Treatment Options for Your Patient

Options that can help prevent recurrent stroke in patients who have had a PFO-associated stroke include closure of the PFO by a percutaneous device, medical therapy with antithrombotic agents, and, in rare cases, a surgical approach.

PFO closure

Closure of a PFO may prevent paradoxical embolism by preventing a venous thrombus from passing through the PFO and thereby reducing the risk of recurrent stroke. While some results are conflicting, evidence from the most recent randomized controlled trials now suggests that PFO closure is effective in reducing the risk of recurrent stroke for select patients who have had a PFO-associated stroke.

For patients who are ≤60 years old, have a PFO, and have experienced an ischemic stroke, PFO closure may be warranted. A critical piece in determining if a patient can benefit from PFO closure is ensuring that a comprehensive stroke workup is completed, concluding that no other evident source of stroke can be found, and the evaluation suggests that the embolism passed through the PFO.

PFO closure is a catheter-based procedure that involves making a very small skin incision, guided by fluoroscopy and intracardiac echocardiography, and inserting a catheter to guide the PFO occluder through the blood vessels to close the PFO.

Shared decision making

Neurologists and cardiologists should discuss consideration of the PFO closure procedure, including benefits, risks, and alternative treatment options with the patient. The patient should understand the immediate and long-term potential benefits and risks of treatment options to make a well-informed decision that considers their values and preferences.

Medical treatment

General measures

Patients with PFO who have an ischemic stroke or transient ischemic attack (TIA), who have not undergone PFO closure, should be treated with all appropriate risk reduction strategies, most importantly, antithrombotic therapy. Other measures include lifestyle modification (diet and exercise), blood pressure reduction, and statins (if indicated).

Antithrombotic therapy

For most patients with an embolic-appearing stroke of unknown cause and a PFO who do not have device closure, antithrombotic therapy with antiplatelet agents is recommended.¹

Another antithrombic option is anticoagulation. However, recent trials that explored anticoagulation treatment for patients with an Embolic Stroke of Unknown Source (ESUS) were negative.² Anticoagulation is indicated for most patients with an ischemic stroke of unknown cause and PFO who have evidence of acute deep vein thrombosis (DVT), pulmonary embolism, other venous thromboembolism (VTE), or a hypercoagulable state.

Surgical closure of PFO

For patients aged ≤60 years who have had an ischemic stroke and have a PFO with no other evident source of stroke and who have a concurrent indication for cardiac surgery, surgical closure of PFO via standard or minimally invasive techniques for secondary stroke prevention may be an alternative to percutaneous PFO closure.

The reported efficacy of surgical closure of a PFO in patients with prior cerebrovascular ischemic events has been variable, and randomized trials comparing surgical PFO closure with percutaneous closure or with medical therapy have not been performed.

Reduce your patients' risk of recurring stroke

Find out how you can reduce the risk of another stroke with PFO closure.

Learn more about PFO closure

References

Kernan WN, Ovbiagele B, Black HR, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack. Stroke. 2014;45:2160-236. doi: 10.1161/STR.0000000000000024.
Diener HC, Sacco RL, Easton JD, et al. Dabigatran for prevention of stroke after embolic stroke of undetermined source. N Engl J Med. 2019;380:1906-17. doi: 10.1056/NEJMoa1813959

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