Team-centred approach is best way of determining need for PFO closure

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Deepak L Bhatt

A meta-analysis, published in The American Journal of Medicine, provides further evidence that percutaneous closure of patent foramen ovale (PFO) in patients with recent cryptogenic stroke significantly reduces the rate of recurrent stroke/transient ischaemic stroke. However, it also appears to be associated with an increased rate of atrial fibrillation/flutter. Cardiovascular News spoke to study investigator Deepak L Bhatt (Brigham and Women’s Hospital, Heart & Vascular Center. Boston, USA) about the findings.

What proportion of patients with a PFO will have a stroke?

A tiny percentage! Routine closure in patients with asymptomatic PFOs should not be performed. On the other hand, PFO closure can be carefully considered in a young patient (≤60 years) with a truly cryptogenic stroke.

What were the key findings of your meta-analysis?

In the randomised clinical trials that we included in our study, PFO closure in young patients with cryptogenic stroke was superior to the medical therapy used. Overall, the rate of recurrent stroke or transient ischaemic attack was reduced from two events to one event per 100 patient-years.

It is important to realise, though, there was a modest amount of heterogeneity in medical therapy. Some patients were on antiplatelet therapy even though many experts might have recommended therapeutic anticoagulation instead.

The meta-analysis showed that PFO was associated with an increased risk of atrial fibrillation/atrial flutter. What do you think are the reasons for this increased risk?

I think a PFO closure device may irritate the atria in susceptible individuals.

Is this increased risk of atrial fibrillation/atrial flutter a concern? For example, is it a barrier to the use of PFO closure?

I think the risk of atrial fibrillation, especially the need for careful follow up, has been underappreciated. It is a concern; potentially, you could make an argument for the need for therapeutic anticoagulation in the first place for presumed cryptogenic stroke. A proportion of cryptogenic stroke is likely due to undocumented atrial fibrillation or pelvic deep venous thrombosis—situations in which anticoagulation would be called for anyway.

Based on the available evidence, when would you use PFO closure?

I think the best method for determining the need for PFO closure is a team approach, with an interventional cardiologist working with a stroke neurologist. If everyone is convinced there really is no other cause for stroke in a young person, then it is reasonable to consider closing the PFO if the procedural risk is low.

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