Patent foramen ovale surgery
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Patent Foramen Ovale Microchapters |
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Diagnosis |
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Treatment |
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Case Studies |
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Patent foramen ovale surgery On the Web |
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American Roentgen Ray Society Images of Patent foramen ovale surgery |
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Risk calculators and risk factors for Patent foramen ovale surgery |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-In-Chief: Priyamvada Singh, M.B.B.S. [2]; Assistant Editor-In-Chief: Kristin Feeney, B.S. [3]
Overview
There is lack of consensus regarding the effectiveness of either surgical or percutaneous closure of patent foramen ovale. Insufficient evidence to recommend device closure for a first stroke exists. PFO closure may be considered for recurrent cryptogenic stroke and high-risk patent foramen ovale (PFO) (atrial septal aneurysm)[1].Some randomized controlled trials to compare the relative effectiveness of medical therapy versus percutaneous closure are on way and in future might be helpful in making therapeutic decisions.
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)[2]
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Practice Recommendations (1) There is insufficient evidence regarding the effectiveness of either surgical or percutaneous closure of PFO (Level U). |
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Rating of Recommendations
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)[3]
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1 Insufficient evidence to recommend device closure for a first stroke. 2 PFO closure may be considered for recurrent cryptogenic stroke on optimal medical treatment |
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European Stroke Organisation guidelines for prevention of recurrent cerebral embolism in patent foramen ovale (DO NOT EDIT)[1]
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1 Device closure should be considered in patients with cryptogenic stroke and high-risk PFO |
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Trial supportive data for percutaneous closure in PFO with recurrent stroke
- Surgical closure of patent foramen ovale is uncommon these days especially after development of percutaneous device closure. Some systematic reviews done to compare medical versus percutaneous closure, found that the rate of recurrent strokes with medical treatment (5.2%) is greater than that with percutaneous closure (1.3%) [4], [5],[6] . However, the results of these systematic reviews should be interpreted carefully, because there was lack of uniformity in the selection criteria, duration of follow up and end points in the individual studies that were used for the systematic review. Some randomized controlled trials to compare the relative effectiveness of medical therapy versus percutaneous closure are on way and in future might be helpful in making therapeutic decisions.
- Studies have found that incidences of major complications such as death, major haemorrhage, need for emergency surgery, tamponade, and fatal pulmonary embolism are low (1.5–2.3%) after percutaneous closure [4], [5], [6]. However, other studies found that some complications like valvular regurgitation [7], residual shunt, atrial fibrillation[8] are increased after percutaneous closure, especially with larger devices [9]. This is a cause for concern as these post-surgical complications are added risk factors for future stroke event.
Technique
The Ampltazer septal occluder (ASO) is the most commonly used device as it allows closure of large cavities, is easy to implant, and boasts high success rates. As an instrument, the ASO consists of two self-expandable round discs connected to each other with a 4-mm waist, made up of 0.004–0.005´´ nitinol wire mesh filled with Dacron fabric. Implantation of the device is relatively easy. The prevalence of residual defect is low. The disadvantages are a thick profile of the device and concern related to a large amount of nitinol (a nickel-titanium compound) in the device and consequent potential for nickel toxicity.
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References
- ↑ 1.0 1.1 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.
- ↑ Messé SR, Silverman IE, Kizer JR, Homma S, Zahn C, Gronseth G; et al. (2004). "Practice parameter: recurrent stroke with patent foramen ovale and atrial septal aneurysm: report of the Quality Standards Subcommittee of the American Academy of Neurology". Neurology. 62 (7): 1042–50. PMID 15078999.
- ↑ 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.
- ↑ 4.0 4.1 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.
- ↑ 5.0 5.1 Homma S, Sacco RL (2005). "Patent foramen ovale and stroke". Circulation. 112 (7): 1063–72. doi:10.1161/CIRCULATIONAHA.104.524371. PMID 16103257.
- ↑ 6.0 6.1 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.