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Patent foramen ovale and stroke

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Observational data from prospective and retrospective trials indicate that a patent foramen ovale (PFO) is associated with the risk of ischemic stroke. The mechanism involved is presumed to be paradoxical embolism from a venous thrombus that travels via the PFO to the systemic circulation causing an ischemic stroke. Primary stroke prevention data for patients with a PFO are nonexistent. Given the substantial prevalence of PFO in the total population (≈25% to 30%), a primary prevention study may not be feasible. However, whether targeted primary prevention for patients with PFOs of certain morphologic characteristics (eg, larger size, greater degree of shunt) would be possible remains undefined. Given the large number of asymptomatic subjects, no therapy is currently recommended. The best treatment modality to prevent recurrent stroke in patients with PFO has not been defined. There are four major treatment choices: surgical closure, percutaneous device closure, medical therapy with anticoagulants, and medical therapy with antiplatelet agents. Regarding medical therapy, the Patent Foramen Ovale in Cryptogenic Stroke Study has demonstrated that antiplatelet and anticoagulant therapies are of equal benefit in preventing recurrent adverse events. Although closure of the PFO, either surgical or percutaneous, may further reduce the event rates, this remains to be demonstrated because no randomized trial to date has compared PFO closure with medical therapy.

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References and Recommended Reading

  1. Franson SV: The Botallo mystery. Clin Cardiol 1999, 22:434–436.

    Google Scholar 

  2. Hagen PT, Scholz DG, Edwards WD: Incidence and size of PFO during the first 10 decades of life: an autopsy study of 965 normal hearts. Mayo Clin Proc 1984, 59:17–20.

    PubMed  CAS  Google Scholar 

  3. Homma S, Di Tullio MR, Sacco RL: Patent foramen ovale and ischemic stroke. In Stroke: Pathophysiology, Diagnosis, and Management. Edited by Barnett HJ, Stein BM. New York: Churchill Livingstone; 1998:1013–1024.

    Google Scholar 

  4. Meissner I, Whinant JP, Khandheria BK, et al.: Prevalence of potential risk factors for stroke assessed by transesophageal echocardiography and carotid ultra-sonography: the SPARC Study. Mayo Clin Proc 1999, 74:862–869.

    Article  PubMed  CAS  Google Scholar 

  5. Webster MW, Chancellor AM, Smith HJ, et al.: Patent foramen ovale in young stroke patients. Lancet 1988, 2:11–12.

    Article  PubMed  CAS  Google Scholar 

  6. Lechat P, Mas JL, Lescault G, et al.: Prevalence of patent foramen ovale in patients with stroke. N Engl J Med 1988, 318:1148–1152.

    Article  PubMed  CAS  Google Scholar 

  7. Di Tullio MR, Sacco RL, Gopal A, et al.: Patent foramen ovale as a risk factor for cryptogentic stroke. Ann Intern Med 1992, 117:461–465.

    PubMed  Google Scholar 

  8. Cohnheim J: Thrombose und Embolie: Vorslesung Über Allgemeine. Pathologie. Berlin, Germany: Hirschwald; 1877:134.

    Google Scholar 

  9. Massaro AR, Hoffman M, Sacco RL, et al.: Detection of paradoxical cerebral embolism using transcranial Doppler in a patient with infarct of undetermined cause. Cerebrovasc Dis 1993, 3:116–119.

    Google Scholar 

  10. Di Tullio MR, Sacco RL, Venketasubramanian N, et al.: Comparison of diagnostic techniques for the detection of a patent foramen ovale in stroke patients. Stroke 1993, 24:1020–1024.

    PubMed  Google Scholar 

  11. 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.

    PubMed  CAS  Google Scholar 

  12. Steiner MM, Di Tullio MR, Rundek T, et al.: Patent foramen ovale size and embolic brain imaging findings among patients with ischemic stroke. Stroke 1998, 29:944–948.

    PubMed  CAS  Google Scholar 

  13. American Heart Association: 2002 Heart and Stroke Statistical Update. Dallas, TX: American Heart Association; 2001.

    Google Scholar 

  14. Sacco RL, Ellenberg JH, Mohr JP, et al.: Infarcts of undetermined cause: the NINCDS Stroke Data Bank. Ann Neurol 1989, 25:382–390.

    Article  PubMed  CAS  Google Scholar 

  15. Overell JR, Bone I, Lees KR: Interatrial septal abnormalities and stroke: a meta-analysis of case-control studies. Neurology 2000, 55:1172–1179. A good review examining the role of PFO and ASA in cryptogenic stroke.

    PubMed  CAS  Google Scholar 

  16. Bogousslavsky J, Garazi S, Jeanrenaud X, et al.: Stroke recurrence in patients with patent foramen ovale: the Lausanne Study, Lausanne Stoke with Paradoxical Embolism Study Group. Neurology 1996, 46:1301–1305.

    PubMed  CAS  Google Scholar 

  17. Mas JL, Zuber M: Recurrent cerebrovascular events in patients with patent foramen ovale, atrial septal aneurysm, or both and cryptogenic stroke or transient ischemic attack. French Study Group on Patent Foramen Ovale and Atrial Septal Aneurysm. Am Heart J 1995, 140:1083–1088.

    Article  Google Scholar 

  18. Hanna JP, Sun JP, Furlan AJ, et al.: Patent foramen ovale and brain infarct. Echocardiographic predictors, recurrence, and prevention. Stroke 1994, 25:782–786.

    PubMed  CAS  Google Scholar 

  19. Hausman D, Mugge A, Daniel WG: Identification of patent foramen ovale permitting paradoxic embolism. J Am Coll Cardiol 1995, 26:1030–1038.

    Article  Google Scholar 

  20. Cujec B, Mainra R, Johnson DH: Prevention of recurrent cerebral ischemic events in patients with patent foramen ovale and cryptogenic strokes or transient ischemic attacks. Can J Cardiol 1999, 15:57–64.

    PubMed  CAS  Google Scholar 

  21. Homma S, Sacco RL, Di Tullio MR, et al.: Effect of medical treatment in stroke patients with patent foramen ovale: patent foramen ovale in Cryptogenic Stroke Study. Circulation 2002, 105:2625–2631. The first randomized clinical trial comparing anticoagulant therapy with antiplatelet therapy in stroke patients with PFO.

    Article  PubMed  Google Scholar 

  22. Levine MN, Raskob G, Landefeld S, Hirsch J: Hemorrhagic complications of anticoagulant treatment. Chest 1995, 108:276S-287S.

    PubMed  CAS  Google Scholar 

  23. Collaborative overview of randomized trials of anti-platelet therapy—III: Reduction in venous thrombosis and pulmonary embolism by antiplatelet prophylaxis among surgical and medical patients. Antiplatelet Trialists’ Collaboration [no authors listed]. BMJ 1994, 308:235–246.

  24. Kaiser LR, Kron IL, Spray TL: In Mastery of Cardiothoracic Surgery. Edited by Kaiser LR, et al. Philadelphia: Lippincott, Williams & Wilkins; 1998.

    Google Scholar 

  25. Harvey JR, Teague SM, Anderson JL, et al.: Clinically silent atrial septal defects with evidence for cerebral embolism. Ann Intern Med 1986, 105:695–697.

    PubMed  CAS  Google Scholar 

  26. Zhu WX, Khandheria BK, Warnes CA, et al.: Closure of patent foramen ovale for cryptogenic stroke in young patients: long-term follow-up [abstract]. Circulation 1992, 86:I-497.

    Google Scholar 

  27. 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 MRI and simultaneous transesophageal and transcranial Doppler ultrasound. Neurology 1996, 47:1162–1166.

    PubMed  CAS  Google Scholar 

  28. Dearani JA, Ugurlu BS, Danielson GK, et al.: Surgical patent foramen ovale closure for prevention of the paradoxical embolism-related cerebrovascular ischemic events. Circulation 1999, 100:II171-II175. The most recent trial on surgical closure.

    PubMed  CAS  Google Scholar 

  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.

    PubMed  CAS  Google Scholar 

  30. Pastorek JS, Allen HD, Davis JT: Current outcomes of surgical closure of secundum atrial septal defects. Am J Cardiol 1994, 74:75–77.

    Article  PubMed  CAS  Google Scholar 

  31. Bridges ND, Hellenbrand W, Latson L, et al.: Transcatheter closure of patent foramen ovale after presumed paradoxical embolism. Circulation 1992, 86:1902–1908.

    PubMed  CAS  Google Scholar 

  32. 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.

    PubMed  CAS  Google Scholar 

  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.

    Article  PubMed  CAS  Google Scholar 

  34. 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. The most recent trial on percutaneous PFO closure.

    Article  PubMed  Google Scholar 

  35. Rodriguez C, Di Tullio MR, Sacco RL, Homma S: Intra-atrial thrombus after surgical closure of patent foramen ovale. J Am Soc Echocardiogr 2001, 14:63–66.

    Article  PubMed  CAS  Google Scholar 

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Authors and Affiliations

  1. Division of Cardiology, Department of Medicine, Columbia University, College of Physicians & Surgeons, 630 West 168th Street, 10032, New York, NY, USA

    Carlos J. Rodriguez MD, MPH & Shunichi Homma MD

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  1. Carlos J. Rodriguez MD, MPH
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  2. Shunichi Homma MD
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Rodriguez, C.J., Homma, S. Patent foramen ovale and stroke. Curr Treat Options Cardio Med 5, 233–240 (2003). https://doi.org/10.1007/s11936-003-0007-y

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