PFO, push-ups and heavy lifting; valsalva provocation before cryptogenic stroke

Author(s): Elle Wade, Martha Robinson, Atul Singla, Aimee Aysenne, Justin A. Salerian

Background: Patent Foramen Ovale (PFO) can serve as a conduit for paradoxical embolus or as a nidus itself for thrombus formation in Cryptogenic Stroke (CS). Debate for PFO closure is ongoing but favors closure in well-selected patients. Four randomized-control trials demonstrated a reduction in stroke recurrence with PFO closure. Patients were selected with high-risk PFO features in DEFENSE-PFO and CLOSE trials.

Cases: This case series describes four patients with CS immediately following or during exercise- induced-Valsalva: Push-ups, bench pressing, and lifting heavy boxes. PFOs with severe shunting during Valsalva were demonstrated with bubble echocardiograms in all cases.

Conclusion: Recent clinical trials have shown benefit of percutaneous PFO closure, especially in younger patients with high-risk PFO features. Valsalva-like straining may provide the hemodynamic terminal-step for embolism to occur in CS patients with PFO. Future PFO-closure screening tools should consider Valsalva-like straining as a criterion towards closure.