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Current Cardiology Reviews

Editor-in-Chief

ISSN (Print): 1573-403X
ISSN (Online): 1875-6557

Review Article

Percutaneous Patent Foramen Ovale Closure: Stroke and Beyond

Author(s): Sandeep Randhawa*, Jawahar L. Mehta and Gaurav Dhar

Volume 20, Issue 3, 2024

Published on: 11 March, 2024

Article ID: e110324227881 Pages: 10

DOI: 10.2174/011573403X276984240304044109

Price: $65

Abstract

Over 750,000 individuals suffer from stroke annually in the United States, with 87% of these strokes being ischemic in nature. Roughly 40% of ischemic strokes occur in individuals 60 years of age or under. A quarter of all ischemic strokes have no identifiable cause despite extensive workup and are deemed cryptogenic in nature. Patent Foramen Ovales (PFO) has been postulated in stroke causation by either paradoxical embolization or platelet activation in the tunnel of the defect. The incidence of PFO is reported to be 15-25% in the general population but rises to 40% in patients with cryptogenic stroke. While the initial trials evaluating PFO closures were non-revealing, subsequent long-term follow-ups, as well as recent trials evaluating PFO closures in cryptogenic stroke patients 60 years of age or under, demonstrated the superiority of percutaneous closure compared to medical therapy alone, leading to FDA approval of PFO closure devices. In this review, we review the diagnosis of PFO, postulated stroke mechanisms, literature supporting PFO closure, patient selection for percutaneous closure, procedural considerations, and associated procedural complications.

Keywords: Patent foramen ovale, cryptogenic stroke, ischemic stroke, patent foramen ovale closure, paradoxical embolism, atrial septal defect, right-to-left shunt.

Graphical Abstract
[1]
Tsao CW, et al. Heart disease and stroke statistics-2022 Update: A report from the american heart association. Circulation 2022; 145(8): 153-639.
[http://dx.doi.org/10.1161/CIR.0000000000001052]
[2]
Sacco RL, Ellenberg JH, Mohr JP, et al. Infarcts of undetermined cause: The NINCDS stroke data bank. Ann Neurol 1989; 25(4): 382-90.
[http://dx.doi.org/10.1002/ana.410250410] [PMID: 2712533]
[3]
Li L, Yiin GS, Geraghty OC, et al. Incidence, outcome, risk factors, and long-term prognosis of cryptogenic transient ischaemic attack and ischaemic stroke: A population-based study. Lancet Neurol 2015; 14(9): 903-13.
[http://dx.doi.org/10.1016/S1474-4422(15)00132-5] [PMID: 26227434]
[4]
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 Clin Proc 1984; 59(1): 17-20.
[http://dx.doi.org/10.1016/S0025-6196(12)60336-X] [PMID: 6694427]
[5]
Meissner I, Whisnant JP, Khandheria BK, et al. Prevalence of potential risk factors for stroke assessed by transesophageal echocardiography and carotid ultrasonography: The SPARC study. Stroke Prevention: Assessment of Risk in a Community. Mayo Clin Proc 1999; 74(9): 862-9.
[http://dx.doi.org/10.4065/74.9.862] [PMID: 10488786]
[6]
Lechat P, Mas JL, Lascault G, et al. Prevalence of patent foramen ovale in patients with stroke. N Engl J Med 1988; 318(18): 1148-52.
[http://dx.doi.org/10.1056/NEJM198805053181802] [PMID: 3362165]
[7]
Overell JR, Bone I, Lees KR. Interatrial septal abnormalities and stroke. Neurology 2000; 55: 1172.
[http://dx.doi.org/10.1212/WNL.55.8.1172]
[8]
Collado FMS, Poulin MF, Murphy JJ, Jneid H, Kavinsky CJ. Patent foramen ovale closure for stroke prevention and other disorders. J Am Heart Assoc 2018; 7(12): e007146.
[http://dx.doi.org/10.1161/JAHA.117.007146] [PMID: 29910192]
[9]
Kasner SE, Rhodes JF, Andersen G, et al. Five-Year outcomes of PFO closure or antiplatelet therapy for cryptogenic stroke. N Engl J Med 2021; 384(10): 970-1.
[http://dx.doi.org/10.1056/NEJMc2033779] [PMID: 33704944]
[10]
Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. PLoS Med 2009; 6(7): e1000097.
[http://dx.doi.org/10.1371/journal.pmed.1000097] [PMID: 19621072]
[11]
Silvestry FE, Cohen MS, Armsby LB, et al. Guidelines for the echocardiographic assessment of atrial septal defect and patent foramen ovale: From the American society of echocardiography and society for cardiac angiography and interventions. J Am Soc Echocardiogr 2015; 28(8): 910-58.
[http://dx.doi.org/10.1016/j.echo.2015.05.015] [PMID: 26239900]
[12]
Hari P, Pai RG, Varadarajan P. Echocardiographic evaluation of patent foramen ovale and atrial septal defect. Echocardiography 2015; 32(S2): S110-24.
[http://dx.doi.org/10.1111/echo.12625] [PMID: 24888883]
[13]
Rana BS, Thomas MR, Calvert PA, Monaghan MJ, Hildick-Smith D. Echocardiographic evaluation of patent foramen ovale prior to device closure. JACC Cardiovasc Imaging 2010; 3(7): 749-60.
[http://dx.doi.org/10.1016/j.jcmg.2010.01.007] [PMID: 20633854]
[14]
Mas JL. Patent foramen ovale, atrial septal aneurysm and ischaemic stroke in young adults. Eur Heart J 1994; 15(4): 446-9.
[http://dx.doi.org/10.1093/oxfordjournals.eurheartj.a060524] [PMID: 8070468]
[15]
Ranoux D, Cohen A, Cabanes L, Amarenco P, Bousser MG, Mas JL. Patent foramen ovale: Is stroke due to paradoxical embolism? Stroke 1993; 24(1): 31-4.
[http://dx.doi.org/10.1161/01.STR.24.1.31] [PMID: 8418547]
[16]
Lamy C, Giannesini C, Zuber M, et al. Clinical and imaging findings in cryptogenic stroke patients with and without patent foramen ovale: The PFO-ASA Study. Atrial Septal Aneurysm. Stroke 2002; 33(3): 706-11.
[http://dx.doi.org/10.1161/hs0302.104543] [PMID: 11872892]
[17]
Schneider B, Hanrath P, Vogel P, Meinertz T. Improved morphologic characterization of atrial septal aneurysm by transesophageal echocardiography: Relation to cerebrovascular events. J Am Coll Cardiol 1990; 16(4): 1000-9.
[http://dx.doi.org/10.1016/S0735-1097(10)80354-7] [PMID: 2212349]
[18]
Mas JL, Arquizan C, Lamy C, et al. Recurrent cerebrovascular events associated with patent foramen ovale, atrial septal aneurysm, or both. N Engl J Med 2001; 345(24): 1740-6.
[http://dx.doi.org/10.1056/NEJMoa011503] [PMID: 11742048]
[19]
Thaler DE, et al. Recurrent stroke predictors differ in medically treated patients with pathogenic vs. other PFOs. Neurology 2014; 83: 221-6.
[http://dx.doi.org/10.1212/WNL.0000000000000589]
[20]
Berthet K, Lavergne T, Cohen A, et al. Significant association of atrial vulnerability with atrial septal abnormalities in young patients with ischemic stroke of unknown cause. Stroke 2000; 31(2): 398-403.
[http://dx.doi.org/10.1161/01.STR.31.2.398] [PMID: 10657412]
[21]
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(6): 1370-82.
[http://dx.doi.org/10.1016/S0735-1097(85)80228-X] [PMID: 4067118]
[22]
Mügge A, Daniel WG, Angermann C, et al. Atrial septal aneurysm in adult patients. A multicenter study using transthoracic and transesophageal echocardiography. Circulation 1995; 91(11): 2785-92.
[http://dx.doi.org/10.1161/01.CIR.91.11.2785] [PMID: 7758185]
[23]
Nakayama R, Takaya Y, Akagi T, et al. Identification of high-risk patent foramen ovale associated with cryptogenic stroke: Development of a scoring system. J Am Soc Echocardiogr 2019; 32(7): 811-6.
[http://dx.doi.org/10.1016/j.echo.2019.03.021] [PMID: 31130417]
[24]
Tanzi A, Onorato E, Casilli F, Anzola GP. Is the search for right-to-left shunt still worthwhile? Acta Neurol Scand 2016; 133(4): 281-8.
[http://dx.doi.org/10.1111/ane.12456] [PMID: 26139358]
[25]
Bayar N, Arslan Ş, Çağırcı G, et al. Assessment of morphology of patent foramen ovale with transesophageal echocardiography in symptomatic and asymptomatic patients. J Stroke Cerebrovasc Dis 2015; 24(6): 1282-6.
[http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2015.01.036] [PMID: 25906928]
[26]
Sadrameli SS, Gadhia RR, Kabir R, Volpi JJ. Patent foramen ovale in cryptogenic stroke and migraine with aura: Does size matter? Cureus 2018; 10(8): e3213.
[http://dx.doi.org/10.7759/cureus.3213] [PMID: 30405989]
[27]
He D, Li Q, Xu G, et al. Clinical and imaging characteristics of PFO‐related stroke with different amounts of right‐to‐left shunt. Brain Behav 2018; 8(11): e01122.
[http://dx.doi.org/10.1002/brb3.1122] [PMID: 30311435]
[28]
Natanzon A, Goldman ME. Patent foramen ovale: Anatomy versus pathophysiology—which determines stroke risk? J Am Soc Echocardiogr 2003; 16(1): 71-6.
[http://dx.doi.org/10.1067/mje.2003.34] [PMID: 12514638]
[29]
King TD, Thompson SL, Steiner C, Mills NL. Secundum atrial septal defect. Nonoperative closure during cardiac catheterization. JAMA 1976; 235(23): 2506-9.
[http://dx.doi.org/10.1001/jama.1976.03260490024013] [PMID: 946659]
[30]
Bridges ND, Hellenbrand W, Latson L, Filiano J, Newburger JW, Lock JE. Transcatheter closure of patent foramen ovale after presumed paradoxical embolism. Circulation 1992; 86(6): 1902-8.
[http://dx.doi.org/10.1161/01.CIR.86.6.1902] [PMID: 1451261]
[31]
Schuchlenz HW, Weihs W, Berghold A, Lechner A, Schmidt R. Secondary prevention after cryptogenic cerebrovascular events in patients with patent foramen ovale. Int J Cardiol 2005; 101(1): 77-82.
[http://dx.doi.org/10.1016/j.ijcard.2004.03.005] [PMID: 15860387]
[32]
Furlan AJ, Reisman M, Massaro J, et al. Closure or medical therapy for cryptogenic stroke with patent foramen ovale. N Engl J Med 2012; 366(11): 991-9.
[http://dx.doi.org/10.1056/NEJMoa1009639] [PMID: 22417252]
[33]
Meier B, Kalesan B, Mattle HP, et al. Percutaneous closure of patent foramen ovale in cryptogenic embolism. N Engl J Med 2013; 368(12): 1083-91.
[http://dx.doi.org/10.1056/NEJMoa1211716] [PMID: 23514285]
[34]
Carroll JD, Saver JL, Thaler DE, et al. Closure of patent foramen ovale versus medical therapy after cryptogenic stroke. N Engl J Med 2013; 368(12): 1092-100.
[http://dx.doi.org/10.1056/NEJMoa1301440] [PMID: 23514286]
[35]
Mas JL, Derumeaux G, Guillon B, et al. Patent foramen ovale closure or anticoagulation vs. antiplatelets after stroke. N Engl J Med 2017; 377(11): 1011-21.
[http://dx.doi.org/10.1056/NEJMoa1705915] [PMID: 28902593]
[36]
Søndergaard L, Kasner SE, Rhodes JF, et al. Patent foramen ovale closure or antiplatelet therapy for cryptogenic stroke. N Engl J Med 2017; 377(11): 1033-42.
[http://dx.doi.org/10.1056/NEJMoa1707404] [PMID: 28902580]
[37]
Lee PH, Song JK, Kim JS, et al. Cryptogenic stroke and high-risk patent foramen ovale. J Am Coll Cardiol 2018; 71(20): 2335-42.
[http://dx.doi.org/10.1016/j.jacc.2018.02.046] [PMID: 29544871]
[38]
Saver JL, Carroll JD, Thaler DE, et al. Long-term outcomes of patent foramen ovale closure or medical therapy after stroke. N Engl J Med 2017; 377(11): 1022-32.
[http://dx.doi.org/10.1056/NEJMoa1610057] [PMID: 28902590]
[39]
Sanna T, Diener HC, Passman RS, et al. Cryptogenic stroke and underlying atrial fibrillation. N Engl J Med 2014; 370(26): 2478-86.
[http://dx.doi.org/10.1056/NEJMoa1313600] [PMID: 24963567]
[40]
Gladstone DJ, Spring M, Dorian P, et al. Atrial fibrillation in patients with cryptogenic stroke. N Engl J Med 2014; 370(26): 2467-77.
[http://dx.doi.org/10.1056/NEJMoa1311376] [PMID: 24963566]
[41]
Brachmann J, Morillo CA, Sanna T, et al. Uncovering atrial fibrillation beyond short-term monitoring in cryptogenic stroke patients. Circ Arrhythm Electrophysiol 2016; 9(1): e003333.
[http://dx.doi.org/10.1161/CIRCEP.115.003333] [PMID: 26763225]
[42]
Kent DM, et al. An index to identify stroke-related vs. incidental patent foramen ovale in cryptogenic stroke. Neurology 2013; 81: 619-25.
[http://dx.doi.org/10.1212/WNL.0b013e3182a08d59]
[43]
Horlick E, Kavinsky CJ, Amin Z, et al. SCAI expert consensus statement on operator and institutional requirements for PFO closure for secondary prevention of paradoxical embolic stroke. Catheter Cardiovasc Interv 2019; 93(5): 859-74.
[http://dx.doi.org/10.1002/ccd.28111] [PMID: 30896894]
[44]
Morais LA, Sousa L, Fiarresga A, et al. RoPE score as a predictor of recurrent ischemic events after percutaneous patent foramen ovale closure. Int Heart J 2018; 59(6): 1327-32.
[http://dx.doi.org/10.1536/ihj.17-489] [PMID: 30305578]
[45]
Elgendy AY, Saver JL, Amin Z, et al. Proposal for updated nomenclature and classification of potential causative mechanism in patent foramen ovale-associated stroke. JAMA Neurol 2020; 77(7): 878-86.
[http://dx.doi.org/10.1001/jamaneurol.2020.0458] [PMID: 32282016]
[46]
Sader MA, De Moor M, Pomerantsev E, Palacios IF. Percutaneous transcatheter patent foramen ovale closure using the right internal jugular venous approach. Catheter Cardiovasc Interv 2003; 60(4): 536-9.
[http://dx.doi.org/10.1002/ccd.10702] [PMID: 14624437]
[47]
Węglarz P, Konarska-Kuszewska E, Zębik T, et al. New methods in diagnosis and therapy transcatheter closure of patent foramen ovale using the internal jugular venous approach. Postepy Kardiol Interwencyjnej 2014; 2(2): 123-7.
[http://dx.doi.org/10.5114/pwki.2014.43520] [PMID: 25061460]
[48]
Carter L, Cavendish JJ. Percutaneous closure of a patent foramen ovale via left axillary vein approach with the Amplatzer Cribriform septal occluder. J Interv Cardiol 2008; 21(1): 28-31.
[http://dx.doi.org/10.1111/j.1540-8183.2007.00313.x] [PMID: 18254787]
[49]
Hussain J, Strumpf R, Ghandforoush A, Jamal A, Diethrich E. Transhepatic approach to closure of patent foramen ovale: Report of 2 cases in adults. Tex Heart Inst J 2010; 37(5): 553-6.
[PMID: 20978566]
[50]
Hijazi ZM, Wang Z, Cao QL, Koenig P, Waight D, Lang R. Transcatheter closure of atrial septal defects and patent foramen ovale under intracardiac echocardiographic guidance: Feasibility and comparison with transesophageal echocardiography. Catheter Cardiovasc Interv 2001; 52(2): 194-9.
[http://dx.doi.org/10.1002/1522-726X(200102)52:2<194:AID-CCD1046>3.0.CO;2-4] [PMID: 11170327]
[51]
Kavinsky CJ, Szerlip M, Goldsweig AM, et al. SCAI guidelines for the management of patent foramen ovale. Journal of the Society for Cardiovascular Angiography & Interventions 2022; 1(4): 100039.
[http://dx.doi.org/10.1016/j.jscai.2022.100039]
[52]
Pristipino C, Germonpré P, Toni D, et al. European position paper on the management of patients with patent foramen ovale. Part II - Decompression sickness, migraine, arterial deoxygenation syndromes and select high-risk clinical conditions. Eur Heart J 2021; 42(16): 1545-53.
[http://dx.doi.org/10.1093/eurheartj/ehaa1070] [PMID: 33507260]
[53]
Demkow M, Malek LA, Ruzyllo W. Avoiding pacemaker lead entrapment during PFO closure. Catheter Cardiovasc Interv 2008; 72(1): 97-9.
[http://dx.doi.org/10.1002/ccd.21547] [PMID: 18412250]
[54]
Wertman B, Azarbal B, Riedl M, Tobis J. Adverse events associated with nickel allergy in patients undergoing percutaneous atrial septal defect or patent foramen ovale closure. J Am Coll Cardiol 2006; 47(6): 1226-7.
[http://dx.doi.org/10.1016/j.jacc.2005.12.017] [PMID: 16545656]
[55]
Rabkin DG, Whitehead KJ, Michaels AD, Powell DL, Karwande SV. Unusual presentation of nickel allergy requiring explantation of an Amplatzer atrial septal occluder device. Clin Cardiol 2009; 32(8): E55-7.
[http://dx.doi.org/10.1002/clc.20427] [PMID: 19455702]
[56]
Marchese N, Pacilli MA, Inchingolo V, Fanelli R, Loperfido F, Vigna C. Residual shunt after percutaneous closure of patent foramen ovale with AMPLATZER occluder devices - influence of anatomic features: A transcranial Doppler and intracardiac echocardiography study EuroIntervention 2013; 9(3): 382-8.
[http://dx.doi.org/10.4244/EIJV9I3A61]
[57]
Chen JZJ, Thijs VN. Atrial fibrillation following patent foramen ovale closure. Stroke 2021; 52(5): 1653-61.
[http://dx.doi.org/10.1161/STROKEAHA.120.030293] [PMID: 33611943]
[58]
Janion M, Kurzawski J. Atrial fibrillation in patients with atrial septal aneurysm. Cardiol J 2007; 14(6): 580-4.
[PMID: 18651525]
[59]
Dowson A, Mullen MJ, Peatfield R, et al. Migraine intervention with STARFlex Technology (MIST) trial: A prospective, multicenter, double-blind, sham-controlled trial to evaluate the effectiveness of patent foramen ovale closure with STARFlex septal repair implant to resolve refractory migraine headache. Circulation 2008; 117(11): 1397-404.
[http://dx.doi.org/10.1161/CIRCULATIONAHA.107.727271] [PMID: 18316488]
[60]
Tobis JM, Charles A, Silberstein SD, et al. Percutaneous closure of patent foramen ovale in patients with migraine. J Am Coll Cardiol 2017; 70(22): 2766-74.
[http://dx.doi.org/10.1016/j.jacc.2017.09.1105] [PMID: 29191325]
[61]
Mojadidi MK, Gevorgyan R, Noureddin N, Tobis JM. The effect of patent foramen ovale closure in patients with platypnea‐orthodeoxia syndrome. Catheter Cardiovasc Interv 2015; 86(4): 701-7.
[http://dx.doi.org/10.1002/ccd.25953] [PMID: 26063336]

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