Implications of detection of foramen ovale patent after cryptogenic ischemic stroke

Therapeutic uncertainty is inherent in decisions in patients with patent foramen ovale (PFO) and cryptogenic stroke. We aimed to determine clinical implications of PFO identification in transesophageal echocardiography (TEE) after a cryptogenic ischemic stroke.

Consecutive TEE done between 2011 and 2015 in patients with previous cryptogenic stroke was evaluated. Clinical implications of PFO identification (closure and/or medical therapy) were retrieved from the medical records and discharge summaries. Adverse events related to therapy, stroke recurrence and death were analyzed during follow-up.

Three-hundred one patients (mean age 59 ± 11 years; 61% male) underwent a TEE, of which 77 (26%) patients had a diagnosis of PFO. Patients with PFO were younger (56 ± 13 versus 60 ± 14, p = 0.03). Of those with PFO, 23 (30%) underwent percutaneous closure of PFO and these patients had more frequently complex or large PFO (p < 0.001 and p = 0.004, respectively). The remaining 54 (70%) were treated with medical therapy: 30 (39%) with antiplatelet therapy and 24 (31%) with oral anticoagulation. During follow-up (44 ± 17 months), only two patients had another stroke (both referred for PFO closure, while they were waiting for the procedure) and two patients, on whom PFO closure was not performed, died (not for cardiovascular causes).

PFO's (size and complexity) and patients' characteristics influenced clinical decision when PFO was detected on TEE. The risk for recurrent stroke was not increased in patients who did not undergo PFO closure; although two patients waiting for PFO closure had recurrent stroke, demonstrating its importance.