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Voudris KV, Poulin MF, Kavinsky CJ. Updates on Patent Foramen Ovale (PFO) Closure. Curr Cardiol Rep 2024:10.1007/s11886-024-02073-y. [PMID: 38913234 DOI: 10.1007/s11886-024-02073-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/13/2024] [Indexed: 06/25/2024]
Abstract
PURPOSE OF REVIEW Patent foramen ovale (PFO) has been previously linked to left circulation thromboembolism and stroke. This review article aims to discuss the latest evidence, updated societal guidelines, diagnostic algorithms and novel therapeutic devices for PFO closure. RECENT FINDINGS PFO closure for cryptogenic stroke and systemic embolization is supported by a large body of evidence and has a strong societal recommendation. Limited data are available for platypnea-orthodeoxia syndrome, although closure appears to be beneficial. Current data do not support routine closure for migraines and decompression Illness. Development of heart-brain teams can improve identification of patients most likely to benefit from closure, utilizing a combination of imaging test and risk score algorithms. Multiple novel devices aiming at reducing complications and improving the long-term impact of current available devices are being evaluated. PFO closure has significantly progressed over the last years, with new data supporting its superiority in reducing risk of recurrent embolic stroke in patients with PFO-related stroke. Additional clinical data are required to provide further refinements on patient selection and guidance on treatment of specific subgroups.
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Affiliation(s)
- Konstantinos V Voudris
- Center for Valve and Structural Heart Disease, Minneapolis Heart Institute, Minneapolis, MN, USA
| | - Marie-France Poulin
- Department of Medicine, Cardiovascular Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, 185 Pilgrim Street, Baker 4, Boston, MA, 02215, USA
| | - Clifford J Kavinsky
- Department of Medicine, Cardiovascular Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, 185 Pilgrim Street, Baker 4, Boston, MA, 02215, USA.
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Karagianni A, Mandalenakis Z, Papadopoulos S, Dellborg M, Eriksson P. Long-term outcome after closure of an atrial shunt in patients aged 60 years or older with ischemic stroke: A nationwide, registry-based, case-control study. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2023. [DOI: 10.1016/j.ijcchd.2022.100438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
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Bianco C, Issaurat P, Vallet H. Désaturation et accident vasculaire cérébral chez une patiente âgée aux urgences : quand le foramen s’en mêle ! ANNALES FRANCAISES DE MEDECINE D URGENCE 2022. [DOI: 10.3166/afmu-2022-0374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Thaler A, Kvernland A, Kelly S, Song C, Aparicio HJ, Mac Grory B, Yaghi S. Stroke Prevention in Patients with Patent Foramen Ovale. Curr Cardiol Rep 2021; 23:183. [PMID: 34718891 DOI: 10.1007/s11886-021-01605-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/31/2021] [Indexed: 01/10/2023]
Abstract
PURPOSE OF REVIEW Patent foramen ovale (PFO) is widely prevalent and studies have suggested an association with ischemic stroke. In this review, we aim to highlight current management of patients with ischemic stroke in the setting of PFO and discuss some areas of controversy. RECENT FINDINGS Upon reviewing the literature, we have found that the evidence regarding the management of patients with cryptogenic stroke and PFO has come a long way in the past several years, and many uncertainties remain in clinical practice. The Risk of Paradoxical Embolism (RoPE) score helps to predict the probability of a pathogenic PFO, and recent trial data confirms the benefit of closure in carefully selected patients. The benefit of closure in older patients and in patients with alternate, competing mechanisms is still uncertain, and the long-term risks of closure are not known. Finally, the efficacy of direct oral anticoagulants (DOACs) in this patient population as compared to other medical therapy or mechanical closure has not yet been investigated. Randomized data is needed to help answer these questions. PFO closure is a safe and effective strategy in reducing stroke risk in carefully selected patients with cryptogenic stroke in the setting of a PFO. More studies are needed to test optimal medical treatment strategies and the safety and efficacy of PFO closure in patient subgroups not included in prior PFO closure trials.
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Affiliation(s)
- Alison Thaler
- Department of Neurology, New York University Grossman School of Medicine, New York, NY, USA
| | - Alexandra Kvernland
- Department of Neurology, New York University Grossman School of Medicine, New York, NY, USA
| | - Sean Kelly
- Department of Neurology, New York University Grossman School of Medicine, New York, NY, USA
| | - Christopher Song
- Department of Internal Medicine, Brown University, Providence, RI, USA
| | - Hugo J Aparicio
- Department of Neurology, Boston University, Boston, MA, USA
- Department of Neurology, Boston Medical Center, Boston, MA, USA
| | | | - Shadi Yaghi
- Department of Neurology, Brown University, 593 Eddy Street APC 5, Providence, RI, 02903, USA.
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Montoro LC, Ortiz MR, Hurtado NP, Ortega MD, Almodovar AR, Saint-Gerons JMS, Bellido FM, Sepulveda JJO, Moyano RV, Moreno MAR, Alvarez-Ossorio MP, Rubio MDM. Impact on daily clinical practice of the latest evidence on percutaneous closure of patent foramen ovale after cryptogenic stroke: a single-center experience. Neurol Sci 2021; 43:1865-1871. [PMID: 34383161 DOI: 10.1007/s10072-021-05524-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 07/25/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION AND OBJECTIVES At the end of 2017, three clinical trials demonstrated that, in selected patients, percutaneous closure of patent foramen ovale (PFO) after cryptogenic stroke (CS) reduces the risk of recurrence. Our aim was to determine the impact of these findings on routine clinical practice in a tertiary hospital. METHODS Patients with CS and percutaneous closure of PFO during 2001-2020 were included. The clinical characteristics of the patient and the anatomical characteristics of the foramen were analyzed. Based on both, the closure indications were classified into three groups according to the latest European recommendations and were analyzed in two periods, before and after the publication date of the clinical trials. RESULTS A total of 293 patients were included. The mean age was 49 ± 11 years, and 15% were older than 60 years. The median RoPE score was 6 [p25-75, 5-7] and 75% had complex anatomy (CA). After the publication of the studies, the frequency of CA and the mean age of the patients were significantly higher (89% vs. 69% p < 0.0005 and 51 ± 11 vs. 48 ± 11 years, p = 0.02, respectively), and the RoPE score, significantly lower (5 [5-7] versus 6 [5-7], p = 0.02). Inadequate closure indications were significantly reduced (8% vs. 18%, p = 0.02). CONCLUSION After the publication of clinical trials that have shown benefit of PFO closure after CS, the number of inappropriate indications for closure has decreased significantly in our institution, with a higher percentage of CA, despite a clinical profile suggestive of lower causal probability of PFO.
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Affiliation(s)
- Lucia Carnero Montoro
- Cardiology Service, Reina Sofia University Hospital, Avenue Menendez Pidal s/n, 14004, Cordoba, Spain.
| | - Martin Ruiz Ortiz
- Cardiology Service, Reina Sofia University Hospital, Avenue Menendez Pidal s/n, 14004, Cordoba, Spain
| | - Nick Paredes Hurtado
- Cardiology Service, Reina Sofia University Hospital, Avenue Menendez Pidal s/n, 14004, Cordoba, Spain
| | - Monica Delgado Ortega
- Cardiology Service, Reina Sofia University Hospital, Avenue Menendez Pidal s/n, 14004, Cordoba, Spain
| | - Ana Rodriguez Almodovar
- Cardiology Service, Reina Sofia University Hospital, Avenue Menendez Pidal s/n, 14004, Cordoba, Spain
| | | | | | | | | | | | | | - Maria Dolores Mesa Rubio
- Cardiology Service, Reina Sofia University Hospital, Avenue Menendez Pidal s/n, 14004, Cordoba, Spain
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Eskandari S, Jalali P. Relationship between patent foramen ovale and COVID-19 in patients admitted to an intensive care unit. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2021; 74:725-726. [PMID: 34030947 PMCID: PMC8096169 DOI: 10.1016/j.rec.2021.04.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 04/23/2021] [Indexed: 01/11/2023]
Affiliation(s)
- Saber Eskandari
- Department of Nursing, School of Nursing & Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Pooya Jalali
- Department of Medicine, Islamic Azad University Tabriz Branch, Tabriz, Iran.
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Eskandari S, Jalali P. [Relationship between patent foramen ovale and COVID-19 in patients admitted to an intensive care unit]. Rev Esp Cardiol 2021; 74:725-726. [PMID: 34092897 PMCID: PMC8166536 DOI: 10.1016/j.recesp.2021.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Saber Eskandari
- Department of Nursing, School of Nursing & Midwifery, Shahid Beheshti University of Medical Sciences, Teherán, Irán
| | - Pooya Jalali
- Department of Medicine, Islamic Azad University Tabriz Branch, Teherán, Irán
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Abstract
Patent foram ovale (PFO) is the most common anatomical cause of an interarterial shunt. It is usually asymptomatic but may cause paradoxical embolism and is a risk factor for non-lacunar cryptogenic cerebral ischemia in young adults. Although the first clinical trials did not show a significant superiority of PFO closure in the secondary prevention of cerebral ischemia as compared with standard antithrombotic treatment, six subsequent randomized clinical trials (CLOSURE I, PC Trial, RESPECT, CLOSE, REDUCE, and DEFENSE-PFO) performed in a sample of cryptogenic stroke in patients aged 60 years or younger provided evidence of a significant reduction of recurrent cerebral ischemia after percutaneous PFO closure. However, the use of percutaneous PFO closure cannot be generalized to the entire population of patients with cerebral ischemia and PFO, but it is indicated in highly selected patients with non-lacunar cryptogenic cerebral infarction with a large right-to-left shunt, an atrial septal aneurysm and no evidence of atrial fibrillation, as well as in association with antithrombotic treatment for an optimal secondary prevention of cerebral ischemia.
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Masjuan J, García-Madrona S, de Felipe A. Cierre del foramen oval permeable en el ictus criptogénico, ¿también en mayores de 60 años? Rev Esp Cardiol (Engl Ed) 2020. [DOI: 10.1016/j.recesp.2019.09.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Masjuan J, García-Madrona S, de Felipe A. Closure of patent foramen ovale in cryptogenic stroke: also in patients older than 60 years? ACTA ACUST UNITED AC 2019; 73:197-199. [PMID: 31882391 DOI: 10.1016/j.rec.2019.09.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 09/27/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Jaime Masjuan
- Servicio de Neurología, Hospital Universitario Ramón y Cajal, Departamento de Medicina, Facultad de Medicina, Universidad de Alcalá, IRYCIS, Madrid, Spain.
| | - Sebastián García-Madrona
- Servicio de Neurología, Hospital Universitario Ramón y Cajal, Departamento de Medicina, Facultad de Medicina, Universidad de Alcalá, IRYCIS, Madrid, Spain
| | - Alicia de Felipe
- Servicio de Neurología, Hospital Universitario Ramón y Cajal, Departamento de Medicina, Facultad de Medicina, Universidad de Alcalá, IRYCIS, Madrid, Spain
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