Surgical prophylaxis secundary to cryptogenic stroke or transient ischemic attack in patients with patent foramen ovale

Abstract

Introduction: Prevention of recurrent cryptogenic strokes or transient ischemic attacks in adults with patent foramen ovale (PFO) represents a therapeutic challenge. Antithrombotic pharmacological treatment is widely used, but its indication is limited because of its significant complications.Objective: To demonstrate the efficacy of the surgical closure of patent foramen ovale (PFO) as prophylaxis secondary to cryptogenic strokes or transient ischemic attacks of undetermined origin.Method: In this study, 31 men and 16 women with previous ischemic cerebral events underwent direct surgical closure of the PFO. Mean age was 40 years (from 27 to 59 years). No coexisting cause of the stroke was found after extensive investigation, including blood coagulation tests, transesophageal contrast echocardiography (TEE), extracranial and transcranial doppler ultrasonography, 24-hour electrocardiographic monitoring, brain magnetic resonance (BMR) and CT scan. Criteria for operation also included at least two of the following: atrial septal aneurysm, multiple cerebral infarcts, multiple cerebral events and a history of Valsalva strain before stroke. Before operation, only one patient had two shunts (1 PFO and 1 intrapulmonary shunt).Results: No complications occurred during or after the operation, but a few hours after the operation transient arrhythmias developed in four patients without atrial fibrillation, hemodynamic instability nor embolism. All patients survived in class I (NYHA) and during a mean followup of 36 months, no patient had recurrence of the stroke or transient ischemic attacks. All patients prospectively underwent BMR and contrast TEE with simultaneous transcranial doppler ultrasonography. A residual right-toleft shunt, smaller than the preoperative one, was observed in only one patient, whereas no lesion was seen on the BMR.Conclusion: It is concluded that surgical closure of PFO in patients with presumed paradoxical embolism is safe and avoids recurrent stroke.Descriptors: Stoke. Heart septum, surgery. Embolism paradoxical. Cardiovasc 2003; 18(3): 242-252 Rev Bras Cir

Surgical Treatment for Thrombus Straddling a Patent Foramen Ovale

“…Guffi [6] demonstrated the efficacy of the surgical closure of PFO as prophylaxis to prevent cryptogenic strokes. However, in Guffi's study, no patients were found to have thrombosis on the edges of the PFO, as was the case in our patient.…”

“…Generally, the diagnosis of paradoxical embolism is presumed [6] . Tests such as D-dimer, venous Doppler of lower limbs, and chest CTs are useful for the study of DVT and PE [5] , but when stroke is concurrent, brain CT and echocardiogram are mandatory [2] .…”