Treating PFOs
In patients who have had no symptoms attributable to the PFO, no treatment is necessary.
In young patients (i.e., under 50 or 55) with PFO who have had a cryptogenic stroke, it does not seem entirely unreasonable to treat, as long as the patient understands that the PFO may indeed just be an incidental finding that has nothing whatsoever to do with the stroke. If therapy is desired, several "levels" of therapy are possible. The patient could be simply be told to try to avoid situations that increase right atrial pressure - avoid constipation, heavy lifting or pushing heavy objects, and deep repetitive coughing. Alternately, the patient could be placed on anticoagulation therapy with Coumadin (or aspirin) to try to prevent blood clots from forming. Finally, the patient could receive a PFO closure device. The patient should be fully informed of the risks of such devices (including death, severe bleeding, fatal pulmonary embolism, and the need for emergency heart surgery) which occur in between 1 and 2% of patients. Ideally, patients who are being considered for therapy with either anticoagulation or a closure device should be asked to participate in a randomized clinical trial, so that at least the "guess" on their therapy will some day be useful to future patients.
Patients with migraine who are desperate enough to agree to PFO closure (and the doctors who are desperate enough to treat them) should also be willing to participate in a randomized trial, for similar reasons.
