Management Of Patent Foramen Ovale Research Articles

Evaluating cost-effectiveness of PFO management strategies: closure with cardioform vs. amplatzer, and treatment with medical therapy alone, for secondary stroke prevention

Aim The aim of this study was to evaluate the cost-effectiveness of patent foramen ovale (PFO) closure using CARDIOFORM Septal Occluders versus AMPLATZER Septal Occluders, as well as compared to Medical Therapy Alone, from a payor perspective in the United States. Methods An economic evaluation compared the value of CARDIOFORM, AMPLATZER, and Medical Therapy Alone. A Markov model simulated a cohort of 1,000 individuals with PFO and a history of cryptogenic stroke, with baseline demographic and clinical characteristics reflecting individuals enrolled in the REDUCE and RESPECT trials over a five-year time horizon. The costs and health consequences associated with complications and adverse events, including recurrent stroke, were compared over a time horizon of 5 years. Results PFO closure using CARDIOFORM was economically dominant, providing both cost-savings and improved effectiveness compared to closure with AMPLATZER. It resulted in an estimated savings of over $1.3 million, an additional 24.8 quality-adjusted life-years (QALYs) gained, and 26 strokes avoided in a cohort of 1,000 patients. When compared to Medical Therapy Alone, closure with CARDIOFORM was found to be cost-effective, with an incremental cost-effectiveness ratio (ICER) of $36,697 per QALY gained. Sensitivity and scenario analysis showed the model findings to be highly robust across reasonable changes to baseline input values and assumptions. Conclusions The results of this analysis suggest that PFO closure using the CARDIOFORM Septal Occluder is the most cost-effective treatment strategy for patients with a PFO-associated stroke, particularly compared to AMPLATZER where it resulted in both cost-saving and improved patient outcomes.

Transjugular intrahepatic portosystemic shunt in patients with splanchnic vein thrombosis: Prevalence and management of patent foramen ovale.

Transjugular intrahepatic portosystemic shunt (TIPS) is an established procedure for the treatment of several complications of portal hypertension (PH), including non-neoplastic portal vein thrombosis (PVT). Selection criteria for TIPS in PVT are not yet well established. Despite anecdotal, cases of thromboembolic events from paradoxical embolism due to the presence of patent foramen ovale (PFO) after TIPS placement have been reported in the literature. Therefore, we aimed at describing our experience in patients with non-neoplastic splanchnic vein thrombosis (SVT) who underwent TIPS following PFO screening. We conducted a single-centre retrospective study, including consecutive patients who underwent TIPS for the complications of cirrhotic and non-cirrhotic portal hypertension (NCPH) and having SVT. Of 100 TIPS placed in patients with SVT, 85 patients were screened for PFO by bubble-contrast transthoracic echocardiography (TTE) with PFO being detected in 22 (26%) cases. PFO was more frequently detected in patients with non-cirrhotic portal hypertension (NCPH) (23% in the PFO group vs. 6% in those without PFO, p = .04) and cavernomatosis (46% in the PFO group vs. 19% in those without PFO, p = .008). Percutaneous closure was effectively performed in 11 (50%) after multidisciplinary evaluation of anatomical and clinical features. No major complications were observed following closure. PFO screening and treatment may be considered feasible for patients with SVT who undergo TIPS placement.

Management of patent foramen ovale; findings from a nationwide survey

Management of patent foramen ovale; findings from a nationwide survey

European Stroke Organisation (ESO) Guidelines on the diagnosis and management of patent foramen ovale (PFO) after stroke.

Patent foramen ovale (PFO) is frequently identified in young patients with cryptogenic ischaemic stroke. Potential stroke mechanisms include paradoxical embolism from a venous clot which traverses the PFO, in situ clot formation within the PFO, and atrial arrhythmias due to electrical signalling disruption. The purpose of this guideline is to provide recommendations for diagnosing, treating, and long-term managing patients with ischaemic stroke and PFO. Conversely, Transient Ischaemic Attack (TIA) was not considered an index event in this context because only one RCT involved TIA patients. However, this subgroup analysis showed no significant differences between TIA and stroke outcomes. The working group identified questions and outcomes, graded evidence, and developed recommendations following the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach and the European Stroke Organisation (ESO) standard operating procedure for guideline development. This document underwent peer-review by independent experts and members of the ESO Guideline Board and Executive Committee. The working group acknowledges the current evidentiary gap in delineating an unequivocal diagnostic algorithm for the detection of PFO. Although transoesophageal echocardiography is conventionally held as the most accurate diagnostic tool for PFO identification, its status as the 'gold standard' remains unsubstantiated by rigorously validated evidence. We found high-quality evidence to recommend PFO closure plus antiplatelet therapy in selected patients aged 18-60 years in whom no other evident cause of stroke is found but a PFO (i.e. PFO-associated stroke). The PASCAL classification system can be used to select such candidates for PFO closure. Patients with both a large right-to-left shunt and an atrial septal aneurysm benefit most from PFO closure. There is insufficient evidence to make an evidence-based recommendation on PFO closure in patients older than 60 and younger than 18 years. We found low quality evidence to suggest against PFO closure in patients with unlikely PFO-related stroke according to the PASCAL classification, except in specific scenarios (Expert Consensus). We suggest against long-term anticoagulation in patients with PFO-associated stroke unless anticoagulation is indicated for other medical reasons. Regarding the long-term AF monitoring after PFO closure, the working group concluded that there remains significant uncertainty regarding the risks and benefits associated with the use of long-term cardiac monitoring, such as implantable loop recorders. This document provides additional guidance, in the form of evidence-based recommendations or expert consensus statements, on diagnostic methods for PFO detection, and medical management after PFO closure.

Management of patent foramen ovale in non-cardiac surgery

Patent foramen ovale (PFO) is a remnant of normal fetal anatomy which may persist into adulthood, mostly asymptomatic. In some adults, PFO may result in a potential for shunting venous thromboembolism to the arterial circulation; less frequently it can cause interatrial, right-to-left shunting of deoxygenated blood. The pathogenesis of several medical conditions is related to the presence of PFO. Some randomized clinical trials have shown evidence of benefit for device closure as compared with medical therapy in patients with cryptogenic stroke. The literature reported several cases of carbon dioxide embolism during general laparoscopic surgery and sometimes stroke after laparoscopic or neurosurgery but there are neither prospective studies addressing these issues, nor randomized clinical trials assessing the effectiveness of pharmacotherapy or interventional procedures at decreasing risk. The European position paper suggests routine monitoring in non-cardiac surgery of patients with a PFO and no actual indications for closure. This article aims to further stratify the risk of periprocedural stroke and paradoxical embolism in this category of patients.

Differences and similarities in interatrial shunts management

Atrial septal defects (ASD) and Patent foramen ovale (PFO) represent the most common congenital heart diseases (CHD) adulthood. These two clinical entities, having different embryological origin, as well as clinical manifestations, clinical course and treatment must be carefully distinguished. Right heart failure and pulmonary hypertension are considered the major determinants of morbidity and mortality in ASD. Conversely, new pathophysiology concepts have been raised in the management of PFO as left atrium cardiopathy. New diagnostic tools, including cardiac magnetic resonance and intracardiac echocardiography have joint transthoracic and transesophageal echocardiography in the diagnostic definition of both ASD and PFO as well as in guiding their percutaneous closure. Moreover, several innovations have been developed in the field of percutaneous ASD and PFO closure devices including new evidence supporting the safety and efficacy of device-based closure. Aim of the present review is to present review we provided and update overview on ASD and PFO, focusing on the novel concepts regarding their pathophysiological and therapeutic aspects.

Cerebrovascular Events in Older Patients With Patent Foramen Ovale: Current Status and Future Perspectives.

Patent foramen ovale (PFO) closure, along with medical therapy, has emerged as the therapeutic gold standard in younger (<60-year-old) patients with a PFO-related stroke for preventing recurrent events. However, PFO management guidelines lack definite recommendations for older (>60 years) patients with a PFO-related cerebrovascular event, a complex group of patients who were mostly excluded from PFO closure clinical trials. Nevertheless, several studies have shown a higher prevalence of PFO among older patients with cryptogenic stroke, and its presence has been associated with an increased risk of recurrent events. Furthermore, older patients exhibit a higher prevalence of high-risk PFO anatomical features, present inherent age-related risk factors that might increase the risk of paradoxical embolism through a PFO, and have a higher incidence of ischemic events after a PFO-related event. Additionally, observational studies have shown the safety and preliminary efficacy of PFO closure in older PFO-related stroke patients. Yet, higher rates of recurrent cerebrovascular events and new-onset atrial fibrillation were observed in some studies among older patients compared to their younger counterparts. After careful case-by-case evaluation, including the assessment of hidden potential cardioembolic sources of a cryptogenic stroke other than PFO, transcatheter PFO closure might be a safe and effective therapeutic option for preventing recurrent thromboembolic events in patients >60 years with a high-risk PFO-associated stroke. Ongoing trials will provide important insights into the role of PFO closure in the elderly population.

SCAI Guidelines for the Management of Patent Foramen Ovale.

Patent foramen ovale (PFO) is a vestigial congenital cardiovascular structure present in around 25% of adults. In most cases, PFO is entirely benign and requires no treatment. However, it may cause serious complications under certain circumstances. These evidence-based guidelines from the Society for Cardiovascular Angiography and Interventions (SCAI) aim to support patients, clinicians, and other stakeholders in decisions about management of PFO. SCAI convened a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. The Evidence Foundation, a registered 501(c)(3) nonprofit organization, provided methodological support for the guideline-development process. Following the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, the guideline panel formulated and prioritized clinical questions in population, intervention, comparison, outcome (PICO) format. A separate technical review team of clinical and methodological experts conducted systematic reviews of the evidence, synthesized data, and graded the certainty of the evidence across outcomes. The guideline panel then reconvened to formulate recommendations and supporting remarks informed by the results of the technical review and additional contextual factors described in the GRADE evidence-to-decision framework. The panel agreed on 13 recommendations to address variations on 5 clinical scenarios. Key recommendations address patient selection for PFO closure in the prevention of recurrent PFO-associated stroke, including populations not commonly included in randomized studies, and scenarios where the PFO closure might serve a role in the prevention of other outcomes such as migraine headaches and decompression illness. The panel has also identified future research priorities to advance the field.

SCAI Technical Review on Management of Patent Foramen Ovale.

Patent foramen ovale (PFO) is a common anatomic variant associated with intermittent right-to-left shunting. Transcatheter PFO closure has been proposed to address multiple clinical conditions including stroke, transient ischemic attack, migraine, and decompression illness. A systematic review was conducted using the GRADE approach to address 5 questions formulated by the Society for Cardiovascular Angiography and Interventions (SCAI) Guideline Panel in patient, intervention, comparator, outcome (PICO) format. Medical literature from January 2015 through May 2021 was searched. Extracted data underwent review and risk-of-bias assessment by 2 independent researchers. Pooled effect estimates were calculated. Certainty of evidence was determined for each query. Our search identified 2701 titles and abstracts, of which 30 met eligibility criteria and informed the technical review. Data were abstracted to address outcomes of PFO closure for patients with and without prior stroke, in comparison to antiplatelet therapy, in comparison to anticoagulation, and with various post-procedure antithrombotic regimens. In appropriately selected patients with prior stroke, transcatheter PFO closure reduces the risk of recurrent stroke more than antiplatelet therapy alone. Evidence to support PFO closure is weaker regarding older patients, anticoagulation, thrombophilia, transient ischemic attack, migraine, and decompression illness. Data from this technical review will inform the SCAI Guideline for Transcatheter Patent Foramen Ovale Closure.

The management of patent foramen ovale in divers: where do we stand?

Diving is a fascinating activity, but it does not come without any cost; decompression illness (DCI) is one of the most frequent diseases occurring in divers. Rapid surfacing after diving causes alveolar rupture and bubbles release, which enter in the systemic circulation and could embolize numerous organs and tissues. The presence of patent foramen ovale (PFO) contributes to the passage of venous gas bubbles into the arterial circulation, increasing the risk of complications related to DCI. The diagnosis is established with a detailed medical history, a comprehensive clinical evaluation, and a multimodal imaging approach. Although the percutaneous closure of PFO is ambiguous for divers, as a primary prevention strategy, transcatheter management is considered as beneficial for DCI recurrence prevention. The aim of this study is to introduce the basic principles of DCI, to review the pathophysiological connection between DCI and PFO, to highlight the risk factors and the optimal treatment, and, last but not least, to shed light on the role of closure as primary and secondary prevention.

SEX DIFFERENCES IN PFO CLOSURE PATIENTS

BACKGROUND Although sex differences have been emphasized in stroke and congenital heart disease, there has been limited investigation on their role in patent foramen ovale (PFO). In fact, key guidelines on the management of PFO do not comment on sex or gender specific considerations in characteristics or outcomes of patients. We aimed to explore differences by sex in baseline profiles, procedural characteristics, and short-term outcomes of patients undergoing transcatheter PFO closure. METHODS AND RESULTS Data of adult patients undergoing transcatheter PFO closure at the Toronto General Hospital from 1997 to 2017 was retrospectively analyzed. Baseline information included demographic characteristics, medical history, diagnostic and procedural information, and periprocedural complications. Post-closure outcomes were captured at index hospitalization and during the first follow-up visit. From 1,032 patients in the cohort sample, 80.7% underwent closure for cryptogenic stroke and 44.8% (n=462) were females. We observed significant sex-related differences at baseline; females were younger, less likely to have a history of smoking, and less likely to have cardiovascular risk factors such as dyslipidemia and coronary artery disease (p < 0.05). No differences were observed in procedural and in-hospital outcomes between sexes. At the first follow-up, recurrent cerebrovascular events were reported in 1.5% and 1.9% of patients in the ‘cryptogenic stroke/TIA indications’ and ‘other indications’ groups respectively, with no significant differences by sex. There were significant sex differences between some symptom presentation both pre- and post-closure, with females more likely to present with migraine symptoms at both timepoints (p < 0.05). CONCLUSION Although no differences in procedural and short-term outcomes between males and females undergoing transcatheter PFO closure were observed, significant baseline differences in characteristics may justify the need for sex-specific risk assessment and PFO closure criteria. There is a critical need for long-term, systematic studies to understand sex and gender differences in the PFO population. Although sex differences have been emphasized in stroke and congenital heart disease, there has been limited investigation on their role in patent foramen ovale (PFO). In fact, key guidelines on the management of PFO do not comment on sex or gender specific considerations in characteristics or outcomes of patients. We aimed to explore differences by sex in baseline profiles, procedural characteristics, and short-term outcomes of patients undergoing transcatheter PFO closure. Data of adult patients undergoing transcatheter PFO closure at the Toronto General Hospital from 1997 to 2017 was retrospectively analyzed. Baseline information included demographic characteristics, medical history, diagnostic and procedural information, and periprocedural complications. Post-closure outcomes were captured at index hospitalization and during the first follow-up visit. From 1,032 patients in the cohort sample, 80.7% underwent closure for cryptogenic stroke and 44.8% (n=462) were females. We observed significant sex-related differences at baseline; females were younger, less likely to have a history of smoking, and less likely to have cardiovascular risk factors such as dyslipidemia and coronary artery disease (p < 0.05). No differences were observed in procedural and in-hospital outcomes between sexes. At the first follow-up, recurrent cerebrovascular events were reported in 1.5% and 1.9% of patients in the ‘cryptogenic stroke/TIA indications’ and ‘other indications’ groups respectively, with no significant differences by sex. There were significant sex differences between some symptom presentation both pre- and post-closure, with females more likely to present with migraine symptoms at both timepoints (p < 0.05). Although no differences in procedural and short-term outcomes between males and females undergoing transcatheter PFO closure were observed, significant baseline differences in characteristics may justify the need for sex-specific risk assessment and PFO closure criteria. There is a critical need for long-term, systematic studies to understand sex and gender differences in the PFO population.

Echocardiography Detection of High-Risk Patent Foramen Ovale Morphology

Patent Foramen Ovale occurs in 25% of the general population1. Several studies suggested that paradoxical embolism through a patent foramen ovale (PFO) correlate with cryptogenic strokes (CS). Many epidemiological and clinical observational studies, showed the association between CS and the presence of PFO. There is still a controversy whether PFO should be closed. The information about PFO morphology might be useful for the management of PFO. This article is discussing a technical information about how echocardiography detects PFO and identifies high risk morphologies for the occurrence of PFO related -stroke.

Contemporary Management of Patent Foramen Ovale: A Multinational Survey on Cardiologists’ Perspective

Objectives The purpose of our survey is to analyze the clinical approach used by interventional and imaging cardiologists to diagnose, treat, and follow-up patients with PFO-related left circulation thromboembolism in different parts of the world with particular emphasis on adherence to current guidelines. Background Firm guidelines do not cover many aspects of PFO-related patient care. Consequently, very disparate approaches exist among clinicians in the real-world. Methods A 24-item electronic questionnaire was sent directly to experienced cardiology specialists practicing at consultant/attending positions directly involved in PFO closure management in the United States, United Kingdom, Gulf countries, and other countries. There were no unanswered questions. Responses were recorded between October 2019 and July 2020. Results Seventy-one responses were obtained: 31 from the UK, 19 from the US, 16 from Gulf countries, 2 from Poland, and 1 response from Australia, Italy, and Switzerland. The overall response rate was 76%. Significant differences between regions were noted in the duration of ECG monitoring during the diagnostic process, PFO closure for left circulation thromboembolism other than stroke/transient ischemic attack, and intraoperative use of intracardiac echocardiography. A similar pattern was noted in the lack of routine screening for thrombophilia and the use of the long-term single antiplatelet therapy. Conclusions The study shows a vast spectrum of opinions on the optimal approach to PFO closure with significant differences between the US, UK, and Gulf countries. The results stress the need for systematic, high-quality data on the diagnostic work-up and follow-up strategies to inform the standardized approach.

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.

Patent foramen ovale (PFO) is implicated in the pathogenesis of a number of medical conditions but to date only one official position paper related to left circulation thromboembolism has been published. This interdisciplinary paper, prepared with the involvement of eight European scientific societies, reviews the available evidence and proposes a rationale for decision making for other PFO-related clinical conditions. In order to guarantee a strict evidence-based process, we used a modified grading of recommendations, assessment, development, and evaluation (GRADE) methodology. A critical qualitative and quantitative evaluation of diagnostic and therapeutic procedures was performed, including assessment of the risk/benefit ratio. The level of evidence and the strength of the position statements were weighed and graded according to predefined scales. Despite being based on limited and observational or low-certainty randomised data, a number of position statements were made to frame PFO management in different clinical settings, along with suggestions for new research avenues. This interdisciplinary position paper, recognising the low or very low certainty of existing evidence, provides the first approach to several PFO-related clinical scenarios beyond left circulation thromboembolism and strongly stresses the need for fresh high-quality evidence on these topics.

Canadian Stroke Best Practice Recommendations: Secondary Prevention of Stroke Update 2020.

The 2020 update of the Canadian Stroke Best Practice Recommendations (CSBPR) for the Secondary Prevention of Stroke includes current evidence-based recommendations and expert opinions intended for use by clinicians across a broad range of settings. They provide guidance for the prevention of ischemic stroke recurrence through the identification and management of modifiable vascular risk factors. Recommendations address triage, diagnostic testing, lifestyle behaviors, vaping, hypertension, hyperlipidemia, diabetes, atrial fibrillation, other cardiac conditions, antiplatelet and anticoagulant therapies, and carotid and vertebral artery disease. This update of the previous 2017 guideline contains several new or revised recommendations. Recommendations regarding triage and initial assessment of acute transient ischemic attack (TIA) and minor stroke have been simplified, and selected aspects of the etiological stroke workup are revised. Updated treatment recommendations based on new evidence have been made for dual antiplatelet therapy for TIA and minor stroke; anticoagulant therapy for atrial fibrillation; embolic strokes of undetermined source; low-density lipoprotein lowering; hypertriglyceridemia; diabetes treatment; and patent foramen ovale management. A new section has been added to provide practical guidance regarding temporary interruption of antithrombotic therapy for surgical procedures. Cancer-associated ischemic stroke is addressed. A section on virtual care delivery of secondary stroke prevention services in included to highlight a shifting paradigm of care delivery made more urgent by the global pandemic. In addition, where appropriate, sex differences as they pertain to treatments have been addressed. The CSBPR include supporting materials such as implementation resources to facilitate the adoption of evidence into practice and performance measures to enable monitoring of uptake and effectiveness of recommendations.

Patent foramen ovale: is it an incidental finding to ignore or a disease to follow?

The authors briefly present two clinical cases and discuss the approach to the management of an incidental finding of patent foramen ovale (PFO) in a young child. We discuss the current controversies in the management of PFO in this age group.

Position paper of the Italian Society of Interventional Cardiology (SICI-GISE): Management of patent foramen ovale in patients with cerebral or systemic thromboembolism - 2020

Patent foramen ovale (PFO) is implicated in the pathogenesis of different clinical syndromes in which it plays variable roles. In 2017 and 2018, four randomized clinical trials were published, allowing for the clarification of certain issues pertaining to cryptogenic stroke. Recently, eight European scientific societies collaborated to the writing of an interdisciplinary international position paper on PFO and cryptogenic stroke, based upon best available evidence, with the aim of defining the principles needed to guide decision making. Nonetheless, a tailored approach is not suitably addressed by standard position documents, considering that decisions about optimal management of PFO patients with left circulation thromboembolism are often challenging, mostly due to comorbidities and complex clinical scenarios.A panel of Italian cardiology experts gathered under the auspices of the Italian Society of Interventional Cardiology (SICI-GISE) for comprehensive discussion and consensus development, with the aim of providing practical recommendations, for both clinical and interventional cardiologists, regarding optimal management of PFO in patients with cerebral or systemic thromboembolism. In this position paper, various clinical scenarios in patients with and without high-risk PFO features are presented and discussed, including PFO patients with associated conditions (e.g. hypercoagulable states, deep vein thrombosis/pulmonary embolism, short runs of atrial fibrillation), and special subsets (e.g. patients with risk factors for atrial fibrillation, patients aged ≥65 years, patients who refused percutaneous PFO closure), with the Panel's recommendations being provided for each scenario.

Impact of Patent Foramen Ovale on Total Knee Arthroplasty Cerebrovascular Accident Perioperative Management.

Venous thromboembolism and ischemic stroke are major complications following total knee arthroplasty (TKA) and potentially are associated with a patent foramen ovale (PFO). Although this association has been shown in other surgical disciplines, it has not been demonstrated in patients undergoing TKA. This study was undertaken to determine whether patients with a PFO would have a significantly increased risk of cerebrovascular accident (CVA) following TKA. The Humana national database was used to identify TKA patients who were stratified by the presence of a PFO from 2007 to 2016. Ninety-day follow-up was used for the primary outcome of CVA. Potential confounding comorbidities also were investigated, including age, sex, anticoagulation, insurance type, arrhythmia, valvular disease, peripheral vascular disease, chronic kidney disease, and diabetes mellitus. Of 153,245 TKAs, a total of 2272 patients had strokes; 479 of these patients had a PFO. On multivariable analysis, PFO remained an independent predictor of CVA postoperatively (odds ratio, 3.824; 95% confidence interval, 2.614-5.406; P<.0001). Other significant comorbidities associated with CVA included arrhythmia, chronic kidney disease, diabetes mellitus, peripheral vascular disease, and coronary valve disease. Importantly, low-molecular weight heparin or factor Xa inhibitor administration postoperatively had a negative correlation with stroke (odds ratio, 0.762; 95% confidence interval, 0.663-0.871; P=.0001 and odds ratio, 0.749; 95% confidence interval, 0.628-0.885; P=.0009, respectively). The findings of the multivariable analysis indicate PFO is associated with early postoperative CVA within 90 days following TKA. If known preoperatively, appropriate referral should be made to a cardiologist for PFO management and anticoagulation to reduce the overall risk of stroke. [Orthopedics. 2020;43(3):e151-e158.].

Patent foramen ovale-related complications in left ventricular assist device patients: a reappraisal for cardiovascular professionals.

Left ventricular assist device (LVAD) implantation is an important treatment option for patients with advanced heart failure. The presence of a patent foramen ovale (PFO) may elicit undesired consequences in LVAD patients: hypoxemia and paradoxical embolization. The variable physiological status of the patient with heart failure can make pre-LVAD implant identification of a PFO elusive. When identified pre- or intraoperatively, PFO is closed at time of LVAD implantation. In the case of delayed diagnosis, percutaneous PFO closure has proven to be a feasible and safe solution. As mechanical circulatory support gains prevalence, it is important to raise awareness of physiological implications of right-to-left shunt during mechanical circulatory support. We reviewed the diagnostic and therapeutic management of PFO in LVAD patients.

Closing the gap on patent foramen ovale and cryptogenic stroke

ABSTRACTIntroduction: The treatment options for prevention of recurrent of cryptogenic stroke in patients with patent foramen ovale (PFO) have been intensely debated in the recent decades. The suggested options were percutaneous closure of PFO versus medical therapy. However, up to these date there is a controversy regarding the indication of percutaneous closure. Multiple meta-analysis and recent randomized control trials showed the benefit of PFO closure when compared with medical therapy alone.Areas covered: The article reviews the prevalence, physiology, diagnosis and treatment options of PFO after cryptogenic stroke. Furthermore, it will discuss the results of randomized control trials that compared the PFO closure to medical therapy.Expert opinion: The association between PFO and unexplained cryptogenic stroke has been well established in the multiple studies. The diagnosis and management of PFO might be challenging in some cases. Although multiple studies showed that PFO closure is associated with lower rates of recurrent stroke in patients presenting with cryptogenic stroke, the indication and patient selection for this intervention are not well established yet in the guidelines.