PFO Closure Recommended for Susceptible Stroke Patients

A new clinical practice guideline recommends that patients with a patent foramen ovale (PFO) who suffered cryptogenic stroke should have it surgically closed.

The BMJ Rapid Recommendations, composed by a panel of experts from the Dutch College of General Practitioners (Utrecht, The Netherlands), University Hospitals of Geneva (Switzerland), the Norwegian Institute of Public Health (FHI, Oslo; Norway), and other institutions, is based on a recent systematic review triggered by three large randomized trials published in September 2017 that suggest PFO closure may reduce the risk of a recurrent ischemic stroke better than antiplatelet and anticoagulant therapies.

The recommendations apply to patients under 60 years with PFO who suffered a cryptogenic ischemic stroke, when extensive workup for other etiologies of stroke is negative. For patients who are open to all options, the panel makes a weak recommendation for PFO closure plus antiplatelet therapy rather than anticoagulant therapy; for patients in whom anticoagulation is contraindicated or declined, they make a strong recommendation for PFO closure plus antiplatelet therapy versus antiplatelet therapy alone; and for patients in whom closure is contraindicated or declined, a weak recommendation is made for anticoagulant therapy, rather than antiplatelet therapy.

Because PFO closure is associated with higher costs, the researchers concede that implementation of the recommendation is likely to have an important cost impact for health funders in the short term. But over the long term, they say PFO closure may reduce costs as a result of reduced stroke rates and reduction in associated costs. They conclude that further trials are needed to address remaining uncertainties, and that new evidence must be assessed in order to judge to what extent it may alter the recommendations. The recommendations were published on July 25, 2018, in BMJ.

“PFO patients suffering cryptogenic stroke have experienced confusion when navigating the treatment decision making process,” said panel member Bray Patrick-Lake, founding director of the PFO Research Foundation (Boulder, CO, USA). “The BMJ working group included patient representatives in the critical assessment of PFO research and thoughtfully produced evidence that can help patients understand what their outcomes are likely to be with available therapies so they can work with their physicians to make an informed treatment decision which incorporates their values and preferences."

When the chambers of a human heart begin to develop, a tunnel is formed between the right and left atria of the heart in order to allow blood to flow directly from the venous to the arterial circulation, circumventing the non-functioning fetal lungs. Following birth, a pressure differential between the right and left atria forms to allow blood flow to the fully functioning lungs, and the tunnel eventually closes completely. When this does not occur, a PFO is formed, allowing blood clots and deoxygenated blood to cross over to the arterial side.

Related Links:
Dutch College of General Practitioners
University Hospitals of Geneva
Norwegian Institute of Public Health