PROGNOSIS AFTER STROKE FOLLOWED BY SURGICAL CLOSURE OF PATENT FORAMENOVALE - A PROSPECTIVE FOLLOW-UP-STUDY WITH BRAIN MRI AND SIMULTANEOUSTRANSESOPHAGEAL AND TRANSCRANIAL DOPPLER ULTRASOUND

Background: The risk of stroke and the long-term prognosis of recurren t strokes in young patients with patent foramen ovale (PFO) are not we ll known. For this reason, the treatment of these patients remains emp irical. An alternative treatment to prolonged antithrombotic therapy m ay be surgical closure of the PFO. Methods: Thirty patients (20 men an d 10 women) with stroke and PFO were prospectively selected among 138 patients with stroke and PFO for a study of surgical closure of PFO at our center. Eligible patients were <60 years old, had negative result s of a systematic search for another cause of stroke (first criterion) , and met two of the four following criteria: (1) recurrent clinical c erebrovascular events or multiple ischemic lesions on brain MR, (2) PF O associated with an atrial septal aneurysm, (3) >50 microbubbles coun ted in the left atrium on contrast transesophageal echocardiography (T EE), and (4) Valsalva maneuver or cough preceding the stroke. Patients selected in this manner for surgery were considered to be a subgroup with a higher risk of stroke recurrence. Results: All patients had a d irect suture of PFO while under cardiopulmonary bypass without recorde d early or delayed significant complication. All patients underwent a new brain MRI and TEE simultaneous with transcranial Doppler ultrasono graphy after contrast injection at 8 +/- 3 months after surgery. After a mean follow-up of 2 years without antithrombotic treatment, no recu rrent cerebrovascular event (stroke or transient ischemic attack [TIA] ) and no new lesion on MRI had developed. Postoperative contrast TEE a nd transcranial Doppler ultrasonography showed that two patients had r esidual interatrial right-to-left shunting, although much smaller than before surgery, associated with single versus double continuous sutur e. Conclusions: Our study of 30 selected stroke patients with surgical suture of PFO showed a stroke recurrence rate of 0% and no significan t complication. Residual right-to-left shunting may be avoided by doub le continuous suture of the PFO. In the absence of controlled studies to guide individual therapeutic decisions, our findings show that PFO closure can be done safely and may be considered to avoid recurrence i n selected patients with long life expectancy and presumed paradoxic e mbolism.