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Surgical prophylaxis of recurrent stroke in patients with patent foramen ovale: a pilot study
M Guffi1, J Bogousslavsky, X Jeanrenaud
1Division of Cardiovascular Surgery, CHUV, University Hospital, Lausanne, Switzerland.
Insights
Surgical closure of patent foramen ovale (PFO) is a safe option for preventing recurrent stroke in patients with presumed paradoxical embolism. This pilot study showed no strokes during a 12.2-month follow-up.
Area of Science:
- Cardiology
- Neurology
- Vascular Surgery
Background:
- Recurrent stroke prevention in patent foramen ovale (PFO) patients is challenging.
- Current treatments like antiplatelets or anticoagulants lack definitive indications.
- PFO is associated with paradoxical embolism, a cause of ischemic stroke.
Purpose of the Study:
- To evaluate the safety and efficacy of direct surgical closure of PFO.
- To assess the recurrence of stroke after PFO closure in patients with presumed paradoxical embolism.
Main Methods:
- Pilot study involving 11 patients (8 men, 3 women) with prior ischemic events and PFO.
- Surgical closure of PFO performed with extensive pre-operative stroke workup.
- Follow-up included clinical assessment, MRI, and contrast echocardiography with transcranial Doppler.
Main Results:
- No intraoperative or postoperative complications were observed.
- Transient arrhythmias occurred in two patients post-surgery.
- No recurrent strokes occurred during a median follow-up of 12.2 months.
- A small residual shunt was detected in one patient; no new lesions on MRI.
Conclusions:
- Surgical PFO closure appears safe for patients with presumed paradoxical embolism.
- No recurrent strokes were observed in the first year post-procedure.
- Further research is needed to determine long-term outcomes and the role of surgery versus antithrombotic therapy.
Abstract:
Prevention of recurrent stroke in adults with patent foramen ovale represents a therapeutic challenge. Antiplatelet or anticoagulant treatment is widely introduced, but its exact indication is not known. In this pilot study, eight men and three women with previous ischemic cerebral events underwent direct surgical closure of the patent foramen ovale. Mean age was 39.4 (from 30 to 58) years. No coexisting cause of stroke was found after extensive investigations, including blood and coagulation tests, echocardiography, 24-hour three-lead electrocardiographic monitoring, extracranial and transcranial Doppler ultrasonography, and cerebral angiography. Criteria for operation also included at least two of the following: atrial septal aneurysm, multiple cerebral infarcts, a history of multiple cerebral events, and Valsalva strain before stroke. Before operation, one patient had two shunts (1 patent foramen ovale, 1 intrapulmonary shunt). No intraoperative or postoperative complications occurred, but a few hours after operation transient arrhythmias developed in two patients without atrial fibrillation, hemodynamic instability, or embolism. During a median follow-up of 12.2 months, no patient had recurrent stroke. All patients prospectively underwent brain magnetic resonance imaging and contrast echocardiography with simultaneous transcranial Doppler ultrasonography. A residual right-to-left interatrial shunt, smaller than the preoperative one, was observed in only one patient, whereas no lesion was seen on magnetic resonance imaging. Our study suggests that surgical closure of patent foramen ovale in patients with presumed paradoxic embolism is safe, with no recurrent stroke in the first year of follow-up. Further studies are needed to evaluate the long-term prognosis of patients with versus without operation and to define the role of operation as an alternative to prolonged antithrombotic treatment.