This Article Full Text Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Windecker, S. Articles by Meier, B. Search for Related Content PubMed PubMed Citation Articles by Windecker, S. Articles by Meier, B. Related Collections Catheter-based coronary and valvular interventions: other Other diagnostic testing Primary and Secondary Stroke Prevention Risk Factors for Stroke Stroke in Children and the Young Other Stroke

(Circulation. 2000;101:893.)
© 2000 American Heart Association, Inc.

Clinical Investigation and Reports

Percutaneous Closure of Patent Foramen Ovale in Patients With Paradoxical Embolism

Long-Term Risk of Recurrent Thromboembolic Events

Stephan Windecker, MD; Andreas Wahl, MD; Tushar Chatterjee, MD; Ali Garachemani, MD; Franz R. Eberli, MD; Christian Seiler, MD; Bernhard Meier, MD

From the Swiss Cardiovascular Center Bern, University Hospital, Bern, Switzerland.

Correspondence to Bernhard Meier, MD, Professor of Cardiology, Swiss Cardiovascular Center Bern, University Hospital, 3010 Bern, Switzerland. E-mail bernhard.meier{at}insel.ch

Background—Patients with a patent foramen ovale (PFO) and paradoxical embolism are at risk for recurrent thromboembolic events. This study investigated the long-term risk of recurrent thromboembolic events in patients with PFO and paradoxical embolism after percutaneous PFO closure.

Methods and Results—Since 1994, a total of 80 patients with PFO and at least 1 paradoxical embolic event (transient ischemic attack [TIA], cerebrovascular accident [CVA], peripheral embolism) have undergone percutaneous PFO closure with 5 different devices. There were 30 women and 50 men, with a mean age of 52±12 years. Sixty patients had only a PFO, whereas 20 patients had both a PFO and an atrial septal aneurysm. The implantation procedure was successful in 78 patients (98%). During 5 years of follow-up (mean, 1.6±1.4 years; range, 0.1 to 5.0 years), the actuarial annual risk to suffer a recurrent thromboembolic event was 2.5% for TIA, 0% for CVA, 0.9% for peripheral emboli, and 3.4% for the combined end point of TIA, CVA, or peripheral embolism. A postprocedural shunt was a predictor of recurrent paradoxical embolism (RR, 4.2; 95% CI, 1.1 to 17.8; P=0.03). The risk for recurrent thromboembolic events in patients with both atrial septal aneurysm and PFO was not significantly increased compared with patients with only PFO (RR, 1.0; 95% CI, 0.2 to 4.7; P=0.95).

Conclusions—Percutaneous PFO closure appears to be a promising technique in the prevention of recurrent systemic thromboembolism in patients with a PFO after a first event. Prospective studies comparing percutaneous PFO closure with antithrombotic medications or surgery must define its therapeutic value.

Key Words: foramen ovale • stroke • embolism

This article has been cited by other articles:

				G. W. Albers, P. Amarenco, J. D. Easton, R. L. Sacco, and P. Teal Antithrombotic and Thrombolytic Therapy for Ischemic Stroke: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition) Chest, June 1, 2008; 133(6_suppl): 630S - 669S. [Abstract] [Full Text] [PDF]

				S D Treadwell, B Thanvi, and T G Robinson Stroke in pregnancy and the puerperium Postgrad. Med. J., May 1, 2008; 84(991): 238 - 245. [Abstract] [Full Text] [PDF]

				A Wahl, M Kunz, A Moschovitis, T Nageh, M Schwerzmann, C Seiler, H P Mattle, S Windecker, and B Meier Long-term results after fluoroscopy-guided closure of patent foramen ovale for secondary prevention of paradoxical embolism Heart, March 1, 2008; 94(3): 336 - 341. [Abstract] [Full Text] [PDF]

				H. Sievert, E. Fischer, C. Heinisch, N. Majunke, A. Roemer, and N. Wunderlich Transcatheter Closure of Patent Foramen Ovale Without an Implant: Initial Clinical Experience Circulation, October 9, 2007; 116(15): 1701 - 1706. [Abstract] [Full Text] [PDF]

				R. Gurtu, R. Grocott-Mason, M. Mason, C. Ilsley, and S. W. Dubrey Paradoxical coronary emboli following a long-haul airline flight Eur J Echocardiogr, October 1, 2007; 8(5): 390 - 392. [Abstract] [Full Text] [PDF]

				M. R. Sukernik and E. Bennett-Guerrero The Incidental Finding of a Patent Foramen Ovale During Cardiac Surgery: Should It Always Be Repaired? A Core Review Anesth. Analg., September 1, 2007; 105(3): 602 - 610. [Abstract] [Full Text] [PDF]

				H. Hara, T. K. Jones, E. R. Ladich, R. Virmani, D. C. Auth, J. E. Eichinger, R. J. Sommer, R. A. Van Tassel, and R. S. Schwartz Patent Foramen Ovale Closure by Radiofrequency Thermal Coaptation: First Experience in the Porcine Model and Healing Mechanisms Over Time Circulation, August 7, 2007; 116(6): 648 - 653. [Abstract] [Full Text] [PDF]

				P. Krieg, H. Lapp, K. Pethig, J. F. Gummert, and T. Bossert Removal of a Left Atrial Thrombus Adherent to a Patent Foramen Ovale Occluder Ann. Thorac. Surg., April 1, 2007; 83(4): 1539 - 1541. [Abstract] [Full Text] [PDF]

				E. Bedard, J. Rodes-Cabau, C. Houde, A. Mackey, D. Rivest, S. Cloutier, M. Noel, A. Marrero, J.-M. Cote, P. Chetaille, et al. Enhanced Thrombogenesis but Not Platelet Activation Is Associated With Transcatheter Closure of Patent Foramen Ovale in Patients With Cryptogenic Stroke Stroke, January 1, 2007; 38(1): 100 - 104. [Abstract] [Full Text] [PDF]

				C. Spies, R. Strasheim, I. Timmermanns, and R. Schraeder Patent foramen ovale closure in patients with cryptogenic thrombo-embolic events using the Cardia PFO occluder Eur. Heart J., February 1, 2006; 27(3): 365 - 371. [Abstract] [Full Text] [PDF]

				J. D.R. Thomson Percutaneous PFO closure, further data but many unanswered questions Eur. Heart J., February 1, 2006; 27(3): 258 - 259. [Full Text] [PDF]

				D. D. Hegland, G. A. Kunz, J. K. Harrison, and A. Wang Clinical problem-solving. A hole in the argument. N. Engl. J. Med., December 1, 2005; 353(22): 2385 - 2390. [Full Text] [PDF]

				M. Schwerzmann and O. Salehian Hazards of percutaneous PFO closure Eur J Echocardiogr, December 1, 2005; 6(6): 393 - 395. [Full Text] [PDF]

				H. Hara, R. Virmani, E. Ladich, S. Mackey-Bojack, J. Titus, M. Reisman, W. Gray, M. Nakamura, M. Mooney, A. Poulose, et al. Patent Foramen Ovale: Current Pathology, Pathophysiology, and Clinical Status J. Am. Coll. Cardiol., November 1, 2005; 46(9): 1768 - 1776. [Abstract] [Full Text] [PDF]

				S. Kumar, I. Khan, R. Milton, A. A. Ali, and D. J. O'Regan Pulmonary and Paradoxical Embolism in Protein C and S Deficient Patient Ann. Thorac. Surg., July 1, 2005; 80(1): 324 - 326. [Abstract] [Full Text] [PDF]

				J. E. Sousa, M. A. Costa, E. M. Tuzcu, J. S. Yadav, and S. Ellis New Frontiers in Interventional Cardiology Circulation, February 8, 2005; 111(5): 671 - 681. [Full Text] [PDF]

				A. Wahl, U. Krumsdorf, B. Meier, H. Sievert, S. Ostermayer, K. Billinger, M. Schwerzmann, U. Becker, C. Seiler, M. Arnold, et al. Transcatheter treatment of atrial septal aneurysm associated with patent foramen ovale for prevention of recurrent paradoxical embolism in high-risk patients J. Am. Coll. Cardiol., February 1, 2005; 45(3): 377 - 380. [Abstract] [Full Text] [PDF]

				R. L. Geggel Conditions Leading to Pediatric Cardiology Consultation in a Tertiary Academic Hospital Pediatrics, October 1, 2004; 114(4): e409 - e417. [Abstract] [Full Text] [PDF]

				G. W. Albers, P. Amarenco, J. D. Easton, R. L. Sacco, and P. Teal Antithrombotic and Thrombolytic Therapy for Ischemic Stroke: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy Chest, September 1, 2004; 126(3_suppl): 483S - 512S. [Abstract] [Full Text] [PDF]

				G.P. Anzola, E. Morandi, F. Casilli, and E. Onorato Does Transcatheter Closure of Patent Foramen Ovale Really "Shut the Door?": A Prospective Study With Transcranial Doppler Stroke, September 1, 2004; 35(9): 2140 - 2144. [Abstract] [Full Text] [PDF]

				S. Windecker, A. Wahl, K. Nedeltchev, M. Arnold, M. Schwerzmann, C. Seiler, H. P. Mattle, and B. Meier Comparison of medical treatment with percutaneous closure of patent foramen ovale in patients with cryptogenic stroke J. Am. Coll. Cardiol., August 18, 2004; 44(4): 750 - 758. [Abstract] [Full Text] [PDF]

				L. A. Wu, J. F. Malouf, J. A. Dearani, D. J. Hagler, G. S. Reeder, G. W. Petty, and B. K. Khandheria Patent Foramen Ovale in Cryptogenic Stroke: Current Understanding and Management Options Arch Intern Med, May 10, 2004; 164(9): 950 - 956. [Abstract] [Full Text] [PDF]

				S. R. Messe, I. E. Silverman, J. R. Kizer, S. Homma, C. Zahn, G. Gronseth, and S. E. Kasner Practice Parameter: Recurrent stroke with patent foramen ovale and atrial septal aneurysm: Report of the Quality Standards Subcommittee of the American Academy of Neurology Neurology, April 13, 2004; 62(7): 1042 - 1050. [Abstract] [Full Text] [PDF]

				G. Devuyst, B. Piechowski-Jozwiak, T. Karapanayiotides, J.-W. Fitting, V. Kemeny, L. Hirt, L. A. Urbano, P. Arnold, G. van Melle, P.-A. Despland, et al. Controlled Contrast Transcranial Doppler and Arterial Blood Gas Analysis to Quantify Shunt Through Patent Foramen Ovale Stroke, April 1, 2004; 35(4): 859 - 863. [Abstract] [Full Text] [PDF]

				M Braun, V Gliech, A Boscheri, S Schoen, G Gahn, H Reichmann, M Haass, R Schraeder, and R.H Strasser Transcatheter closure of patent foramen ovale (PFO) in patients with paradoxical embolism: Periprocedural safety and mid-term follow-up results of three different device occluder systems Eur. Heart J., March 1, 2004; 25(5): 424 - 430. [Abstract] [Full Text] [PDF]

				A. J. Furlan Patent Foramen Ovale and Recurrent Stroke: Closure is the Best Option: Yes Stroke, March 1, 2004; 35(3): 803 - 804. [Full Text] [PDF]

				M Schwerzmann, S Windecker, A Wahl, H Mehta, K Nedeltchev, H Mattle, C Seiler, and B Meier Percutaneous closure of patent foramen ovale: impact of device design on safety and efficacy Heart, February 1, 2004; 90(2): 186 - 190. [Abstract] [Full Text] [PDF]

				M. J Landzberg and P. Khairy Indications for the closure of patent foramen ovale Heart, February 1, 2004; 90(2): 219 - 224. [Full Text] [PDF]

				U. Krumsdorf, S. Ostermayer, K. Billinger, T. Trepels, E. Zadan, K. Horvath, and H. Sievert Incidence and clinical course of thrombus formation on atrial septal defect and patient foramen ovale closure devices in 1,000 consecutive patients J. Am. Coll. Cardiol., January 21, 2004; 43(2): 302 - 309. [Abstract] [Full Text] [PDF]

				M. W. Rich The Management of Venous Thromboembolic Disease in Older Adults J. Gerontol. A Biol. Sci. Med. Sci., January 1, 2004; 59(1): M34 - 41. [Abstract] [Full Text] [PDF]

				J. Resley, D. Fitzgerald, R. Albus, and P. Massimiano Pericardial patch closure of an atrial septal defect using endoscopic robotic technology Perfusion, December 1, 2003; 18(6): 365 - 367. [Abstract] [PDF]

				P. Khairy, C. P. O'Donnell, and M. J. Landzberg Transcatheter Closure versus Medical Therapy of Patent Foramen Ovale and Presumed Paradoxical Thromboemboli: A Systematic Review Ann Intern Med, November 4, 2003; 139(9): 753 - 760. [Abstract] [Full Text] [PDF]

				R. D Rakhit Learning on the Web. Case 2: patent foramen ovale (PFO) and paradoxical embolism. Heart, November 1, 2003; 89(11): 1362 - 1362. [Full Text]

				G Casolo, G F Gensini, G Santoro, and L Rega Anomalous origin of the circumflex artery and patent foramen ovale: a rare cause of myocardial ischaemia after percutaneous closure of the defect Heart, August 1, 2003; 89(8): e23 - 23. [Abstract] [Full Text] [PDF]

				J. Borgermann, K. Hakim, I. Friedrich, and C. Diez Recurrent thromboembolic events after percutaneous device closure of patent foramen ovale Interactive CardioVascular and Thoracic Surgery, June 1, 2003; 2(2): 125 - 127. [Abstract] [Full Text] [PDF]

				B. Meier and J. E. Lock Contemporary Management of Patent Foramen Ovale Circulation, January 7, 2003; 107(1): 5 - 9. [Full Text] [PDF]

				K. Fukahara, K. Minami, N. Reiss, D. Fassbender, and R. Koerfer Systemic allergic reaction to the percutaneous patent foramen ovale occluder J. Thorac. Cardiovasc. Surg., January 1, 2003; 125(1): 213 - 214. [Full Text] [PDF]

				R. K. Deeik, R. M. Thomas, P. Sakiyalak, S. Botkin, B. Blakeman, and M. Bakhos Minimal access closure of patent foramen ovale: is it also recommended for patients with paradoxical emboli? Ann. Thorac. Surg., October 1, 2002; 74(4): S1326 - 1329. [Abstract] [Full Text] [PDF]

				D. R. Holmes Jr and A. Cabalka Was Your Mother Right--: Do We Always Need to Close the Door? Circulation, August 27, 2002; 106(9): 1034 - 1036. [Full Text] [PDF]

				F. Martin, P. L. Sanchez, E. Doherty, P. J. Colon-Hernandez, G. Delgado, I. Inglessis, N. Scott, J. Hung, M. E. E. King, F. Buonanno, et al. Percutaneous Transcatheter Closure of Patent Foramen Ovale in Patients With Paradoxical Embolism Circulation, August 27, 2002; 106(9): 1121 - 1126. [Abstract] [Full Text] [PDF]

				M. U. Braun, D. Fassbender, S. P. Schoen, M. Haass, R. Schraeder, W. Scholtz, and R. H. Strasser Transcatheter closure of patent foramen ovale in patients with cerebral ischemia J. Am. Coll. Cardiol., June 19, 2002; 39(12): 2019 - 2025. [Abstract] [Full Text] [PDF]

				L. Bruch, A. Parsi, M. O. Grad, S. Rux, T. Burmeister, H. Krebs, and F. X. Kleber Transcatheter Closure of Interatrial Communications for Secondary Prevention of Paradoxical Embolism: Single-Center Experience Circulation, June 18, 2002; 105(24): 2845 - 2848. [Abstract] [Full Text] [PDF]

				S. Homma, R. L. Sacco, M. R. Di Tullio, R. R. Sciacca, J.P. Mohr, and for the PFO in Cryptogenic Stroke Study (PICSS) In Effect of Medical Treatment in Stroke Patients With Patent Foramen Ovale: Patent Foramen Ovale in Cryptogenic Stroke Study Circulation, June 4, 2002; 105(22): 2625 - 2631. [Abstract] [Full Text] [PDF]

				K Nedeltchev, M Arnold, A Wahl, M Sturzenegger, E E Vella, S Windecker, B Meier, and H P Mattle Outcome of patients with cryptogenic stroke and patent foramen ovale J. Neurol. Neurosurg. Psychiatry, March 1, 2002; 72(3): 347 - 350. [Abstract] [Full Text] [PDF]

				A. M. Forteza, A. Rabinstein, S. Koch, G. Zych, J. Chandar, J. G. Romano, and I. C. Bustillo Endovascular Closure of a Patent Foramen Ovale in the Fat Embolism Syndrome: Changes in the Embolic Patterns as Detected by Transcranial Doppler Arch Neurol, March 1, 2002; 59(3): 455 - 459. [Abstract] [Full Text] [PDF]

				O. Grebe, M. Giesler, H. A. Kestler, V. Hombach, and M. Hoher Magnetic Resonance Imaging After Percutaneous Closure of a Patent Foramen Ovale Circulation, November 27, 2001; 104 (22): e117 - e118. [Full Text] [PDF]

				M. R. Sukernik, B. Mets, and E. Bennett-Guerrero Patent Foramen Ovale and its Significance in the Perioperative Period Anesth. Analg., November 1, 2001; 93(5): 1137 - 1146. [Full Text] [PDF]

				A. Wahl, B. Meier, B. Haxel, K. Nedeltchev, M. Arnold, E. Eicher, M. Sturzenegger, C. Seiler, H. P. Mattle, and S. Windecker Prognosis after percutaneous closure of patent foramen ovale for paradoxical embolism Neurology, October 9, 2001; 57(7): 1330 - 1332. [Abstract] [Full Text] [PDF]

				L. Torracca, G. Ismeno, and O. Alfieri Totally endoscopic computer-enhanced atrial septal defect closure in six patients Ann. Thorac. Surg., October 1, 2001; 72(4): 1354 - 1357. [Abstract] [Full Text] [PDF]

				J M Strotmann, W Voelker, and P Schanzenbaecher Persistence of the eustachian valve in secundum atrial septal defects: possible implications for cerebral embolism and transcatheter closure procedures Heart, July 1, 2001; 86(1): e5 - 5. [Abstract] [Full Text] [PDF]

				J. R. Overell, K. R. Lees, I. Bone, S. Windecker, A. Wahl, T. Chatterjee, A. Garachemani, F. R. Eberli, C. Seiler, and B. Meier Percutaneous Closure of Patent Foramen Ovale in Patients With Paradoxical Embolism Response Circulation, March 13, 2001; 103 (10): e56 - e56. [Full Text] [PDF]

				N. ALP, N. CLARKE, and A. P BANNING How should patients with patent foramen ovale be managed? Heart, March 1, 2001; 85(3): 242 - 244. [Full Text]

				S. Sastry, C. McCollum, S. Windecker, A. Wahl, T. Chatterjee, A. Garachemani, F. R. Eberli, C. Seiler, and B. Meier Patent Foramen Ovale and Stroke Response Circulation, February 27, 2001; 103 (8): e46 - e47. [Full Text] [PDF]

				A. Franke and P. Hanrath The role of atrial septal abnormalities in cryptogenic stroke -- still questionable? Eur. Heart J., February 1, 2001; 22(3): 198 - 200. [PDF]

				T. M. Hyers, G. Agnelli, R. D. Hull, T. A. Morris, M. Samama, V. Tapson, and J. G. Weg Antithrombotic Therapy for Venous Thromboembolic Disease Chest, January 1, 2001; 119(1_suppl): 176S - 193S. [Full Text] [PDF]

				P. A. Berdat, T. Chatterjee, J.-P. Pfammatter, S. Windecker, B. Meier, and T. Carrel Surgical management of complications after transcatheter closure of an atrial septal defect or patent foramen ovale J. Thorac. Cardiovasc. Surg., December 1, 2000; 120(6): 1034 - 1039. [Abstract] [Full Text] [PDF]

C. Biben, R. Weber, S. Kesteven, E. Stanley, L. McDonald, D. A. Elliott, L. Barnett, F. Koentgen, L. Robb, M. Feneley, et al. Cardiac Septal and Valvular Dysmorphogenesis in Mice Heterozygous for Mutations in the Homeobox Gene Nkx2-5 Circ. Res., November 10, 2000; 87(10): 888 - 895.