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