Patent foramen ovale and atrial fibrillation as causes of cryptogenic stroke: is treatment with surgery superior to device closure and anticoagulation? A review of the literature

Abstract

Closure of persistent foramen ovale (PFO) to avoid cryptogenic strokes is performed globally with enthusiasm but lacks prove of efficacy. We present a 79-year-old man who had had a PFO device introduced nine years previously because of cryptogenic strokes presenting as syncopes. The patient was referred from his general practitioner with two new syncopes. Transthoracic echocardiography revealed no cardiac causes of embolism. Transesophageal echocardiography (TEE) revealed a misplaced device like an umbrella in a storm, but no septum defects. Holter revealed seconds-long episodes of atrial fibrillation (AF). The patient was successfully treated with anticoagulation.A literature review showed that: (i) the efficacy of PFO closure devices has not been proven in any trial, but was demonstrated in a meta-analysis comparing three different devices; (ii) PFO devices are rarely controlled by TEE during or after insertion; (iii) residual shunts are detected in up to 45% of cases; (iv) there is an increased rate of post-arrhythmic complications; (v) the risk of AF in congenital heart disease increases with increasing age, with a 13% risk of transient ischemic attacks and stroke; and (vi) surgical treatment of PFO was found to have a 4.1% risk of complications including stroke.The question to be asked is whether device closure of PFO should be avoided, considering that PFO is a congenital heart defect with risks of AF and (cryptogenic) stroke? Heart surgery should be a treatment option for symptomatic PFO.

A Case Series Coexistence of PFO with Other Conditions - Who’s the Culprit?

“…This also comes with a 13% risk of TIAs and stroke. 12 Our patient had both patent foramen ovale and atrial fibrillation. Anticoagulation was used and no patent foramen ovale closure had been done.…”

The association between patent foramen ovale and unexplained syncope in pediatric patients

“…Second, the emboli caused by the repeated opening of the foramen ovale or lower limb veins fall off and enter the left atrium. Then the emboli are pushed into the systemic circulation from the left atrium, leading to arterial embolism, which may lead to stroke, myocardial infarction, and syncope [ 17 , 18 ]. Third, venous blood shunted from the right atrium to the left heart system makes the cerebral blood supply become mixed arteriovenous blood supplies, causing transient cerebral ischemia and hypoxia, resulting in syncope [ 19 ].…”

Correlation between percutaneous patent foramen ovale closure and recurrence of unexplained syncope

“…The main mechanism of syncope in PFO patients may be paradoxical embolism. Therefore, we speculate that the possible mechanism of syncope caused by PFO is as follows: (1) The emboli formed by the repeated opening of the foramen ovale or by lower extremity veins fall off and enter the left atrium, from which they are pushed into the systemic circulation with the pumping of blood, resulting in arterial embolisms that may cause stroke, myocardial infarction, and syncope ( 33 , 34 ). (2) Venous blood is largely shunted from the right atrium to the left heart system and mixed arteriovenous blood supplies the brain, which can cause transient cerebral ischemia and hypoxia, resulting in syncope ( 35 – 37 ).…”