Patent foramen ovale (PFO), stroke and pregnancy.

Patent foramen ovale (PFO)-related stroke is increasingly recognized as an important etiology of ischemic embolic stroke—accounting for up to 50% of strokes previously considered ‘cryptogenic’ or with an unknown mechanism. As a ‘back door to the brain,’ PFO can allow venous clots to enter arterial circulation via interatrial right-to-left shunting, potentially resulting in ischemic stroke. We observe that clinically, PFO-related stroke affects women of childbearing age, and that pregnancy—owing to major changes in hemocoagulative, hormonal, and cardiovascular parameters—can enhance stroke risks. However, no systematic study has been performed and little is known regarding complications, pregnancy outcomes and treatment for PFO-related stroke during pregnancy. To identify and characterize the complications and clinical outcomes related to PFOs during pregnancy, we performed a literature review and analysis from all reported cases of pregnancy with PFO-related complications in the medical literature from 1970 to 2015. We find that during pregnancy and postpartum, PFO is associated with complications affecting multiple organs, including the brain, heart and lung. The three principal complications reported are stroke, pulmonary emboli and myocardial infarction. In contrast to other pregnancy-related stroke etiologies, which peak during later pregnancy and postpartum, PFO-related stroke peaks during early pregnancy (first and second trimester—60%), and most patients had good neurological outcome (77%). In patients with PFO with recurrent stroke during pregnancy, additional key factors include high-risk PFO morphology (atrial septal aneurysm), larger right-to-left shunt, multiple gestation and concurrent hypercoagulability. Compared to strokes of other etiologies during pregnancy, most PFO stroke patients experienced uneventful delivery (93%) of healthy babies with a good clinical outcome. We conclude with recommended clinical treatment strategies for pregnant patients with PFO suggested by the data from these cases, and the clinical experience of our Cardio-Neurology Clinic.

卵圆孔未闭（PFO）相关的卒中日益被认为是缺血性栓塞性卒中的一个重要病因——在先前被认为是“隐源性”或机制不明的卒中中占比高达50%。作为“通往大脑的后门”，PFO可使静脉血栓通过心房内右向左分流进入动脉循环，有可能导致缺血性卒中。我们观察到，在临床上，PFO相关的卒中影响育龄女性，并且由于血液凝固性、激素和心血管参数的重大变化，怀孕会增加卒中风险。然而，尚未进行系统研究，对于怀孕期间PFO相关卒中的并发症、妊娠结局和治疗知之甚少。为了确定和描述怀孕期间与PFO相关的并发症和临床结局，我们对1970年至2015年医学文献中所有报告的伴有PFO相关并发症的妊娠病例进行了文献回顾和分析。我们发现，在怀孕和产后期间，PFO与影响多个器官（包括大脑、心脏和肺）的并发症有关。报告的三种主要并发症是卒中、肺栓塞和心肌梗死。与其他妊娠相关的卒中病因在妊娠后期和产后达到高峰不同，PFO相关的卒中在妊娠早期（孕早期和孕中期 - 60%）达到高峰，并且大多数患者神经功能预后良好（77%）。在怀孕期间反复发生卒中的PFO患者中，其他关键因素包括高危PFO形态（房间隔瘤）、较大的右向左分流、多胎妊娠以及并发的高凝状态。与怀孕期间其他病因的卒中相比，大多数PFO卒中患者顺利分娩（93%）出健康婴儿，临床结局良好。我们根据这些病例的数据以及我们心脑血管神经病学诊所的临床经验，总结了针对患有PFO的孕妇的推荐临床治疗策略。