IJCS | Volume 33, Nº4, July and August 2020

and transesophageal study (TEE) using agitated saline solution with adequately performed Valsalva maneuver throughout the steps. TTEwill test the quality of contrast arrival and Valsava maneuver will be diagnostic in most cases. TCD will help quantify the shunt by means of a more precise bubble count, and TEE will define the anatomy for interventional planning (Figure 1). Large shunts and high-risk anatomic PFO are well-depicted by three-dimensional echocardiogram, allowing for a better periprocedural guidance and the achievement of optimal results. In younger patients, who face a longer period of recurrent stroke risk, and in patients with contraindications to long-term anticoagulation, the benefits of transcatheter therapy is less debatable, and contemporary devices have promoted a reduction in the incidence of complications, even though not negligible 8 . Since the publication by Kutty et al., 9 when available evidence pointed to uncertainty regarding the potential benefits of PFO closure compared to medical treatment alone, some well conducted studies have broken this paradigm, such as the one carried out by Wahl et al., 10 They enrolled 308 consecutive patients to either undergo PFO closure (n = 150) or maintain medical therapy (n = 158), and demonstrated a significant reduction in the composite endpoint of stroke, transient ischemic attack (TIA) and peripheral embolism in the PFO closure group (11% vs 21%, hazard ratio = 0.43; 95% CI = 0.20–0.94; P = 0.033). Since then, new evidence has emerged and data fromnew studies, using newdevices, andwell-designed patient selection, have allowed for the establishment of very solid recommendations for this treatment option in selected patients, as stated in the recently updated AAN guidelines 3 . In the present paper, Pereira and cols 4 also highlight the increased risk of atrial fibrillation in patients undergoing PFO closure (RR for PFO closure, 4.64; 95% CI, 2.38 to 9.01; p < 0.01), which reinforces the need for adequate selection, as well as careful balance of risk and benefits when indicating this procedure. The choice for intervention should preferably contemplate centers with large expertise and low rates of procedural complications. In summary, the present study refines the existing evidence for additional risk reduction of PFO closure vs medical treatment alone, through the analysis of less biased data derived from the original clinical trials, as clearly stated by the authors 4 . Considering that many patients are particularly young and may benefit from a long-lasting risk reduction promoted by the intervention, these findings acquire even greater importance. The constant pursue for updated data as science moves forward is invaluable, in light of newer and refined transcatheter techniques and the development of new anticoagulant drugs. Ischemic stroke Cryptogenic Stroke Rule out : Large-artery atherosclerosis, cardioembolism, and other identiÞable causes Diagnostic Workup PFO diagnosis TCD Multidisciplinary Evaluation Structural Intervention Specialist Cardiologist Neurologist Echocardiographist Clinical Evaluation PFO Closure PFO closure suitability Procedure Planning PFO diagnosed TTE TCD 3D TEE PFO Figure 1 – Flowchart of PFO closure in cryptogenic stroke. PFO = patent foramen ovale, TTE = Transthoracic echocardiogram, TCD = transcranial Doppler, 3D TEE = three-dimensional transesophageal echocardiogram 319 Felix & Alcantara PFO closure in stroke, an evolving question Int J Cardiovasc Sci. 2020; 33(4):318-320 Editorial