Intraoperative PFO Repair May Raise Stroke Risk


Repair of incidental patent foramen ovale that is diagnosed during cardiothoracic surgery may be associated with an increased risk of postoperative stroke, according to findings from a large retrospective study.

Although Dr. Richard A. Krasuski and his associates at the Cleveland Clinic found no concurrent increase in perioperative complications or death after patent foramen ovale repair, they argued that their finding of a potentially increased risk of stroke “should discourage routine surgical closure and foster further investigation to delineate whether there is any benefit in terms of long-term stroke prevention and which patients might benefit from this intervention.”

Patent foramen ovales (PFOs) have become a common incidental finding with the widespread use of intraoperative transesophageal echocardiography (TEE) during cardiothoracic surgery, although cardiothoracic surgeons manage the discoveries with a high degree of variability, according to Dr. Krasuski and his colleagues.

In one survey, 28% of surgeons said that they always closed intraoperatively diagnosed PFO while performing planned operations with cardiopulmonary bypass pump support and 10% said they never did.

In addition, 11% of the respondents reported that they always converted a planned off-pump procedure to on-pump to close the PFO (J. Cardiothorac. Vasc. Anesth. 2005;19:150–4).

In the current study, Dr. Krasuski and his colleagues identified 13,092 patients who had undergone cardiothoracic surgery with intraoperative TEE at the Cleveland Clinic during 1995–2006. They excluded patients who had been previously diagnosed with a PFO or an atrial septal defect (JAMA 2009;302:290–7).

The investigators found that 2,277 (17%) patients with an intraoperatively discovered PFO were diagnosed with the defect at a nearly constant rate during the study period, although the rate of repair steadily increased to a peak of almost 40% in 2003.

Compared with 1,638 patients who did not undergo PFO repair, the 639 patients who underwent PFO repair during the study period were significantly more likely to be women (33% vs. 42% in the repaired group); younger (64 years vs. 61 years); and undergoing mitral or tricuspid valve surgery (32% vs. 51%); and to have a history of transient ischemic attack or stroke (10% vs. 16%); a dilated left atrium (51% vs. 61%); and atrial fibrillation (10% vs. 13%).

Patients with a repaired PFO also had significantly fewer comorbidities than did those with an unrepaired PFO. These included hypertension, previous myocardial infarction, smoking, peripheral vascular disease, and carotid artery disease.

There were no important differences in perioperative outcomes between patients with an incidentally discovered PFO and those with no PFO.

However, patients who underwent PFO repair were 2.5 times more likely to have an in-hospital stroke than were patients with an unrepaired PFO after the researchers controlled for differences between the groups. In-hospital strokes occurred in 2.8% of patients with a repaired PFO and in 1.2% of those with an unrepaired PFO.

The researchers did not find any differences in comparisons of long-term mortality between patients with and without a PFO, or between patients with a repaired or an unrepaired PFO. Survivors in the study had a mean follow-up of 5.6 years.

“One might argue that no long-term difference was detected because surgeons were able to properly select patients undergoing repair, but this seems improbable given our extensive propensity-matched analysis.

“In contrast, we feel these data suggest that asymptomatic PFO in our population was likely a benign entity and repair might have increased the risk of postoperative stroke,” the investigators wrote.

The researchers were unaware of what medications the patients were taking before and after surgery, such as anticoagulation or antiplatelet therapy.

Dr. Krasuski reported having served as a consultant to Gore Medical and on the speakers bureau of AGA Medical.

The finding of a potentially increased risk of stroke 'should discourage routine surgical [PFO] closure.'

Source Dr. Krasuski

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