A 22-year-old female is on chronic remission treatment for ulcerative colitis, initially presented acutely after experiencing a sudden loss of vision in the right eye. This was found to be secondary to an acute occlusion of the retinal artery. During her hospitalization, she experienced a sudden weakness in the left side of her body. The weakness gradually resolved over 72 hours of onset. The patient was evaluated by the attending medical services and was diagnosed to have a cryptogenic stroke with recurrent embolization. She was initiated on low dose aspirin and the novel oral anticoagulant rivaroxaban.
As part of the screening of the embolization source, the patient had a magnetic resonance angiography of the brain which revealed nonspecific bilateral periventricular and subcortical white matter hyperintense foci. Ultrasound Doppler of both carotid arteries was negative. The screening for hematologic hypercoagulable conditions, autoimmune disease, and heparin induced thrombocytopenia was also negative. The holter ECG surveillance showed no evidence of arrhythmia. The tras-thoracic echocardiography revealed a small PFO with a restricted shunt from the left to the right side. Further cardiac evaluation by trans-esophageal echocardiography yielded a small fenestrated secondum ASD (0.8 cm x 1.2 cm) associated with mild right ventricular volume overload. The rest of the cardiac imaging was non-significant. Both the mitral and aortic valves were normal in structure and function with no evident clots in the left atrial appendage.
After addressing the patient’s condition in the combined interventional cardiology and cardiac surgery meeting, it was decided that the patient would be better served by a surgical closure of the ASD as opposed to a device closure. The fenestrated ASD and the inability to conclusively exclude a possible embolization source within the heart by imaging were strong points for the surgical closure. The heart was approached via a median sternotomy. Cardio-pulmonary bypass was initiated through direct aortic and bi-caval cannulation. The heart was arrested with blood cardioplegia and the right atrium was opened. The fenestrated ASD and the floppy rims were conglomerated in one clean defect. Further inspection of the left heart through the defect was seemingly insignificant except when the cooptation margins of the P2/A2 scallops of the mitral valve leaflets were pulled in view from the left ventricular cavity. Two discrete masses (0.3 cm x 0.2 cm x 0.2 cm) were adherent to the margins of the P2/A2 scallops. They were easily picked-out with a tissue forceps (see supplementary video). The site of the extracted mass left a central mitral regurgitation jet which was negated by placing an annuoplasty band.
Post-operatively, the patient made a quick recovery. Her post-operative echocardiographic study showed no residual shunting and a normally functioning mitral valve. She was discharged home on aspirin and rivaroxabam for 3 months, then to continue treatment with low dose aspirin indefinitely. Both the histopathology and culture of the specimens were negative for any organisms or growth. The findings were consistent with a mature clot formation. The patient continues to do well on all subsequent clinic visits.