Transcatheter Closure of Patent Foramen Ovale

troke or transient ischemic attack without an apparent cardiovascular source is often described as "cryptogenic" and is frequently caused by paradoxical embolization.Patent foramen ovale (PFO) is the most commonly identified source of right-to-left shunting (RLS) and hence actively searched for after cryptogenic stroke.If identified, transcatheter closure (TCC) is generally advised.However, the less commonly observed pulmonary arteriovenous malformation and atrial septal defect/septal fenestration also facilitate paradoxical embolism and can be eliminated through transcatheter intervention.Occasionally, these defects can coexist, making their identification even more challenging.Agitated saline contrast injection is the most commonly used method to screen for RLS and similarly to evaluate effectiveness after TCC of PFO.Recently published randomized trials have demonstrated the effectiveness of TCC of PFO in reducing recurrent cryptogenic stroke.1,2 Patients included in these trials were relatively young (18-60 years) with traditional cardiovascular risk factors and underwent thorough investigation to ensure that paradoxical embolization through a PFO was the most plausible stroke cause.Meta-analysis of the 5 large randomized trials included 3627 patients with a mean follow-up of 3.7 years demonstrated a significant reduction in ischemic stroke after device closure (absolute risk reduction, 2.11%; and relative risk reduction, 50.5%).3 New-onset atrial fibrillation was more common after TCC (odds ratio, 5.15; 95% CI, 2.18-12.15),although it resolved within 45 days of closure in 75%. 3 Recently, the US Food and Drug Administration approved both the Amplatzer PFO Occluder and the Gore Cardioform Device for treating cryptogenic stroke believed to be caused by PFO.TCC of PFO in patients with paradoxical embolism is ideally intended to achieve complete elimination of RLS, as persistent RLS after closure can increase the risk of recurrent stroke or peripheral embolization.4 Despite recruiting highly selected patients in whom stroke was believed to be exclusively caused by paradoxical embolization through PFO, studies of TCC generally demonstrated a mere reduction and not total elimination of stroke recurrence at medium-term follow-up, 1 with the exception of the CLOSE trial (Patent Foramen Ovale Closure or Anticoagulants Versus Antiplatelet Therapy to Prevent Stroke Recurrence). 2 The remaining questions after these trials include the following: Who are the patients who experience stroke recurrence, what are the underlying mechanisms of these events, and what is the significance of a positive RLS after PFO closure?Plausible explanations include (1) the PFO was merely a bystander in some patients, (2) an alternative pathology existed that may have facilitated RLS and paradoxical embolization (ie, a pulmonary arteriovenous malformation or small atrial septal defect/septal fenestration that was not occluded during TCC), (3) there was a residual shunt through the treated PFO, or (4) a left-sided thromboembolic process was previously missed or developed de novo (Figure ). Transcatheter Closure of Patent Foramen OvaleNot Always an "Open or Shut" Case

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