Key Points
➤ For patients with cryptogenic stroke and PFO, percutaneous PFO
closure probably reduces the risk of stroke recurrence (HR-0.41,
summary rate difference -0.67% per year), probably is associated
with a periprocedural complication rate of 3.9%, and probably is
associated with the development of serious non-periprocedural atrial
fibrillation (RR-2.72, summary rate difference 0.33% per year).
➤ For patients with cryptogenic stroke and PFO, anticoagulation
medication and antiplatelet medication are possibly equally effective
at reducing recurrent stroke.
Management
Recommendations Regarding Percutaneous PFO Closure
➤ 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, as was performed in all positive
PFO closure trials (B).
➤ In patients being considered for PFO closure, clinicians should obtain
brain imaging to confirm stroke size and distribution, assessing for an
embolic pattern or a lacunar infarct (typically involving a single deep
perforator <1.5 cm in diameter) (B).
➤ In patients being considered for PFO closure, clinicians should
obtain complete vascular imaging (MRA or CTA) of the cervical
and intracranial vessels to look for dissection, vasculopathy, and
atherosclerosis (B).
➤ In patients being considered for PFO closure, clinicians must perform
a baseline ECG to look for atrial fibrillation (A).
➤ Select patients being considered for PFO closure thought to be at risk
of atrial fibrillation should receive prolonged cardiac monitoring for at
least 28 days (B).
Note: Risk factors for atrial fibrillation include: age ≥50 years, hypertension,
obesity, sleep apnea, enlarged left atrium, elevated NT-proBNP, frequent premature
atrial contractions, and increased P wave dispersion. Recently published guidelines
from the American Heart Association, American College of Cardiolog y, and Heart
Rhythm Society recommend prolonged ECG monitoring following cryptogenic stroke
for patients older than 40 years, although more research is needed to define the yield
in unselected young patients and in patients with PFO.
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