From the Guidelines
Yes, a patent foramen ovale (PFO) can cause cerebrovascular accidents (CVAs) or transient ischemic attacks (TIAs) in carefully selected patients, particularly those with a history of cryptogenic stroke before age 60 1. PFO is a small opening between the two upper chambers of the heart that normally closes shortly after birth but remains open in approximately 25% of adults. This opening can allow blood clots to bypass the lungs and travel directly from the right to the left side of the heart, potentially reaching the brain and causing a stroke or TIA, a mechanism known as paradoxical embolism.
Key Considerations
- The risk of PFO causing CVA or TIA is significant in patients who have had a cryptogenic stroke before age 60 1.
- Treatment options for patients with a history of cryptogenic stroke and PFO include antiplatelet therapy, anticoagulation, or PFO closure via a minimally invasive procedure 1.
- Recent clinical trials, such as the CLOSE trial, the REDUCE trial, and the RESPECT trial, have shown that PFO closure plus antiplatelet therapy is superior to antiplatelet therapy alone in preventing recurrent stroke in carefully selected patients 1.
- The decision to treat a PFO should be individualized based on factors such as the size of the PFO, presence of an atrial septal aneurysm, and the patient's risk factors for recurrent stroke 1.
Recommendations
- For carefully-selected patients with a recent ischemic stroke or TIA attributed to a PFO, PFO device closure plus long-term antiplatelet therapy is recommended over long-term antithrombotic therapy alone, provided the patient meets specific criteria, including age 18–60 years, a confirmed diagnosis of a nonlacunar embolic ischemic stroke or a TIA with positive neuroimaging or cortical symptoms, and a thorough etiological evaluation to exclude alternate etiologies 1.
- For patients requiring long-term anticoagulation, the decision regarding PFO closure remains unclear, and decisions should be based on individual patient characteristics and risk versus benefit profile 1.
- Patient counseling and shared decision-making, taking into account patient values and preferences, are important considerations when deciding on the treatment of a PFO 1.
From the Research
PFO and CVA/TIA Relationship
- PFO has been recognized as a potential cause of transient ischemia attack (TIA) and stroke, especially in younger patients 2.
- The therapeutic options for PFO include medical treatment, surgical PFO closure, or catheter closure 2.
- Studies have shown that PFO closure can reduce the risk of recurrent stroke in carefully selected young cryptogenic stroke patients 3, 4.
Risk of Recurrent Stroke/TIA
- The risk of recurrent stroke/TIA after PFO closure is relatively low, with a rate of 0.98 recurrent strokes per 100 patient-years 5.
- Pre-existing vascular risk factors, such as hypertension, and a hypercoagulable state are associated with recurrent ischemic stroke/TIA 5.
- The benefit of PFO closure is particularly evident in patients with embolic appearing strokes, large right-to-left shunt, or an associated atrial septal aneurysm 3, 4.
PFO Closure and Complications
- PFO closure is a technically simple procedure, but it carries inherent potential risks, such as atrial fibrillation and major bleeding complications 2, 3.
- The rate of new-onset atrial fibrillation is higher in patients who undergo PFO closure compared to those who receive medical treatment alone 3.
- Successful device implantation and effective PFO closure can be achieved in the majority of patients, with a success rate of 96% and 91%, respectively 3.
PFO Prevalence and Association with Cryptogenic Events
- PFO is highly prevalent in the general population, present in about one in four adults 4.
- The association between PFO and cryptogenic events remains at older ages, and the population burden of PFO-associated events is substantial 6.
- Randomized trials of PFO closure at older ages are required to determine the efficacy and safety of this procedure in this population 6.