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

Ever since the observation was made linking a higher prevalence of a patent foramen ovale (PFO) in younger individuals with cryptogenic stroke (CS), there has been a vigorous debate as to the role the PFO plays and a search for the optimal management strategy to prevent recurrent CS. Data from observational studies from the past two decades have demonstrated the superiority of percutaneous device closure over medical therapy. The recent publication of three randomized controlled trials (RCTs), which failed to demonstrate the superiority of percutaneous closure has reignited the controversy as to how best treat these patients. In this article, we will review the contemporary literature from the past three years including the results from new meta-analyses of medical therapy and device closure. In addition, we will review the three published randomized control trials to date (ie, CLOSURE I, the PC trial, and RESPECT) along with a meta-analysis of their results. While on primary intention-to-treat analysis, the three RCTs failed to demonstrate a superiority of percutaneous PFO closure vs medical therapy, a closer look at the data seems to suggest a trend toward benefit. We come to the conclusion that the issue of optimal treatment of PFO in patients with CS is far from settled and is unlikely to be a "one size fits all" approach due to the heterogeneity of this condition. In our opinion, based on the entirety of available data, both observational and randomized, there is likely a role for percutaneous device closure in select patients with CS in whom a PFO is the likely cause of their first stroke and will remain a significant risk for recurrent neurologic events. The article will go on to review current indications for atrial septal defect (ASD) closure and will highlight safety, efficacy and caveats regarding this technique.