AAN Updates Advice on PFO Closure After Stroke

Megan Brooks

April 30, 2020

Percutaneous closure of patent foramen ovale (PFO) can now be recommended for some patients with cryptogenic ischemic stroke in order to prevent recurrent events, the American Academy of Neurology (AAN) says in a practice advisory update.

"The update was prompted by the publication of three new PFO closure trials, as well as additional follow-up results from one of the earlier trials," Steven R. Messé, MD, University of Pennsylvania School of Medicine, Philadelphia, told Medscape Medical News.

In the prior advisory, from 2016, the AAN committee concluded that percutaneous PFO closure should not be routinely recommended for patients with cryptogenic ischemic stroke.

"However, with this new evidence, the major change in guidance for clinicians is that PFO closure may be recommended for select patients," Messé said.

"Specifically, PFO closure should be considered for patients under 60 years of age with an embolic-appearing stroke who have received a thorough workup and found no other potential etiology besides the PFO," he explained.

The updated advisory was published online April 29 in Neurology.

It has been endorsed by the American Heart Association/American Stroke Association, the Society for Cardiovascular Angiography and Interventions, and the European Academy of Neurology.

The three studies that led to the new guidance were the REDUCE and CLOSE trials, as well as the RESPECT trial, for which long-term results are available. They were published September 14, 2017, in the New England Journal of Medicine.

As reported by Medscape Medical News, all three studies showed that the procedure significantly decreased the rate of recurrent ischemic stroke compared with medical therapy in relatively young patients who had experienced a cryptogenic stroke and had a PFO.

PFO is common and usually does not cause any problems for most people. "However, while there is generally a very low risk of stroke in patients with PFO, in younger people who have had a stroke without any other possible causes identified, closing the PFO may reduce the risk of having another stroke better than medication alone," Messé said in a statement.

The updated practice advisory makes the following recommendations:

  • In patients being considered for PFO closure, clinicians should ensure that an appropriately thorough evaluation has been performed to rule out alternative mechanisms of stroke (level B).

  • For patients in whom an alternative, higher-risk mechanism of stroke has been identified, clinicians should not routinely recommend PFO closure (level B).

  • Clinicians should counsel patients that having a PFO is common; that it occurs in about 1 in 4 adults in the general population; that it is difficult to determine with certainty whether their PFO caused their stroke; and that PFO closure probably reduces recurrent stroke risk in select patients (level B).

  • For patients younger than 60 years with a PFO and embolic-appearing infarct for whom no other mechanism of stroke has been identified, clinicians may recommend closure following a discussion of potential benefits (absolute recurrent stroke risk reduction of 3.4% at 5 years) and risks (periprocedural complication rate of 3.9% and increased absolute rate of non-periprocedural atrial fibrillation of 0.33% per year) (level C).

  • For patients who opt to receive medical therapy alone without PFO closure, clinicians may recommend an antiplatelet medication such as aspirin or anticoagulation (level C).

In the AAN statement, Messé notes that the risk for a second stroke in people with PFO for whom no other possible cause of stroke has been identified is "very low, approximately 1% per year while being treated with just medication alone. Also, it is difficult to determine with absolute certainty that the PFO is the cause of a person's stroke. So it is important that people with PFO are educated about the benefits and risks of PFO closure."

The authors have disclosed no relevant financial relationships.

Neurology. Published online April 29, 2020. Abstract

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