Current Treatment Options in Neurology

, Volume 7, Issue 6, pp 483–490

The management of patients with patent foramen ovale and stroke

  • Irene Meissner

Opinion statement

The management of patients with patent foramen ovale (PFO) and stroke remains uncertain. What is known is that PFO is a very common finding in the general population. The risk of initial and recurrent stroke in individuals with PFO is relatively low. With the advent of transesophageal echocardiography, PFO is more commonly being diagnosed. There are insufficient data to support a benefit of warfarin over aspirin in preventing recurrent stroke in most patients with PFO. In those with PFO and a history of a procoagulant state or deep venous thrombosis, anticoagulation may be indicated after weighing the risks of anticoagulation against potential benefits in preventing recurrent stroke. PFO closure does not guarantee the prevention of future stroke and should be addressed case by case, with consideration of patients for entry into ongoing clinical trials of safety, efficacy, and durability.


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References and Recommended Reading

  1. 1.
    Heart Disease and Stroke Statistics-2005 Update. Dallas, TX: American Heart Association; 2005.Google Scholar
  2. 2.
    Petty GW, Brown RD, Whining JP, et al.: Ischemic stroke subtypes: a population based study of incidence and risk factors. Stroke 1999, 30:2513–2516. A population-based estimate of the magnitude of the underlying disorder.PubMedGoogle Scholar
  3. 3.
    Woo D, Goebel J, Miller R, et al.: Incidence rates of first-ever ischemic stroke subtypes among blacks: a population-based study. Stroke 1999, 30:2517–2522.PubMedGoogle Scholar
  4. 4.
    Seib G: Incidence of patent foramen ovale cordis in adult American whites and American Negroes. Am J Anat 1934, 55:511–525.CrossRefGoogle Scholar
  5. 5.
    Hagen PT, Scholz DG, Edwards WD: Incidence and size of patent foramen ovale during the first 10 decades of life: an autopsy study of 965 normal hearts. Mayo Clinic Proc 1984, 59:17–20.Google Scholar
  6. 6.
    Meissner I, Whisnant JP, Khandheria BK, et al.: Prevalence of potential risk factors for stroke assessed by transesophageal echocardiography: the SPARC study. Stroke Prevention: Assessment of Risk in a Community. Mayo Clin Proc 1999, 74:862–869. A unique, prospective population-based, longitudinal TEE study.PubMedCrossRefGoogle Scholar
  7. 7.
    Meissner I: Outcome data from SPARC. J Am Coll Cardiol 2005, In press.Google Scholar
  8. 8.
    Agmon Y, Khandheria BK, Meissner I, et al.: Comparison of frequency of patent foramen ovale by transesophageal echocardiography in patients with cerebral ischemic events versus in subjects in the general population. Am J Cardiol 2001, 88:330–332. Population-based insights into the variability of PFO detection rates.PubMedCrossRefGoogle Scholar
  9. 9.
    Hanley PC, Tajik AJ, Hynes JK, et al.: Diagnosis and classification of atrial septal aneurysm by two-dimensional echocardiography: report of 80 consecutive cases. J Am Coll Cardiol 1985, 6:1370–1382.PubMedCrossRefGoogle Scholar
  10. 10.
    Agmon Y, Khandheria BK, Meissner I, et al.: Frequency of atrial septal aneurysms in patients with cerebral ischemic events. Circulation 1999, 99:1942–1944. Nonreferral, population-based estimates of prevalence of ASA and its association with PFO.PubMedGoogle Scholar
  11. 11.
    Albers GW, Comess KA, DeRook FA, et al.: Transesophageal echocardiographic findings in stroke subtypes. Stroke 1994, 25:23–28.PubMedGoogle Scholar
  12. 12.
    Jeanrenaud X, Bogousslavsky J, Payot M, et al.: Patent foramen ovale and cerebral infarct in young patients [in French]. Schweiz Med Wochenschr 1990, 120:823–829.PubMedGoogle Scholar
  13. 13.
    Ranoux D, Cohen A, Cabanes L, et al.: Patent foramen ovale: is stroke due to paradoxical embolism? Stroke 1993, 24:31–34.PubMedGoogle Scholar
  14. 14.
    Lechat P, Mas JL, Lascault G, et al.: Prevalence of patent foramen ovale in young stroke patients. Lancet 1988, 2:11–12.Google Scholar
  15. 15.
    Di Tullio M, Sacco RL, Gopal A, et al.: Patent foramen ovale as a risk factor for cryptogenic stroke. Ann Intern Med 1992, 117:461–465. Example of effect of nonpopulation-based study and controls, and of nonincident strokes, on study conclusions.PubMedGoogle Scholar
  16. 16.
    de Beider MA, Tourikis L, Leech G, et al.: Risk of patent foramen ovale for thromboembolic events in all age groups. Am J Cardiol 1992, 69:1316–1320.CrossRefGoogle Scholar
  17. 17.
    Cabanes L, Mas JL, Cohen A, et al.: Atrial septal aneurysm and patent foramen ovale as risk factors for cryptogenic stroke in patients less than 55 years of age: a study using transesophageal echocardiography. Stroke 1993, 24:1865–1873.PubMedGoogle Scholar
  18. 18.
    Labovitz AJ, Camp A, Castello R, et al.: Usefulness of transesophageal echocardiography in unexplained cerebral ischemia. Am J Cardiol 1993, 72:1448–1452.PubMedCrossRefGoogle Scholar
  19. 19.
    Homma S, Di Tullio MR, Sacco RL, et al.: Characteristics of patent foramen ovale associated with cryptogenic stroke: a biplane transesophageal echocardiographic study. Stroke 1994, 25:582–586.PubMedGoogle Scholar
  20. 20.
    Petty GW, Khandheria BK, Chu CP, et al.: Patent foramen ovale in patients with cerebral infarction: a transesophageal echocardiographic study. Arch Neurol 1997, 54:819–822.PubMedGoogle Scholar
  21. 21.
    Lindgren A, Roijer A, Norwing B, et al.: Carotid artery and heart disease in subtypes of cerebral infarction. Stroke 1994, 25:2356–2362.PubMedGoogle Scholar
  22. 22.
    Roijer A, Lindfren A, Algotsson L, et al.: Cardiac changes in stroke patients and controls evaluated with transesophageal echocardiography. Scand CardiovascJ 1997, 31:329–337. A population-based study showing similar PFO prevalence in patients with stroke, compared with randomly selected community controls.Google Scholar
  23. 23.
    Overell JR, Bone I, Lees KR: Interatrial septal abnormalities and stroke: a meta-analysis of case-control studies. Neurology 2000, 55:1172–1179. A meta-analysis illustrating the widely heterogeneous reporting of stroke risk with PFO.PubMedGoogle Scholar
  24. 24.
    Meier B, Lock JE: Contemporary management of patent foramen ovale. Circulation 2003, 107:5–9.PubMedCrossRefGoogle Scholar
  25. 25.
    MasJL, Arquizan C, Lamy C, et al.: Patent Foramen Ovale and Atrial Septal Aneurysm Study Group. Recurrent cerebrovascular events associated with patent foramen ovale, atrial septal aneurysm, or both. NEnglJMed 2001, 345:1740–1746. A substantially sized multicenter study evaluating stroke recurrence in patients with PFO, illustrating the controversies in management.CrossRefGoogle Scholar
  26. 26.
    HommaS, Sacco RL, Di Tullio MR, et al.: PFO in Cryptogenic Stroke (PICCS) Investigators. Effect of medical treatment in stroke patients with patent foramen ovale: Patent Foramen Ovale in Cryptogenic Stroke Study. Circulation 2002, 105:2625–2631. Results of a clinical trial evaluating aspirin versus warfarin in patients with PFO.PubMedCrossRefGoogle Scholar
  27. 27.
    Messe SR, Silverman IE, Kizer Jr: Practice parameter: recurrent stroke with patent foramen ovale and atrial septal aneurysm. Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2004, 62:1042–1050. Evidence-based guidelines for management of patients with cryptogenic stroke, PFO, or ASA.PubMedGoogle Scholar
  28. 28.
    Bogousslavsky J, Garazi S, Jeanrenaud X, et al.: Stroke recurrence in patients with patent foramen ovale: The Lausanne Study. Neurology 1996, 46:1301–1305.PubMedGoogle Scholar
  29. 29.
    Homma S, Di Tullio MR, Sacco RL, et al.: Surgical closure of patent foramen ovale in cryptogenic stroke patients. Stroke 1997, 28:2376–2381.PubMedGoogle Scholar
  30. 30.
    Dearani JA, Ugurlu BS, Danielson GK, et al.: Surgical patent foramen ovale closure for prevention of paradoxical embolism-related cerebrovascular ischemic events. Circulation 1999, 100(Suppl):II171-II175.PubMedGoogle Scholar
  31. 31.
    Devuyst G, Bogousslavsky J, Ruchat P, et al.: Prognosis after stroke followed by surgical closure of patent foramen ovale: a prospective follow-up study with brain MREI and simultaneous transesophageal and transcranial Doppler ultrasound. Neurology 1996,47:1162–1166.PubMedGoogle Scholar
  32. 32.
    Braun MU, Fassbender D, Schoen SP, et al.: Transcatheter closure of patent foramen ovale in patients with cerebral ischemia. J Am Coll Cardiol 2002, 39:2019–2025.PubMedCrossRefGoogle Scholar
  33. 33.
    Hung J, Landzberg MJ, Jenkins KJ, et al.: Closure of patent foramen ovale for paradoxical emboli: intermediate-term risk of recurrent neurological events following transcatheter device placement. J Am Coll Cardiol 2000, 35:1311–1316.PubMedCrossRefGoogle Scholar
  34. 34.
    Windecker S, Wahl A, Chatterjee T, et al.: Percutaneous closure of patent foramen ovale in patients with paradoxical embolism: long-term risk of recurrent thromboembolic events. Circulation 2000, 101:893–898.PubMedGoogle Scholar
  35. 35.
    Martin F, Sanchez PL, Doherty E, et al.: Percutaneous transcatheter closure of patent foramen ovale in patients with paradoxical embolism. Circulation 2002, 106:1121–1126.PubMedCrossRefGoogle Scholar
  36. 36.
    Del Sette M, Angeli S, Leandri M, et al.: Migraine with aura and right-to-left shunt on transcranial Doppler: a case-control study. Cerebrovasc Dis 1998, 8:327–330.PubMedCrossRefGoogle Scholar
  37. 37.
    Anzola GP, Mangoni M, Guindani M, et al.: Potential source of cerebral embolism in migraine with aura: a transcranial Doppler study. Neurology 1999, 52:1622–1625.PubMedGoogle Scholar
  38. 38.
    Wilmhurst P, Nightingale S: Relationship between migraine and cardiac and pulmonary right-to-left shunts. Clin Sci 2001, 100:215–220.CrossRefGoogle Scholar
  39. 39.
    Lamy C, Giannesini C, Zuber M, for the Patent Foramen Ovale and Atrial Septal Aneurysm Study Group: Clinical and imaging findings in cryptogenic stroke patients with and without patent foramen ovale. The PFO-ASA Study. Stroke 2002, 33:706–711.PubMedCrossRefGoogle Scholar
  40. 40.
    Post MC, Thijs V, Herroelen L, et al.: Closure of patent foramen ovale is associated with a decrease in prevalence of migraine. Neurology 2004, 62:1439–1440.PubMedGoogle Scholar
  41. 41.
    Schwerzmann M, Wiher S, Nedeltchev K, et al.: Percutaneous closure of patent foramen ovale reduces the frequency of migraine attacks. Neurology 2004, 62:1399–1401.PubMedGoogle Scholar

Copyright information

© Current Science Inc 2005

Authors and Affiliations

  • Irene Meissner
    • 1
  1. 1.Department of NeurologyMayo ClinicRochesterUSA

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