Closing the gap on patent foramen ovale and cryptogenic stroke

ABSTRACT

Introduction: The treatment options for prevention of recurrent of cryptogenic stroke in patients with patent foramen ovale (PFO) have been intensely debated in the recent decades. The suggested options were percutaneous closure of PFO versus medical therapy. However, up to these date there is a controversy regarding the indication of percutaneous closure. Multiple meta-analysis and recent randomized control trials showed the benefit of PFO closure when compared with medical therapy alone.

Areas covered: The article reviews the prevalence, physiology, diagnosis and treatment options of PFO after cryptogenic stroke. Furthermore, it will discuss the results of randomized control trials that compared the PFO closure to medical therapy.

Expert opinion: The association between PFO and unexplained cryptogenic stroke has been well established in the multiple studies. The diagnosis and management of PFO might be challenging in some cases. Although multiple studies showed that PFO closure is associated with lower rates of recurrent stroke in patients presenting with cryptogenic stroke, the indication and patient selection for this intervention are not well established yet in the guidelines.

KEYWORDS:

• PFO closure
• medical therapy
• diagnosis
• prevalence
• PFO physiology
• Stroke

Article highlights

• 40% of ischemic strokes have unknown etiology and called “cryptogenic strokes. 25% of foramen ovale remains patent during adulthood

• TEE with bubble study is considered the gold standard test for PFO detection. However, it requires sedation. Transthoracic echocardiography is considered an acceptable alternative modality with high sensitivity and specificity.

• Patients under 60 years old with cryptogenic stroke and contraindication for anticoagulation. PFO closure + antiplatelet is recommended (weak).

• Patients who refuse or have contraindication for PFO closure. Anticoagulation rather than antiplatelet is recommended.

• The optimal choice for recurrent stroke prevention in PFO patients is not established in the guidelines yet. Further research study is required to set the criteria for patient selection who can get the benefit from PFO closure or optimizing medical therapy regimen.

• PFO closure should be team-approach that include neurologist, cardiologist, interventional and congenital cardiologist.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer Disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.