Dr Steven R MesseSteven R. Messé, MD, FAAN
The American Academy of Neurology (AAN) has announced the publication of a new guidance regarding the closure of a patent foramen ovale (PFO) for individuals who have had a stroke, recommending that closure be considered in only specific instances for those under the age of 60.1,2

For patients who are younger than 60 years old with a PFO, the guideline stated that closure be recommended when accompanied by embolic-appearing infarct and without another mechanism of stroke, and once a discussion of potential benefits and risks is conducted. Those benefits include an absolute risk reduction for recurrent stroke of 3.4% at 5 years, and those risks include a periprocedural complication rate of 3.9% and increased absolute rate of non-periprocedural atrial fibrillation of 0.33% per year.

Additionally, for individuals who choose to receive medical therapy alone without PFO closure, the advisory notes that clinicians can recommend an antiplatelet medication such as aspirin or anticoagulation therapy.

“It’s important to note that having a PFO is common, and that most people with PFO will never know they have it because it usually does not cause any problems,” author Steven R. Messé, MD, FAAN, associate professor of neurology, Perelman School of Medicine, University of Pennsylvania, said in a statement. “However, while there is generally a very low risk of stroke in patients with PFO, in younger people who have had a stroke without any other possible causes identified, closing the PFO may reduce the risk of having another stroke better than medication alone.”
 
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This practice advisory, which was endorsed by the American Heart Association/American Stroke Association (AHA/ASA), the Society for Cardiovascular Angiography and Interventions (SCAI), and the European Academy of Neurology (EAN), was an update to a 2016 advisory. Previously, they had determined there was a lack of evidence to support PFO closure to prevent further stroke, but in recent years, new data has suggested that closure in addition to anticoagulation medication can reduce the risk of future strokes better than medication alone.

Altogether, Messé and colleagues noted that the currently available data indicate a number of recommendations for practice. These included that clinicians should ensure that thorough evaluation to rule out other stroke mechanisms has been conducted and that those with a higher risk of alternative mechanisms should not be routinely recommended for PFO closure.

Counseling recommendations included informing patients of the commonness of PFO, the difficulty in determining PFO as the cause of stroke, and that PFO closure can result in reduced risk of recurrent stroke in some patients.

“The risk of a second stroke in people with PFO and no other possible causes of stroke is very low, approximately 1% per year while being treated with just medication alone,” said Messé. “Also, it is difficult to determine with absolute certainty that the PFO is the cause of a person’s stroke. So, it is important that people with PFO are educated about the benefits and risks of PFO closure.”

To find out about the impact this update may have and what have been the discussions and debates around PFO closure that have persisted in the medical community, NeurologyLive spoke with Jeremy Payne, MD, PhD, director, Stroke Center, Banner-University Medical Center Phoenix. Watch him offer his insight below.
View the full guideline recommendation by clicking here.

The AAN annual meeting was canceled due to COVID-19, but the coverage was not. For coverage of annual meeting accepted science, click here.
REFERENCES
1. AAN updates recommendation on closure of common heart defect after stroke [press release]. Minneapolis, MN: AAN; Published April 29, 2020. Accessed May 1, 2020. aan.com/PressRoom/Home/PressRelease/3790
2. Messe 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. First published April 29, 2020. doi: 10.1212/WNL.0000000000009443.