Skip to main content
Key Specialties
Anesthesiology Cardiology Dermatology Diabetology Endocrinology Gastroenterology General Medicine Geriatrics Hematology Infectious Diseases Internal Medicine Nephrology Neurology Obstetrics and Gynecology Oncology Pediatrics Psychiatry Radiology Respiratory Medicine Rheumatology Surgery Urology
Congress Coverage
2024 ESC Congress 2024 EAN Congress 2024 ASCO Annual Meeting 2024 ACC Congress
Clinical Collections
Advances in Alzheimer’s

ERS Congress 2024

Keep up to date on the latest news from the annual European Respiratory Society conference.
ADVANCED SEARCH
Log in
Top
Current Cardiology Reports
Published in:

24-06-2024 | Atrial Septal Defect | New Therapies for Cardiovascular Disease (AA Bavry and M Massoomi, Section Editors)

Updates on Patent Foramen Ovale (PFO) Closure

Authors: Konstantinos V. Voudris, Marie-France Poulin, Clifford J. Kavinsky

Published in: Current Cardiology Reports | Issue 7/2024

Login to get access

Abstract

Purpose of Review

Patent foramen ovale (PFO) has been previously linked to left circulation thromboembolism and stroke. This review article aims to discuss the latest evidence, updated societal guidelines, diagnostic algorithms and novel therapeutic devices for PFO closure.

Recent Findings

PFO closure for cryptogenic stroke and systemic embolization is supported by a large body of evidence and has a strong societal recommendation. Limited data are available for platypnea-orthodeoxia syndrome, although closure appears to be beneficial. Current data do not support routine closure for migraines and decompression Illness. Development of heart-brain teams can improve identification of patients most likely to benefit from closure, utilizing a combination of imaging test and risk score algorithms. Multiple novel devices aiming at reducing complications and improving the long-term impact of current available devices are being evaluated.

Summary

PFO closure has significantly progressed over the last years, with new data supporting its superiority in reducing risk of recurrent embolic stroke in patients with PFO-related stroke. Additional clinical data are required to provide further refinements on patient selection and guidance on treatment of specific subgroups.
Literature
1.
Tsao CW, Aday AW, Almarzooq ZI, Anderson CAM, Arora P, Avery CL, et al. Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association. Circulation. 2023;147(8):e93–621.PubMedCrossRef
2.
National Center for Health Statistics. Multiple Cause of Death 2018–2021 on CDC WONDER Database. [Internet].
3.
Jackson G, Chari K. National hospital care survey demonstration projects: stroke inpatient hospitalizations. Natl Health Stat Report. 2019;132:1–11.
4.
Lippmann H, Rafferty T. Patent foramen ovale and paradoxical embolization: a historical perspective. Yale J Biol Med. 1993;66(1):11–7.PubMedPubMedCentral
5.
Lechat P, Mas JL, Lascault G, Loron P, Theard M, Klimczac M, et al. Prevalence of patent foramen ovale in patients with stroke. N Engl J Med. 1988;318(18):1148–52.PubMedCrossRef
6.
Webster MW, Chancellor AM, Smith HJ, Swift DL, Sharpe DN, Bass NM, et al. Patent foramen ovale in young stroke patients. Lancet. 1988;2(8601):11–2.PubMedCrossRef
7.
Cabanes L, Mas JL, Cohen A, Amarenco P, Cabanes PA, Oubary P, et al. Atrial septal aneurysm and patent foramen ovale as risk factors for cryptogenic stroke in patients less than 55 years of age. A study using transesophageal echocardiography Stroke. 1993;24(12):1865–73.PubMed
8.
Overell JR, Bone I, Lees KR. Interatrial septal abnormalities and stroke: a meta-analysis of case-control studies. Neurology. 2000;55(8):1172–9.PubMedCrossRef
9.
Sørensen HT, Horvath-Puho E, Pedersen L, Baron JA, Prandoni P. Venous thromboembolism and subsequent hospitalisation due to acute arterial cardiovascular events: a 20-year cohort study. Lancet. 2007;370(9601):1773–9.PubMedCrossRef
10.
Cramer SC, Rordorf G, Maki JH, Kramer LA, Grotta JC, Burgin WS, et al. Increased pelvic vein thrombi in cryptogenic stroke: results of the Paradoxical Emboli from Large Veins in Ischemic Stroke (PELVIS) study. Stroke. 2004;35(1):46–50.PubMedCrossRef
11.
Najem B, Lefrancq E, Unger P. Images in cardiovascular medicine. Thrombus trapped in patent foramen ovale and bilateral pulmonary embolism: a one-stop shop ultrasound diagnosis. Circulation. 2008;118(11):e154–5.PubMedCrossRef
12.
Ofori CS, Moore LC, Hepler G. Massive cerebral infarction caused by paradoxical embolism: detection by transesophageal echocardiography. J Am Soc Echocardiogr. 1995;8(4):563–6.PubMedCrossRef
13.
Pearson AC, Nagelhout D, Castello R, Gomez CR, Labovitz AJ. Atrial septal aneurysm and stroke: A transesophageal echocardiographic study. J Am Coll Cardiol. 1991;18(5):1223–9.PubMedCrossRef
14.
Mas J-L, Derumeaux G, Guillon B, Massardier E, Hosseini H, Mechtouff L, et al. Patent Foramen ovale closure or anticoagulation vs. antiplatelets after stroke. N Engl J Med. 2017;377(11):1011–21.PubMedCrossRef
15.
Saver JL, Carroll JD, Thaler DE, Smalling RW, MacDonald LA, Marks DS, et al. Long-Term Outcomes of Patent Foramen Ovale Closure or Medical Therapy after Stroke. N Engl J Med. 2017;377(11):1022–32.PubMedCrossRef
16.
Cabanes L, Coste J, Derumeaux G, Jeanrenaud X, Lamy C, Zuber M, et al. Interobserver and intraobserver variability in detection of patent foramen ovale and atrial septal aneurysm with transesophageal echocardiography. J Am Soc Echocardiogr. 2002;15(5):441–6.PubMedCrossRef
17.
Mas JL, Arquizan C, Lamy C, Zuber M, Cabanes L, Derumeaux G, et al. Recurrent cerebrovascular events associated with patent foramen ovale, atrial septal aneurysm, or both. N Engl J Med. 2001;345(24):1740–6.PubMedCrossRef
18.
Garg A, Thawabi M, Rout A, Sossou C, Cohen M, Kostis JB. Recurrent stroke reduction with patent foramen ovale closure versus medical therapy based on patent foramen ovale characteristics: A meta-analysis of randomized controlled trials. Cardiology. 2019;144(1–2):40–9.PubMedCrossRef
19.
Furlan AJ, Reisman M, Massaro J, Mauri L, Adams H, Albers GW, et al. Closure or medical therapy for cryptogenic stroke with patent foramen ovale. N Engl J Med. 2012;366(11):991–9.PubMedCrossRef
20.
Meier B, Kalesan B, Mattle HP, Khattab AA, Hildick-Smith D, Dudek D, et al. Percutaneous closure of patent foramen ovale in cryptogenic embolism. N Engl J Med. 2013;368(12):1083–91.PubMedCrossRef
21.
Kernan WN, Ovbiagele B, Black HR, Bravata DM, Chimowitz MI, Ezekowitz MD, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack. Stroke. 2014;45(7):2160–236.PubMedCrossRef
22.
23.
Thaler DE, Wahl A. Critique of closure or medical therapy for cryptogenic stroke with patent foramen ovale: the hole truth? Stroke. 2012;43(11):3147–9.PubMedCrossRef
24.
Jurczyk D, Macherey-Meyer S, Rawish E, Stiermaier T, Eitel I, Frerker C, et al. New-onset atrial fibrillation after percutaneous patent foramen ovale closure: a meta-analysis. Clin Res Cardiol. 2023.
25.
Carroll JD, Saver JL, Thaler DE, Smalling RW, Berry S, MacDonald LA, et al. Closure of patent foramen ovale versus medical therapy after cryptogenic stroke. N Engl J Med. 2013;368(12):1092–100.PubMedCrossRef
26.
Lee PH, Song JK, Kim JS, Heo R, Lee S, Kim DH, et al. Cryptogenic Stroke and High-Risk Patent Foramen Ovale: The DEFENSE-PFO Trial. J Am Coll Cardiol. 2018;71(20):2335–42.PubMedCrossRef
27.
Søndergaard L, Kasner SE, Rhodes JF, Andersen G, Iversen HK, Nielsen-Kudsk JE, et al. Patent foramen ovale closure or antiplatelet therapy for cryptogenic stroke. N Engl J Med. 2017;377(11):1033–42.PubMedCrossRef
28.
Mas J-L, Derex L, Guerin P, Guillon B, Habib G, Juliard J-M, et al. Transcatheter closure of patent foramen ovale to prevent stroke recurrence in patients with otherwise unexplained ischaemic stroke: expert consensus of the French Neurovascular Society and the French Society of Cardiology. Arch Cardiovasc Dis. 2019;112(8–9):532–42.PubMedCrossRef
29.
Lee J-Y, Song J-K, Song J-M, Kang D-H, Yun S-C, Kang D-W, et al. Association between anatomic features of atrial septal abnormalities obtained by omni-plane transesophageal echocardiography and stroke recurrence in cryptogenic stroke patients with patent foramen ovale. Am J Cardiol. 2010;106(1):129–34.PubMedCrossRef
30.
Turc G, Lee J-Y, Brochet E, Kim JS, Song J-K, Mas J-L. Atrial septal aneurysm, shunt size, and recurrent stroke risk in patients with patent foramen ovale. J Am Coll Cardiol. 2020;75(18):2312–20.PubMedCrossRef
31.
Kleindorfer DO, Towfighi A, Chaturvedi S, Cockroft KM, Gutierrez J, Lombardi-Hill D, et al. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. Stroke. 2021;52(7):e364–467.PubMedCrossRef
32.
Kavinsky CJ, Szerlip M, Goldsweig AM, Amin Z, Boudoulas KD, Carroll JD, et al. SCAI guidelines for the management of patent foramen ovale. J Soc Cardiovasc Angiogr Interv. 2022;1(4). SCAI latest Guidelines for the Management of Patent Foramen Ovale. This document evaluates the evidence regarding PFO closure providing guidance to practicing physicians.
33.
Kent DM, Ruthazer R, Weimar C, Mas JL, Serena J, Homma S, et al. An index to identify stroke-related vs incidental patent foramen ovale in cryptogenic stroke. Neurology. 2013;81(7):619–25.PubMedPubMedCentralCrossRef
34.
Pristipino C, Sievert H, D’ascenzo F, Mas J-L, Meier B, Scacciatella P, et al. European position paper on the management of patients with patent foramen ovale. General approach and left circulation thromboembolism. EuroIntervention. 2019;14(13):1389–402. The European position paper on the management of patients with patent foramen ovale provides diagnostic algorithms for patient evaluation and closure recommendations.PubMedCrossRef
35.
Wintzer-Wehekind J, Alperi A, Houde C, Côté JM, Del Val D, Côté M, et al. Transcatheter closure of patent foramen ovale in patients older than 60 years of age with cryptogenic embolism. Rev Esp Cardiol (Engl Ed). 2020;73(3):219–24.PubMedCrossRef
36.
Takafuji H, Hosokawa S, Ogura R, Hiasa Y. Percutaneous transcatheter closure of high-risk patent foramen ovale in the elderly. Heart Vessels. 2019;34(10):1657–62.PubMedCrossRef
37.
Mariucci E, Donti A, Salomone L, Marcia M, Guidarini M, Formigari R, et al. Recurrent stroke after transcatheter pfo closure in cryptogenic stroke or Tia: long-term follow-up. Cardiol Res Pract. 2017;2017:9849425.PubMedPubMedCentralCrossRef
38.
Scacciatella P, Jorfida M, Biava LM, Meynet I, Zema D, D’Ascenzo F, et al. Insertable cardiac monitor detection of silent atrial fibrillation in candidates for percutaneous patent foramen ovale closure. J Cardiovasc Med (Hagerstown). 2019;20(5):290–6.PubMedCrossRef
39.
Kim RJ, Girardi LN. “Lots of Clots”: Multiple thromboemboli including a huge paradoxical embolus in a 29-year old man. Int J Cardiol. 2008;129(2):e50–2.PubMedCrossRef
40.
Ahmed S, Siddiqui AK, Mattana J, Sadiq A, Borgen E. Paradoxical arterial emboli causing acute limb ischemia in a patient with essential thrombocytosis. Am J Med Sci. 2003;326(3):156–8.PubMedCrossRef
41.
Kleber FX, Hauschild T, Schulz A, Winkelmann A, Bruch L. Epidemiology of myocardial infarction caused by presumed paradoxical embolism via a patent foramen ovale. Circ J. 2017;81(10):1484–9.PubMedCrossRef
42.
Pavoni D, Zanuttini D, Spedicato L, Mazzaro E, Ugolino L. Large interatrial thrombus-in-transit resulting in acute myocardial infarction complicated by atrioventricular block and cardiogenic shock. J Am Coll Cardiol. 2012;59(14):1329-.PubMedCrossRef
43.
Moon R, Bove A. Transcatheter occlusion of patent foramen ovale: a prevention for decompression illness? Undersea Hyperb Med. 2004;31:271–4.PubMed
44.
Honěk J, Šrámek M, Šefc L, Januška J, Fiedler J, Horváth M, et al. High-grade patent foramen ovale is a risk factor of unprovoked decompression sickness in recreational divers. J Cardiol. 2019;74(6):519–23.PubMedCrossRef
45.
Honěk J, Šrámek M, Honěk T, Tomek A, Šefc L, Januška J, et al. Patent foramen ovale closure is effective in divers. J Am Coll Cardiol. 2020;76(9):1149–50.PubMedCrossRef
46.
Anderson G, Ebersole D, Covington D, Denoble PJ. The effectiveness of risk mitigation interventions in divers with persistent (patent) foramen ovale. Diving Hyperb Med. 2019;49(2):80–7.PubMedPubMedCentralCrossRef
47.
Koopsen R, Stella PR, Thijs KM, Rienks R. Persistent foramen ovale closure in divers with a history of decompression sickness. Neth Hear J. 2018;26(11):535–9.CrossRef
48.
Wilmshurst P, Nightingale S. The role of cardiac and pulmonary pathology in migraine: a hypothesis. Headache. 2006;46(3):429–34.PubMedCrossRef
49.
Dowson A, Mullen MJ, Peatfield R, Muir K, Khan AA, Wells C, et al. Migraine Intervention With STARFlex Technology (MIST) trial: a prospective, multicenter, double-blind, sham-controlled trial to evaluate the effectiveness of patent foramen ovale closure with STARFlex septal repair implant to resolve refractory migraine headache. Circulation. 2008;117(11):1397–404.PubMedCrossRef
50.
Mattle HP, Evers S, Hildick-Smith D, Becker WJ, Baumgartner H, Chataway J, et al. Percutaneous closure of patent foramen ovale in migraine with aura, a randomized controlled trial. Eur Heart J. 2016;37(26):2029–36.PubMedCrossRef
51.
Tobis JM, Charles A, Silberstein SD, Sorensen S, Maini B, Horwitz PA, et al. Percutaneous closure of patent foramen ovale in patients with migraine: The PREMIUM trial. J Am Coll Cardiol. 2017;70(22):2766–74.PubMedCrossRef
52.
Mojadidi MK, Kumar P, Mahmoud AN, Elgendy IY, Shapiro H, West B, et al. Pooled analysis of PFO occluder device trials in patients with PFO and migraine. J Am Coll Cardiol. 2021;77(6):667–76.PubMedCrossRef
53.
Sommer RJ, Nazif T, Privitera L, Robbins BT. Retrospective review of thienopyridine therapy in migraineurs with patent foramen ovale. Neurology. 2018;91(22):1002–9.PubMedCrossRef
54.
Reisman AM, Robbins BT, Chou DE, Yugrakh MS, Gross GJ, Privitera L, et al. Ticagrelor for refractory migraine/patent foramen ovale (TRACTOR). An open-label pilot study. 2018;91(22):1010–7.
55.
Cheng TO. Platypnea-orthodeoxia syndrome: etiology, differential diagnosis, and management. Catheter Cardiovasc Interv. 1999;47(1):64–6.PubMedCrossRef
56.
Shah AH, Osten M, Leventhal A, Bach Y, Yoo D, Mansour D, et al. Percutaneous intervention to treat platypnea-orthodeoxia syndrome. JACC Cardiovasc Interv. 2016;9(18):1928–38.PubMedCrossRef
57.
Mojadidi MK, Gevorgyan R, Noureddin N, Tobis JM. The effect of patent foramen ovale closure in patients with platypnea-orthodeoxia syndrome. Catheter Cardiovasc Interv. 2015;86(4):701–7.PubMedCrossRef
58.
Pedersen TAL, Larsen SH, Nielsen-Kudsk JE. Closure of a patent foramen ovale in patients with platypnoea–orthodeoxia: A rare and overlooked cause of dyspnoea and hypoxaemia. Scandinavian Cardiovascular Journal. 2015;49(6):357–60.PubMedCrossRef
59.
Sanna T, Diener HC, Passman RS, Di Lazzaro V, Bernstein RA, Morillo CA, et al. Cryptogenic stroke and underlying atrial fibrillation. N Engl J Med. 2014;370(26):2478–86.PubMedCrossRef
60.
Kent DM, Saver JL, Kasner SE, Nelson J, Carroll JD, Chatellier G, et al. Heterogeneity of treatment effects in an analysis of pooled individual patient data from randomized trials of device closure of patent foramen ovale after stroke. Jama. 2021;326(22):2277–86. This study by Kent et al demonstrated the benefit of a novel stratification model, the (PASCAL) Classification System, combining the ROPE score with anatomic and physiologic features.PubMedPubMedCentralCrossRef
61.
Khan F, Derbas LA, Messé SR, Kavinsky C, Kasner SE, Favilla CG. Management of Patients With Patent Foramen Ovale and Stroke: A National Survey of Interventional Cardiologists and Vascular Neurologists. J Am Heart Assoc. 2023;12(13):e029451.PubMedPubMedCentralCrossRef
62.
Chaturvedi A, Moroni F, Axline M, Tomdio A, Mojadidi MK, Gertz Z. Comparative evaluation of intracardiac, transesophageal, and transthoracic echocardiography in the assessment of patent foramen ovale: A retrospective single-center study. Catheter Cardiovasc Interv. 2023;102(7):1348–56.PubMedCrossRef
63.
Bartel T, Konorza T, Arjumand J, Ebradlidze T, Eggebrecht H, Caspari G, et al. Intracardiac echocardiography is superior to conventional monitoring for guiding device closure of interatrial communications. Circulation. 2003;107(6):795–7.PubMedCrossRef
64.
Moon J, Park Y, Park SJ, Oh PC, Jang AY, Chung WJ, et al. Comparison of intracardiac echocardiography and transesophageal echocardiography for image guidance in percutaneous patent foramen ovale closure. Medicina (Kaunas). 2020;56(8).
65.
Boccalandro F, Baptista E, Muench A, Carter C, Smalling RW. Comparison of intracardiac echocardiography versus transesophageal echocardiography guidance for percutaneous transcatheter closure of atrial septal defect. Am J Cardiol. 2004;93(4):437–40.PubMedCrossRef
66.
Trabattoni D, Gaspardone A, Sgueglia Gregory A, Fabbiocchi F, Gioffrè G, Montorsi P, et al. AMPLATZER versus Figulla occluder for transcatheter patent foramen ovale closure. EuroIntervention. 2017;12(17):2092–9.PubMedCrossRef
67.
Kenny D, Eicken A, Dähnert I, Boudjemline Y, Sievert H, Schneider MB, et al. A randomized, controlled, multi-center trial of the efficacy and safety of the Occlutech Figulla Flex-II Occluder compared to the Amplatzer Septal Occluder for transcatheter closure of secundum atrial septal defects. Catheter Cardiovasc Interv. 2019;93(2):316–21.PubMedCrossRef
68.
Snijder RJR, Renes LE, Suttorp MJ, Ten Berg JM, Post MC. Percutaneous patent foramen ovale closure using the Occlutech Figulla device: More than 1,300 patient-years of follow up. Catheter Cardiovasc Interv. 2019;93(6):1080–4.PubMedCrossRef
69.
Gaspardone A, De Marco F, Sgueglia GA, De Santis A, Iamele M, D’Ascoli E, et al. Novel percutaneous suture-mediated patent foramen ovale closure technique: early results of the NobleStitch EL Italian Registry. EuroIntervention. 2018;14(3):e272–9.PubMedCrossRef
70.
Chaudhry-Waterman N, Shapiro S, Thompson J. Use of the NobleStitch™ EL for the treatment of patients with residual right-to-left shunt following device closure of PFO. Clin Case Rep. 2021;9(4):1929–32.PubMedPubMedCentralCrossRef
71.
Horlick E, Kavinsky CJ, Amin Z, Boudoulas KD, Carroll JD, Hijazi ZM, et al. SCAI expert consensus statement on operator and institutional requirements for PFO closure for secondary prevention of paradoxical embolic stroke. Catheter Cardiovasc Interv. 2019;93(5):859–74.PubMedCrossRef
72.
Bass TA, Abbott JD, Mahmud E, Parikh SA, Aboulhosn J, Ashwath ML, et al. 2023 ACC/AHA/SCAI Advanced Training Statement on Interventional Cardiology (Coronary, Peripheral Vascular, and Structural Heart Interventions). J Am Coll Cardiol. 2023;81(14):1386–438.PubMedCrossRef
Metadata
Title
Updates on Patent Foramen Ovale (PFO) Closure
Authors
Konstantinos V. Voudris
Marie-France Poulin
Clifford J. Kavinsky
Publication date
24-06-2024
Publisher
Springer US
Published in
Current Cardiology Reports / Issue 7/2024
Print ISSN: 1523-3782
Electronic ISSN: 1534-3170
DOI
https://doi.org/10.1007/s11886-024-02073-y

Other articles of this Issue 7/2024

Current Cardiology Reports 7/2024 Go to the issue

Nuclear Cardiology (V Dilsizian, Section Editor)

Inflammation and Myocardial Blood Flow in Cardiac Sarcoidosis

Ischemic Heart Disease (D Mukherjee, Section Editor)

Social Isolation, Loneliness, and Cardiovascular Mortality: The Role of Health Care System Interventions

Cardiovascular Critical Care (A Higgins and R Lee, Section Editors)

Left Ventricular Unloading in Extracorporeal Membrane Oxygenation: A Clinical Perspective Derived from Basic Cardiovascular Physiology

Echocardiography (JM Gardin and AH Waller, Section Editors)

The Role of Multimodality Imaging in Cardiomyopathy

Cardiac PET, CT, and MRI (P Cremer, Section Editor)

Assessing Regurgitation Severity, Adverse Remodeling, and Fibrosis with CMR in Primary Mitral Regurgitation

Ischemic Heart Disease (D Mukherjee, Section Editor)

Role of Cyp2c19 Genotype-Guided Antiplatelet Therapy After Percutaneous Coronary Intervention

2024 ESC Congress

Noise pollution dangerous for heart health

02-09-2024 Myocardial Infarction News

Two studies underscore the adverse impact of noise pollution on the risk for and prognosis after myocardial infarction.

Read more

Post-TAVI follow up: deploying virtual assistants

02-09-2024 Transcatheter Aortic Valve Implantation News

Antihypertensives: more effective at morning or night?

02-09-2024 Hypertension News

Low Lp(a) levels unlikely to increase the risk of diabetes

02-09-2024 Type 2 Diabetes News

» View more highlights on the 2024 ESC Congress hub page

A quick guide to ECGs

Electrocardiography Training Course

Improve your ECG interpretation skills with this comprehensive, rapid, interactive course. Expert advice provides detailed feedback as you work through 50 ECGs covering the most common cardiac presentations to ensure your practice stays up to date. 

PD Dr. Carsten W. Israel
Developed by: Springer Medizin
Start the cases

Keynote webinar | Spotlight on medication adherence

Webinar | 27-06-2024 | 18:00 (CEST)

Medication non-adherence is a major barrier to effective healthcare delivery; half of all patients do not follow their doctor’s recommendations or treatment plan.

Our experts explain the fundamentals with a practical discussion of how to manage non-adherence in two common scenarios: hypertension and asthma control.

Prof. Kevin Dolgin
Prof. Florian Limbourg
Prof. Anoop Chauhan
Developed by: Springer Medicine
Watch now
Image Credits