In Reply Dr Rigatelli and Mr Zuin suggest the need to further characterize PFO to identify subgroups of the population with PFO who are at increased risk of perioperative stroke and hence, targets for preoperative optimization.
Rigatelli and Zuin conclude that only large right-to-left shunts will significantly increase the risk of paradoxical embolism, and that “the presence of a tiny PFO and mild or trivial right-to-left shunting should not be claimed as a risk factor for noncardiac surgery, particularly in patients aged 55 years and older.” However, a systematic review and meta-analysis of all available prospective studies reporting recurrent cryptogenic strokes in medically treated patients with PFO did not show a statistically significant association between the functional magnitude of right-to-left shunt and the risk of recurrent cerebrovascular events.1 Other groups have examined proposed echocardiographic risk features including presence of right-to-left shunt at rest and atrial septal aneurysm and found no evidence that such features increase the risk of PFO-attributable cryptogenic stroke.2
Ng PY, Houle TT, Eikermann M. Patent Foramen Ovale and Risk of Perioperative Stroke—Reply. JAMA. 2018;319(24):2557–2558. doi:10.1001/jama.2018.5736
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