J Stroke.  2022 Sep;24(3):335-344. 10.5853/jos.2022.01697.

Transcatheter Patent Foramen Ovale Closure in Stroke Patients with Thrombophilia: Current Status and Future Perspectives

• Farjat-Pasos JI
• Nuche J
• Mesnier J
• Panagides V
• Cloutier S
• Houde C
• Rodés-Cabau J

• KMID: 2534262
• DOI: http://doi.org/10.5853/jos.2022.01697

Abstract

Transcatheter patent foramen ovale (PFO) closure is a safe and effective treatment for secondary prevention after a PFO-associated stroke as demonstrated in multiple large randomized clinical trials. However, these trials excluded a significant proportion of patients who could have benefited from percutaneous PFO closure due to coexisting potential confounders such as additional thromboembolic risk factors, namely thrombophilia. Since scarce and conflicting data existed on such patients, current clinical management guidelines on patients with PFO mainly recommended against PFO closure in patients with thrombophilia and failed to provide any recommendation on the type and duration of antithrombotic treatment after transcatheter PFO closure. In the past 2 years, there has been new evidence supporting transcatheter PFO closure as a clinically meaningful alternative (vs. medical treatment) in this high-risk group of patients, along with additional data supporting the important role of systematic screening for thrombophilia in PFO-associated cerebrovascular events. This review article provides an updated overview of the incidence, clinical characteristics and outcomes of PFO closure in patients with thrombophilia, also commenting on the most appropriate medical treatment after PFO closure and future perspectives in the field.

Keyword

Foramen ovale, patent; Thrombophilia; Ischemic stroke

Figure

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  Figure 1. Recurrent cerebral ischemic events before transcatheter patent foramen ovale (PFO) closure in patients with or without thrombophilia. Event-free rate and 95% confidence intervals (dashed lines) of recurrent cerebral ischemia before percutaneous PFO closure in patients who did (squares) and those who did not have an associated thrombophilia (triangles). Reproduced from Giardini et al. [6], with permission from Elsevier.

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  Figure 2. Rate of primary endpoints in patients with or without thrombophilia according to their treatment allocation after a patent foramen ovale (PFO)-related cerebrovascular event. Kaplan-Meier cumulative estimates demonstrate that PFO closure significantly reduced recurrent events of stroke or transient ischemic attack compared with medical therapy in patients with thrombophilia to a greater extent than medical therapy alone. Reproduced with permission from Liu et al [9].

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  Figure 3. Long-term outcomes of patients with or without hypercoagulable state after patent foramen ovale (PFO) closure as primary prevention strategy before a left systemic cerebrovascular event. Kaplan-Meier estimates of survival free of neurological events in patients with significant hypercoagulable state according to closure of PFO. Dash line represents patients who underwent PFO closure whereas the continuous line represents patients who received only medical treatment. Reproduced from Buber et al. [11], with permission from Karger Publishers. CVA, cerebrovascular accident; TIA, transient ischemic attack.

Reference

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