advances in the management of infective endocarditis, heart failure, valvular diseases, and coronary artery disease have significantly changed the management of such patients, but have also revealed new concerns related to assessment of ischemic versus hemorrhagic risk in the setting of antithrombotic use. The current review article aims to discuss these advances especially as they pertain to the stroke neurology practice.

Keywords: Anticoagulants; Atrial fibrillation; Cardioembolism; Ischemic stroke; Left atrial appendage closure; Patent foramen ovale closure.

Figure 1.

Placement of an insertable cardiac monitor. The insertable cardiac monitor is placed under the skin using an injection system through a simple incision. Reproduced with permission of Medtronic, Inc. (http://www.medtronic.com).

Figure 2.

Left atrial appendage (LAA) closure devices and schematics of their deployment. Different types of LAA closure devices are seen. Endocardial devices include (A) WATCHMAN^™ (image provided courtesy of Boston Scientific, c2018 Boston Scientific Corporation or its affiliates, http://www.bostonscientific.com) and (B) AMPLATZER^™ AMULET^™ (reproduced with permission of St. Jude Medical, c2018, https://www.sjmglobal.com). (C) The hybrid (endocardial and epicardial) LARIAT^™ suture delivery system for LAA exclusion (reproduced with permission of SENTREHEART, c2018, http://www.sentreheart.com) and (D) AtriClip^™ for surgical clipping (reproduced with permission of AtriCure, c2018, https://www.atricure.com). Devices are trademarks of their respective companies, all rights reserved.

Figure 3.

Schematic of patent foramen ovale (PFO) closure. Schematic illustrating the endovascular procedure used to close a PFO using AMPLATZER^™ PFO Occluder (St. Jude Medical). (A) The catheter is inserted through the PFO, (B, C) followed by expansion of the left sided disc and (D) deployment of the device to occlude the PFO (showing the device in place). AMPLATZER and St. Jude Medical are trademarks of St. Jude Medical, LLC or its related companies. Reproduced with permission of St. Jude Medical, c2018 (https://www.sjmglobal.com). All rights reserved.