PFO and ASD Closure in Adulthood: Where Do We Stand?

Area of Science:

• Cardiology
• Neurology
• Interventional Cardiology

Background:

• A patent foramen ovale (PFO) is frequently observed in younger individuals experiencing cryptogenic stroke (CS).
• Historically, observational studies suggested percutaneous device closure was superior to medical therapy for preventing recurrent CS.
• Recent randomized controlled trials (RCTs) have challenged this notion, reigniting the debate on optimal management.

Purpose of the Study:

• To review contemporary literature and recent meta-analyses on medical therapy versus percutaneous PFO closure for CS.
• To analyze the results of three major RCTs (CLOSURE I, PC, RESPECT) and their meta-analysis.
• To discuss the role of PFO closure in select CS patients and current indications for atrial septal defect (ASD) closure.

Main Methods:

• Review of literature published within the last three years.
• Analysis of new meta-analyses on medical therapy and device closure.
• Examination of three key RCTs and their combined meta-analysis.

Main Results:

• Primary intention-to-treat analysis of the three RCTs did not demonstrate superiority of percutaneous PFO closure over medical therapy for CS.
• A closer examination of the RCT data suggests a potential trend toward benefit with device closure.
• The heterogeneity of PFO-related CS suggests a "one size fits all" approach is unlikely.

Conclusions:

• The optimal treatment strategy for PFO in CS patients is not definitively settled.
• Percutaneous device closure may be beneficial for select patients with CS where PFO is the likely cause and poses a significant risk for recurrence.
• The article also reviews current indications, safety, efficacy, and caveats of ASD closure techniques.