Patent foramen ovale increases stroke risk in older people

Advances in the management of cardioembolic stroke associated with patent foramen ovale

Patent foramen ovale (PFO) describes a valve in the interatrial septum that permits shunting of blood or thrombotic material between the atria. PFOs are present in approximately 25% of the healthy population and are not associated with any pathology in the vast majority of cases. However, comparisons between patients with stroke and healthy controls suggest that PFOs may be causative of stroke in certain patients whose stroke is otherwise cryptogenic. Options for the diagnosis of PFO include transthoracic echocardiography, transesophageal echocardiography, and transcranial Doppler ultrasonography. PFOs associated with an interatrial septal aneurysm seem to be more strongly linked to risk of recurrent stroke. Therapeutic options for secondary stroke prevention in the setting of a PFO include antiplatelet therapy, anticoagulation, and percutaneous device closure. Recent randomized clinical trials suggest that percutaneous closure reduces the subsequent risk of stroke in appropriately selected patients, with a large relative benefit but small absolute benefit. Referral for percutaneous PFO closure should therefore be considered in certain patients after a multidisciplinary, patient centered discussion. Areas for future study include structural biomarkers to aid in determining the role of PFO closure in older people with possible PFO associated stroke, the role of direct oral anticoagulants, and very long term outcomes after device closure.

Prior Stroke in PFO Patients Is Associated With Both PFO-Related and -Unrelated Factors

Background and Purpose: To identify factors associated with prior stroke at presentation in patients with cryptogenic stroke (CS) and patent foramen ovale (PFO).

Methods: We studied cross-sectional data from the International PFO Consortium Study (NCT00859885). Patients with first-ever stroke and those with prior stroke at baseline were analyzed for an association with PFO-related (right-to-left shunt at rest, atrial septal aneurysm, deep venous thrombosis, pulmonary embolism, and Valsalva maneuver) and PFO-unrelated factors (age, gender, BMI, hypertension, diabetes mellitus, hypercholesterolemia, smoking, migraine, coronary artery disease, aortic plaque). A multivariable analysis was used to adjust effect estimation for confounding, e.g., owing to the age-dependent definition of study groups in this cross-sectional study design.

Results: We identified 635 patients with first-ever and 53 patients with prior stroke. Age, BMI, hypertension, diabetes mellitus, hypercholesterolemia, coronary artery disease, and right-to-left shunt (RLS) at rest were significantly associated with prior stroke. Using a pre-specified multivariable logistic regression model, age (Odds Ratio 1.06), BMI (OR 1.06), hypercholesterolemia (OR 1.90) and RLS at rest (OR 1.88) were strongly associated with prior stroke.Based on these factors, we developed a nomogram to illustrate the strength of the relation of individual factors to prior stroke.

Conclusion: In patients with CS and PFO, the likelihood of prior stroke is associated with both, PFO-related and PFO-unrelated factors.

Cryptogenic stroke over 60 years of age: should patent foramen ovale be closed?

Patent foramen ovale (PFO) is an anatomical communication between the left and the right atrium due to the lack of completed sealing of the fossa ovalis. Epidemiologic data, for the most part derived from young populations studies, suggested that PFO, allowing paradoxical embolization of thrombotic material from the venous to the arterial district, could play a significant role in the pathogenesis of cryptogenic ischaemic cerebral events. Recently, three randomized studies in patients ≤60 years of age demonstrated the superiority of percutaneous closure of PFO over medical antithrombotic treatment. Several studies, on the other hand, indicated that also in older patients with cryptogenic cerebral ischaemia, there was an higher prevalence of PFO in patients at low atherosclerosis and cardioembolic risk, and increased incidence of adverse cerebral events (mostly cryptogenic in patients treated medically, but likely due to a new cause in patients who had percutaneous closure of PFO). Advanced age is associated with more risk factors for deep vein thrombosis, and consequent paradoxical embolization through the PFO, so much so that careful consideration should be given to patients over the age of 60 years with cryptogenic stroke, as to not forgo the benefit of percutaneous closure of PFO, merely for anagraphic consideration. This consideration is particularly poignant in light of the more recent technical advances now available, such as direct percutaneous suture, mostly appealing for elderly patients, for its better tolerability and high safety both peri-procedural and during the follow-up, as well as the lack of necessity for antithrombotic treatment.