Patent foramen ovale closure for secondary prevention of cryptogenic stroke

ABSTRACT

Introduction: A patent foramen ovale (PFO) is highly prevalent among the adult population. It allows shunting of blood through the inter-atrial septum and has been associated with cryptogenic stroke, transient ischemic attack, platypnea–orthodeoxia syndrome, decompression sickness (e.g. deep-water divers), and migraines.

Areas Covered: In this manuscript, we will review the anatomy of PFO with particular emphasis on the factors associated with increased risk of paradoxical embolization, as well as the different modalities for the diagnosis of PFO. We will discuss medical, surgical, and transcatheter therapy for secondary prevention in patients with PFO and cryptogenic stroke, and summarize the data from observational studies, randomized controlled trials (RCTs), and meta-analysis of RCTs that have established the beneficial effect of transcatheter PFO closure in this patient population. Finally, we will provide a brief overview of the role of transcatheter PFO closure in patients with migraine.

Expert Opinion: Transcatheter closure is the preferred treatment option in young (<60 years) patients with PFO and cryptogenic stroke. A multi-disciplinary approach with input from clinical cardiologist, neurologist, hematologist, cardiac surgeon, and interventional cardiologist provides the best therapeutic plan for each patient taking into account the available data, but also medical, social, and occupational considerations.

KEYWORDS:

• Patent foramen ovale
• PFO closure
• cryptogenic stroke
• transient ischemic attack
• migraine

Article highlights

• A patent foramen ovale (PFO) is present in approximately 50% of young patients presenting with ischemic stroke.

• Contrast-enhanced transesophageal echocardiography, transthoracic echocardiography, and transcranial doppler are the imaging modalities of choice for the diagnosis of PFO and right-to-left shunting.

• Anatomical characteristics of a ‘high-risk’ PFO include size >2 mm, atrial septal aneurysm, prominent Eustachian valve, and large (≥20 microbubbles) right-to-left shunt.

• The term ‘PFO-associated stroke’ (instead of cryptogenic stroke) should be used in patients presenting with an embolic infarct and with a medium-risk to high-risk PFO in whom other causes of ischemic stroke have been excluded.

• Based on evidence from recent randomized controlled trials, transcatheter PFO closure is the treatment of choice in young (<60 years of age) patients with PFO-associated stroke.

• The safety and efficacy of PFO closure in older patients >60 years of age with PFO-associated stroke, the optimal strategy and duration of antiplatelet therapy following PFO closure, and the role of PFO closure in patients with migraine, decompression sickness, and platypnea-orthodeoxia syndrome warrant further investigation.

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

 A reviewer on this manuscript has disclosed that they receive tutor fees from Abbott. Peer reviewers on this manuscript have no other relevant financial relationships or otherwise to disclose.

Additional information

Funding

This paper was not funded.