Young people with a history of strokes caused by blood clots should be evaluated for a congenital condition characterized by a hole in the heart. If present, surgical closure should be considered to prevent future stroke, according to an editorial by a Weill Cornell Medicine and NewYork-Presbyterian neurologist.
Patent foramen ovale (PFO) is a hole in the wall between the right and left sides of the heart. It occurs when the foramen ovale – a normal hole that is present in fetal hearts to allow blood to bypass the lungs – fails to close after birth. This happens in about 25 percent of the population. PFO is a risk factor for ischemic stroke—which constitutes 87 percent of all strokes—because the hole allows blood clots to travel directly from the heart to the brain. Whether or not surgical closure of a PFO prevents stroke has long been a matter of debate among physicians.
In an editorial published Dec. 26 in JAMA Neurology, stroke expert Dr. Hooman Kamel, an associate professor of neurology and of neuroscience in the Feil Family Brain and Mind Research Institute at Weill Cornell Medicine, argues that data from recent clinical trials confirms that PFO closure should be considered in certain stroke patients. “Clinicians can now make recommendations with much more certainty about the risks and benefits, and eligible patients have an additional proven treatment option for preventing stroke,” said Dr. Kamel, who is also a neurologist at NewYork-Presbyterian/Weill Cornell Medical Center.
Recent research shows that PFO closure should be considered only in patients under 60 who have had an ischemic stroke that has no other apparent cause, Dr. Kamel said. PFO closure should not be offered to patients with other types of stroke, as these are not caused by PFO, or to those with transient ischemic attack (so-called “mini-stroke”).
It is also important to note that PFO should not automatically be considered the cause of an ischemic stroke, Dr. Kamel stressed. “Before agreeing to PFO closure, patients should ask whether their profile fits the profile of patients in the clinical trials,” he said. “If it does not, there is no knowing whether PFO closure will lead to more benefit than harm.” Patients should be fully evaluated for other stroke risk factors before rushing to surgery to close a PFO.
At Weill Cornell Medicine and NewYork-Presbyterian, the decision to close a PFO is made in consultation with a multidisciplinary team of neurologists and interventional cardiologists. “A good relationship between the two services is crucial,” said Dr. Harsimran Singh, the David S. Blumenthal Assistant Professor of Medicine at Weill Cornell Medicine and a cardiologist at NewYork-Presbyterian/Weill Cornell Medical Center, who performs the PFO closure procedure. “Presence of a PFO alone is not enough reason to close. We work together with our colleagues in neurology to really evaluate every patient. I think patients appreciate the collaborative approach – they know they are getting our best advice.”
Even when indicated, PFO closure does not provide lifelong protection against stroke, because patients can develop other risk factors as they age. This is another crucial reason for multidisciplinary care, Dr. Kamel said.
“When a decision is made to perform PFO closure, our interventional cardiologists have the experience and skill to perform these procedures safely, and our stroke neurologists then provide expert follow-up care,” he said. “Patients should receive lifelong monitoring and intensive management of common stroke risk factors such as hypertension.”