Clinical Utility of Transcatheter PFO Exploration in Cryptogenic Stroke Patients With Negative TEE but High Suspicion of PFO-Related Etiology.

Background: Patent foramen ovale (PFO) has been identified as a potential risk factor for cryptogenic stroke (CS). Although transesophageal echocardiography (TEE) is considered the gold standard for PFO detection, false-negative results remain a clinical concern, particularly in CS patients with high suspicion of PFO-related etiology.

Aims: To evaluate the clinical utility of transcatheter PFO exploration (TPFOE) in CS patients with negative TEE findings but high suspicion of PFO-related etiology.

Methods: Between January 2019 and May 2022, 30 CS patients with high suspicion of PFO-related etiology were enrolled. All showed grade III/IV RLS on contrast transthoracic echocardiography (cTTE) despite negative TEE. Each patient underwent TPFOE. Patients with confirmed PFO proceeded directly to immediate PFO closure, whereas negative cases received antiplatelet therapy alone. Follow‑up with transthoracic echocardiography (TTE), chest X‑ray, and electrocardiography (ECG) was performed at 12 h and at 1, 3, 6, and 12 months after the procedure.

Results: The study cohort comprised 14 males and 16 females, with a median age of 41.5 years (interquartile range: 34-48 years). TPFOE successfully identified PFO in 28 patients (93.3%), all of whom subsequently underwent successful interventional closure. Follow-up TTE confirmed ideal device position and morphology without residual shunting. The remaining two patients (6.7%) had negative exploration results, and they received antiplatelet therapy alone. No recurrent cerebrovascular events were reported in any patient during the follow-up period.

Conclusion: TEE, though the gold standard for PFO diagnosis, carries a non‑negligible false‑negative rate. In CS patients with negative TEE but high suspicion of PFO-related etiology, TPFOE demonstrated potential as an adjunctive technique to increase PFO detection. Further studies are warranted to better define its diagnostic value for PFO in this patient population.