Pfo Closure Tia

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Introduction

PFO (Patent Foramen Ovale) is a congenital heart defect that can increase the risk of stroke or TIA (Transient Ischemic Attack).
PFO closure is a procedure to close the hole in the heart, which can reduce the risk of recurrent strokes or TIAs.
Studies show mixed results on the necessity and effectiveness of PFO closure, with some suggesting it should not be routinely recommended.
PFO closure is generally considered for patients with recurrent cerebral ischemic events, a large right-to-left shunt, and a high risk for deep venous thrombosis.
Medical therapy, including antiplatelet or anticoagulation treatment, is an alternative to PFO closure, but its effectiveness varies.

Definition: A PFO is a hole in the heart that didn't close the way it should after birth.
Prevalence: About one in five Americans has a PFO, often without symptoms.
Risk Factor: PFO can increase the risk of stroke or TIA, especially in younger patients.
Paradoxical Embolism: PFO allows blood clots to pass from the right to the left side of the heart, potentially causing a stroke.
Studies: Multiple studies have shown a higher prevalence of PFO in patients with cryptogenic stroke compared to the general population.

Procedure: PFO closure involves inserting a device through a catheter to close the hole in the heart.
Devices: Various devices are used, including Amplatzer, Helex, and Cardioseal.
Success Rate: The procedure is generally successful, with a low complication rate.
Complications: Minor complications can include atrial fibrillation and device embolization.
Follow-Up: Regular follow-up with transesophageal echocardiogram (TEE) is recommended to check for residual shunts.

Medical Therapy: Includes antiplatelet therapy (aspirin, clopidogrel) and anticoagulation therapy (warfarin).
Effectiveness: Studies suggest no significant benefit of anticoagulation over antiplatelet therapy.
Recurrent Events: Medical therapy has a higher recurrence rate of stroke or TIA compared to PFO closure.
PICSS Study: Found similar recurrent stroke/TIA rates between warfarin and aspirin cohorts.
Meta-Analyses: Show a proportional decrease in recurrent cerebral events with PFO closure compared to medical therapy.

Complications: Include atrial fibrillation, device embolization, and minor complications like asymptomatic thrombus.
Mortality: One patient in a study died from septicemia post-procedure.
Residual Shunt: Found in a small percentage of patients, sometimes requiring a second occluder.
Long-Term Risks: Include potential for recurrent stroke or TIA, though reduced compared to medical therapy.
Device-Specific Issues: Older devices had higher complication rates; newer devices show improved safety.

Guidelines: Recommend PFO closure for patients under 60 with embolic-appearing infarct and no other stroke mechanism identified.
SCAI Guidelines: Suggest PFO closure for patients with thrombophilia and prior PFO-associated stroke.
Clinical Trials: Recent trials show mixed results on the routine recommendation of PFO closure.
Patient Selection: Important to identify patients who might benefit most from the procedure.
Discussion: Clinicians should discuss potential benefits and risks with patients before deciding on PFO closure.