title: Cardiac procedures to prevent stroke: patent foramen ovale closure/left atrial appendage occlusion.
abstract: Stroke is a major contributor to population morbidity and mortality. Cardiac thromboembolic sources are an important potential cause of stroke. Left atrial appendage (LAA) thromboembolism in association with atrial fibrillation is a major contributor to stroke occurrence, particularly in elderly individuals. Patent foramen ovale (PFO) acts as a potential conduit from the right-sided circulation to the brain, and has been suggested to be an important factor in cryptogenic stroke in the young patients. Advances in interventional cardiology have made it possible to deal with these potential stroke sources (LAA and PFO), but the available methods have intrinsic limitations that must be recognized. Furthermore, the potential value of LAA and PFO closure depends on our ability to identify when the target structure is importantly involved in stroke risk; this is particularly challenging for PFO. This article addresses the clinical use of PFO and LAA closure in stroke prevention. We discuss technical aspects of closure devices and methods, questions of patient selection, and clinical trials evidence. We conclude that for PFO closure, the clinical trials evidence is thus far negative in the broad cryptogenic stroke population, but closure might nevertheless be indicated for selected high-risk patients. LAA closure has an acceptable balance between safety and efficacy for atrial fibrillation patients with high stroke risk and important contraindications to oral anticoagulation. Much more work needs to be done to optimize the devices and techniques, and better define patient selection for these potentially valuable procedures.
authors.affiliation: Department of Cardiology, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain.
authors.forename: Xavier
authors.initials: X
authors.lastname: Freixa
authors.affiliation: Department of Cardiology, Hospital de Sant Pau, Autonomous University of Barcelona, Barcelona, Spain.
authors.forename: Dabit
authors.initials: D
authors.lastname: Arzamendi
authors.affiliation: Interbalkan European Medical Center, Thessaloniki, Greece.
authors.forename: Apostolos
authors.initials: A
authors.lastname: Tzikas
authors.affiliation: Department of Medical Specialties, Cardiology Division, Université de Genève, Geneva, Switzerland.
authors.forename: Stephane
authors.initials: S
authors.lastname: Noble
authors.affiliation: Department of Medicine, Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada.
authors.forename: Arsene
authors.initials: A
authors.lastname: Basmadjian
authors.affiliation: Department of Medicine, Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada.
authors.forename: Patrick
authors.initials: P
authors.lastname: Garceau
authors.affiliation: Department of Medicine, Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada. Electronic address: reda.ibrahim@icm-mhi.org.
authors.forename: Réda
authors.initials: R
authors.lastname: Ibrahim
mesh_terms: D020517:Atrial Appendage / Q000601:surgery*; D006328:Cardiac Catheterization / Q000379:methods*; D006348:Cardiac Surgical Procedures / Q000379:methods*; D054092:Foramen Ovale, Patent / Q000150:complications / Q000601:surgery*; D006801:Humans; D020521:Stroke / Q000209:etiology / Q000517:prevention & control*; D016896:Treatment Outcome