Cardiology Letters 2019, 28(2):72-86

Management of the Patent Foramen Ovale in cryptogenic ischemic stroke - Statement of the Slovak Society of Cardiology and Slovak Neurological Society

Dúbrava J¹, Šimková I², Brozman M³, Gdovinová Z⁴, Kaldarárová M⁵, Krivošík M⁶, Studenčan M⁷, Turčáni P⁸

¹ Oddelenia neinvazívnej kardiológie, Nemocnica sv. Cyrila a Metoda, Univerzitná nemocnica Bratislava

² Klinika kardiológie a angiológie Lekárskej fakulta Slovenskej zdravotníckej univerzita a Národný ústav srdcových a cievnych chorôb, a. s., Bratislava

³ Neurologickej klinika Fakulty sociálnych vied a zdravotníctva Univerzita Konštantína Filozofa a Fakultnej nemocnice Nitra

⁴ Neurologickej klinika Lekárská fakulta Univerzita Pavla Jozefa Šafárika a Univerzitnej nemocnice Louisa Pasteura Košice

⁵ Detského kardiocentra, Národný ústav srdcových a cievnych chorôb, a. s., Bratislava

⁶ II. neurologickej klinika Lekárská fakulta Univerzita Komenského a Univerzitnej nemocnice Bratislava

⁷ Kardiocentrum Fakultnej nemocnice s poliklinikou Jána Adama Reimana Prešov

⁸ I. neurologickej klinika Lekárská fakulta Univerzity Komenského a Univerzitnej nemocnice Bratislava, Slovenská republika

Summary.

Background: Management of patients with patent foramen ovale (PFO) after cryptogenic ischemic stroke or transient ischemic attack (TIA) is inconsistent and significantly different in various institutions. Professional societies in Slovakia have not yet published a statement on this issue.

Aims: To create a statement that would allow interested physicians the same approach to the management of PFO in patients with cryptogenic ischemic stroke or TIA.

Methods: The opinion was drawn up by experts of the Slovak Society of Cardiology and the Slovak Neurological Society on the basis of published randomized clinical trials, registries and meta-analyses comparing the PFO closure and the pharmacologic prevention of the stroke/TIA.

Results: For carefully selected patients, the PFO closure plus subsequent antiplatelet therapy is superior to the antiplatelet therapy alone in secondary stroke prevention. The percutaneous PFO closure is indicated in strictly selected patients aged 18-65 years with confirmed cryptogenic ischemic stroke, TIA or systemic embolization with high probability of causal link to PFO according to clinical, anatomical and imaging factors. The exclusion of all identifiable causes of ischemic stroke/TIA is a prerequisite for the PFO closure. The consensus of the "heart-brain" team is required to indicate the PFO closure. In patients with PFO and cryptogenic ischemic stroke/TIA without indication of PFO occlusion, oral anticoagulant therapy or antiplatelet therapy should be selected individually according to the risk of bleeding and the risk of stroke recurrence. PFO closure increases the risk of atrial fibrillation, but does not increase the risk of major bleeding or all-cause mortality. For the PFO closure, the Amplatzer PFO Occluder may be preferred due to a lower risk of atrial fibrillation. There is insufficient evidence to compare percutaneous closure vs. anticoagulant therapy with respect to the prevention of recurrent stroke or TIA in PFO patients. The patient has to be involved in decision making for the choice of therapy after thorough instruction on the risk-benefit of percutaneous PFO closure.

Conclusion: The statement of the scientific societies provides the platform for a unified management of PFO in secondary prevention of ischemic stroke or TIA according to the current evidence-based medicine.

Keywords: patent foramen ovale; ischemic stroke; transient ischemic attack; percutaneous closure secondary prevention

Published: February 1, 2019  Show citation