Management of patent foramen ovale in embolic stroke of undetermined source patients: Malaysian experts' consensus.

INTRODUCTION: About 20 to 40% of ischaemic stroke causes are cryptogenic. Embolic stroke of undetermined source (ESUS) is a subtype of cryptogenic stroke which is diagnosed based on specific criteria. Even though patent foramen ovale (PFO) is linked with the risk of stroke, it is found in about 25% of the general population, so it might be an innocent bystander. The best way to treat ESUS patients with PFO is still up for discussion. MATERIALS AND METHODS: Therefore, based on current evidence and expert opinion, Malaysian expert panels from various disciplines have gathered to discuss the management of ESUS patients with PFO. This consensus sought to educate Malaysian healthcare professionals to diagnose and manage PFO in ESUS patients based on local resources and facilities. RESULTS: Based on consensus, the Malaysian expert recommended PFO closure for embolic stroke patients who were younger than 60, had high RoPE scores and did not require long-term anticoagulation. However, the decision should be made after other mechanisms of stroke have been ruled out via thorough investigation and multidisciplinary evaluation. The PFO screening should be made using readily available imaging modalities, ideally contrasttransthoracic echocardiogram (c-TTE) or contrasttranscranial Doppler (c-TCD). The contrast-transesophageal echocardiogram (c-TEE) should be used for the confirmation of PFO diagnosis. The experts advised closing PFO as early as possible because there is limited evidence for late closure. For the post-closure follow-up management, dual antiplatelet therapy (DAPT) for one to three months, followed by single antiplatelet therapy (APT) for six months, is advised. Nonetheless, with joint care from a cardiologist and a neurologist, the multidisciplinary team will decide on the continuation of therapy.

Infective endocarditis caused by Brucella melitensis: a case report highlighting the importance of history taking and laboratory analysis.

We present a case of Brucella endocarditis in a 13 year old patient with known aortic stenosis. She was admitted to the National Heart Institute/Institut Jantung Negara, Malaysia with complains of fever, pain and swelling of left knee. Transthoracic echocardiography and transesophageal echocardiography showed no evidence of vegetations on the aortic valve. Differential diagnosis was made based on clinical manifestations, positive serology tests and isolation of Brucella melitensis from blood culture. The patient has a history of consumption of unpasteurised goat's milk prior to clinical symptoms. Although rare, the case emphasize that Brucella could be a potential complication of infective endocarditis (IE) involving patient who consumed unpasteurised goat's milk. The diagnosis of bacterial endocarditis based on clinical findings and supported by laboratory results has led to the appropriate treatment of this patient. To the best of our knowledge, this is the first case reported for Brucella endocarditis in Malaysia.