2 | CASE REPORT
A 74-year-old woman with sudden right hemiparesis was admitted to our
hospital with a diagnosis of acute ischemic stroke. She was treated with
intravenous tissue plasminogen
activator and thrombectomy in the left M2 segment of the middle cerebral
artery, after which her symptoms improved remarkably (modified Rankin
scale 0). The patient met the criteria of ESUS and a thorough
examination was performed to determine the cause. Transesophageal
echocardiography showed minor plaque formation in the aortic arch (a
potential cause of aortogenic embolism) and absence of a patent foramen
ovale (a potential cause of paradoxical embolism). Although CPAF was not
identified by telemetry at admission, it was suspected and we decided to
implant an ICM device. However, SIT was observed by chest X-ray. Thus,
the ICM device was implanted into the right chest in a symmetrical
position (Figure 1).
We used fluoroscopy to locate the heart. An ICM (BIOMONITOR
IIITM; Biotronik, Berlin, Germany) was then inserted
into the right margin of the 3rd to
6th intercostal sternum along the long axis shadow of
the heart using the provided tools. The procedure duration was 5 min and
the fluoroscopy time was 15 s. There were no complications during the
procedure.
AF was successfully detected at 28 days after ICM insertion (Figure 2A).
Figure 2B shows the sudden drop rate alarm, the feature unique to the
BIOMONITOR III⢠device. It shows the moment when rhythm changed from AF
to sinus rhythm. P wave can be clearly seen during the sinus rhythm. AF
was then detected on a number of occasions.
Aspirin was used initially for prevention of recurrent ischemic stroke.
However, we changed to edoxaban after CPAF was detected.