journal article
Open Access
Oct 21, 2021
How Old is Too Old? Closure of Patent Foramen Ovale in Older Patients
Abstract
Percutaneous closure of a patent foramen ovale (PFO) reduces the risk of recurrent cryptogenic stroke specifically in younger patients. The three randomized controlled trials that led to the widespread adoption of PFO closure excluded patients over the age of 60 years. Older patients frequently have other cardiac and vascular conditions that are common risk factors for stroke, whereas paradoxical embolism through a PFO is relatively rare. Younger patients theoretically benefit the most from closure due to longer lifetime exposure risk and absence of other traditional risk factors. PFO in older patients with cryptogenic strokes is often encountered in clinical practice, making up an increasing number of cardiology referrals, yet cardiologists lack guidelines and evaluation tools for these patients. This review explores the history of PFO closure – emphasizing data in older adults – and discusses the evaluation and treatment of older people with cryptogenic stroke and PFO while further trials in this important population are awaited.
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References
39
[1]
Di Tullio M, Sacco RL, Gopal A, et al. Patent foramen ovale as a risk factor for cryptogenic stroke. Ann Intern Med 1992;117:461–5. https://doi.org/10.7326/0003-4819-117-6-461; PMID: 1503349.
10.7326/0003-4819-117-6-461
[2]
Lechat P, Mas JL, Lascault G, et al. Prevalence of patent foramen ovale in patients with stroke. N Engl J Med 1988;318:1148–52. https://doi.org/10.1056/NEJM198805053181802; PMID: 3362165.
10.1056/nejm198805053181802
[3]
Saver JL, Carroll JD, Thaler DE. Long-term outcomes of patent foramen ovale closure or medical therapy after stroke. N Engl J Med 2017;377:1022–32. https://doi.org/10.1056/NEJMoa1610057; PMID: 28902590.
10.1056/nejmoa1610057
[4]
Mas JL, Derumeaux G, Guillon B, et al. Patent foramen ovale closure or anticoagulation vs. antiplatelets after stroke. N Engl J Med 2017;377:1011–21. https://doi.org/10.1056/NEJMoa1705915; PMID: 28902593.
[5]
Søndergaard L, Kasner SE, Rhodes JF, et al. Patent foramen ovale closure or antiplatelet therapy for cryptogenic stroke. N Engl J Med 2017;377:1033–42. https://doi.org/10.1056/NEJMoa1707404; PMID: 28902580.
10.1056/nejmoa1707404
[6]
Wiktor DM, Carroll JD. The case for selective patent foramen ovale closure after cryptogenic stroke. Circ Cardiovasc Interv 2018;11:e004152. https://doi.org/10.1161/CIRCINTERVENTIONS.117.004152; PMID: 29870380.
10.1161/circinterventions.117.004152
[7]
Ntaious G, Papavasileiou V, Sagris D, et al. Closure of patient foramen ovale versus medical therapy in patients with cryptogenic stroke or transient ischemic attack: updated systematic review and meta-analysis. Stroke 2018;49:412–8. https://doi.org/10.1161/STROKEAHA.117.020030; PMID: 29335335.
10.1161/strokeaha.117.020030
[8]
Stortecky S, Costa BR, Mattle HP, et al. Percutaneous closure of patent foramen ovale in patients with cryptogenic embolism: a network meta-analysis. Eur Heart J 2015;36:120–8. https://doi.org/10.1093/eurheartj/ehu292; PMID: 25112661.
10.1093/eurheartj/ehu292
[9]
Nasir UB, Qureshi WT, Jogu H, et al. Updated meta-analysis of closure of patent foramen ovale versus medical therapy after cryptogenic stroke. Cardiovasc Revasc Med 2019;20:187–93. https://doi.org/10.1016/j.carrev.2018.06.001; PMID: 30905408.
10.1016/j.carrev.2018.06.001
[10]
Agarwal S, Bajaj NS, Kumbhani DJ, et al. Meta-analysis of transcatheter closure versus medical therapy for patent foramen ovale in prevention of recurrent neurological events after presumed paradoxical embolism. JACC Cardiovasc Interv 2012;5:777–89. https://doi.org/10.1016/j.jcin.2012.02.021; PMID: 22814784.
10.1016/j.jcin.2012.02.021
[11]
Messé SR, Gronseth GS, Kent DM, et al. Practice advisory update summary: Patent foramen ovale and secondary stroke prevention: Report of the Guideline Subcommittee of the American Academy of Neurology. Neurology 2020;94:876–85. https://doi.org/10.1212/WNL.0000000000009443; PMID: 32350058.
10.1212/wnl.0000000000009443
[12]
Horlick E, Kavinsky CJ, Amin Z, 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;93:859-74. https://doi.org/10.1002/ccd.28111; PMID: 30896894.
10.1002/ccd.28111
[13]
Sadler TW. Langman’s Essential Medical Embryology. Philadelphia, PA: Lippincott Williams and Wilkins, 2004.
[14]
Hagen PT, Scholz DG, Edwards WD. Incidence and size of patent foramen ovale during the first 10 decades of life: an autopsy study of 965 normal hearts. Mayo Clin Proc 1984;59:17–20. https://doi.org/10.1016/S0025-6196(12)60336-X; PMID: 6694427.
10.1016/s0025-6196(12)60336-x
[15]
Bridges ND, Hellenbrand W, Latson L, et al. Transcatheter closure of patent foramen ovale after presumed paradoxical embolism. Circulation 1992;86:1902–8. https://doi.org/10.1161/01.CIR.86.6.1902; PMID: 1451261.
10.1161/01.cir.86.6.1902
[16]
Kent DM, Ruthazer R, Weimar C, et al. An index to identify stroke-related vs incidental patent foramen ovale in cryptogenic stroke. Neurology 2013;81:619–25. https://doi.org/10.1212/WNL.0b013e3182a08d59; PMID: 23864310.
10.1212/wnl.0b013e3182a08d59
[17]
Handke M, Harloff A, Olschewski M, et al. Patent foramen ovale and cryptogenic stroke in older patients. N Engl J Med 2007;357:2262–8. https://doi.org/10.1056/NEJMoa071422; PMID: 18046029.
10.1056/nejmoa071422
[18]
Lee PH, Song JK, Kim JS, et al. Cryptogenic stroke and high-risk patent foramen ovale: The DEFENSE-PFO trial. J Am Coll Cardiol 2018;71:2335–42. https://doi.org/10.1016/j.jacc.2018.02.046; PMID: 29544871.
[19]
Takafuji H, Hosokawa S, Ogura R, Hasa Y. Percutaneous transcatheter closure of high-risk patent foramen ovale in the elderly. Heart Vessels 2019;34:1657–62. https://doi.org/10.1007/s00380-019-01379-0; PMID: 30868214.
10.1007/s00380-019-01379-0
[20]
Scacciatella P, Meynet I, Presbitero P, et al. Recurrent cerebral ischemia after patent foramen ovale percutaneous closure in older patients: a two-center registry study: PFO Closure in Older Patients. Catheter Cardiovasc Interv 2016;87:508–14. https://doi.org/10.1002/ccd.26053; PMID: 26106024.
10.1002/ccd.26053
[21]
Lansberg MG, O’Donnell MJ, Khatri P, et al. Antithrombotic and thrombolytic therapy for ischemic stroke: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012;141(Suppl 2):e601S–36. https://doi.org/10.1378/chest.141.4.1129b; PMID: 22315273.
10.1378/chest.141.4.1129b
[22]
Kernan WN, Ovbiagele B, Black HR, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014;45:2160–236. https://doi.org/10.1161/STR.0000000000000024; PMID: 24788967.
[23]
Messé SR, Gronseth GS, Kent DM, et al. Practice advisory update summary: patent foramen ovale and secondary stroke prevention. Report of the Guideline Subcommittee of the American Academy of Neurology. Neurology 2020;94:876–85. https://doi.org/10.1212/WNL.0000000000009443; PMID: 32350058.
10.1212/wnl.0000000000009443
[24]
Pristipino C, Sievert H, D’Ascenzo F, et al. European position paper on the management of patients with patent foramen ovale. General approach and left circulation thromboembolism. Eur Heart J 2019;40:3182–95. https://doi.org/10.1093/eurheartj/ehy649; PMID: 30358849.
[25]
Silvestry FE, Cohen MS, Armsby LB, et al. Guidelines for the echocardiographic assessment of atrial septal defect and patent foramen ovale: from the American Society of Echocardiography and Society for Cardiac Angiography and Interventions. J Am Soc Echocardiogr 2015;28:910–58. https://doi.org/10.1016/j.echo.2015.05.015; PMID: 26239900.
10.1016/j.echo.2015.05.015
[26]
Woods TD, Patel A. A critical review of patent foramen ovale detection using saline contrast echocardiography: when bubbles lie. J Am Soc Echocardiogr 2006;19:215–22. https://doi.org/10.1016/j.echo.2005.09.023; PMID: 16455428.
10.1016/j.echo.2005.09.023
[27]
Gazzaniga P, Buscarini E, Leandro G, et al. Contrast echocardiography for pulmonary arteriovenous malformations screening: does any bubble matter? Eur J Echocardiogr 2009;10:513–8. https://doi.org/10.1093/ejechocard/jen317; PMID: 19091794.
10.1093/ejechocard/jen317
[28]
Schneider B, Zienkiewicz T, Jansen V, et al. Diagnosis of patent foramen ovale by transesophageal echocardiography and correlation with autopsy findings. Am J Cardiol 1996;77:1202–9. https://doi.org/10.1016/S0002-9149(96)00163-4; PMID: 8651096.
10.1016/s0002-9149(96)00163-4
[29]
Pearson AC, Labovitz AJ, Tatineni S, Gomez, CR. Superiority of transesophageal echocardiography in detecting cardiac source of embolism in patients with cerebral ischemia of uncertain etiology. J Am Coll Cardiol 1991;17:66–72. https://doi.org/10.1016/0735-1097(91)90705-E; PMID: 1987242.
10.1016/0735-1097(91)90705-e
[30]
Droste DW, Lakemeier S, Wichter T, et al. Optimizing the technique of contrast transcranial Doppler ultrasound in the detection of right-to-left shunts. Stroke 2002;33:2211–6. https://doi.org/10.1161/01.STR.0000027884.03365.AC; PMID: 12215589.
10.1161/01.str.0000027884.03365.ac
[31]
Ay H, Oliveira-Filho J, Buonanno FS, et al. Diffusion-weighted imaging identifies a subset of lacunar infarction associated with embolic source. Stroke 1999;30:2644–50. https://doi.org/10.1161/01.STR.30.12.2644; PMID: 10582991.
10.1161/01.str.30.12.2644
[32]
January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Heart Rhythm 2019;16:e66–93. https://doi.org/10.1016/j.hrthm.2019.01.024; PMID: 30703530.
[33]
Lattanzi S, Cagnetti C, Pulcini A, et al. The P-wave terminal force in embolic strokes of undetermined source. J Neurol Sci 2017;375:175–8. https://doi.org/10.1016/j.jns.2017.01.063; PMID: 28320124.
10.1016/j.jns.2017.01.063
[34]
Homma S, Sacco RL, Di Tullio MR, et al. Effect of medical treatment in stroke patients with patent foramen ovale: patent foramen ovale in Cryptogenic Stroke Study. Circulation 2002;105:2625–31. https://doi.org/10.1161/01.cir.0000017498.88393.44; PMID: 12045168.
10.1161/01.cir.0000017498.88393.44
[35]
Schuchlenz HW, Saurer G, Weihs W, et al. Persisting eustachian valve in adults: relation to patent foramen ovale and cerebrovascular events. J Am Soc Echocardiogr 2004;17:231–3. https://doi.org/10.1016/j.echo.2003.12.003; PMID: 14981420.
10.1016/j.echo.2003.12.003
[36]
Lattanzi S, Rinaldi C, Pulcini A, et al. Clinical phenotypes of embolic strokes of undetermined source. Neurol Sci 2021;42:297–300. https://doi.org/10.1007/s10072-020-04700-2; PMID: 32914246.
10.1007/s10072-020-04700-2
[37]
Furlon A, Reisman M, Massaro J, et al. Closure or medical therapy for cryptogenic stroke with patent foramen ovale. N Engl J Med 2012:366:991–9. https://doi.org/10.1056/NEJMoa1009639; PMID: 22417252.
10.1056/nejmoa1009639
[38]
Meier B, Kalesan, B, Mattle H, et al. Percutaneous closure of patent foramen ovale in cryptogenic embolism. N Engl J Med 2013;368:1083–91. https://doi.org/10.1056/NEJMoa1211716; PMID: 23514285.
10.1056/nejmoa1211716
[39]
Carroll J, Saver J, Thaler D, et al. Closure of patent foramen ovale versus medical therapy after cryptogenic stroke. N Engl J Med 2013;368:1092–100. https://doi.org/10.1056/NEJMoa1301440; PMID: 23514286.
10.1056/nejmoa1301440
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- Oct 21, 2021
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Cite This Article
Carlos Vazquez-Sosa, Stacey D Clegg, James C Blankenship (2021). How Old is Too Old? Closure of Patent Foramen Ovale in Older Patients. US Cardiology Review, 15. https://doi.org/10.15420/usc.2020.40