Patent Foramen Ovale and Cryptogenic Stroke: Integrated Management

Abstract

Patent foramen ovale (PFO) is a common cardiac abnormality with a prevalence of 25% in the general population. PFO has been associated with the paradoxical embolism causing cryptogenic stroke and systemic embolization. Results from clinical trials, meta-analyses, and position papers support percutaneous PFO device closure (PPFOC), especially if interatrial septal aneurysms coexist and in the presence of large shunts in young patients. Remarkably, accurately evaluating patients to refer to the closure strategy is extremely important. However, the selection of patients for PFO closure is still not so clear. The aim of this review is to update and clarify which patients should be considered for closure treatment.

Keywords: PFO-associated syndromes; Patent foramen ovale (PFO); cryptogenic stroke; device closure; interatrial septal aneurysms.

Figure 1

(A) Mid-esophageal four-chamber view at 0 degrees and mid-esophageal bi-caval view at 90 degrees, simultaneously obtained by 2D-TEE X-plane modality. Simultaneous biplane mode (X-plane) allows us to obtain two simultaneous 2D images. (B) Cropped 3D-TEE image with zoom 3D modality. A complex tunnel PFO is shown. The 3D-TEE image shows a long septum primum (SP), widely separated from the septum secundum (SS). The Chiari network (CN) in the right atrium is displayed. IVC: inferior vena cava; SP: septum primum; PFO: patent formen ovale; SS: septum secundum; CN: Chiari network; LA: left atrium.

Figure 2

A 3D-TEE real-time microbubble test. Microbubbles opacify the right atrium (RA). Several microbubbles (red arrows) pass through the PFO, reaching the left atrium (LA) from the RA. SP: septum primum; PFO: patent formen ovale; SS: septum secundum; RA: right atrium.