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Cerebral ischaemia: the strategy of percutaneous closure of the patent foramen ovale

By Cristiano Antonino Last updated Jun 4, 2023

Pervious foramen ovale is a frequent condition in adulthood, will be encountered occasionally and some patients may present with paradoxical embolism followed by symptomatic cerebral ischaemic events

This will be due to improper passage of small thrombotic, gaseous or other materials from the right to the left side of the heart and consequently entering the systemic circulation.

Percutaneous closure of the patent foramen ovale will be used to avoid recurrences of cerebral ischaemic phenomena.

It may happen that in some patients with a cerebral ischaemic event, the causes that led to the event may not be identified; the patent foramen ovale will be considered a risk factor as it may trigger cerebral ischaemia.

Emboli that develop in the venous system could pass through the femoral oval pervious femur into the arterial system and trigger ischaemic events, especially in the brain.

Percutaneously closing this passage will prevent emboli from passing from the venous system to the arterial system.

This method will be used in order to prevent cerebral ischaemic events, thus having a preventive function aimed at eliminating risk factors for further probable ischaemic attacks and/or strokes.

When is percutaneous closure of the foramen ovale pervious?

In patients who are prone to thromboembolic ischaemic events in the arterial circulation, without apparent cause, a foramen ovale pervio will be sought.

The central nervous system will be most affected; we will then proceed to search for all probable causes of a cerebral ischaemic event.

An electrocardiogram at rest and then a Holter ECG, which in some cases may be prolonged for up to 72 hours, will be carried out to detect any atrial fibrillation causing the cerebral ischaemic event.

By means of the colour Doppler echocardiogram, it will be possible to rule out possible thrombi or intracardiac defects; with the Doppler echo of the supra-aortic trunks, possible plaques at the level of the carotid arteries will be highlighted.

If these tests prove negative, the foramen ovale is searched for.

The trans-cranial echodoppler will be the test to discover the possible presence of a patent foramen ovale; however, the trans-oesophageal echocardiogram is preferred to obtain anatomical details for optimal planning of the percutaneous closure procedure.

If the presence of a patent foramen ovale is confirmed, the indications for foramen closure will be followed.

Even in the case of paediatric patients with cerebral ischaemic events, closure of the patent foramen ovale will be used

In patients over 65 years of age with cryptogenic stroke and a patent foramen ovale, due to the high risk of atrial fibrillation, the most frequent cause of cerebral stroke, it is recommended to screen with an implantable loop recorder for about 6 months in order to exclude paroxysmal atrial fibrillation with greater certainty.

If the loop recorder is negative, percutaneous closure may be considered, especially in those patients who exhibit features that make the foramen ovale pervious at high risk of cerebral ischaemic events.

Closure of the foramen ovale pervio is a highly invasive procedure that will see the implantation of specific prostheses to occlude the ‘communication’.

Once the procedure is complete, and after a 24-hour bedding period to prevent bleeding of the wound, the patient can resume his or her daily activities on a regular basis, though avoiding sports activities for a period of about 6 months.

It will be necessary to follow antiplatelet drug therapy for a period of about 6 months following the operation; antiplatelet therapy should be continued for a period of 5 years following the operation.

One year after the procedure, trans-cranial ultrasound will be performed to ascertain the closure of the foramen ovale.

Complications related to this procedure are rare: among the most ‘important’ will be injury to some cardiac structure, thrombus formation on the implanted device and embolisation of the prosthesis itself.

In general, if this happens, the prosthesis will be retrieved; if the retrieval fails, surgery will have to be performed to remove the embolised prosthesis.

As technologies develop, the foramen will be closed with sutures using percutaneous access, thus avoiding the implantation of a prosthesis.

This direct suturing procedure can be performed on the awake patient using the trans-thoracic echocardiogram to monitor the procedure; however, this modality will only be used in certain cases.

This technique will be limited to foramen ovale with specific and limited anatomical features.

Percutaneous closure of the foramen ovale is indicated in those with foramen ovale who develop a cerebral ischaemic event without apparent cause.