Cardioembolic Stroke: Mechanisms and Therapeutics

Abstract

Cardioembolic stroke accounts for nearly 30% of all known stroke mechanisms. This percentage may be underestimated, however, when considering the large proportion of cryptogenic strokes that likely have a covert cardiac source. Although it is well known that cardioembolic stroke can occur in the setting of atrial fibrillation, other mechanisms such as a systolic heart failure, patent foramen ovale, valvular dysfunction, and aortic arch atheroma are commonly encountered in daily practice. The authors provide an overview on the epidemiology, pathogenesis, diagnostic evaluation, and secondary prevention treatment strategies for cardioembolic stroke.

Keywords

stroke - transient ischemic attack - cardioembolism - stroke prevention - patent foramen ovale

• References

• 1 Mozaffarian D, Benjamin EJ, Go AS. , et al; Writing Group Members; American Heart Association Statistics Committee; Stroke Statistics Subcommittee. Heart disease and stroke statistics-2016 update: a report from the American Heart Association. Circulation 2016; 133 (04) e38-e360
• 2 Adams Jr HP, Bendixen BH, Kappelle LJ. , et al. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke 1993; 24 (01) 35-41
• 3 Kolominsky-Rabas PL, Weber M, Gefeller O, Neundoerfer B, Heuschmann PU. Epidemiology of ischemic stroke subtypes according to TOAST criteria: incidence, recurrence, and long-term survival in ischemic stroke subtypes: a population-based study. Stroke 2001; 32 (12) 2735-2740
• 4 Yaghi S, Elkind MS. Cryptogenic stroke: A diagnostic challenge. Neurol Clin Pract 2014; 4 (05) 386-393
• 5 Hart RG, Diener HC, Coutts SB. , et al; Cryptogenic Stroke/ESUS International Working Group. Embolic strokes of undetermined source: the case for a new clinical construct. Lancet Neurol 2014; 13 (04) 429-438
• 6 Arboix A, Alio J. Acute cardioembolic cerebral infarction: answers to clinical questions. Curr Cardiol Rev 2012; 8 (01) 54-67
• 7 Meschia JF, Barrett KM, Chukwudelunzu F. , et al; Siblings with Ischemic Stroke Study (SWISS) Investigators. Interobserver agreement in the trial of org 10172 in acute stroke treatment classification of stroke based on retrospective medical record review. J Stroke Cerebrovasc Dis 2006; 15 (06) 266-272
• 8 Caplan LR. Caplan's stroke. In: Caplan LR. , ed. Caplan's Stroke. Philadelphia: Saunders Elsevier; 2009: 64-86
• 9 Jauch EC, Saver JL, Adams Jr HP. , et al; American Heart Association Stroke Council; Council on Cardiovascular Nursing; Council on Peripheral Vascular Disease; Council on Clinical Cardiology. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013; 44 (03) 870-947
• 10 González RG, Schaefer PW, Buonanno FS. , et al. Diffusion-weighted MR imaging: diagnostic accuracy in patients imaged within 6 hours of stroke symptom onset. Radiology 1999; 210 (01) 155-162
• 11 Ay H, Buonanno FS, Rordorf G. , et al. Normal diffusion-weighted MRI during stroke-like deficits. Neurology 1999; 52 (09) 1784-1792
• 12 Barber PA, Darby DG, Desmond PM. , et al. Prediction of stroke outcome with echoplanar perfusion- and diffusion-weighted MRI. Neurology 1998; 51 (02) 418-426
• 13 Sachdeva G, Saeed A, Jani V, Razak A. Radiological portrait of embolic strokes. Cardiol Clin 2016; 34 (02) 269-278
• 14 Wessels T, Röttger C, Jauss M, Kaps M, Traupe H, Stolz E. Identification of embolic stroke patterns by diffusion-weighted MRI in clinically defined lacunar stroke syndromes. Stroke 2005; 36 (04) 757-761
• 15 Lamy C, Giannesini C, Zuber M. , et al. Clinical and imaging findings in cryptogenic stroke patients with and without patent foramen ovale: the PFO-ASA Study. Atrial septal aneurysm. Stroke 2002; 33 (03) 706-711
• 16 Nah HW, Lee JW, Chung CH. , et al. New brain infarcts on magnetic resonance imaging after coronary artery bypass graft surgery: lesion patterns, mechanism, and predictors. Ann Neurol 2014; 76 (03) 347-355
• 17 Rizos T, Güntner J, Jenetzky E. , et al. Continuous stroke unit electrocardiographic monitoring versus 24-hour Holter electrocardiography for detection of paroxysmal atrial fibrillation after stroke. Stroke 2012; 43 (10) 2689-2694
• 18 Flint AC, Banki NM, Ren X, Rao VA, Go AS. Detection of paroxysmal atrial fibrillation by 30-day event monitoring in cryptogenic ischemic stroke: the Stroke and Monitoring for PAF in Real Time (SMART) Registry. Stroke 2012; 43 (10) 2788-2790
• 19 Gladstone DJ, Spring M, Dorian P. , et al; EMBRACE Investigators and Coordinators. Atrial fibrillation in patients with cryptogenic stroke. N Engl J Med 2014; 370 (26) 2467-2477
• 20 Sanna T, Diener HC, Passman RS. , et al; CRYSTAL AF Investigators. Cryptogenic stroke and underlying atrial fibrillation. N Engl J Med 2014; 370 (26) 2478-2486
• 21 Kurt M, Shaikh KA, Peterson L. , et al. Impact of contrast echocardiography on evaluation of ventricular function and clinical management in a large prospective cohort. J Am Coll Cardiol 2009; 53 (09) 802-810
• 22 Saric M, Armour AC, Arnaout MS. , et al. Guidelines for the use of echocardiography in the evaluation of a cardiac source of embolism. J Am Soc Echocardiogr 2016; 29 (01) 1-42
• 23 Katsanos AH, Giannopoulos S, Frogoudaki A. , et al. The diagnostic yield of transesophageal echocardiography in patients with cryptogenic cerebral ischaemia: a meta-analysis. Eur J Neurol 2016; 23 (03) 569-579
• 24 McGrath ER, Paikin JS, Motlagh B, Salehian O, Kapral MK, O'Donnell MJ. Transesophageal echocardiography in patients with cryptogenic ischemic stroke: a systematic review. Am Heart J 2014; 168 (05) 706-712
• 25 Rustemli A, Bhatti TK, Wolff SD. Evaluating cardiac sources of embolic stroke with MRI. Echocardiography 2007; 24 (03) 301-308 , discussion 308
• 26 Bottini PB, Carr AA, Prisant LM, Flickinger FW, Allison JD, Gottdiener JS. Magnetic resonance imaging compared to echocardiography to assess left ventricular mass in the hypertensive patient. Am J Hypertens 1995; 8 (03) 221-228
• 27 Anderson LJ, Holden S, Davis B. , et al. Cardiovascular T2-star (T2*) magnetic resonance for the early diagnosis of myocardial iron overload. Eur Heart J 2001; 22 (23) 2171-2179
• 28 Fayad ZA, Nahar T, Fallon JT. , et al. In vivo magnetic resonance evaluation of atherosclerotic plaques in the human thoracic aorta: a comparison with transesophageal echocardiography. Circulation 2000; 101 (21) 2503-2509
• 29 Yaghi S, Song C, Gray WA, Furie KL, Elkind MS, Kamel H. Left atrial appendage function and stroke risk. Stroke 2015; 46 (12) 3554-3559
• 30 Král M, Šaňák D, Veverka T. , et al. Troponin T in acute ischemic stroke. Am J Cardiol 2013; 112 (01) 117-121
• 31 James P, Ellis CJ, Whitlock RM, McNeil AR, Henley J, Anderson NE. Relation between troponin T concentration and mortality in patients presenting with an acute stroke: observational study. BMJ 2000; 320 (7248): 1502-1504
• 32 Kamel H, O'Neal WT, Okin PM, Loehr LR, Alonso A, Soliman EZ. Electrocardiographic left atrial abnormality and stroke subtype in the atherosclerosis risk in communities study. Ann Neurol 2015; 78 (05) 670-678
• 33 Kamel H, Soliman EZ, Heckbert SR. , et al. P-wave morphology and the risk of incident ischemic stroke in the Multi-Ethnic Study of Atherosclerosis. Stroke 2014; 45 (09) 2786-2788
• 34 Kamel H, Elkind MS, Bhave PD. , et al. Paroxysmal supraventricular tachycardia and the risk of ischemic stroke. Stroke 2013; 44 (06) 1550-1554
• 35 Patton KK, Ellinor PT, Heckbert SR. , et al. N-terminal pro-B-type natriuretic peptide is a major predictor of the development of atrial fibrillation: the Cardiovascular Health Study. Circulation 2009; 120 (18) 1768-1774
• 36 Folsom AR, Nambi V, Bell EJ. , et al. Troponin T, N-terminal pro-B-type natriuretic peptide, and incidence of stroke: the atherosclerosis risk in communities study. Stroke 2013; 44 (04) 961-967
• 37 Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke 1991; 22 (08) 983-988
• 38 Heeringa J, van der Kuip DA, Hofman A. , et al. Prevalence, incidence and lifetime risk of atrial fibrillation: the Rotterdam study. Eur Heart J 2006; 27 (08) 949-953
• 39 Friberg L, Hammar N, Rosenqvist M. Stroke in paroxysmal atrial fibrillation: report from the Stockholm Cohort of Atrial Fibrillation. Eur Heart J 2010; 31 (08) 967-975
• 40 Gamra H, Murin J, Chiang CE, Naditch-Brûlé L, Brette S, Steg PG. ; RealiseAF investigators. Use of antithrombotics in atrial fibrillation in Africa, Europe, Asia and South America: insights from the International RealiseAF Survey. Arch Cardiovasc Dis 2014; 107 (02) 77-87
• 41 Brathwaite D, Weissman C. The new onset of atrial arrhythmias following major noncardiothoracic surgery is associated with increased mortality. Chest 1998; 114 (02) 462-468
• 42 Joshi KK, Tiru M, Chin T, Fox MT, Stefan MS. Postoperative atrial fibrillation in patients undergoing non-cardiac non-thoracic surgery: a practical approach for the hospitalist. Hosp Pract (1995) 2015; 43 (04) 235-244
• 43 Gialdini G, Nearing K, Bhave PD. , et al. Perioperative atrial fibrillation and the long-term risk of ischemic stroke. JAMA 2014; 312 (06) 616-622
• 44 Vadmann H, Nielsen PB, Hjortshøj SP. , et al. Atrial flutter and thromboembolic risk: a systematic review. Heart 2015; 101 (18) 1446-1455
• 45 Meschia JF, Bushnell C, Boden-Albala B. , et al; American Heart Association Stroke Council; Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology; Council on Functional Genomics and Translational Biology; Council on Hypertension. Guidelines for the primary prevention of stroke: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014; 45 (12) 3754-3832
• 46 Kernan WN, Ovbiagele B, Black HR. , et al; American Heart Association Stroke Council, Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, and Council on Peripheral Vascular Disease. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014; 45 (07) 2160-2236
• 47 Shively BK, Gelgand EA, Crawford MH. Regional left atrial stasis during atrial fibrillation and flutter: determinants and relation to stroke. J Am Coll Cardiol 1996; 27 (07) 1722-1729
• 48 Glotzer TV, Daoud EG, Wyse DG. , et al. The relationship between daily atrial tachyarrhythmia burden from implantable device diagnostics and stroke risk: the TRENDS study. Circ Arrhythm Electrophysiol 2009; 2 (05) 474-480
• 49 Healey JS, Connolly SJ, Gold MR. , et al; ASSERT Investigators. Subclinical atrial fibrillation and the risk of stroke. N Engl J Med 2012; 366 (02) 120-129
• 50 Kamel H, Okin PM, Elkind MS, Iadecola C. Atrial fibrillation and mechanisms of stroke: time for a new model. Stroke 2016; 47 (03) 895-900
• 51 Hill AB. The environment and disease: association or causation?. Proc R Soc Med 1965; 58: 295-300
• 52 Birman-Deych E, Radford MJ, Nilasena DS, Gage BF. Use and effectiveness of warfarin in Medicare beneficiaries with atrial fibrillation. Stroke 2006; 37 (04) 1070-1074
• 53 Halperin JL, Dorian P. Trials of novel oral anticoagulants for stroke prevention in patients with non-valvular atrial fibrillation. Curr Cardiol Rev 2014; 10 (04) 297-302
• 54 Potpara TS, Dagres N, Mujović N. , et al. Decision-making in clinical practice: oral anticoagulant therapy in patients with non-valvular atrial fibrillation and a single additional stroke risk factor. Adv Ther 2016; xx: 1-21
• 55 Berge E, Abdelnoor M, Nakstad PH, Sandset PM. Low molecular-weight heparin versus aspirin in patients with acute ischaemic stroke and atrial fibrillation: a double-blind randomised study. HAEST Study Group. Heparin in Acute Embolic Stroke Trial. Lancet 2000; 355 (9211): 1205-1210
• 56 Paciaroni M, Agnelli G, Falocci N. , et al. Early recurrence and cerebral bleeding in patients with acute ischemic stroke and atrial fibrillation: effect of anticoagulation and its timing: The RAF Study. Stroke 2015; 46 (08) 2175-2182
• 57 Seiffge DJ, Traenka C, Polymeris A. , et al. Early start of DOAC after ischemic stroke: risk of intracranial hemorrhage and recurrent events. Neurology 2016; 87 (18) 1856-1862
• 58 Macha K, Volbers B, Bobinger T. , et al. Early initiation of anticoagulation with direct oral anticoagulants in patients after transient ischemic attack or ischemic stroke. J Stroke Cerebrovasc Dis 2016; 25 (09) 2317-2321
• 59 Douketis JD, Berger PB, Dunn AS. , et al. The perioperative management of antithrombotic therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th ed.). Chest 2008; 133: 299s-339s
• 60 Douketis JD, Spyropoulos AC, Kaatz S. , et al; BRIDGE Investigators. Perioperative bridging anticoagulation in patients with atrial fibrillation. N Engl J Med 2015; 373 (09) 823-833
• 61 Schulman S, Carrier M, Lee AY. , et al; Periop Dabigatran Study Group. Perioperative Management of Dabigatran: A Prospective Cohort Study. Circulation 2015; 132 (03) 167-173
• 62 Beyer-Westendorf J, Gelbricht V, Förster K. , et al. Peri-interventional management of novel oral anticoagulants in daily care: results from the prospective Dresden NOAC registry. Eur Heart J 2014; 35 (28) 1888-1896
• 63 Mohr JP, Thompson JL, Lazar RM. , et al; Warfarin-Aspirin Recurrent Stroke Study Group. A comparison of warfarin and aspirin for the prevention of recurrent ischemic stroke. N Engl J Med 2001; 345 (20) 1444-1451
• 64 Longstreth Jr WT, Kronmal RA, Thompson JL. , et al. Amino terminal pro-B-type natriuretic peptide, secondary stroke prevention, and choice of antithrombotic therapy. Stroke 2013; 44 (03) 714-719
• 65 Blackshear JL, Odell JA. Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation. Ann Thorac Surg 1996; 61 (02) 755-759
• 66 Yarmohammadi H, Varr BC, Puwanant S. , et al. Role of CHADS2 score in evaluation of thromboembolic risk and mortality in patients with atrial fibrillation undergoing direct current cardioversion (from the ACUTE Trial Substudy). Am J Cardiol 2012; 110 (02) 222-226
• 67 Reddy VY, Doshi SK, Sievert H. , et al; PROTECT AF Investigators. Percutaneous left atrial appendage closure for stroke prophylaxis in patients with atrial fibrillation: 2.3-Year Follow-up of the PROTECT AF (Watchman Left Atrial Appendage System for Embolic Protection in Patients with Atrial Fibrillation) Trial. Circulation 2013; 127 (06) 720-729
• 68 Holmes Jr DR, Kar S, Price MJ. , et al. Prospective randomized evaluation of the Watchman Left Atrial Appendage Closure device in patients with atrial fibrillation versus long-term warfarin therapy: the PREVAIL trial. J Am Coll Cardiol 2014; 64 (01) 1-12
• 69 Freudenberger RS, Hellkamp AS, Halperin JL. , et al; SCD-HeFT Investigators. Risk of thromboembolism in heart failure: an analysis from the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT). Circulation 2007; 115 (20) 2637-2641
• 70 Solheim S, Seljeflot I, Lunde K. , et al. Frequency of left ventricular thrombus in patients with anterior wall acute myocardial infarction treated with percutaneous coronary intervention and dual antiplatelet therapy. Am J Cardiol 2010; 106 (09) 1197-1200
• 71 Schwalm JD, Ahmad M, Salehian O, Eikelboom JW, Natarajan MK. Warfarin after anterior myocardial infarction in current era of dual antiplatelet therapy: a randomized feasibility trial. J Thromb Thrombolysis 2010; 30 (02) 127-132
• 72 Vaitkus PT, Barnathan ES. Embolic potential, prevention and management of mural thrombus complicating anterior myocardial infarction: a meta-analysis. J Am Coll Cardiol 1993; 22 (04) 1004-1009
• 73 Eckman PM, John R. Bleeding and thrombosis in patients with continuous-flow ventricular assist devices. Circulation 2012; 125 (24) 3038-3047
• 74 Kato TS, Schulze PC, Yang J. , et al. Pre-operative and post-operative risk factors associated with neurologic complications in patients with advanced heart failure supported by a left ventricular assist device. J Heart Lung Transplant 2012; 31 (01) 1-8
• 75 Parikh NS, Cool J, Karas MG, Boehme AK, Kamel H. Stroke risk and mortality in patients with ventricular assist devices. Stroke 2016; 47 (11) 2702-2706
• 76 Homma S, Thompson JL, Pullicino PM. , et al; WARCEF Investigators. Warfarin and aspirin in patients with heart failure and sinus rhythm. N Engl J Med 2012; 366 (20) 1859-1869
• 77 Kumar G, Goyal MK. Warfarin versus aspirin for prevention of stroke in heart failure: a meta-analysis of randomized controlled clinical trials. J Stroke Cerebrovasc Dis 2013; 22 (08) 1279-1287
• 78 Di Tullio MR, Sacco RL, Sciacca RR, Jin Z, Homma S. Patent foramen ovale and the risk of ischemic stroke in a multiethnic population. J Am Coll Cardiol 2007; 49 (07) 797-802
• 79 Meissner I, Khandheria BK, Heit JA. , et al. Patent foramen ovale: innocent or guilty? Evidence from a prospective population-based study. J Am Coll Cardiol 2006; 47 (02) 440-445
• 80 Kent DM, Dahabreh IJ, Ruthazer R. , et al. Device closure of patent foramen ovale after stroke: pooled analysis of completed randomized trials. J Am Coll Cardiol 2016; 67 (08) 907-917
• 81 Kent DM, Ruthazer R, Weimar C. , et al. An index to identify stroke-related vs incidental patent foramen ovale in cryptogenic stroke. Neurology 2013; 81 (07) 619-625
• 82 Lethen H, Flachskampf FA, Schneider R. , et al. Frequency of deep vein thrombosis in patients with patent foramen ovale and ischemic stroke or transient ischemic attack. Am J Cardiol 1997; 80 (08) 1066-1069
• 83 Cramer SC, Rordorf G, Maki JH. , et al. Increased pelvic vein thrombi in cryptogenic stroke: results of the Paradoxical Emboli from Large Veins in Ischemic Stroke (PELVIS) study. Stroke 2004; 35 (01) 46-50
• 84 Stöllberger C, Slany J, Schuster I, Leitner H, Winkler WB, Karnik R. The prevalence of deep venous thrombosis in patients with suspected paradoxical embolism. Ann Intern Med 1993; 119 (06) 461-465
• 85 Liberman AL, Daruwalla VJ, Collins JD. , et al. Diagnostic yield of pelvic magnetic resonance venography in patients with cryptogenic stroke and patent foramen ovale. Stroke 2014; 45 (08) 2324-2329
• 86 Homma S, Sacco RL, Di Tullio MR, Sciacca RR, Mohr JP. ; PFO in Cryptogenic Stroke Study (PICSS) Investigators. Effect of medical treatment in stroke patients with patent foramen ovale: patent foramen ovale in Cryptogenic Stroke Study. Circulation 2002; 105 (22) 2625-2631
• 87 Kent DM, Dahabreh IJ, Ruthazer R. , et al. Anticoagulant vs. antiplatelet therapy in patients with cryptogenic stroke and patent foramen ovale: an individual participant data meta-analysis. Eur Heart J 2015; 36 (35) 2381-2389
• 88 Furlan AJ, Reisman M, Massaro J. , et al; CLOSURE I Investigators. Closure or medical therapy for cryptogenic stroke with patent foramen ovale. N Engl J Med 2012; 366 (11) 991-999
• 89 Carroll JD, Saver JL, Thaler DE. , et al; RESPECT Investigators. Closure of patent foramen ovale versus medical therapy after cryptogenic stroke. N Engl J Med 2013; 368 (12) 1092-1100
• 90 Meier B, Kalesan B, Mattle HP. , et al; PC Trial Investigators. Percutaneous closure of patent foramen ovale in cryptogenic embolism. N Engl J Med 2013; 368 (12) 1083-1091
• 91 Ntaios G, Papavasileiou V, Makaritsis K, Michel P. PFO closure vs. medical therapy in cryptogenic stroke or transient ischemic attack: a systematic review and meta-analysis. Int J Cardiol 2013; 169 (02) 101-105
• 92 Kitsios GD, Dahabreh IJ, Abu Dabrh AM, Thaler DE, Kent DM. Patent foramen ovale closure and medical treatments for secondary stroke prevention: a systematic review of observational and randomized evidence. Stroke 2012; 43 (02) 422-431
• 93 Otto CMBR. Valvular heart disease. In: Mann DLZD, Libby P, Bonow RO, Braunwald E. , eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. Philadelphia: Elsevier; 2015
• 94 Chandrashekhar Y, Westaby S, Narula J. Mitral stenosis. Lancet 2009; 374 (9697): 1271-1283
• 95 Whitlock RP, Sun JC, Fremes SE, Rubens FD, Teoh KH. Antithrombotic and thrombolytic therapy for valvular disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141: e576S-600S
• 96 Nishimura RA, Otto CM, Bonow RO. , et al; American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 63 (22) e57-e185
• 97 Fox CS, Vasan RS, Parise H. , et al; Framingham Heart Study. Mitral annular calcification predicts cardiovascular morbidity and mortality: the Framingham Heart Study. Circulation 2003; 107 (11) 1492-1496
• 98 Rodriguez CJ, Bartz TM, Longstreth Jr WT. , et al. Association of annular calcification and aortic valve sclerosis with brain findings on magnetic resonance imaging in community dwelling older adults: the cardiovascular health study. J Am Coll Cardiol 2011; 57 (21) 2172-2180
• 99 Kohsaka S, Jin Z, Rundek T. , et al. Impact of mitral annular calcification on cardiovascular events in a multiethnic community: the Northern Manhattan Study. JACC Cardiovasc Imaging 2008; 1 (05) 617-623
• 100 Cannegieter SC, Rosendaal FR, Wintzen AR, van der Meer FJ, Vandenbroucke JP, Briët E. Optimal oral anticoagulant therapy in patients with mechanical heart valves. N Engl J Med 1995; 333 (01) 11-17
• 101 Cannegieter SC, Rosendaal FR, Briët E. Thromboembolic and bleeding complications in patients with mechanical heart valve prostheses. Circulation 1994; 89 (02) 635-641
• 102 Daneault B, Kirtane AJ, Kodali SK. , et al. Stroke associated with surgical and transcatheter treatment of aortic stenosis: a comprehensive review. J Am Coll Cardiol 2011; 58 (21) 2143-2150
• 103 Yanagawa B, Pettersson GB, Habib G. , et al. Surgical management of infective endocarditis complicated by embolic stroke: practical recommendations for clinicians. Circulation 2016; 134 (17) 1280-1292
• 104 Baddour LM, Wilson WR, Bayer AS. , et al; American Heart Association Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in the Young, Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and Stroke Council. Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Scientific Statement for Healthcare Professionals From the American Heart Association. Circulation 2015; 132 (15) 1435-1486
• 105 Karalis DG, Quinn V, Victor MF. , et al. Risk of catheter-related emboli in patients with atherosclerotic debris in the thoracic aorta. Am Heart J 1996; 131 (06) 1149-1155
• 106 Katz ES, Tunick PA, Rusinek H, Ribakove G, Spencer FC, Kronzon I. Protruding aortic atheromas predict stroke in elderly patients undergoing cardiopulmonary bypass: experience with intraoperative transesophageal echocardiography. J Am Coll Cardiol 1992; 20 (01) 70-77
• 107 Cohen A, Tzourio C, Bertrand B, Chauvel C, Bousser MG, Amarenco P. ; FAPS Investigators. French Study of Aortic Plaques in Stroke. Aortic plaque morphology and vascular events: a follow-up study in patients with ischemic stroke. Circulation 1997; 96 (11) 3838-3841
• 108 Amarenco P, Cohen A, Tzourio C. , et al. Atherosclerotic disease of the aortic arch and the risk of ischemic stroke. N Engl J Med 1994; 331 (22) 1474-1479
• 109 Blackshear JL, Zabalgoitia M, Pennock G. , et al. Warfarin safety and efficacy in patients with thoracic aortic plaque and atrial fibrillation. SPAF TEE Investigators. Stroke prevention and atrial fibrillation. Transesophageal echocardiography. Am J Cardiol 1999; 83 (03) 453-455 , A9
• 110 Di Tullio MR, Russo C, Jin Z, Sacco RL, Mohr JP, Homma S. ; Patent Foramen Ovale in Cryptogenic Stroke Study Investigators. Aortic arch plaques and risk of recurrent stroke and death. Circulation 2009; 119 (17) 2376-2382
• 111 Amarenco P, Davis S, Jones EF. , et al; Aortic Arch Related Cerebral Hazard Trial Investigators. Clopidogrel plus aspirin versus warfarin in patients with stroke and aortic arch plaques. Stroke 2014; 45 (05) 1248-1257
• 112 Hiratzka LF, Bakris GL, Beckman JA. , et al; American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines; American Association for Thoracic Surgery; American College of Radiology; American Stroke Association; Society of Cardiovascular Anesthesiologists; Society for Cardiovascular Angiography and Interventions; Society of Interventional Radiology; Society of Thoracic Surgeons; Society for Vascular Medicine. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the diagnosis and management of patients with thoracic aortic disease. A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology,American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons,and Society for Vascular Medicine. J Am Coll Cardiol 2010; 55 (14) e27-e129
• 113 Keeling IM, Oberwalder P, Anelli-Monti M. , et al. Cardiac myxomas: 24 years of experience in 49 patients. Eur J Cardiothorac Surg 2002; 22 (06) 971-977
• 114 Wang Z, Chen S, Zhu M. , et al. Risk prediction for emboli and recurrence of primary cardiac myxomas after resection. J Cardiothorac Surg 2016; 11: 22
• 115 Selkane C, Amahzoune B, Chavanis N. , et al. Changing management of cardiac myxoma based on a series of 40 cases with long-term follow-up. Ann Thorac Surg 2003; 76 (06) 1935-1938
• 116 Sun JP, Asher CR, Yang XS. , et al. Clinical and echocardiographic characteristics of papillary fibroelastomas: a retrospective and prospective study in 162 patients. Circulation 2001; 103 (22) 2687-2693
• 117 Gowda RM, Khan IA, Nair CK, Mehta NJ, Vasavada BC, Sacchi TJ. Cardiac papillary fibroelastoma: a comprehensive analysis of 725 cases. Am Heart J 2003; 146 (03) 404-410