Interventional cardiology

PFO closure supported for cryptogenic stroke patients

Percutaneous device closure of patent foramen ovale (PFO) is coming into favour as a secondary preventive measure in patients with cryptogenic stroke.

Writing in the MJA, a cardiology team from St Vincent’s Hospital Melbourne said evidence for a reduction in recurrent stroke following PFO closure has strengthened in recent years.

They said trials such as CLOSE, Gore REDUCE and RESPECT demonstrated a significant reduction in recurrent stroke in patients with PFO closure plus antiplatelet therapy compared to medical therapy alone.

“Multidisciplinary involvement is key, including a stroke unit and a structural heart team to identify the most appropriate patients,” they said.

“In patients who proceed with device closure, technical success is high (~ 99%) and is followed by dual antiplatelet therapy for 3–6 months.”

However the trials have shown that complications of device closure can include atrial tachyarrhythmias (5–7%), venous vascular access complications (2%), device thrombosis (< 1%) and device embolisation (< 1%).

“Procedural long term safety (> 10 years) is promising, with a recurrent ischaemic stroke event rate of 1% and a major bleeding event rate of 2%.”

However Dr Francis Ha, Dr Heath Adams and Dr Sonny Palmer said there was as yet no data on the impact of device closure on overall survival.

“It may be argued, however, that stroke with significant neurological deficit may be a worse outcome.”

“Stroke with residual neurological deficit is catastrophic, particularly for young, high functioning and otherwise healthy individuals,” they said.

“PFO device closure has existed for several decades, and the recent randomised data finally establish the procedure as a reliable and safe secondary preventive measure in select candidates with cryptogenic left circulation thromboembolism.”

Recently updated Australian Clinical Guidelines for Stroke Management have recommended percutaneous closure of the PFO in ischaemic stroke patients aged <60 in whom a patent foramen ovale is considered the likely cause of stroke after thorough exclusion of other aetiologies.

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