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Apostolos A, Tsiachris D, Drakopoulou M, Trantalis G, Oikonomou G, Ktenopoulos N, Simopoulou C, Katsaros O, Tsalamandris S, Aggeli C, Tsivgoulis G, Tsioufis C, Toutouzas K. Atrial Fibrillation After Patent Foramen Ovale Closure: Incidence, Pathophysiology, and Management. J Am Heart Assoc 2024; 13:e034249. [PMID: 38639354 PMCID: PMC11179870 DOI: 10.1161/jaha.124.034249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Accepted: 02/06/2024] [Indexed: 04/20/2024]
Abstract
This comprehensive review explores the incidence, pathophysiology, and management of atrial fibrillation (AF) following percutaneous closure of patent foramen ovale (PFO). Although AF is considered a common adverse event post PFO closure, its incidence, estimated at <5%, varies based on monitoring methods. The review delves into the challenging task of precisely estimating AF incidence, given subclinical AF and diverse diagnostic approaches. Notably, a temporal pattern emerges, with peak incidence around the 14th day after closure and a subsequent decline after the 45th day, mimicking general population AF trends. The pathophysiological mechanisms behind post PFO closure AF remain elusive, with proposed factors including local irritation, device-related interference, tissue stretch, and nickel hypersensitivity. Management considerations encompass rhythm control, with flecainide showing promise, and anticoagulation tailored to individual risk profiles. The authors advocate for a personalized approach, weighing factors like age, comorbidities, and device characteristics. Notably, postclosure AF is generally considered benign, often resolving spontaneously within 45 days, minimizing thromboembolic risks. Further studies are required to refine understanding and provide evidence-based guidelines.
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Affiliation(s)
- Anastasios Apostolos
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
| | - Dimitrios Tsiachris
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
| | - Maria Drakopoulou
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
| | - Georgios Trantalis
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
| | - Georgios Oikonomou
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
| | - Nikolaos Ktenopoulos
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
| | - Chrysavgi Simopoulou
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
| | - Odysseas Katsaros
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
| | - Sotirios Tsalamandris
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
| | - Constantina Aggeli
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
| | - Georgios Tsivgoulis
- Second Department of Neurology, Medical SchoolNational and Kapodistrian University of Athens, Attikon University Hospital of AthensAthensGreece
| | - Costas Tsioufis
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
| | - Konstantinos Toutouzas
- First Department of Cardiology, Medical SchoolNational and Kapodistrian University of Athens, Hippokration General HospitalAthensGreece
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Eichelmann A, Kubini R, Nachoski D, Kosinski C, Becker M, Aljalloud A. Patent foramen ovale closure versus drug therapy in patients over 60 years and a follow-up of 5 years. Clin Cardiol 2024; 47:e24251. [PMID: 38445759 PMCID: PMC10915992 DOI: 10.1002/clc.24251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 02/15/2024] [Accepted: 02/21/2024] [Indexed: 03/07/2024] Open
Abstract
BACKGROUND The advantages of patent foramen ovale (PFO) closure as protection from a recurrence of stroke remains controversial compared to drug therapy, especially in patients over 60 years. HYPOTHESIS The aim of the study is to compare recurrence of stroke in patients over 60 years old with PFO closure versus drug therapy alone. METHODS We included 342 patients over 60 years who suffered a crytopgenic stroke, and were also accepted for a PFO closure. 199 patients refused a PFO closure and were treated with medical therapy alone, whereas 143 patients underwent a PFO closure procedure. RESULTS The mean follow up time was 5.5 ± 1.5 years. All patients in Group B showed persistent shunt in the follow-up period (n = 199, 100%). In Group A, seven patients were diagnosed with residual shunt during echocardiography examination (5%). A new onset of atrial fibrillation occurred in seven patients in Group A (5%) and six patients in Group B (3%), p = .117. Recurrent stroke occurred in 3 patients in Group A (2%) and 11 patients in Group B (6%), p = .021. One patient died of unknown reason (1%) and two patients were lost due to neurological death (1%) in Group B, whereas no patients in Group A died during the follow-up period. CONCLUSION Our results show that strict exclusion of patients over 60 years from PFO closure should be reconsidered. As life expectancies are increasing, patients should be considered for same treatment as younger patients, since the outcomes are improved compared to patients treated with medical therapy alone.
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Affiliation(s)
| | - Ralf Kubini
- Rhein‐Maas Hospital, Department of CardiologyNephrology and Internal Intensive CareWürselenGermany
| | - Dejan Nachoski
- Rhein‐Maas Hospital, Department of CardiologyNephrology and Internal Intensive CareWürselenGermany
| | | | - Michael Becker
- Rhein‐Maas Hospital, Department of CardiologyNephrology and Internal Intensive CareWürselenGermany
| | - Ali Aljalloud
- Rhein‐Maas Hospital, Department of CardiologyNephrology and Internal Intensive CareWürselenGermany
- Department of Cardiac SurgeryRWTH University Hospital AachenAachenGermany
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Do AP, Nguyen HM, Thi Thu Nguyen H, Ta CM, Bui STT, Pham HM. Recurrent paradoxical cerebral embolism caused by a thrombus entrapped in a patent foramen ovale: a case report. Ann Med Surg (Lond) 2023; 85:5765-5769. [PMID: 37915658 PMCID: PMC10617831 DOI: 10.1097/ms9.0000000000001343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 09/12/2023] [Indexed: 11/03/2023] Open
Abstract
Introduction A thrombus straddling the patent foramen ovale (PFO) is a very rare clinical entity. Optimal management remains unclear due to the availability of various therapeutic options; thus, an individualized approach is recommended. Case presentation The authors describe a case presenting with recurrent cerebral embolism and a large and mobile thrombus straddled in the PFO. Historically, cardiac surgery, thrombolysis or anticoagulation were possible management options for this patient. However, there are no guidelines on what the optimal treatment is. Our patient was a poor surgical candidate because of advanced age and multiple comorbidities. Furthermore, she had a recent ischaemic stroke which was a relative contraindication to thrombolysis. After consulting the Heart Team, medical treatment alone with systemic anticoagulation was administered. Subsequent transthoracic echocardiography (TTE) after 1 week showed complete thrombus resolution. After 4 months, the PFO was successfully occluded with an Amplatzer device. The patient received rehabilitation therapy and had good functional recovery. Clinical discussion Anticoagulant therapy alone was chosen because of high risk for surgery. Complete thrombus resolution was achieved after 1 week although the initial thrombus size was quite large. Nevertheless, this approach may not be applicable to every patient. In addition to TTE, multimodality imaging using transesophageal echocardiography and cardiac magnetic resonance is helpful to identify the mechanism of stroke, which in our case is a thrombus-straddled PFO, and to make early treatment decisions. Serial TTEs help assess the response to anticoagulation. An individualized approach should be made with a multidisciplinary Heart Team. Conclusion Echocardiography plays an important role in the diagnosis and treatment evaluation for patients with a thrombus straddling a PFO. An individualized approach to manage the patient should be made with a multidisciplinary Heart Team.
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Affiliation(s)
| | | | - Hoai Thi Thu Nguyen
- Vietnam Heart Institute, Bach Mai Hospital
- Department of Internal Medicine, VNU—University of Medicine and Pharmacy
| | | | | | - Hung Manh Pham
- Vietnam Heart Institute, Bach Mai Hospital
- Department of Internal Medicine, Hanoi Medical University, Hanoi, Vietnam
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Patel U, Dengri C, Pielykh D, Baskar A, Tar MI, Patel G, Patel N, Kothari N, Selvam SA, Sharma AM, Venkata VS, Shah S, Mahmood SN, Peela AS. Secondary Prevention of Cryptogenic Stroke and Outcomes Following Surgical Patent Foramen Ovale Closure Plus Medical Therapy vs. Medical Therapy Alone: An Umbrella Meta-Analysis of Eight Meta-Analyses Covering Seventeen Countries. Cardiol Res 2023; 14:342-350. [PMID: 37936625 PMCID: PMC10627369 DOI: 10.14740/cr1526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 08/09/2023] [Indexed: 11/09/2023] Open
Abstract
Background Cryptogenic stroke (CS) is an exclusion diagnosis that accounts for 10-40% of all ischemic strokes. Patent foramen ovale (PFO) is found in 66% of patients with CS, while having a prevalence of 25-30% in the general population. The primary aim was to evaluate the risk of recurrent stroke following surgical PFO closure plus medical therapy vs. medical therapy alone amongst CS, an embolic stroke of undetermined source (ESUS), or transient ischemic attack (TIA). The secondary aim was to evaluate new-onset non-valvular atrial fibrillation, mortality, and major bleeding. Methods We conducted an umbrella meta-analysis using PRISMA guidelines on English studies comparing surgical PFO closure plus medical therapy versus medical therapy alone for managing CS. We extracted data on interventions and outcomes and used random-effects models with generic inverse variance to calculate relative risks (RRs) with 95% confidence intervals for outcome calculations. Results A comprehensive search yielded 54,729 articles on CS and 65,001 on surgical PFO closure, with 1,591 studies focusing on PFO closure and medical therapy for secondary CS, ESUS, or TIA prevention. After excluding non-meta-analyses, 52 eligible meta-analyses were identified, and eight studies were selected for outcome evaluation, excluding non-English, non-human, and studies before January 2019 as of August 31, 2021. Among a total of 41,880 patients, 14,942 received PFO closure + medical therapy, while 26,938 patients received medical therapy alone. Our umbrella meta-analysis showed that PFO closure plus medical therapy had a 64% lower risk of recurrent strokes than medical therapy alone (pooled RR: 0.36). PFO closure plus medical therapy was associated with 4.94 times higher risk of atrial fibrillation. There was no difference in the risk of death or bleeding between both groups. Conclusion In patients with CS, PFO closure, in addition to medical therapy, reduces the risk of recurrence. More research is needed to assess the efficacy of early closure as well as specific risk profiles that would benefit from early intervention to reduce the burden of stroke.
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Affiliation(s)
- Urvish Patel
- Department of Neurology and Public Health, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- These authors contributed equally to the article
| | - Chetna Dengri
- Department of Neurology, Cleveland Clinic Florida, Weston, FL 33331, USA
- These authors contributed equally to the article
| | - David Pielykh
- Odessa National Medical University, Valikhovskiy Lane 2, Odessa 65000, Ukraine
| | - Aakash Baskar
- K.A.P. Viswanatham Government Medical College, Musiri, Trichy, Tamilnadu 621006, India
| | - Muhammad Imtiaz Tar
- Touro University Nevada College of Osteopathic Medicine, Henderson, NV 89014, USA
| | | | - Neel Patel
- Department of Public Health, Icahn School of Medicine at Mount Sinai, New York, NY 10029 USA
| | - Nishel Kothari
- Dartmouth Hitchcock Medical Center, Lebanon, NH 03766, USA
| | - Renu
- Department of Medicine, Sarojini Naidu Medical College, Agra, Uttar Pradesh 282003, India
| | - Sri Abirami Selvam
- Department of Internal Medicine, St Mary Medical Center, Langhorne, PA 19047, USA
| | - Amit Munshi Sharma
- Department of Medicine, Geisinger Commonwealth School of Medicine, Scranton, PA 18510, USA
| | | | - Shamik Shah
- Department of Neurology, Stormont Vail Health, Topeka, KS, USA
| | - Syed Nazeer Mahmood
- Department of Medicine, Section of Pulmonary/Critical Care, MedStar Washington Hospital Center, Washington, DC 5333, USA
| | - Appala Suman Peela
- Department of Family Medicine, UNC Health Southeastern, Lumberton, NC 28358, USA
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Percutaneous Closure of Patent Foramen Ovale after Anterior Spinal Cord Infarction. Case Rep Cardiol 2022; 2022:2171350. [PMID: 35547864 PMCID: PMC9085360 DOI: 10.1155/2022/2171350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 02/15/2022] [Indexed: 12/05/2022] Open
Abstract
In patients with a patent foramen ovale (PFO) who have had a cryptogenic ischemic stroke, percutaneous closure reduces its recurrence risk. However, its role in spinal cord infarction (SCI) is less well-established. A few case reports describe the putative causative role of PFO in SCI. We present a case of a teenager with cryptogenic anterior SCI in the setting of a deep vein thrombosis and a high risk-PFO who underwent successful percutaneous closure.
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Thomson VS, Aaron S, Samson D N, Krupa J, Prabhakar AT, Jose J, George P, George OK, Joseph G, Yadav BK. Patent foramen ovale closure in India; Feasibility, challenges and mid-term outcomes. Indian Heart J 2021; 73:656-659. [PMID: 34627589 PMCID: PMC8514405 DOI: 10.1016/j.ihj.2021.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 07/19/2021] [Accepted: 09/01/2021] [Indexed: 10/25/2022] Open
Abstract
Patent foramen ovale closure (PFO) is an underutilized therapy, and our study explored the challenges and feasibility of PFO closure in the Indian setting. Eighty patients with Embolic Stroke of Undetermined Source (ESUS) were screened by transcranial Doppler (TCD) for PFO. Twenty-nine patients underwent successful closure. High-risk features of a long tunnel, inter-atrial septal aneurysm, and large defect were present in 31%, 28%, and 59%. Transcranial Doppler had a sensitivity and specificity of 78% and 53% (p = 0.02) to detect PFO. Anticoagulation was withdrawn in 85% of patients post closure. Two patients had residual shunts at follow-up of 19 (9,34) months.
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Affiliation(s)
- Viji S Thomson
- Department of Cardiology, Christian Medical College and Hospital, Vellore, 632004, India.
| | - Sanjith Aaron
- Department of Neurology, Christian Medical College and Hospital, Vellore, 632004, India
| | - Nathaniel Samson D
- Department of Cardiology, Christian Medical College and Hospital, Vellore, 632004, India
| | - Jesu Krupa
- Department of Cardiology, Christian Medical College and Hospital, Vellore, 632004, India
| | - A T Prabhakar
- Department of Neurology, Christian Medical College and Hospital, Vellore, 632004, India
| | - John Jose
- Department of Cardiology, Christian Medical College and Hospital, Vellore, 632004, India
| | - Paul George
- Department of Cardiology, Christian Medical College and Hospital, Vellore, 632004, India
| | - Oommen K George
- Department of Cardiology, Christian Medical College and Hospital, Vellore, 632004, India
| | - George Joseph
- Department of Cardiology, Christian Medical College and Hospital, Vellore, 632004, India
| | - Bijesh Kumar Yadav
- Department of Biostatistics, Christian Medical College and Hospital, Vellore, 632004, India
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Omedè P, Bocchino PP, De Filippo O, D’Ascenzo F. Patent foramen ovale closure in a patient with vena cava filter: a case report. Eur Heart J Case Rep 2021; 5:ytab284. [PMID: 34377917 PMCID: PMC8343425 DOI: 10.1093/ehjcr/ytab284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 02/23/2021] [Accepted: 06/30/2021] [Indexed: 11/16/2022]
Abstract
Background The presence of a patent foramen ovale (PFO) is associated with several medical conditions, including cryptogenic left circulation thromboembolism. PFO closure was demonstrated to reduce recurrent ischaemic stroke in patients with prior cryptogenic stroke. The presence of an inferior vena cava filter (IVCF), however, may impede a transfemoral PFO closure procedure. Case summary We describe the case of a 50-year-old man with a PFO suffering from ischaemic stroke from paradoxical thromboembolism originating from deep vein thrombosis and requiring an IVCF. After deep vein thrombosis resolution, due to the high risk of stroke recurrences, the patient was recommended PFO closure. IVCF retrieval by the interventional radiologist was first attempted but failed. A transfemoral PFO closure procedure was thus endeavoured with the IVCF in place and was successful. The patient was then discharged in good clinical status and no stroke recurrences were reported at 5 months follow-up. Discussion Albeit an IVCF provides benefit in patients with recurrent thromboembolic events despite adequate anticoagulation therapy, its presence may hinder interventional procedures necessitating delivery systems to advance through the inferior vena cava. We reported on a successful PFO closure procedure via a femoral venous access in a patient with an IVCF in place, thus demonstrating the feasibility of advancing delivery systems through an IVCF. As interventional procedures requiring the advancement of delivery systems through the inferior vena cava are becoming increasingly common, the feasibility of IVCF crossing with catheters and delivery systems alike paves the way for novel interventional possibilities.
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Affiliation(s)
- Pierluigi Omedè
- Division of Cardiology, Department of Medical Sciences, University of Turin, “Città della Salute e della Scienza” Hospital, Corso Bramante 88/90, 10126 Turin, Italy
| | - Pier Paolo Bocchino
- Division of Cardiology, Department of Medical Sciences, University of Turin, “Città della Salute e della Scienza” Hospital, Corso Bramante 88/90, 10126 Turin, Italy
| | - Ovidio De Filippo
- Division of Cardiology, Department of Medical Sciences, University of Turin, “Città della Salute e della Scienza” Hospital, Corso Bramante 88/90, 10126 Turin, Italy
| | - Fabrizio D’Ascenzo
- Division of Cardiology, Department of Medical Sciences, University of Turin, “Città della Salute e della Scienza” Hospital, Corso Bramante 88/90, 10126 Turin, Italy
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Martín Mañero C, Medina Durán P, Morales Delgado N, Martín Rioboó E. [Patent foramen ovale. An update for primary care]. Semergen 2021; 47:189-196. [PMID: 33509725 DOI: 10.1016/j.semerg.2020.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 12/08/2020] [Accepted: 12/10/2020] [Indexed: 10/22/2022]
Abstract
Patent foramen ovale (FOP) is the most prevalent cause of cryptogenic strokes in people under 60 years old. Although it is usually asymptomatic, it has a high risk of producing paradoxical embolism and, therefore, stroke with indeterminate outcomes. The study should be started based on clinical suspicion, and includes a multidisciplinary assessment and a determination of the type of treatment to be performed. The therapeutic possibilities range from conservative treatment (indefinite antithrombotic treatment), to its percutaneous closure (currently the most widely used). The first objective is to decrease the number of stroke recurrences. Conservative treatment should be reserved for those cases of low embolic risk. The risk assessment must be individualised, fundamentally based on the anatomical characteristics of the FOP and the patient clinic picture. The use of the RoPE risk scale (The Risk of Paradoxical Embolism) should be a tool to consider.
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Affiliation(s)
- C Martín Mañero
- Medicina Familiar y Comunitaria, Centro de Salud Ribera del Muelle, Distrito Sanitario Bahía de Cádiz-La Janda, Puerto Real, Cádiz, España
| | - P Medina Durán
- Servicio de Urgencias, Hospital Alta Resolución Montilla, Montilla, Córdoba, España
| | - N Morales Delgado
- Medicina Familiar y Comunitaria, Unidad de Gestión Clínica Poniente, Distrito Sanitario Córdoba Guadalquivir, Córdoba, España
| | - E Martín Rioboó
- Unidad de Gestión Clínica Poniente, Distrito Sanitario Córdoba Guadalquivir, Grupo de Investigación clínico-epidemiológica (GICEAP), IMIBIC, Hospital Reina Sofía Córdoba, Córdoba, España.
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[Cryptogenic stroke and patent foramen ovale : S2e guidelines]. DER NERVENARZT 2019; 89:1143-1153. [PMID: 30255469 DOI: 10.1007/s00115-018-0609-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Diener HC, Grau A, Baldus S. Cryptogenic stroke and patent foramen ovale (abridged and translated version). Neurol Res Pract 2019; 1:1. [PMID: 33324867 PMCID: PMC7650129 DOI: 10.1186/s42466-019-0008-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 01/20/2019] [Indexed: 02/03/2023] Open
Abstract
Interventional patent foramen ovale (PFO) closure should be performed in patients aged 16 to 60 years (after extensive neurological and cardiological diagnostic work-up) with a history of cryptogenic ischaemic stroke and patent foramen ovale, with moderate or extensive right-to-left shunt. In patients with cryptogenic ischaemic stroke and patent foramen ovale, who reject a PFO closure, there is no evidence of superiority of oral anticoagulation over antiplatelet therapy. Therefore, secondary prevention should be performed with aspirin or clopidogrel. Atrial fibrillation, pericardial tamponade, and pulmonary embolism are reported complications during and after implantation of an occluder. However, these events are so rare that they should not influence the recommendation for implantation. This article is an abridged and translated version of the guideline published in Nervenarzt: Diener, HC., für die Deutsche Gesellschaft für Neurologie (DGN), Grau, A.J. et al. Nervenarzt (2018) 89: 1143. 10.1007/s00115-018-0609-y.
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Affiliation(s)
| | - Armin Grau
- DSG German Stroke Society, Berlin, Germany
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Pristipino C, Sievert H, D'Ascenzo F, Mas JL, Meier B, Scacciatella P, Hildick-Smith D, Gaita F, Toni D, Kyrle P, Thomson J, Derumeaux G, Onorato E, Sibbing D, Germonpré P, Berti S, Chessa M, Bedogni F, Dudek D, Hornung M, Zamorano J. European position paper on the management of patients with patent foramen ovale. General approach and left circulation thromboembolism. EUROINTERVENTION 2019; 14:1389-1402. [PMID: 30141306 DOI: 10.4244/eij-d-18-00622] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/03/2023]
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Fiorelli EM, Carandini T, Gagliardi D, Bozzano V, Bonzi M, Tobaldini E, Comi GP, Scarpini EA, Montano N, Solbiati M. Secondary prevention of cryptogenic stroke in patients with patent foramen ovale: a systematic review and meta-analysis. Intern Emerg Med 2018; 13:1287-1303. [PMID: 30032341 DOI: 10.1007/s11739-018-1909-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 07/12/2018] [Indexed: 01/27/2023]
Abstract
The aim of our study is to compare patent foramen ovale (PFO) closure versus medical treatment and antiplatelet versus anticoagulant therapy in patients with cryptogenic stroke (CS) and PFO. We conducted a systematic review and meta-analysis with trial sequential analysis (TSA) of randomized trials. Primary outcomes are stroke or transient ischemic attack (TIA) and all-cause mortality. Secondary outcomes are peripheral embolism, bleeding, serious adverse events, myocardial infarction and atrial dysrhythmias. We performed an intention to treat meta-analysis with a random-effects model. We include six trials (3677 patients, mean age 47.3 years, 55.8% men). PFO closure is associated with a lower recurrence of stroke or TIA at a mean follow-up of 3.88 years compared to medical therapy [risk ratio (RR) 0.55, 95% CI 0.38-0.81; I2 = 40%]. The TSA confirms this result. No difference is found in mortality (RR 0.74, 95% CI 0.35-1.60; I2 = 0%), while PFO closure is associated with a higher incidence of atrial dysrhythmias (RR 4.55, 95% CI 2.16-9.60; I2 = 25%). The rate of the other outcomes is not different among the two groups. The comparison between anticoagulant and antiplatelet therapy shows no difference in terms of stroke recurrence, mortality and bleeding. There is conclusive evidence that PFO closure reduces the recurrence of stroke or TIA in patients younger than 60 years of age with CS. More data are warranted to assess the consequences of the increase in atrial dysrhythmias and the advantage of PFO closure over anticoagulants.
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Affiliation(s)
- Elisa Maria Fiorelli
- Department of Internal Medicine, IRCCS Foundation Ca' Granda, Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Tiziana Carandini
- Neurodegenerative Disease Unit, University of Milan, Dino Ferrari Centre, IRCCS Foundation Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy.
| | - Delia Gagliardi
- Dino Ferrari Centre, Neuroscience Section, Department of Pathophysiology and Transplantation (DEPT), University of Milan, Neurology Unit, IRCCS Foundation Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Viviana Bozzano
- Department of Internal Medicine, IRCCS Foundation Ca' Granda, Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Mattia Bonzi
- Department of Internal Medicine, IRCCS Foundation Ca' Granda, Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Eleonora Tobaldini
- Department of Internal Medicine, IRCCS Foundation Ca' Granda, Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Giacomo Pietro Comi
- Dino Ferrari Centre, Neuroscience Section, Department of Pathophysiology and Transplantation (DEPT), University of Milan, Neurology Unit, IRCCS Foundation Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Elio Angelo Scarpini
- Neurodegenerative Disease Unit, University of Milan, Dino Ferrari Centre, IRCCS Foundation Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Nicola Montano
- Department of Internal Medicine, IRCCS Foundation Ca' Granda, Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Monica Solbiati
- Department of Internal Medicine, IRCCS Foundation Ca' Granda, Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
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Lai JCL, Tse G, Wu WK, Gong M, Bazoukis G, Wong WT, Wong SH, Lampropoulos K, Baranchuk A, Tse LA, Xia Y, Li G, Wong MC, Chan YS, Mu N, Dong M, Liu T. Patent foramen ovale closure versus medical therapy for stroke prevention: A systematic review and meta-analysis of randomized controlled trials. F1000Res 2017; 6:2178. [PMID: 30271571 PMCID: PMC6137413 DOI: 10.12688/f1000research.13444.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/17/2018] [Indexed: 10/11/2023] Open
Abstract
Background: Previous randomized trials on patent foramen ovale (PFO) closure versus medical therapy for stroke prevention were inconclusive. Recently, two new randomized trials and new findings from an extended follow-up of a previous trial have been published on this topic. We conducted a systematic review and meta-analysis of randomized trials comparing PFO closure with medical therapy for stroke prevention. Methods: PubMed and Cochrane Library were searched until 16 th September 2017. The following search terms were used for PubMed: "patent foramen ovale" AND (stroke OR embolism) and "randomized" AND "Trial". For Cochrane Library, the following terms were used: "patent foramen ovale" AND "closure" AND (stroke OR embolism). Results: A total of 91 and 55 entries were retrieved from each database using our search strategy respectively, of which six studies on five trials met the inclusion criteria. This meta-analysis included 1829 patients in the PFO closure arm (mean age: 45.3 years; 54% male) and 1972 patients in the medical therapy arm (mean age: 45.1 years; 51% male). The median follow-up duration was 50 ± 30 months. When compared to medical therapy, PFO closure significantly reduced primary endpoint events with a risk ratio [RR] of 0.60 (95% CI: 0.44-0.83, P < 0.0001; I 2: 15%). It also reduced stroke (RR: 0.50, 95% CI: 0.35-0.73, P < 0.0001; I 2: 32%) despite increasing the risk of atrial fibrillation/flutter (RR: 1.90, 95% CI: 1.23-2.93, P < 0.01; I 2: 43%). However, it did not reduce transient ischemic accident events (0.75; 95% CI: 0.51-1.10, P = 0.14; I 2: 0%), all-cause bleeding (RR: 0.89; 95% CI: 0.44-1.78, P = 0.74; I 2: 51%) or gastrointestinal complications (RR: 0.92; 95% CI: 0.32-2.70, P = 0.88; I 2: 0%). Conclusions: PFO closure significantly reduces risk of stroke when compared to medical treatment and should therefore be considered for stroke prevention in PFO patients.
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Affiliation(s)
- Jenny Chi Ling Lai
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, Hong Kong
- Li Ka Shing Institute of Health Sciences, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Gary Tse
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, Hong Kong
- Li Ka Shing Institute of Health Sciences, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - William K.K. Wu
- Li Ka Shing Institute of Health Sciences, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, Hong Kong
- Department of Anaesthesia and Intensive Care, State Key Laboratory of Digestive Disease, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Mengqi Gong
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular disease, Department of Cardiology, Tianjin Institute of Cardiology, The Second Hospital of Tianjin Medical University, Tianjin, 300211, China
| | - George Bazoukis
- Second Department of Cardiology, Evangelismos General Hospital of Athens, Athens, Greece
| | - Wing Tak Wong
- School of Life Sciences, Chinese University of Hong Kong, Hong Kong, Hong Kong
- State Key Laboratory of Agrobiotechnology, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Sunny Hei Wong
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, Hong Kong
- Li Ka Shing Institute of Health Sciences, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | | | - Adrian Baranchuk
- Division of Cardiology, Kingston General Hospital, Queen’s University, Kingston, ON, Canada
| | - Lap Ah Tse
- JC School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Yunlong Xia
- Department of Cardiovascular Medicine, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Guangping Li
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular disease, Department of Cardiology, Tianjin Institute of Cardiology, The Second Hospital of Tianjin Medical University, Tianjin, 300211, China
| | - Martin C.S. Wong
- JC School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Yat Sun Chan
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, Hong Kong
- Li Ka Shing Institute of Health Sciences, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Nan Mu
- Department of Gynecology and Obstetrics, Yantai Yuhuangding Hospital Affiliated to Qingdao University, Yantai, Shandong, 264000, China
| | - Mei Dong
- Department of Gynecology and Obstetrics, Yantai Yuhuangding Hospital Affiliated to Qingdao University, Yantai, Shandong, 264000, China
| | - Tong Liu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular disease, Department of Cardiology, Tianjin Institute of Cardiology, The Second Hospital of Tianjin Medical University, Tianjin, 300211, China
| | - International Health Informatics Study (IHIS) Network
- Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, Hong Kong
- Li Ka Shing Institute of Health Sciences, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, Hong Kong
- Department of Anaesthesia and Intensive Care, State Key Laboratory of Digestive Disease, Chinese University of Hong Kong, Hong Kong, Hong Kong
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular disease, Department of Cardiology, Tianjin Institute of Cardiology, The Second Hospital of Tianjin Medical University, Tianjin, 300211, China
- Second Department of Cardiology, Evangelismos General Hospital of Athens, Athens, Greece
- School of Life Sciences, Chinese University of Hong Kong, Hong Kong, Hong Kong
- State Key Laboratory of Agrobiotechnology, Chinese University of Hong Kong, Hong Kong, Hong Kong
- Division of Cardiology, Kingston General Hospital, Queen’s University, Kingston, ON, Canada
- JC School of Public Health and Primary Care, Chinese University of Hong Kong, Hong Kong, Hong Kong
- Department of Cardiovascular Medicine, First Affiliated Hospital of Dalian Medical University, Dalian, China
- Department of Gynecology and Obstetrics, Yantai Yuhuangding Hospital Affiliated to Qingdao University, Yantai, Shandong, 264000, China
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