The Closure trial – PFO and stroke

It took some time until the Closure data has been turned into a publication (this happend today). We review the evidence for PFOs vs. Stroke and then step into the muddy waters of interventional PFO closure, the critique of the study.

Here is my view on this:

  • PFO can be a cause of stroke. I truly believe it, when I get a good history of Valsalvas beforehand, find a DVT or – better (worse for the patient) – a pulmonary embolism, or even  a thrombus in situ. Otherwise I am hesitant to diagnose it, if any other cause is at least remotely possible.
  • PFO + ASA? I have never been convinced about thrombi being formed at this highly mobile atrial septum. Why shouldn’t it be even better if it is more mobile – scares of the thrombi…? So I don’t really share our german neurologic guidelines opinion that an ASA is worse and should lead to anticoagulation.
  • Therapy in PFO + stroke if reasonable causal relationship is proven? Our guidelines dictate anticoagulation if ASA is present, o/w ASS. Why not anticoagulate them all, assuming that a DVT must exist or at least have existed and thus a venous vessel wall injury persists? Then after half a year, switch to ASS.
  • PFO closure? Don’t. Unless… recurrent strokes on medical therapy, problems with anticoagulation, …
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