CARDIOVASCULAR JOURNAL OF AFRICA • Volume 34, No 1, January–April 2023 AFRICA 35 SA Heart consensus statement on closure of patent foramen ovale 2021 J Hitzeroth, P van der Bijl, F Michel, R Meel, BJ Cupido, E Klug Abstract A patent foramen ovale (PFO) is associated with numerous clinical conditions. The most severe of these is cryptogenic stroke. This consensus statement aims to provide a clinical guideline on which patients should be offered PFO closure. Keywords: patent foramen ovale, PFO, cryptogenic stroke, cryptogenic arterial embolism, PFO closure Submitted 23/10/21, accepted 7/2/22 Published online 8/6/22 Cardiovasc J Afr 2023; 34: 35–39 www.cvja.co.za DOI: 10.5830/CVJA-2022-009 Patent foramen ovale (PFO) has been associated with various clinical syndromes, including left-sided (paradoxical) thromboembolic events, decompression sickness, migraine and various arterial deoxygenation syndromes. A PFO is however present in close to 25% of the general population,1 and it is therefore very difficult to distinguish whether the presence of a PFO is merely an incidental finding or indeed the cause for the patient’s clinical presentation. It is therefore important to make a careful assessment with regard to the benefit of closure of the PFO for each individual patient. The best evidence for the benefits of percutaneous PFO closure is in the setting of patients presenting with cryptogenic stroke. The current consensus statement will therefore deal with this clinical scenario in greater detail, as well as provide some guidance regarding indications for PFO closure in other clinical conditions. It should be noted from the outset that PFO closure for secondary stroke prevention should be performed in centres with experience in the required diagnostic work-up and procedure. It is recommended that patients undergoing the procedure are entered into a registry to ensure quality of care and monitoring of long-term outcomes. What investigations are required prior to consideration of PFO closure? A cryptogenic arterial embolism is defined as an ischaemic event in an arterial bed for which no cause can be identified after detailed investigation. These patients should then be screened for the presence of a PFO, especially in the setting of an ischaemic stroke. Initial investigations in the evaluation of patients with a stroke aim to rule out other causes such as: • The presence of a large-vessel stenosis or occlusion in the territory of the infarct (atherosclerotic, dissection). • Undiagnosed paroxysmal atrial fibrillation (AF). Paroxysmal occult AF is particularly important to rule out as a cause, because AF-related thrombus usually arises from the left atrial appendage and PFO closure would not prevent recurrences. Implantable cardiac rhythm monitors (ICM) may be necessary to detect AF. If AF is not evident on initial ECG or 24-hour Holter ECG, then patients at high risk for AF (Table 1) should have an ICM implanted and be monitored for three to six months to rule out AF prior to a decision regarding PFO closure.2,3 • Other cardioembolic stroke aetiology, such as dilated cardiomyopathy, intracardiac thrombus, atrial myxoma. • Lacunar (small-vessel) stroke. • Hypercoagulable/auto-immune states, for example, antiphospholipid syndrome and hyperhomocysteinemia. Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa F Michel, PhD R Meel, MB ChB, MMed, Cert Cardiol, PhD E Klug, MB BCh, FCP (SA), MMed, drklug@tickerdoc.co.za Medical School, University of Cape Town, Cape Town, South Africa J Hitzeroth, MB ChB, FCP, Cert Cardiol BJ Cupido, MB ChB, FCP, Cert Cardio, M Phil Netcare, Kuils River Hospital, Cape Town, South Africa P van der Bijl, MB ChB, MMed, PhD, FCP, Cert Cardiol Review Article Table 1. Risk factors for AF Uncontrolled hypertension Structural cardiac abnormalities (LVH/LAE/valve pathology) Uncontrolled diabetes mellitus Chronic heart failure Obesity Non-sustained atrial tachycardia Respiratory disease Thyroid abnormalities LAE, left atrial enlargement, LVH, left ventricular hypertrophy.
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