Patent Foramen Ovale Treatment Strategies Correspond to an Index Predicting Pathogenicity

Christopher Parr,Malek Kass,Brittany Perija,Shuangbo Liu,Nasir Shaikh

doi:10.7759/cureus.4778

Christopher Parr, Malek Kass + Show 3 more

Open Access

https://doi.org/10.7759/cureus.4778

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Journal: Cureus	Publication Date: May 30, 2019
Citations: 1	License type: cc-by

Affiliation: University of Manitoba, University of Toronto

Abstract

Background: Percutaneous closure of patent foramen ovale (PFO) in patients with cryptogenic stroke (CS) may reduce the risk of recurrent stroke. By performing closure only in those with high risk of recurrent PFO related strokes, patient selection may be improved. The Risk of Paradoxical Embolism (RoPE) score is a point-based index developed to estimate the probability that the index CS was attributable to patent foramen ovale. We aimed to evaluate whether management strategies using conventional clinical judgement for patients with CS and PFO corresponded with RoPE scores.Methods: We performed a single-centre retrospective chart review of adult patients with CS or transient ischemic attack who were evaluated for PFO closure from January 1, 2011 to December 31, 2017. Patients were categorized based on the treatment strategy of percutaneous closure or medical management. RoPE scores were computed and clinical outcomes evaluated.Results: A total of 154 patients were included: 63 patients underwent percutaneous closure and 91 patients were treated medically. Mean RoPE scores for closure and medical groups were 6.9±1.5 and 4.7±1.9, respectively (p<0.001). For patients who underwent percutaneous closure, successful device delivery was achieved in all patients and there were no immediate complications.Conclusion: In this single-centre study, patients selected for percutaneous PFO closure based on conventional clinical judgement were more likely to have elevated PFO attributable risk, based on the RoPE score.

Highlights

Patent foramen ovale (PFO) is more prevalent in patients with cryptogenic stroke (CS) than in the general population [1]
Recent trials including CLOSE [4], REDUCE [5], and the long-term outcome data from RESPECT [6] suggest lower risks of recurrent ischemic stroke for patients treated with patent foramen ovale (PFO) closure, yet patient selection differed between these three major studies
Our findings demonstrate that the selection of patients for PFO closure based on clinician discretion in our centre is in agreement with high Risk of Paradoxical Embolism (RoPE) scores

Summary

Introduction

Patent foramen ovale (PFO) is more prevalent in patients with cryptogenic stroke (CS) than in the general population [1]. Studies have identified a variety of potential mechanisms by which PFO may lead to ischemic stroke [2,3], the most prominent being paradoxical emboli. Given this theoretical causality, it has been proposed that PFO closure may lead to a reduction in morbidity and mortality. The prevalence of PFO in otherwise structurally normal hearts is 27.3% [7], but not all PFOs inevitably result in a stroke With such a high general prevalence of PFO, identifying which PFO are incidental versus potentially pathogenic may help identify patients who may benefit from percutaneous closure [8]. We aimed to evaluate whether management strategies using conventional clinical judgement for patients with CS and PFO corresponded with RoPE scores

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Conclusion