From the Guidelines
The incidental finding of a Patent Foramen Ovale (PFO) has significant implications, particularly in patients with a history of cryptogenic stroke, as it may be a potential cause of paradoxical embolism.
Implications of PFO
- The presence of a PFO is common in the general population, occurring in approximately 25% of individuals 1.
- However, not all PFOs are pathogenic, and the decision to close a PFO should be made on a case-by-case basis, taking into account the individual's risk factors and medical history.
PFO Closure
- PFO closure is recommended for carefully selected patients aged 60 years or younger with an unexplained embolic stroke event who are found to have a PFO and do not require chronic anticoagulant therapy for another reason 1.
- The CLOSE trial and REDUCE trial demonstrated that PFO closure was superior to medical therapy for prevention of stroke recurrence in carefully selected patients 1.
- The RESPECT trial also reported a benefit of PFO closure in reducing the risk of recurrent ischemic stroke, particularly in patients with an atrial septal aneurysm or a "substantial" shunt size 1.
Medical Therapy
- Antiplatelet therapy is recommended for patients with cryptogenic stroke and PFO who are not undergoing anticoagulation therapy 1.
- Anticoagulation therapy may be considered in patients with a venous source of embolism or those at high risk of recurrent deep vein thrombosis 1.
Patient Counseling
- Patients considering PFO closure should be counseled about the benefits and risks of the procedure, including the potential for procedural complications such as atrial fibrillation 1.
- The decision to close a PFO should be made after careful consideration of the individual's risk factors, medical history, and personal preferences 1.
From the Research
Implications of an Incidental Finding of a Patent Foramen Ovale (PFO)
The implications of an incidental finding of a PFO can be significant, particularly in patients with cryptogenic stroke. Some key points to consider include:
- The presence of a PFO is associated with an increased risk of cryptogenic stroke, but it is not always clear whether the PFO is pathogenically related to the stroke or an incidental finding 2, 3, 4, 5, 6
- The probability that a PFO is incidental in patients with cryptogenic stroke is estimated to be around 33% in age-inclusive studies, but this probability can vary depending on patient characteristics such as age and the presence of an atrial septal aneurysm 2
- Patient characteristics and certain echocardiography-derived anatomical and hemodynamic features of PFO can provide assistance in estimating the probability of paradoxical embolism 4
- The optimal strategy for secondary prevention of paradoxical embolism in patients with a PFO remains unclear, with some studies suggesting that PFO closure may be beneficial, while others have not shown a significant benefit over medical therapy 3, 5
Clinical Significance of PFO
The clinical significance of a PFO can be complex and depends on various factors, including:
- The presence of cryptogenic stroke or other clinical conditions associated with PFO, such as migraines or sleep apnea 5
- The size and morphology of the PFO, as well as the presence of an atrial septal aneurysm or other atrial abnormalities 6
- The degree of right-to-left shunt and the presence of intrinsic coagulation-anticoagulation systems imbalance 6
- The patient's age and other risk factors for stroke, such as hypertension or diabetes 2, 6
Therapeutic Strategies
Therapeutic strategies for patients with a PFO and cryptogenic stroke are evolving and may include:
- Medical therapy with antiplatelets or anticoagulants 3
- Percutaneous transcatheter closure of the PFO 3, 5
- Lifestyle modifications and risk factor management to reduce the risk of stroke recurrence 6
- Further investigation and research are needed to determine the optimal therapeutic approach for patients with a PFO and cryptogenic stroke 3, 5, 6