Surgical Closure of Combined Symptomatic Patent Foramen Ovale and Atrial Septum Aneurysm for Prevention of Recurrent Cerebral Emboli

Abstract

Background: Patients with patent foramen ovale (PFO) have an undefined but certainly considerable risk of repeated cerebral ischemia due to paradoxical embolism. Especially, if a cerebrovascular event has already occurred and the combination with an atrial septum aneurysm (ASA) is present this risk increases tremendously. The aim of this study was to demonstrate that surgical closure of PFO in combination with an ASA is safe and useful in preventing recurrent strokes. Methods: Ten patients with previous cerebral ischemia, proven by CT or MRI, and PFO in combination with an ASA were prospectively scheduled for surgical closure. Patients with extracardiac sources of embolic disease were excluded from this study. However, one patient suffered from a hypercoagulability syndrome. Results: All patients (mean age 35.5 ± 19.1 years) underwent direct suture of the PFO and plication of the ASA with the aid of cardiopulmonary bypass and cardioplegic arrest (n = 3) or ventricular fibrillation (n = 7). Mean operation time was 123.1 ± 20.2 minutes; mean bypass time was 34.5 ± 9.9 minutes. There was no mortality or significant postoperative morbidity. Mean hospital stay was 5.1 ± 1.5 days. During a follow-up of >4 years, no recurrent stroke or transient ischemic attack occurred and no patient received anticoagulation therapy. Conclusion: Our data suggest that surgical closure of PFO in combination with ASA in patients with previous stroke is safe and efficacious to prevent recurrent strokes and avoids lifelong anticoagulation.

Long term follow up after percutaneous closure of PFO in 357 patients with paradoxical embolism: Difference in occlusion systems and influence of atrial septum aneurysm

“…However, recent studies reported a higher re-event rate under anti-platelet therapy with aspirin and an advantage for interventional closure [22,36]. Surgery as an alternative treatment showed a wide range of re-event rates from zero to 19.5% within 18 months [37][38][39][40]. In contrast, the periinterventional rate of severe complications in percutaneous closure techniques is very low.…”

VI. Other Types of Cerebrovascular Disorders

“…For secondary prevention, surgical closure of the PFO and percutaneous transcatheter closure of the foramen ovale have been developed, but their benefits have not been established [91][92][93][94][95]. The relationship between PFOs and migraine has been pointed out, and percutaneous transcatheter closure of the foramen ovale has been reported to improve migraines 93 (IIb).…”

Cryptogenic stroke in patients with patent foramen ovale

“…The major disadvantage of surgical closure is that it requires thoracotomy and cardiopulmonary bypass. There have been several nonrandomized limited series addressing safety and efficacy [6,20,21]. Although peri-operative mortality is minimal, morbidity includes atrial fibrillation, pericardial drainage for effusion, repeat surgery for exploration for bleeding source, wound infection, and postpericardiotomy syndrome.…”