PFO and Cryptogenic Stroke: New Clarity on Reducing Risk

By William E. Downey, MD, Medical Director, Interventional Cardiology

All of us are born with a patent foramen ovale (PFO) – a flap valve between the left and right atria. In three out of four of us, this seals over in the first few years of life. The problem? This flap valve remains in 25 percent of us. While the majority will never experience a problem, in some people, venous thrombus can pass through this opening to the systemic circulation and cause a stroke.

Lower Recurrent Stoke Risk With PFO Closure

For more than 25 years, we’ve been able to close a PFO with catheter-based techniques. However, until now, doctors faced a lack of clear data about whether doing so reduces the risk of a recurrent stroke.

Three multicenter clinical trials this year have given doctors more clarity. RESPECT, REDUCE and CLOSE each randomized patients with PFO and a history of cryptogenic stroke to either PFO closure accompanied by medical therapy or medical therapy alone and followed patients for several years. 

Published simultaneously in the New England Journal of Medicine, these trials clearly demonstrated that PFO closure reduces the risk of recurrent stroke substantially more than medical therapy alone. 

Specifically, the annual risk of recurrent stroke with medical therapy alone is about 1 percent, and this is reduced to less than 0.5 percent per year with PFO closure. Importantly, this risk and benefit appeared to be stable over multiple years. For a 35-year-old patient, the risk of a recurrent stroke by retirement age could decrease from 30 percent to less than 15 percent with PFO closure.

It’s important to emphasize that this applies only to patients with ischemic stroke likely to be of embolic etiology and not explained by carotid disease or atrial fibrillation. It does not apply to lacunar strokes. Evaluation includes neurologic assessment including an MRI demonstrating the stroke, outpatient cardiac monitoring to exclude atrial fibrillation, transthoracic echocardiogram with bubble study to both demonstrate the PFO and exclude other cardiac etiologies of thromboembolism, and evaluation for hypercoagulability.

Refer Your Patient for PFO Closure

At Sanger Heart & Vascular Institute, we perform PFO closures regularly with an expert team. The procedure is catheter-based and done using conscious sedation rather than general anesthesia. Most commonly, patients go home the same day and return to work or their daily activities within just a few days.

Do you have a patient who may benefit from PFO closure? We can help.

We work hand-in-hand with you until the patient can safely be transitioned back to your care. You’ll remain a critical member of the team throughout the patient’s evaluation, treatment and follow-up, and you’ll even have our cell phone numbers in case of any questions.

Contact us to learn more or to refer a patient. Reach us at 704-617-8154 or SHVIStructuralHeart@AtriumHealth.org.