Patent foramen ovale surgery

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-In-Chief: Ifeoma Odukwe, M.D. [2], Priyamvada Singh, M.B.B.S. [3], Kristin Feeney, B.S. [4]

Overview

Surgical closure and percutaneous closure may be used to treat patent foramen ovale but percutaneous closure is preferred over surgical closure. Asymptomatic patients do not require surgery. Percutaneous closure is associated with more decrease in recurrent stroke risk when compared with medical therapy although it is may be associated with vascular injury, atrial fibrillation, and device fracture. CardioSEAL septal occluder and Amplatzer PFO occluder are FDA approved devices used in the percutaneous closure of a patent foramen ovale. American Academy of Neurology recommend that clinicians must counsel patients by informing them of how common the condition is and the effectiveness of percutaneous closure. American Heart Association recommends percutaneous closure may be considered in patients with patent foramen ovale and deep vein thrombosis, depending on the risk of recurrent of deep vein thrombosis.

Surgery

Surgical Closure

Percutaneous Closure

  • Percutaneous closure with a large-sized device cause impingement of the surrounding structures that may lead to some late complications.
  • The annual recurrence rate of stroke/transient ischemic attack is 0 to 5%.

Federal Drug Administration (FDA) Approved Percutaneous Devices for Patent Foramen Ovale Closure

CardioSEAL Septal Occlusion System

  • Approved in April 2018.

Amplatzer PFO Occluder

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International Guidelines for Prevention of Recurrent Cerebral Embolism in Patent Foramen Ovale

American Academy of Neurology Guidelines for Prevention of Recurrent Cerebral Embolism in Patent Foramen Ovale (DO NOT EDIT)[10]

Practice Recommendations

1) Clinicians must counsel patients considering percutaneous PFO closure that having a PFO is common; it occurs in about 1 in 4 people; it is impossible to determine with certainty whether their PFOs caused their strokes or TIAs; the effectiveness of the procedure for reducing stroke risk remains uncertain; and the procedure is associated with relatively uncommon, yet potentially serious, complications (Level A).

2) Clinicians should not routinely offer percutaneous PFO closure to patients with cryptogenic ischemic stroke outside of a research setting (Level R). In rare circumstances, such as recurrent strokes despite adequate medical therapy with no other mechanism identified, clinicians may offer the AMPLATZER PFO Occluder if it is available (Level C).

  • There is no possible benefit of percutaneous PFO closure with the STARFlex device in preventing stroke compared with medical therapy alone (The STARFlex is no longer available in the USA).
  • Percutaneous closure with the AMPLATZER PFO occluder is associated with a possible decrease in the risk of recurrent stroke, possible decrease in the risk of new-onset atrial fibrillation, and a high likelihood of associated procedural complication risk of 3.4%.

Rating of Recommendations

A = Established as effective, ineffective, or harmful for the given condition in the specified population.

B = Probably effective, ineffective, or harmful for the given condition in the specified population.

C = Possibly effective, ineffective, or harmful for the given condition in the specified population.

U = Data inadequate or conflicting. Given current knowledge, treatment (test, predictor) is unproven.

American Heart Association/American Stroke Association Guidelines for Prevention of Recurrent Cerebral Embolism in Patent Foramen Ovale (DO NOT EDIT)[11][12]

1) For patients with a cryptogenic ischaemic stroke or transient ischaemic attack and a PFO without evidence for deep vein thrombosis, available data do not support a benefit for PFO closure (Class III; Level of Evidence A).

2) In the setting of PFO and deep vein thrombosis, PFO closure by a transcatheter device might be considered depending on the risk of recurrent deep vein thrombosis (Class IIb; Level of Evidence C).

Class I = Conditions for which there is evidence for and/ or general agreement that the procedure or treatment is useful and effective.

Class II = Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment.

Class IIa = The weight of evidence or opinion is in favor of the procedure or treatment.

Class IIb = Usefulness/efficacy is less well established by evidence or opinion.

Class III = Conditions for which there is evidence and/ or general agreement that the procedure or treatment is not useful/effective and in some cases may be harmful.

Therapeutic recommendations:

Level of Evidence A = Derived from multiple randomized clinical trials or meta-analyses.

Level of Evidence B = Data derived from a single randomized trial or nonrandomized studies.

Level of Evidence C = Consensus opinion of experts, case studies, or standard of care.

Diagnostic recommendations:

Level of Evidence A = Data derived from multiple prospective cohort studies using a reference standard applied by a masked evaluator.

Level of Evidence B = Data derived from a single grade A study or one or more case-control studies, or studies using a reference standard applied by an unmasked evaluator.

Level of Evidence C = Consensus opinion of experts.

European Stroke Organization Guidelines for Prevention of Recurrent Cerebral Embolism in Patent Foramen Ovale (DO NOT EDIT)[13]

1) Device closure should be considered in patients with cryptogenic stroke and high-risk PFO.

References

  1. 1.0 1.1 1.2 1.3 Kutty, Shelby; Sengupta, Partho P.; Khandheria, Bijoy K. (2012). "Patent Foramen Ovale". Journal of the American College of Cardiology. 59 (19): 1665–1671. doi:10.1016/j.jacc.2011.09.085. ISSN 0735-1097.
  2. Yuan, Kristy; Kasner, Scott Eric (2018). "Patent foramen ovale and cryptogenic stroke: diagnosis and updates in secondary stroke prevention". Stroke and Vascular Neurology. 3 (2): 84–91. doi:10.1136/svn-2018-000173. ISSN 2059-8688.
  3. Staubach S, Steinberg DH, Zimmermann W, Wawra N, Wilson N, Wunderlich N; et al. (2009). "New onset atrial fibrillation after patent foramen ovale closure". Catheter Cardiovasc Interv. 74 (6): 889–95. doi:10.1002/ccd.22172. PMID 19626689.
  4. Alaeddini J, Feghali G, Jenkins S, Ramee S, White C, Abi-Samra F (2006). "Frequency of atrial tachyarrhythmias following transcatheter closure of patent foramen ovale". J Invasive Cardiol. 18 (8): 365–8. PMID 16877784.
  5. Khairy P, O'Donnell CP, Landzberg MJ (2003). "Transcatheter closure versus medical therapy of patent foramen ovale and presumed paradoxical thromboemboli: a systematic review". Ann Intern Med. 139 (9): 753–60. PMID 14597460.
  6. Homma S, Sacco RL (2005). "Patent foramen ovale and stroke". Circulation. 112 (7): 1063–72. doi:10.1161/CIRCULATIONAHA.104.524371. PMID 16103257.
  7. Wöhrle J (2006). "Closure of patent foramen ovale after cryptogenic stroke". Lancet. 368 (9533): 350–2. doi:10.1016/S0140-6736(06)69087-9. PMID 16876648.
  8. Schoen SP, Boscheri A, Lange SA, Braun MU, Fuhrmann J, Kappert U; et al. (2008). "Incidence of aortic valve regurgitation and outcome after percutaneous closure of atrial septal defects and patent foramen ovale". Heart. 94 (7): 844–7. doi:10.1136/hrt.2007.132662. PMID 18070946.
  9. 9.0 9.1 Collado, Fareed Moses S.; Poulin, Marie‐France; Murphy, Joshua J.; Jneid, Hani; Kavinsky, Clifford J. (2018). "Patent Foramen Ovale Closure for Stroke Prevention and Other Disorders". Journal of the American Heart Association. 7 (12). doi:10.1161/JAHA.117.007146. ISSN 2047-9980.
  10. Messé, Steven R.; Gronseth, Gary; Kent, David M.; Kizer, Jorge R.; Homma, Shunichi; Rosterman, Lee; Kasner, Scott E. (2016). "Practice advisory: Recurrent stroke with patent foramen ovale (update of practice parameter)". Neurology. 87 (8): 815–821. doi:10.1212/WNL.0000000000002961. ISSN 0028-3878.
  11. Furie KL, Kasner SE, Adams RJ, Albers GW, Bush RL, Fagan SC; et al. (2011). "Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack: a guideline for healthcare professionals from the american heart association/american stroke association". Stroke. 42 (1): 227–76. doi:10.1161/STR.0b013e3181f7d043. PMID 20966421.
  12. Kernan, Walter N.; Ovbiagele, Bruce; Black, Henry R.; Bravata, Dawn M.; Chimowitz, Marc I.; Ezekowitz, Michael D.; Fang, Margaret C.; Fisher, Marc; Furie, Karen L.; Heck, Donald V.; Johnston, S. Claiborne (Clay); Kasner, Scott E.; Kittner, Steven J.; Mitchell, Pamela H.; Rich, Michael W.; Richardson, DeJuran; Schwamm, Lee H.; Wilson, John A. (2014). "Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack". Stroke. 45 (7): 2160–2236. doi:10.1161/STR.0000000000000024. ISSN 0039-2499.
  13. European Stroke Organisation (ESO) Executive Committee. ESO Writing Committee (2008). "Guidelines for management of ischaemic stroke and transient ischaemic attack 2008". Cerebrovasc Dis. 25 (5): 457–507. doi:10.1159/000131083. PMID 18477843.


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