The management of patients with patent foramen ovale and stroke

Patent foramen ovale closure in the management of cryptogenic stroke: a review of current literature and guideline statements

OBJECTIVE

The management recommendations for patent foramen ovale (PFO) closure in cryptogenic stroke are rapidly evolving. The data has expanded recently with four major trials demonstrating superiority of percutaneous device closure over medical management in preventing cryptogenic stroke recurrence. This paper aims to review the current literature for referring physicians who may encounter patients with patent foramen ovale before referring these patients to stroke specialists and/or interventional cardiologists.

METHOD

For this Narrative review, we conducted a broad literature search with expert selection of relevant data. Our search included a review of the currently available trials, guideline statements, position papers, cost-effectiveness of device closure data, as well as the impact of device closure on quality of life.

RESULTS

Most European societies are now in favor of evaluating all patients aged 60 years or younger with recent cryptogenic stroke in the setting of a PFO after careful consideration of the patient's echocardiographic and clinical risk factors. On the other hand, American societies, except for the American Academy of Neurology, have not yet passed official updated recommendations.

CONCLUSION

PFO closure can be considered for the prevention of recurrent cryptogenic stroke in patients aged ≤60 years after a thorough evaluation and discussion about benefits and potential risks (including but not limited to atrial fibrillation) of the procedure. Accumulating evidence supports prognostic, quality of life, and economic benefit from percutaneous PFO closure with newer generation closure devices in the right subset of patients.

HIGHLIGHTS

Data from 4 major trials (RESPECT, CLOSE, DEFENSE-PFO, REDUCE) demonstrates the superiority of PFO closure over medical management alone in preventing cryptogenic stroke recurrence. Trials investigated mostly patients ≤60 years old, and therefore results may not be generalizable to the entire population. Further randomized trials evaluating the safety and efficacy of PFO closure in patients older than 60 years are warranted.Atrial fibrillation is one of the most common "occult" causes of cryptogenic stroke and should be excluded by ambulatory electrocardiographic monitoring. It is important to also rule out other causes of stroke, including hypercoagulable states, atherosclerotic lesions, other cardioembolic sources, and arterial dissection.Complications of PFO procedure include new-onset AF, development of scar tissue, risk of aortic root dilation and subsequent erosions, and potential thrombi formation on the device.PFO closure with medical therapy is more cost-effective than medical therapy alone.Patients who underwent PFO closure had lower rates of depression, anxiety, and stress compared to those who did undergo closure.Development of the RoPE score has helped clinicians identify patients with cryptogenic stroke and PFO who might be a candidate for PFO closure. A score of 7, 8, and 9-10 corresponds to a causal risk of 72%, 84%, and 88%, respectively, and defines a subset of patients who may benefit from PFO closure.Current guidelines recommend determining the need for PFO closure on a case-by-case basis, depending on risk factors, in patients age 60 or less with recent cryptogenic stroke in the setting of PFO.

Transesophageal echocardiography in patients with cryptogenic stroke: does it alter their management? A 3-year retrospective study in a single non-referral centre

BACKGROUND

Cardiac embolism is estimated to be the aetiology of ischemic cerebral-vascular insults (CVI) in 25% of cases. Transesophageal echocardiography (TEE) is a reliable and widely used examination in the diagnosticwork-up of stroke. TEE is superior to transthoracic echocardiography (TTE) in the search of minor sources of cardiac embolism but it is time consuming and has its inherent risks.

AIM

The aim of this study was to determine whether in patients younger than 65 years of age with CVI our TEE-findings would alter their management. Only patients in whom nor the medical record, nor TTE, nor Carotid Ultrasonography could establish an aetiology, were included.

METHODS

A 3-year retrospective study was done in patients admitted to the stroke unit of a regional medical centre covering 110,000 inhabitants. The TEE-database was reviewed and all TEE's performed in eligible patients were selected. Minor and major sources of cardiac embolism were listed. The impact of TEE-findings on the management of CVI was evaluated.

RESULTS

Fifty-four patients fulfilled the criteria for this study. The mean age was 52 years (range 18 - 65). A major source of cardiac embolism was seen in 6 cases (11.1%). Four patients (7.4%) had infective endocarditis (IE) with vegetations. A small apical thrombosis in a patient with isolated left ventricular non-compaction was noted and in 1 patient dysfunction of a mechanical prosthetic valve was documented. The most frequently encountered minor source of cardiac embolism was a patent foramen ovale (PFO) or small atrial septal defect (ASD) with documented right-to-left shunt during Valsalva manoeuvre (15 patients, 27.8%). Of these 15 patients, an atrial septum aneurysm(ASA) was seen in 7 patients (13%). Our TEE-findings altered the management of CVI substantially in 21 cases (38.9%). The 4 patients with IE and the patient with mechanical valve dysfunction had cardiac surgery. Twelve patients (22.2%) were referred for percutaneous closure of the PFO/ASD. Three patients with PFO/ASD and the patient with IVNC were treated with maintenance therapy of oral anticoagulation.

CONCLUSION

In 1 out of 3 patients, younger than 65 years, suffering from CVI in whom nor medical history, nor TTE, nor Carotid Ultrasound could reveal the cause of the CVI our TEE-findings altered their management.