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Iskander B, Anwer F, Oliveri F, Fotios K, Panday P, Arcia Franchini AP, Hamid P. Amplatzer Patent Foramen Ovale Occluder Device-Related Complications. Cureus 2022; 14:e23756. [PMID: 35402119 PMCID: PMC8980243 DOI: 10.7759/cureus.23756] [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: 09/12/2021] [Accepted: 04/01/2022] [Indexed: 11/05/2022] Open
Abstract
Patent foramen ovale (PFO) is a standard variant that is present in 25% of the whole adult population. In a certain population, PFO can lead to cerebrovascular accidents. Mechanism of cerebrovascular accidents can be by paradoxical embolization from the right circulation or in situ thrombosis. Diagnosis of a PFO-responsible cerebrovascular accident is based on a thorough work-up to exclude other possible etiologies and detect PFO on trans-thoracic or trans-esophageal echocardiography with bubble study and/or Doppler. Over the last few years, multiple studies have supported that percutaneous PFO closure is superior to medical therapy in the secondary prevention of cerebrovascular accidents. However, numerous adverse events have been linked to PFO closure devices in general compared to medical therapy as new-onset atrial fibrillation, residual shunt, device-related thrombus, bleeding, deep vein thrombosis, pulmonary embolism, and inter-atrial septal erosions. Amplatzer device is one of the PFO occluder devices approved by the FDA. Device-related adverse events have been addressed by comparing the Amplatzer device with other PFO occluder devices. Based on the new data, we expect to see more complications related to PFO closure in the coming few years. We reviewed different studies that looked at the PFO closure-related complications and the trials comparing adverse events in the Amplatzer PFO occluder device compared to other devices. Amplatzer PFO occluder device is either superior or non-statistically different from other PFO occluder devices related to new-onset atrial fibrillation and residual shunt. More studies are needed to address the other less common adverse events. Since many of the device-related complications appear many years after device placement, a long-term follow-up is recommended.
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Kolte D, Palacios IF. Patent foramen ovale closure for secondary prevention of cryptogenic stroke. Expert Rev Cardiovasc Ther 2021; 19:211-220. [PMID: 33605829 DOI: 10.1080/14779072.2021.1878026] [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] [Indexed: 10/22/2022]
Abstract
Introduction: A patent foramen ovale (PFO) is highly prevalent among the adult population. It allows shunting of blood through the inter-atrial septum and has been associated with cryptogenic stroke, transient ischemic attack, platypnea-orthodeoxia syndrome, decompression sickness (e.g. deep-water divers), and migraines.Areas Covered: In this manuscript, we will review the anatomy of PFO with particular emphasis on the factors associated with increased risk of paradoxical embolization, as well as the different modalities for the diagnosis of PFO. We will discuss medical, surgical, and transcatheter therapy for secondary prevention in patients with PFO and cryptogenic stroke, and summarize the data from observational studies, randomized controlled trials (RCTs), and meta-analysis of RCTs that have established the beneficial effect of transcatheter PFO closure in this patient population. Finally, we will provide a brief overview of the role of transcatheter PFO closure in patients with migraine.Expert Opinion: Transcatheter closure is the preferred treatment option in young (<60 years) patients with PFO and cryptogenic stroke. A multi-disciplinary approach with input from clinical cardiologist, neurologist, hematologist, cardiac surgeon, and interventional cardiologist provides the best therapeutic plan for each patient taking into account the available data, but also medical, social, and occupational considerations.
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Affiliation(s)
- Dhaval Kolte
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Igor F Palacios
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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Abdelghani M, Nassif M, de Bruin-Bon RH, Al-Amin AM, El-Baz MS, El-Shedoudy SA, Mulder BJ, de Winter RJ, Bouma BJ. Aortic Root Geometric and Dynamic Changes After Device Closure of Interatrial Shunts. J Am Soc Echocardiogr 2019; 32:1016-1026.e5. [DOI: 10.1016/j.echo.2019.03.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 03/23/2019] [Accepted: 03/26/2019] [Indexed: 11/24/2022]
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Updated meta-analysis of closure of patent foramen ovale versus medical therapy after cryptogenic stroke. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2019; 20:187-193. [DOI: 10.1016/j.carrev.2018.06.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 06/02/2018] [Accepted: 06/04/2018] [Indexed: 11/27/2022]
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Abdelaziz HK, Saad M, Abuomara HZ, Nairooz R, Pothineni NVK, Madmani ME, Roberts DH, Mahmud E. Long-term outcomes of patent foramen ovale closure or medical therapy after cryptogenic stroke: A meta-analysis of randomized trials. Catheter Cardiovasc Interv 2018; 92:176-186. [PMID: 29726616 DOI: 10.1002/ccd.27636] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 03/09/2018] [Accepted: 03/25/2018] [Indexed: 11/07/2022]
Abstract
OBJECTIVES To examine long-term clinical outcomes with transcatheter patent foramen ovale (PFO) closure versus medical therapy alone in patients with cryptogenic stroke. BACKGROUND A long-standing debate regarding the optimal approach for the management of patients with PFO after a cryptogenic stroke exists. METHODS An electronic search was performed for randomized clinical trials (RCTs) reporting clinical outcomes with PFO closure vs. medical therapy alone after stroke. Random effects DerSimonian-Laird risk ratios (RR) were calculated. The main outcome was recurrence of stroke. Other outcomes included transient ischemic attack (TIA), new-onset atrial fibrillation/flutter (AF/AFL), major bleeding, serious adverse events, and device-related complications. All-cause mortality was also examined. RESULTS Five RCTs with a total of 3,440 patients were included. At a mean follow-up of 4.02 ± 1.57 years, PFO closure was associated with less recurrence of stroke (RR = 0.43; 95% CI 0.19-0.91; P = .027) compared with medical therapy alone. No difference was observed between both strategies for TIA (P = .21), major bleeding (P = .69), serious adverse events (P = .35), and all-cause death (P = .48). However, PFO closure, was associated with increased new-onset AF/AFL (P < .001), risk of pulmonary embolism (P = .04), and device-related complications (P < .001). On a subgroup analysis, stroke recurrence rate remained lower in PFO closure arm regardless of the type of closure device used (Pinteraction = .50), or the presence of substantial shunt in the majority of study population (Pinteraction = .13). CONCLUSIONS Transcatheter PFO closure reduces the recurrence of stroke compared with medical therapy alone, with no significant safety concerns. Close follow-up of patients after PFO closure is recommended to detect new-onset atrial arrhythmias.
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Affiliation(s)
- Hesham K Abdelaziz
- Lancashire Cardiac Center, Blackpool Victoria Hospital, Blackpool, United Kingdom.,Division of Cardiovascular Medicine, Ain Shams University, Cairo, Egypt
| | - Marwan Saad
- Division of Cardiovascular Medicine, Ain Shams University, Cairo, Egypt.,Division of Cardiovascular Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Hossamaldin Z Abuomara
- Lancashire Cardiac Center, Blackpool Victoria Hospital, Blackpool, United Kingdom.,Division of Cardiovascular Medicine, Ain Shams University, Cairo, Egypt
| | - Ramez Nairooz
- Division of Cardiovascular Medicine, University of Southern California, California
| | - Naga Venkata K Pothineni
- Division of Cardiovascular Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Mohamed E Madmani
- Division of Cardiovascular Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - David H Roberts
- Lancashire Cardiac Center, Blackpool Victoria Hospital, Blackpool, United Kingdom
| | - Ehtisham Mahmud
- Division of Cardiovascular Medicine, University of California, San Diego Sulpizio Cardiovascular Center, La Jolla, California
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Zdradzinski MJ, Elkin RL, Lee JM, Qureshi AM, El-Mallah W, Krasuski RA. Contributors to and impact of residual shunting after device closure of atrial septal defects. Am Heart J 2016; 177:112-9. [PMID: 27297856 DOI: 10.1016/j.ahj.2016.03.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2015] [Accepted: 03/30/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND The prevalence of residual shunt in patients after device closure of atrial septal defect and its impact on long-term outcome has not been previously defined. METHODS From a prospective, single-institution registry of 408 patients, we selected individuals with agitated saline studies performed 1 year after closure. Baseline echocardiographic, invasive hemodynamic, and comorbidity data were compared to identify contributors to residual shunt. Survival was determined by review of the medical records and the Social Security Death Index. Survival analysis according to shunt included construction of Kaplan-Meier curves and Cox proportional hazards modeling. RESULTS Among 213 analyzed patients, 27% were men and age at repair was 47 ± 17 years. Thirty patients (14%) had residual shunt at 1 year. Residual shunt was more common with Helex (22%) and CardioSEAL/STARFlex (40%) occluder devices than Amplatzer devices (9%; P = .005). Residual shunts were more common in whites (79% vs 46%, P = .004). At 7.3 ± 3.3 years of follow-up, 13 (6%) of patients had died, including 8 (5%) with Amplatzer, 5 (25%) with CardioSEAL/STARFlex, and 0 with Helex devices. Patients with residual shunting had a higher hazard of death (20% vs 4%, P = .001; hazard ratio 4.95 [1.59-14.90]). In an exploratory multivariable analysis, residual shunting, age, hypertension, coronary artery disease, and diastolic dysfunction were associated with death. CONCLUSIONS Residual shunt after atrial septal defect device closure is common and adversely impacts long-term survival.
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Affiliation(s)
- Michael J Zdradzinski
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH
| | - Rachel L Elkin
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH
| | - Joanne M Lee
- Cardiovascular Medicine, Cleveland Clinic's Heart and Vascular Institute, Cleveland, OH
| | - Athar M Qureshi
- Pediatric Cardiology, Texas Children's Hospital/Baylor College of Medicine, Houston, TX
| | - Wael El-Mallah
- Cardiovascular Medicine, Texas Tech University Health Sciences Center, Lubbock, TX
| | - Richard A Krasuski
- Cardiology Division, Duke University Health System/Duke University School of Medicine, Durham, NC.
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Pickett CA, Villines TC, Ferguson MA, Hulten EA. Percutaneous closure versus medical therapy alone for cryptogenic stroke patients with a patent foramen ovale: meta-analysis of randomized controlled trials. Tex Heart Inst J 2014; 41:357-67. [PMID: 25120387 DOI: 10.14503/thij-13-3879] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Of cryptogenic stroke patients younger than 55 years of age, up to 61% have had a patent foramen ovale (PFO). Observational studies have revealed reductions in recurrent neurologic events through PFO closure versus medical therapy, and randomized controlled trials have shown nonsignificant trends toward benefit. We systematically searched for randomized controlled trials of percutaneous PFO closure with medical therapy versus medical therapy alone in patients with cryptogenic stroke and performed a meta-analysis of treatment outcomes. The primary endpoint was combined death, stroke, and transient ischemic attack. We included 3 trials. Of 2,303 total patients, 1,150 underwent PFO closure and 1,153 received medical therapy (median follow-up period, 2.6 yr). The pooled incidence of the primary endpoint was 1.2 events per 100 patient-years in the closure group (95% confidence interval [CI], 0.2-2.3) and 1.8 in the therapy group (95% CI, 0.7-2.9) (P=0.32); the number needed to treat was 167 (range, 100-500). The corresponding pooled hazard ratio was 0.67 (95% CI, 0.44-1.01; P=0.054) in favor of closure. Closure was associated with an increased risk of atrial fibrillation: relative risk=3.51 (95% CI, 1.44-8.55; P=0.006). When stratified by device, use of the Amplatzer™ PFO Occluder resulted in significant stroke-prevention benefit over medical therapy alone: hazard ratio=0.44 (95% CI, 0.21-0.95; P=0.037). When compared with medical therapy alone, PFO closure with medical therapy showed a trend toward a decreased hazard of combined events, although the absolute event reduction was small and the number needed to treat was high.
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Affiliation(s)
- Christopher A Pickett
- Cardiology Service (Drs. Ferguson, Pickett, and Villines) and Interventional Cardiology (Dr. Ferguson), Walter Reed National Military Medical Center, Bethesda, Maryland 20889; and Cardiovascular Division, Department of Medicine (Dr. Hulten), Brigham and Women's Hospital, Boston, Massachusetts 02115
| | - Todd C Villines
- Cardiology Service (Drs. Ferguson, Pickett, and Villines) and Interventional Cardiology (Dr. Ferguson), Walter Reed National Military Medical Center, Bethesda, Maryland 20889; and Cardiovascular Division, Department of Medicine (Dr. Hulten), Brigham and Women's Hospital, Boston, Massachusetts 02115
| | - Michael A Ferguson
- Cardiology Service (Drs. Ferguson, Pickett, and Villines) and Interventional Cardiology (Dr. Ferguson), Walter Reed National Military Medical Center, Bethesda, Maryland 20889; and Cardiovascular Division, Department of Medicine (Dr. Hulten), Brigham and Women's Hospital, Boston, Massachusetts 02115
| | - Edward A Hulten
- Cardiology Service (Drs. Ferguson, Pickett, and Villines) and Interventional Cardiology (Dr. Ferguson), Walter Reed National Military Medical Center, Bethesda, Maryland 20889; and Cardiovascular Division, Department of Medicine (Dr. Hulten), Brigham and Women's Hospital, Boston, Massachusetts 02115
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Riaz IB, Dhoble A, Mizyed A, Hsu CH, Husnain M, Lee JZ, Lotun K, Lee KS. Transcatheter patent foramen ovale closure versus medical therapy for cryptogenic stroke: a meta-analysis of randomized clinical trials. BMC Cardiovasc Disord 2013; 13:116. [PMID: 24330204 PMCID: PMC3890573 DOI: 10.1186/1471-2261-13-116] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Accepted: 12/06/2013] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND There is an association between cryptogenic stroke and patent foramen ovale (PFO). The optimal treatment strategy for secondary prevention remains unclear. The purpose of this study was to analyze aggregate data examining the safety and efficacy of transcatheter device closure versus standard medical therapy in patients with PFO and cryptogenic stroke. METHODS A search of published data identified 3 randomized clinical trials for inclusion. The primary outcome was a composite end-point of death, stroke and transient-ischemic attack (TIA). Pre-defined subgroup analysis was performed with respect to baseline characteristics including age, sex, atrial septal aneurysm and shunt size. Data was synthesized using a random effects model and results presented as hazard ratios (HRs) with 95% confidence intervals (CIs). RESULTS A cohort of 2,303 patients with a history of cryptogenic stroke and PFO were randomized to device closure (n = 1150) and medical therapy (n = 1153). Mean follow-up was 2.5 years. Transcatheter closure was not superior to medical therapy in the secondary prevention of stroke or TIA in intention-to-treat analysis (HR: 0.66, 95% CI: 0.43 to 1.01; p = 0.056). However, the results were statistically significant using per-protocol analysis (HR: 0.64, 95% CI: 0.41 to 0.98; p = 0.043). Males had significant benefit with device closure (HR: 0.48, 95% CI: 0.24 to 0.96; p = 0.038). CONCLUSIONS In this meta-analysis, using intention-to-treat analysis, transcatheter device closure of PFO was not superior to standard medical therapy in the secondary prevention of cryptogenic stroke. Transcatheter closure was superior using per-protocol analysis.
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Affiliation(s)
- Irbaz Bin Riaz
- Department of Internal Medicine, University of Arizona, Tucson, AZ 85714, USA
| | - Abhijeet Dhoble
- Department of Cardiovascular Diseases, University of Arizona, 3950 S Country Club Road, Suite 200, Tucson, AZ 85714, USA
| | - Ahmad Mizyed
- Department of Cardiovascular Diseases, University of Arizona, 3950 S Country Club Road, Suite 200, Tucson, AZ 85714, USA
| | - Chiu-Hsieh Hsu
- Department of Biostatistics, University of Arizona, Tucson, AZ 85714, USA
| | - Muhammad Husnain
- Department of Cardiovascular Diseases, University of Arizona, 3950 S Country Club Road, Suite 200, Tucson, AZ 85714, USA
| | - Justin Z Lee
- Department of Internal Medicine, University of Arizona, Tucson, AZ 85714, USA
| | - Kapildeo Lotun
- Department of Cardiovascular Diseases, University of Arizona, 3950 S Country Club Road, Suite 200, Tucson, AZ 85714, USA
| | - Kwan S Lee
- Department of Cardiovascular Diseases, University of Arizona, 3950 S Country Club Road, Suite 200, Tucson, AZ 85714, USA
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Hakeem A, Marmagkiolis K, Hacioglu Y, Uretsky BF, Gundogdu B, Leesar M, Bailey SR, Cilingiroglu M. Safety and efficacy of device closure for patent foramen ovale for secondary prevention of neurological events: Comprehensive systematic review and meta-analysis of randomized controlled trials. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2013; 14:349-55. [PMID: 24080379 DOI: 10.1016/j.carrev.2013.08.010] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Revised: 08/13/2013] [Accepted: 08/19/2013] [Indexed: 11/17/2022]
Abstract
BACKGROUND Controversy persists regarding the management of patients with cryptogenic stroke and patent foramen ovale (PFO). We performed a meta-analysis of randomized controlled trials comparing PFO closure with medical therapy. METHODS AND RESULTS A prospective protocol was developed and registered using the following data sources: PubMed, Cochrane Register of Controlled Trials, conference proceedings, and Internet-based resources of clinical trials. Primary analyses were performed using the intention-to-treat method. Three randomized trials comparing percutaneous PFO closure vs. medical therapy for secondary prevention of embolic neurological events formed the data set. Baseline characteristics were similar. During long-term follow-up, the pooled incidence of the primary endpoint (composite of stroke, death, or fatal stroke) was 3.4% in the PFO closure arm and 4.8% in the medical therapy group [risk-reduction (RR) 0.7 (0.48-1.06); p=0.09]. The incidence of recurrent neurological events (secondary endpoint) was 1.7% for PFO closure and 2.7% for medical therapy [RR 0.66 (0.35-1.24), p=0.19]. There was no difference in terms of death or adverse events between the two groups. CONCLUSIONS While this meta-analysis of randomized clinical trials demonstrated no statistical significance in comparison to medical therapy, there was a trend towards overall improvement in outcomes in the PFO closure group.
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Affiliation(s)
- Abdul Hakeem
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
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Rengifo-Moreno P, Palacios IF, Junpaparp P, Witzke CF, Morris DL, Romero-Corral A. Patent foramen ovale transcatheter closure vs. medical therapy on recurrent vascular events: a systematic review and meta-analysis of randomized controlled trials. Eur Heart J 2013; 34:3342-52. [PMID: 23847132 DOI: 10.1093/eurheartj/eht285] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND In patients with cryptogenic stroke, transcatheter (TC) closure of a patent foramen ovale (PFO) has not been shown to better prevent recurrent vascular events than medical therapy. However, randomized controlled trials (RCT) to date have included few vascular events, and lack of power has been raised as an important concern. OBJECTIVE To conduct a systematic review and meta-analysis of existing RCT published studies assessing the recurrence of vascular events after TC PFO closure when compared to medical therapy. METHODS Using the search terms "patent foramen ovale", "PFO", "stroke", "percutaneous closure" and "transcatheter closure", Medline, Pubmed, Embase, and Cochrane databases were reviewed from inception through April 2013, with no language restrictions. Only studies in adult humans were considered. Additional references were obtained from the bibliographies of studies reviewed. The following criteria were used for study selection: 1) randomized controlled trial, 2) subjects were adult patients with cryptogenic stroke who were randomized to TC PFO closure or medical treatment (antiplatelet therapy and/or anticoagulation), and 3) reported outcomes included cardiac death, all death, stroke, transient ischemic attack, and peripheral embolism. Methodological and descriptive data, adverse events (including raw data and risk estimates), as well as procedural success and complications were abstracted in duplicate from each study independently, and agreement was tested. We followed rigorously the recommended guidelines for reporting and conducting and assessing quality of meta-analysis of RCT. The primary endpoints pre-specified in advance were recurrent vascular events, and composite endpoint of death, and recurrent vascular events. RESULTS Three studies were identified as meeting selection criteria. These included a total of 2,303 patients, with 1,150 patients randomized to TC PFO closure and 1,153 patients randomized to medical therapy. Mean follow-up was 3.5 years. Baseline characteristics (age, sex, and cardiovascular risk factors) were similar across studies. Intention-to-treat analyses showed a statistically significant risk reduction in stroke and/or transient ischemic attack in the TC PFO closure group when compared to medical treatment, pooled HR = 0.59, 95%CI (0.36-0.97), P = 0.04. The combined outcome of death, and vascular events, showed a borderline statistically significant benefit for TC PFO closure when compared to medical treatment, pooled HR = 0.67, 95%CI (0.44-1.00), P = 0.05 Subjects with a substantial PFO shunt seem to benefit the most with TC PFO closure, pooled HR = 0.35, 95%CI (0.12-1.03), P = 0.06, however, it did not reach statistical significance. CONCLUSION These results suggest that in patients with cryptogenic stroke, TC PFO closure may be beneficial in reducing the risk of recurrent vascular events when compared to medical treatment. The benefit of TC PFO closure may be greater in patients with a substantial shunt.
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Affiliation(s)
- Pablo Rengifo-Moreno
- The Institute for Heart and Vascular Health and Cardiovascular Diseases, Einstein Medical Center, Philadelphia, PA, USA
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