Heghine Khachatryan: PFO, Cryptogenic Stroke, and Factor V Leiden – Closure or Lifelong Anticoagulation?
Heghine Khachatryan, Editor-in-Chief of Hemostasis Today, Head of Hemophilia and Thrombosis Center at Yeolyan Hematology and Oncology Center, shared a post on LinkedIn:
”PFO, Cryptogenic Stroke, and Factor V Leiden: Closure or Lifelong Anticoagulation?
Clinical decision-making becomes particularly complex when a patient presents with cryptogenic stroke, patent foramen ovale (PFO), and homozygous Factor V Leiden thrombophilia.
The key question often raised in practice is:
Should the PFO be closed, or should the patient remain on long-term anticoagulation alone?
Current evidence suggests that the answer is not straightforward and requires careful patient selection.
Several elements must be evaluated before making a decision:
- Age of the patient (particularly <60 years)
- Whether the stroke is truly PFO-associated after a complete diagnostic work-up
- Presence of venous thromboembolism or paradoxical embolism
- High-risk PFO anatomy (large shunt, atrial septal aneurysm)
- Underlying prothrombotic conditions such as Factor V Leiden mutation
In patients with strong evidence suggesting paradoxical embolism, many experts increasingly favor PFO closure combined with antithrombotic therapy, rather than relying on medical therapy alone.
However, Factor V Leiden thrombophilia alone does not necessarily prove that the stroke mechanism is arterial or PFO-mediated, and decisions should always be individualized.
In my view, the optimal strategy often involves multidisciplinary discussion between neurologists, cardiologists, and hematologists.
Personally, in a young patient with cryptogenic stroke, PFO, and homozygous Factor V Leiden, I tend to consider PFO closure plus long-term antithrombotic strategy, rather than leaving the defect open.
But this remains an area where clinical judgment and shared decision-making are critical.
I would be very interested to hear the perspectives of colleagues.
How do you approach patients with PFO, cryptogenic stroke, and inherited thrombophilia?
Do you favor:
- PFO closure
- Lifelong anticoagulation
- A combined strategy?
Your experience and insights would be highly valuable for this discussion.”
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