Multidisciplinary management of patent foramen ovale (PFO) and cryptogenic stroke/TIA

Naqibullah Mirzada, Per Ladenvall, Per-Olof Hansson, Peter Eriksson, Mikael Dellborg

GUCH Centre, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden; Dept of Molecular and Clinical Medicine/Cardiology, Institute of Medicine, Sahlgrenska Academy Gothenburg University, Gothenburg, Sweden

Purpose: Patent foramen ovale (PFO) has been implicated as a risk factor for cryptogenic ischemic stroke (CS). However, there is still a lack of widely accepted, undisputed indications for PFO closure. The present study describes the concept of the multidisciplinary PFO conference and a decision making process for closure versus no closure that was developed into a formalized clinical algorithm, and presents the results of implementing these, in terms of number and proportion of PFO closures as well as repeat referrals.
Design: Five specialists in neurology, cardiology, internal medicine, thromboembolism, and echocardiography evaluated the clinical data of 311 patients at PFO conferences during 2006 to 2009. The main criteria for closure were patients with first-ever CS with PFO and atrial septal aneurysm, or patients with recurrent CS and PFO without atrial septal aneurysm.
Results: A total of 143 patients (46%) were accepted for closure and 167 patients were rejected. Patients accepted for closure were younger (mean 50 years versus 58 years) (P <0.001). The acceptance rate for PFO closure was similar throughout these years, with an average of 45%. Three of 167 patients (1.8%) initially rejected for PFO closure were re-referred due to recurrent stroke, and the PFO closure was subsequently performed.
Conclusion: The acceptance rate of less than 50% in the present study underscores the complex relationship between CS and PFO. Whatever the criteria used for PFO closure, any unit caring for these patients needs to have a rigorous process to avoid overtreatment as well as undertreatment and to ensure that personal preferences and economic incentives do not steer the selection process. Our algorithm provides a stable acceptance rate and a low rate of repeat referrals.

Keywords: patent foramen ovale, cryptogenic stroke, clinical algorithm, patent foramen ovale closure