Journal of Postgraduate Medicine Medknow Publications and Staff Society of Seth GS Medical College and KEM Hospital, Mumbai, India ISSN: 0022-3859 EISSN: 0972-2823 Vol. 50, Num. 4, 2004, pp. 309-309

Journal of Postgraduate Medicine, Vol. 50, No. 4, October-December, 2004, pp. 309

Letter To Editor

Cerebral infarction in a 17-year old boy – Is it truly primary APLA syndrome?

Namboodiri KKN, Krishnamoorthy KM, Rajeev E

Department of Cardiology, Sri Chitra Institute Of Science And Technology, Thiruvananthapuram
Correspondence Address:Department of Cardiology, Sri Chitra Institute Of Science And Technology, Thiruvananthapuram, kknnamboodiri@sctimst.ac.in

Code Number: jp04105

Sir,

The grand-round case by Kubba S et al. in July issue of the Journal was interesting.[1] We would like to offer some remarks.

First, while determining the appropriate therapy for patients with stroke and patent foramen ovale (PFO), a distinction has to be made between those with an ′innocent′ PFO and those with a causative PFO. This has important treatment implications.[2] The index patient does not come under the second group i.e. the subset that needs consideration for closure of PFO. Valvular lesions and bradyarrhyhmias themselves can account for stroke in this case. Closure of PFO in these cases will not require these patients from being on oral anticoagulants, if lupus anticoagulant (LA) was presumed to be truly positive. However if mitral valve repair is being planned, concomitant PFO closure can be contemplated.

Secondly, different authors have found variable positivity of LA varying from 16%-40% in stroke patients. Positivity does not carry any significance if patients are on warfarin. The status of warfarin therapy at the time of sampling is not clear in the index case. Moreover, quantitative estimation should have been done as false positivity is reported with various conditions. Medium or high titres only help to identify patients at risk for thrombosis.[3] Attributing mitral regurgitation and, even complete heart block (CHB) to LA in such a setting appears incorrect. Lifelong oral anticoagulant therapy, with its antecedent risk, is not advisable without proper evaluation in such patients.

In the index case, the history of syncope justifies permanent pacemaker implantation (PPI). But, not all patients with isolated CHB should receive PPI, unlike what is mentioned in the article. Congenital third-degree atrioventricular block in an asymptomatic neonate, child, or adolescent with a narrow QRS complex of acceptable rate and normal ventricular function is only a class 2 b indication for PPI.[4]

REFERENCES

1.	Kubba S, Rohit MK, Vijayvergiya R, Singh T. Cerebral infarction in a 17-year-old boy. J Postgrad Med 2004;50:123-4.   Back to cited text no. 1  [PUBMED]  [FULLTEXT] [BIOLINE]
2.	McGraw D, Harper R. Patent foramen ovale and cryptogenic cerebral infarction. Intern Med J 2001;31:42-7.  Back to cited text no. 2
3.	Galli M, Luciani D, Bertolini G, Barbui T. Lupus anticoagulants are stronger risk factors for thrombosis than anticardiolipin antibodies in the antiphospholipid syndrome: a systematic review of the literature. Blood 2003;101:1827-32.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.	Gregoratos G, Cheitlin MD, Conill A, Epstein AE, Fellows C, Ferguson TB Jr, et al. ACC/AHA guidelines for implantation of cardiac pacemakers and antiarrhythmia devices: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Pacemaker Implantation). J Am Coll Cardiol 1998;31:1175-209.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]

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