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Patent foramen ovale (PFO) and stroke - to close or not to close by Mind Map: Patent foramen ovale (PFO) and
stroke - to close or not to close
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Patent foramen ovale (PFO) and stroke - to close or not to close

1. PFO and stroke a meta-analysis of case-control studies

Alsheikh-Ali et al, Stroke 2009

http://www.ncbi.nlm.nih.gov/pubmed/19443800

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Cryptogenic stroke vs stroke of dtermined cause

Cryptogenic stroke vs controls without stroke

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5. Risk of stroke recurrence

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List of reviews

Mas et al NEJM 2001

PFO-ASA study

http://www.ncbi.nlm.nih.gov/pubmed/11742048

2. Is stroke due to paradoxical embolism?

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reference

Halperin and fuster

Proven

presence of thrombus within an intracardiac defect at autopsy or echocardiography

Presumed

Arterial embolism with no evidence of left sided circulation source

Venous thrombosis and or pulmonary embolism

Elevation of the right heart pressure, sustained or transitory (Valsalva's maneuver)

Venous thrombosis

Low rate of DVT in most studies

Pelvic vein thrombosis

Hypercoagulable state

G20210A, factor V Leiden mutation

Circumstances predisposing to DVT

prolonged immobility

Valsalva-provoking activity

3. Other potential stroke mechanisms

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paroxysmal Atrial fibrillation

Direct embolisation from thrombi formed locally in the PFO tunnel or in the ASA

Occult stroke cause associated with PFO

etc.. see pic

4. Atrial septal aneurysm

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Reference

Handke et al, NEJM 2007, http://www.ncbi.nlm.nih.gov/pubmed/18046029

Goel et al Am J Cardiol 2009, picture, http://www.ncbi.nlm.nih.gov/pubmed/19101242

6. Options for secondary prevention

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Antiplatelet therapy

reduce recurrent ischemic events in the generality of ischaemic stroke survivors

well-tolerated

Oral anticoagulants

7. PICCS study, Reference, Homma et al, circulation 2002, http://www.ncbi.nlm.nih.gov/pubmed/12045168, picture

PFO closure

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references, Wohrle,lancet 2006, http://www.ncbi.nlm.nih.gov/pubmed/16876648, MIST 20008, NMT Medical Announces Preliminary Results of CLOSURE I, press release

Drawbacks of PFO closure, is not relevant if a PFO-unrelated mechanism is the cause of stroke, offers a false assurance and may lead to less incentive to comply wiht secondary prevention recommendations, doesn't avoid the need for long-term medical therapy, doesn't guarantee shunt closure, doesn't prevent thrombo-embolism

Does PFO closure reduce stroke recurrence?, Series of transcatheter PFO closure, Nonrandomised comparisons of PFO closure with medical treatment

CLOSE RCT

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7. Our curent practice

Antiplatelet therapy

Oral anticoagulants

PFO closure

recurrent ischemic event despite optimal antithrombotic therapy

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8. Take home message

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Author of presentation

J.L. Mas

http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=DetailsSearch&term=Mas+jl[Author]

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