Surgical Patent Foramen Ovale Closure for Prevention of Paradoxical Embolism-Related Cerebrovascular Ischemic Events

Abstract

Background-The role of surgical closure of patent foramen ovale (PFO) for cerebral infarction (CI) or transient ischemic attack (TIA) resulting from paradoxical embolism is unclear, and its effect on recurrence is unknown. Our objective was to determine the outcome of surgical closure of PFO in patients with a prior ischemic neurological event, define the rate of CI or TIA recurrence after PFO closure, and identify risk factors for these recurrences. Methods and Results-We retrospectively analyzed 91 patients (58 men, 33 women) with Ն1 previous cerebrovascular ischemic events who underwent surgical PFO closure between April 1982 and March 1998. The presence of a PFO with a right-to-left shunt was confirmed with transesophageal echocardiography. Mean age was 44.2Ϯ12.2 years. The index event was a CI in 59 and a TIA in 32; a Valsalva-like episode preceded the event in 15 patients. Deep venous thrombosis was documented in 9 patients, and a hypercoagulable state was identified in 10. Surgical closure was performed with extracorporeal circulation by either direct suture (nϭ82) or patch closure (nϭ9). Limited incisions were used in 18.7% of patients. There was no operative mortality. Morbidity included transient atrial fibrillation (nϭ11), pericardial drainage for effusion (nϭ4), exploration for bleeding (nϭ3), and superficial wound infection (nϭ1). Follow-up totaled 176.3 patient-years, and mean follow-up was 2.0 years. No one had a CI, and 8 had a TIA during follow-up, with 1 caused by temporal arteritis. Transesophageal echocardiography demonstrated all closures to be intact in these patients. The overall freedom from TIA recurrence during follow-up was 92.5Ϯ3.2% at 1 year and 83.4Ϯ6.0% at 4 years. Having multiple neurological events before PFO closure was the only significant risk factor for TIA or CI recurrence after closure by univariate analysis (Pϭ0.05); the small number of post-PFO closure cerebral ischemic events precluded multivariate analysis. Conclusions-Surgical closure of PFO can be performed with minimal morbidity and mortality. PFO closure may decrease the risk of recurrent stroke or TIA and may avoid lifelong anticoagulation in the young adult if there is no other indication. Recurrent cerebrovascular ischemic events after surgery should prompt further evaluation to identify causes other than paradoxical embolism. (Circulation. 1999;100[suppl II]:II-171-II-175.)

Contemporary Management of Patent Foramen Ovale

“…Hence, surgical PFO closure seems completely supplanted by the percutaneous approach. This is supported by the fact that recurrence rates for cerebrovascular accidents or transient ischemic attacks after surgical closure have been reported as 4% 32 to 20% 33 per year.…”

“…At least 5 additional devices have been used clinically abroad. 32 The implantation can be performed with a single femoral venous puncture under fluoroscopy without echocardiographic guidance. The PFO can be passed by sliding along the septum primum, coming from the inferior vena cava with a wire or a curved catheter.…”

Recurrent cerebrovascular ischaemic events in patients with interatrial septal abnormalities: a follow-up study

“…It is noteworthy that these patients were considered at high risk because of a "large" shunt or multiple ischaemic lesions. In the initial experience with surgical closure, Devuyst et al reported no recurrent event in 32 patients [22], but papers by Homma et al (19.5% recurrence rate at 13 months) and the Mayo Clinic (7.5% at 1 year and 16.6% at 4 years) were disappointing [23,24]. Surgery has been superseded by the percutaneous transcatheteral approach due to the absence of open-heart surgery [25].…”

Percutaneous Transcatheter Closure of Patent Foramen Ovale in Patients With Paradoxical Embolism

“…[23][24][25] Mixed results of surgical closure of PFO in patients with paradoxical embolism have been reported. Dearani et al 26 reported their results in 91 patients with cryptogenic stroke who underwent surgical closure of a PFO. Although they had no operative mortality, atrial fibrillation occurred in 11 patients, and pericardial effusion occurred in 6 patients, with 4 of them requiring pericardiocentesis.…”