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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.

PFO and TIA Relationship [1]

  • 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.

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PFO Closure Procedure [2]

  • 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.

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Medical Therapy vs. PFO Closure [1]

  • 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.

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Risks and Complications [2]

  • 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.

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Guidelines and Recommendations [3]

  • 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.

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Related Videos

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<div class="-md-ext-youtube-widget"> { "title": "Managing Healthy Young Adults with PFO-Associated Stroke", "link": "https://www.youtube.com/watch?v=tSuRadQkXFk", "channel": { "name": ""}, "published_date": "Aug 16, 2022", "length": "" }</div>

<div class="-md-ext-youtube-widget"> { "title": "The case for PFO closure: Preventing recurrent stroke in ...", "link": "https://www.youtube.com/watch?v=cC6PI2Xrtbo", "channel": { "name": ""}, "published_date": "Aug 17, 2021", "length": "" }</div>

<div class="-md-ext-youtube-widget"> { "title": "What is PFO? | Closure of Patent Foramen Ovale to treat ...", "link": "https://www.youtube.com/watch?v=xMz5yqxlmZ8", "channel": { "name": ""}, "published_date": "Dec 5, 2019", "length": "" }</div>