Management Of Patent Foramen Ovale Research Articles

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.

European position paper on the management of patients with patent foramen ovale. General approach and left circulation thromboembolism.

The presence of a patent foramen ovale (PFO) is implicated in the pathogenesis of a number of medical conditions; however, the subject remains controversial and no official statements have been published. This interdisciplinary paper, prepared with involvement of eight European scientific societies, aims to review the available trial evidence and to define the principles needed to guide decision making in patients with PFO. In order to guarantee a strict process, position statements were developed with the use of 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 of particular management options were weighed and graded according to predefined scales. Despite being based often on limited and non-randomised data, while waiting for more conclusive evidence, it was possible to conclude on a number of position statements regarding a rational general approach to PFO management and to specific considerations regarding left circulation thromboembolism. For some therapeutic aspects, it was possible to express stricter position statements based on randomised trials. This position paper provides the first largely shared, interdisciplinary approach for a rational PFO management based on the best available evidence.

European position paper on the management of patients with patent foramen ovale. General approach and left circulation thromboembolism.

The presence of a patent foramen ovale (PFO) is implicated in the pathogenesis of a number of medical conditions; however, the subject remains controversial and no official statements have been published. This interdisciplinary paper, prepared with involvement of eight European scientific societies, aims to review the available trial evidence and to define the principles needed to guide decision making in patients with PFO. In order to guarantee a strict process, position statements were developed with the use of 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 of particular management options were weighed and graded according to predefined scales. Despite being based often on limited and non-randomised data, while waiting for more conclusive evidence, it was possible to conclude on a number of position statements regarding a rational general approach to PFO management and to specific considerations regarding left circulation thromboembolism. For some therapeutic aspects, it was possible to express stricter position statements based on randomised trials. This position paper provides the first largely shared, interdisciplinary approach for a rational PFO management based on the best available evidence.

Stroke in young adults: Five new things.

The incidence of stroke in young adults is increasing, mainly driven by an increasing incidence of ischemic stroke in this population. We provide new information that has been recently presented regarding the risk factor prevalence, some specific etiologic causes, and management strategies in ischemic stroke in this population. Recent studies indicate a rapid increase in traditional risk factors in young adults. New information regarding the management of patent foramen ovale in cryptogenic stroke and cervical artery dissection is available. Stroke in young adults is a rapidly growing problem with deep public health implications. There are many areas in this field, which require further research.

Patent Foramen Ovale Closure Versus Medical Therapy for Cryptogenic Ischemic Stroke: A Topical Review.

Managing young and middle-aged patients with cryptogenic ischemic stroke and a patent foramen ovale (PFO) is a common clinical dilemma for neurologists, cardiologists, and primary care physicians. Each year, ≈18 000 patients in the United States and 345 000 worldwide, aged 18 to 60, present with a PFO and an embolic stroke of otherwise undetermined source (Figure 1).1–5 Leading treatment options to prevent stroke recurrence include antiplatelet medications, anticoagulant medications, and percutaneously placed PFO closure devices. Lacking randomized trial data, choosing among these options was long a quandary for physicians. But major new trial results in 2017 to 2018,6–9 added to earlier trials reported in 2012 to 2013,10–12 have transformed the evidential foundation for PFO management. This topical review appraises and synthesizes the accumulated trial findings and considers how they may best inform physician and patient treatment decision-making. Figure 1. Annual incidence of cryptogenic ischemic stroke in young and middle-aged adults with patent foramen ovale (PFO). Broad estimates of annual incidence in ( A ) United States; ( B ) globally.1–5 Right-to-left shunts enable thrombi that form in, and dislodge from, the venous system to bypass filtration in the pulmonary vasculature, paradoxically cross to the arterial tree, and travel to and occlude recipient cerebral arteries. PFOs are the most common causes of right-to-left shunts, present in about one quarter of all adults. During fetal life, the interatrial septum separating the right and left atria initially forms with a tunnel, the foramen ovale, that enables maternally oxygenated blood to bypass the fetal pulmonary circulation and nourish arterial beds directly. This interatrial passage closes in most individuals during the first 3 months after birth. However, in about one quarter of the population, the passage remains patent lifelong. The mean diameter of persisting PFOs is 4.9 mm (range, …

Management of patent foramen ovale in patients with cryptogenic stroke: Is device closure superior to medical treatment? A brief review.

Background:Recent randomized controlled trial (RCTs) comparing percutaneous closure with antithrombotic treatment in patients with patent foramen ovale (PFO) and cryptogenic stroke revealed inconsistent results. Indeed, there is still no consensus on the management of these patients, namely closure or medical therapy treatment.Methods:To take stock of the PFO management after cryptogenic stroke, we conducted a literature review that included 16 articles dealing with different therapeutic strategies and long-term outcomes of these results.Results:The reviewed studies showed great methodological diversity rendering an exhaustive and balanced comparison between studies difficult. Low recurrence rates under prevention regimens, crossovers, procedure- and device-related complications, as well as inappropriate patient selection might explain the inconsistency of trials. However, despite the methodological heterogeneity certain patterns could be detected. It appears that device closure as secondary prevention measure is an effective and safe procedure reducing the recurrence of neurological events in cryptogenic stroke patients <60 years with large PFOs. Standardization of procedures and larger trials are needed to arrive to definitive conclusions.Conclusion:In cryptogenic stroke patients <60 years with large PFOs, PFO closure seems to be safe and more effective compared to medical treatment alone. For all other patients group, for example, patients >60 years further trials are needed to clarify the role of PFO closure.

Evidence-Based Management of Patent Foramen Ovale in Patients With Ischemic Stroke

Evidence-Based Management of Patent Foramen Ovale in Patients With Ischemic Stroke

Canadian stroke best practice recommendations: Secondary prevention of stroke, sixth edition practice guidelines, update 2017.

The 2017 update of The Canadian Stroke Best Practice Recommendations for the Secondary Prevention of Stroke is a collection of current evidence-based recommendations intended for use by clinicians across a wide range of settings. The goal is to provide guidance for the prevention of ischemic stroke recurrence through the identification and management of modifiable vascular risk factors. Recommendations include those related to diagnostic testing, diet and lifestyle, smoking, hypertension, hyperlipidemia, diabetes, antiplatelet and anticoagulant therapies, carotid artery disease, atrial fibrillation, and other cardiac conditions. Notable changes in this sixth edition include the development of core elements for delivering secondary stroke prevention services, the addition of a section on cervical artery dissection, new recommendations regarding the management of patent foramen ovale, and the removal of the recommendations on management of sleep apnea. The Canadian Stroke Best Practice Recommendations include a range of supporting materials such as implementation resources to facilitate the adoption of evidence to practice, and related performance measures to enable monitoring of uptake and effectiveness of the recommendations. The guidelines further emphasize the need for a systems approach to stroke care, involving an interprofessional team, with access to specialists regardless of patient location, and the need to overcome geographic barriers to ensure equity in access within a universal health care system.

Percutaneous closure of the patent foramen ovale: A cardiological perspective

A patent foramen is commonly found in the general population.Evidence exists that a patent foramen ovale (PFO) and atrial septal aneurysm are strongly associated with cryptogenic stroke. Associations with migraine have also been described, but the status of cause and effect is less clear. Management of PFO is controversial and no form of therapy has been properly evaluated. PFO closure devices are readily available and can be safely and effectively implanted percutaneously. Complication rates are low and symptoms are improved in most patients. At present, there is a lack of guidelines for the treatment of PFO and results of prospective randomised trials are eagerly awaited.

Update on the Management of Patent Foramen Ovale in 2017: Indication for Closure and Literature Review

Patent foramen ovale (PFO) is a common congenital abnormality with a high prevalence of approximately 25 % in the general population and an even higher incidence of about 40 % in the cryptogenic stroke population. PFO closure in cryptogenic stroke patients as a treatment modality for the secondary prevention of recurrent stroke has been much debated and studied. Several completed randomized clinical trials sought to answer the question of whether PFO closure is beneficial for cryptogenic stroke patients. Until the most recent of these trials, no significant benefit had been demonstrated. Based on newer evidence, in October 2016 the US Food and Drug Administration approved the first dedicated closure device for PFO. This review article describes the association between PFO and cryptogenic stroke, reviews current diagnostic modalities of PFO assessment, discusses management approaches, and reviews randomized clinical trials, practice guidelines, and consensus statements. Associations between PFO and other conditions such as migraine headaches, platypnea-orthodeoxia syndrome, and decompression sickness in divers are also briefly reviewed.

Cryptogenic Stroke: Making the Management Less Cryptic.

Cryptogenic stroke (CS) accounts for 20% to 40% of ischemic strokes. CS is defined as a cortical infarct suggestive of an embolic stroke with no identifiable cardiac etiology, large vessel occlusive disease, or small vessel lacunar stroke. The likely etiologies for CS are patent foramen ovale (PFO) and paroxysmal atrial fibrillation, which can be detected by transesophageal echocardiography and long-term cardiac rhythm monitoring. In a busy academic hospital, the stroke service is frequently asked to provide a rational approach to patients with such a presentation. The 2011 American Heart Association/American Stroke Association recommends that antiplatelet therapy is "reasonable" (Class IIa; Level of Evidence B) for patients with PFO and a clinical presentation of CS. Confounding PFO management is the lack of a controlled trial comparing anticoagulation with antiplatelet therapy in patients with CS, despite the belief that the primary mechanism of PFO-mediated stroke would be that it serves as a conduit for venous emboli. Data from 3 recent prospective PFO closure device trials further compound the management protocols for these patients. Also complicating the management of CS is increasing evidence that paroxysmal atrial fibrillation may be found as often as 30% with extensive monitoring and long-term follow-up of 36 months. Based on these recent developments, we summarize the factors that we deemed relevant in our approach to patients with CS.

Multidisciplinary position paper on the management of patent foramen ovale in the presence of cryptogenic cerebral ischemia - Italian version 2013

There is no generally accepted consensus on the management of patent foramen ovale (PFO) in the presence of cryptogenic cerebral ischemia, because of the lack of conclusive evidence. The aim of this position paper was to develop and promote a joint approach based on available data that may be shared by different specialists, while waiting for definite results from randomized controlled trials. A position statement was produced involving the major national scientific societies. The task force members were nominated by the presidents and/or executive boards of each society or working group, as appropriate, based on their previous work in relevant topic areas. Specific task force working groups prepared the drafts. In order to achieve maximum agreement, these drafts were merged and distributed to the scientific societies for local evaluation. The ensuing final draft, merging all the revisions, was reviewed by the task force and finally approved by all scientific societies. The following issues were addressed: definitions of transient ischemic attack (TIA) and both symptomatic and asymptomatic cryptogenic stroke; formulation of a diagnostic workup for patients with clinical event(s) and PFO; recommendations regarding medical and interventional treatment options considering individual risk factors based on the three available randomized trials and other observational studies; recommendations regarding requirements for operators and centers in Italy; definition of a follow-up evaluation protocol. In conclusion, available data provided the basis for the first multi-society position paper on the management of cryptogenic stroke/TIA and PFO.

Diagnosis and management of patent foramen ovale.

What is a patent foramen ovale? The fossa ovalis is an overlap flap between the two layers of the atrial septum (septum primum on the left atrial side and septum secondum on the right atrial side). In the fetus there is communication between the left and right atria. Oxygenated blood drains from the umbilical vein via the ductus venosus to the inferior vena cava and then the right atrium. Blood does not flow to the fetal lungs as the pulmonary vascular resistance is high and instead goes via the foramen ovale and ductus arteriosus to the systemic circulation (Figure 1). After the fetus is delivered, breathing causes the pulmonary vasculature resistance to fall with a subsequent increase in cardiac blood flow and increase in left atrial pressure. This causes the primum and secondum septae to fuse together, closing the foramen ovale. In 25–40% of individuals this closure is not complete and a flap or tunnel between the atria remains – the patent foramen ovale (Hagen et al, 1984) (Figure 2). In around 1% of the population, the septae are large and mobile and an atrial septal aneurysm exists (Silver and Dorsey, 1978). The definition of an atrial septal aneurysm varies but a consensus view is that

(587) - Single Center, 23 Year Experience With PFO Management During HeartMate LVAD Implants

Patent foramen ovale (PFO) is a common occurrence in patients undergoing LVAD placement yet reports describe operative closure in less than 5% of implants. Missed PFO may lead to paradoxical emboli, hypoxia and necessity of under driving the LVAD. Intraoperative transesophageal echocardiography (TEE) can fail to detect this problem. Routine intraoperative visual inspection of the septum is easily performed but frequently unnecessary. Intraoperative pulmonary artery compression and coincident bubble doppler TEE makes PFO diagnosis reliable.

Comparison of the Effect on Right Atrial Pressure of Abdominal Compression Versus the Valsalva Maneuver

When the right atrial pressure (RAP) exceeds the left atrial pressure, right-to-left shunting can occur. Normally, the Valsalva maneuver is used to facilitate elevation of RAP. However, performing the Valsalva maneuver can be problematic in certain situations. The aim of this study was to test the hypothesis that the application of abdominal pressure would increase the pressure within the right atrium compared with the left atrium, making it an adequate alternative to the Valsalva maneuver. Twelve patients were prospectively evaluated during right-sided cardiac catheterization with the application of abdominal pressure as well as a Valsalva maneuver. RAP and left atrial pressure were measured simultaneously. In 11 patients, the mean RAP was lower than the mean pulmonary capillary wedge pressure at baseline. The mean RAP was significantly higher than the mean pulmonary capillary wedge pressure during abdominal compression (24.8 ± 9.9 vs 21.6 ± 8.8 mm Hg, p = 0.001). When the Valsalva maneuver was performed, mean RAP was also significantly higher than the mean pulmonary capillary wedge pressure (25.3 ± 10.9 vs 22.1 ± 10.3 mm Hg, p = 0.008). In conclusion, abdominal compression is similar to an optimal Valsalva maneuver for increasing RAP and thus the right-to-left pressure gradient. Performing abdominal compression provides a simple alternative to the Valsalva maneuver for creating a transient increase in RAP.

Multidisciplinary management of patent foramen ovale (PFO) and cryptogenic stroke/TIA

PurposePatent foramen ovale (PFO) has been implicated as a risk factor for cryptogenic ischemic stroke (CS). However, there is still a lack of widely accepted, undisputed indications for PFO closure. The present study describes the concept of the multidisciplinary PFO conference and a decision making process for closure versus no closure that was developed into a formalized clinical algorithm, and presents the results of implementing these, in terms of number and proportion of PFO closures as well as repeat referrals.DesignFive specialists in neurology, cardiology, internal medicine, thromboembolism, and echocardiography evaluated the clinical data of 311 patients at PFO conferences during 2006 to 2009. The main criteria for closure were patients with first-ever CS with PFO and atrial septal aneurysm, or patients with recurrent CS and PFO without atrial septal aneurysm.ResultsA total of 143 patients (46%) were accepted for closure and 167 patients were rejected. Patients accepted for closure were younger (mean 50 years versus 58 years) (P < 0.001). The acceptance rate for PFO closure was similar throughout these years, with an average of 45%. Three of 167 patients (1.8%) initially rejected for PFO closure were re-referred due to recurrent stroke, and the PFO closure was subsequently performed.ConclusionThe acceptance rate of less than 50% in the present study underscores the complex relationship between CS and PFO. Whatever the criteria used for PFO closure, any unit caring for these patients needs to have a rigorous process to avoid overtreatment as well as undertreatment and to ensure that personal preferences and economic incentives do not steer the selection process. Our algorithm provides a stable acceptance rate and a low rate of repeat referrals.

Management of patients with patent foramen ovale and cryptogenic stroke

To organize a common approach on the management of patent foramen ovale (PFO) and cryptogenic stroke that may be shared by different specialists. The management of PFO related to cryptogenic stroke is controversial, despite an increase in interventional closure procedures. A consensus statement was developed by approaching Italian national cardiological, neurological, and hematological scientific societies. Task force members were identified by the president and/or the boards of each relevant scientific society or working group, as appropriate. Drafts were outlined by specific task force working groups. To obtain a widespread consensus, these drafts were merged and distributed to the scientific societies for local evaluation and revision by as many experts as possible. The ensuing final draft, merging all the revisions, was reviewed by the task force and finally approved by scientific societies. Definitions of transient ischemic attack and both symptomatic and asymptomatic cryptogenic strokes were specified. A diagnostic workout was identified for patients with candidate event(s) and patient foramen ovale to define the probable pathogenesis of clinical events and to describe individual PFO characteristics. Further recommendations were provided regarding medical and interventional therapy considering individual risk factors of recurrence. Finally, follow-up evaluation was appraised. Available data provided the basis for a shared approach to management of cryptogenic ischemic cerebral events and PFO among different Italian scientific societies. Wider international initiatives on the topic are awaited.

Management of patients with patent foramen ovale and cryptogenic stroke: A collaborative, multidisciplinary, position paper

To organize a common approach on the management of patent foramen ovale (PFO) and cryptogenic stroke that may be shared by different specialists. The management of PFO related to cryptogenic stroke is controversial, despite an increase in interventional closure procedures. A consensus statement was developed by approaching Italian national cardiological, neurological, and hematological scientific societies. Task force members were identified by the president and/or the boards of each relevant scientific society or working group, as appropriate. Drafts were outlined by specific task force working groups. To obtain a widespread consensus, these drafts were merged and distributed to the scientific societies for local evaluation and revision by as many experts as possible. The ensuing final draft, merging all the revisions, was reviewed by the task force and finally approved by scientific societies. Definitions of transient ischemic attack and both symptomatic and asymptomatic cryptogenic strokes were specified. A diagnostic workout was identified for patients with candidate event(s) and patient foramen ovale to define the probable pathogenesis of clinical events and to describe individual PFO characteristics. Further recommendations were provided regarding medical and interventional therapy considering individual risk factors of recurrence. Finally, follow-up evaluation was appraised. Available data provided the basis for a shared approach to management of cryptogenic ischemic cerebral events and PFO among different Italian scientific societies. Wider international initiatives on the topic are awaited.

Management of patent foramen ovale in cryptogenic stroke

There is currently no consensus on the optimal management of cryptogenic stroke in the presence of a patent foramen ovale (PFO). Some physicians do not believe in the added value of PFO closure in cryptogenic stroke, whereas, for others, cryptogenic stroke represents a situation where PFO closure would be the best management. Because of a lack of well-designed randomized trials, guidelines do not provide a clear answer. Therefore, the cardiological and neurovascular societies in Belgium decided to write an attempt at an expert opinion paper.

Management of patent foramen ovale in cryptogenic stroke.

There is currently no consensus on the optimal management of cryptogenic stroke in the presence of a patent foramen ovale (PFO). Some physicians do not believe in the added value of PFO closure in cryptogenic stroke, whereas, for others, cryptogenic stroke represents a situation where PFO closure would be the best management. Because of a lack of well-designed randomized trials, guidelines do not provide a clear answer. Therefore, the cardiological and neurovascular societies in Belgium decided to write an attempt at an expert opinion paper.