Closure of a patent foramen ovale for the prevention of stroke

Abstract

The prevention of stroke has attracted great interest related to two major issues: (1) the enormous patient and family consequences of the impact of stroke in their lives and accordingly their great interest in preventing either an initial event or a recurrent event. Stroke may be considered the most devastating complication of cardiovascular disease. (2) The societal impact and cost of the complications of stroke both as mortality but as importantly long-term disability. Cardioembolic strokes are associated with the highest mortality and morbidity and also have the highest rate of recurrence. The role of a patent foramen ovale (PFO) has received great attention in part because of the graphic images both postmortem and echocardiographic of thrombi transiting the PFO right to left resulting in stroke or systemic thromboembolism. Several strategies have been developed including the intuitively obvious one of mechanically closing the PFO; multiple devices have been developed and are now used clinically. Assessment of the effect of device closure on stroke or transient ischaemic attack has been difficult. This is related to several factors including the high prevalence of PFO in the entire population compared with the low incidence of embolic events, the specific population in which the device is tested, and the fact that medical therapy can be effective in some patients. There is still controversy about optimal patient selection criteria for device implantation and its role relative to medical therapy. Optimal patients in whom to consider implantation include patients with cryptogenic stroke, particularly those with recurrent events.