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Goldsweig AM, Batlivala SP, Al-Azizi K, Aggarwal V, Babatunde I, Falck-Ytter Y, Morgan RL. SCAI Technical Review on Management of Patent Foramen Ovale. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2022; 1:100040. [PMID: 39131927 PMCID: PMC11307539 DOI: 10.1016/j.jscai.2022.100040] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 08/13/2024]
Abstract
Background Patent foramen ovale (PFO) is a common anatomic variant associated with intermittent right-to-left shunting. Transcatheter PFO closure has been proposed to address multiple clinical conditions including stroke, transient ischemic attack, migraine, and decompression illness. Methods A systematic review was conducted using the GRADE approach to address 5 questions formulated by the Society for Cardiovascular Angiography and Interventions (SCAI) Guideline Panel in patient, intervention, comparator, outcome (PICO) format. Medical literature from January 2015 through May 2021 was searched. Extracted data underwent review and risk-of-bias assessment by 2 independent researchers. Pooled effect estimates were calculated. Certainty of evidence was determined for each query. Results Our search identified 2701 titles and abstracts, of which 30 met eligibility criteria and informed the technical review. Data were abstracted to address outcomes of PFO closure for patients with and without prior stroke, in comparison to antiplatelet therapy, in comparison to anticoagulation, and with various post-procedure antithrombotic regimens. Conclusion In appropriately selected patients with prior stroke, transcatheter PFO closure reduces the risk of recurrent stroke more than antiplatelet therapy alone. Evidence to support PFO closure is weaker regarding older patients, anticoagulation, thrombophilia, transient ischemic attack, migraine, and decompression illness. Data from this technical review will inform the SCAI Guideline for Transcatheter Patent Foramen Ovale Closure.
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Affiliation(s)
- Andrew M. Goldsweig
- Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Sarosh P. Batlivala
- Heart Institute, Cincinnati Children's Hospital Medical Center & Division of Pediatric Cardiology, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Karim Al-Azizi
- Baylor Scott & White Health, The Heart Hospital, Plano, Texas
| | - Vikas Aggarwal
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan (Frankel Cardiovascular Center), Ann Arbor, Michigan
- Section of Cardiology, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | | | - Yngve Falck-Ytter
- Evidence Foundation, Cleveland Heights, Ohio
- VA Northeast Ohio Healthcare System, Cleveland, Ohio
- Case Western University, Cleveland, Ohio
| | - Rebecca L. Morgan
- Evidence Foundation, Cleveland Heights, Ohio
- Case Western University, Cleveland, Ohio
- Department of Health Research Methods, McMaster University, Hamilton, Ontario, Canada
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Kavinsky CJ, Szerlip M, Goldsweig AM, Amin Z, Boudoulas KD, Carroll JD, Coylewright M, Elmariah S, MacDonald LA, Shah AP, Spies C, Tobis JM, Messé SR, Senerth E, Falck-Ytter Y, Babatunde I, Morgan RL. SCAI Guidelines for the Management of Patent Foramen Ovale. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2022; 1:100039. [PMID: 39131947 PMCID: PMC11307505 DOI: 10.1016/j.jscai.2022.100039] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 08/13/2024]
Abstract
Background Patent foramen ovale (PFO) is a vestigial congenital cardiovascular structure present in around 25% of adults. In most cases, PFO is entirely benign and requires no treatment. However, it may cause serious complications under certain circumstances. Objective These evidence-based guidelines from the Society for Cardiovascular Angiography and Interventions (SCAI) aim to support patients, clinicians, and other stakeholders in decisions about management of PFO. Methods SCAI convened a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. The Evidence Foundation, a registered 501(c)(3) nonprofit organization, provided methodological support for the guideline-development process. Following the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, the guideline panel formulated and prioritized clinical questions in population, intervention, comparison, outcome (PICO) format. A separate technical review team of clinical and methodological experts conducted systematic reviews of the evidence, synthesized data, and graded the certainty of the evidence across outcomes. The guideline panel then reconvened to formulate recommendations and supporting remarks informed by the results of the technical review and additional contextual factors described in the GRADE evidence-to-decision framework. Results The panel agreed on 13 recommendations to address variations on 5 clinical scenarios. Conclusions Key recommendations address patient selection for PFO closure in the prevention of recurrent PFO-associated stroke, including populations not commonly included in randomized studies, and scenarios where the PFO closure might serve a role in the prevention of other outcomes such as migraine headaches and decompression illness. The panel has also identified future research priorities to advance the field.
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Affiliation(s)
| | - Molly Szerlip
- Baylor Scott & White The Heart Hospital, Plano, Texas
| | | | - Zahid Amin
- AdventHealth Medical Group, Orlando, Florida
| | | | - John D. Carroll
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | | | | | | | | | - Christian Spies
- Sutter Health Palo Alto Medical Foundation, Burlingame, California
| | | | - Steven R. Messé
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Emily Senerth
- Society for Cardiovascular Angiography & Interventions, Washington, DC
| | - Yngve Falck-Ytter
- Case Western Reserve University/VA Northeast Ohio Healthcare System, Cleveland, Ohio
| | | | - Rebecca L. Morgan
- Department of Health Research Methods, McMaster University, Hamilton, Ontario, Canada
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Pan X, Xu L, Zhou C, Zhang Z, Sun H. Meta-analysis of patent foramen ovale closure versus medical therapy for prevention of recurrent ischemic neurological events: Impact of medication type. Medicine (Baltimore) 2021; 100:e26473. [PMID: 34160457 PMCID: PMC8238362 DOI: 10.1097/md.0000000000026473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 06/08/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND The optimal treatment strategy for patent foramen ovale (PFO) patients with cryptic stroke remains controversial. We performed this meta-analysis to evaluate the effect of PFO closure versus different types of medical therapy. METHODS We searched PubMed, Embase, and Cochrane databases. The primary efficacy endpoints were the composite outcome of recurrent stroke and/or transient ischemic attack (TIA). Secondary efficacy endpoints included separate stroke and TIA. Safety endpoints included new-onset atrial fibrillation (AF)/atrial flutter and bleeding. RESULTS Compared with antiplatelet therapy, PFO closure significantly reduced the risk of composite outcome (odds ratio [OR] 0.37, 95% confidence interval [CI] 0.27-0.51), stroke (OR 0.22, 95% CI 0.13-0.36], and TIA (OR 0.57, 95% CI 0.34-0.98); Compared with the mixed medical therapy group (consist of antiplatelet therapy, anticoagulant therapy, or both), PFO closure still showed some benefits, but the effect was not as significant as that of antiplatelet therapy (composite outcome: OR 0.53, 95% CI 0.41-0.69; stroke: OR 0.48, 95% CI 0.34-0.68; TIA: OR 0.69, 95% CI 0.50-0.96); Compared with anticoagulant therapy, PFO closure showed no benefit (composite outcome: OR 0.77, 95% CI 0.46-1.28; stroke: OR 0.59, 95% CI 0.28-1.25; TIA: OR 1.01, 95% CI 0.50-2.04). In terms of safe endpoints, compared with antiplatelet therapy and anticoagulant therapy, PFO closure increased the risk of AF/atrial flutter (OR 9.56, 95% CI 2.85-32.06; OR 18.96, 95% CI 1.11-323.8, respectively) and reduced the risk of bleeding (OR 0.50, 95% CI 0.24-1.05; OR 0.13, 95% CI 0.04-0.46, respectively); compared with mixed medical therapy, PFO closure increased the risk of AF/atrial flutter (OR 4.40,95% CI 2.24-8.67), but there was no difference in bleeding (OR 0.97, 95% CI 0.56-1.68). CONCLUSIONS With the addition of anticoagulants, the benefit of PFO closure decreased gradually. Patient groups that adopt individualized medical therapy strategies may benefit more.
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Affiliation(s)
- Xuemei Pan
- Department of Ultrasound, The Third People's Hospital of Yichang City
| | - Liang Xu
- Department of Ultrasound, The First College of Clinical Medical Sciences, China Three Gorges University, Yichang, Hubei Province, China
| | - Chang Zhou
- Department of Ultrasound, The First College of Clinical Medical Sciences, China Three Gorges University, Yichang, Hubei Province, China
| | - Zhi Zhang
- Department of Ultrasound, The Third People's Hospital of Yichang City
| | - Heng Sun
- Department of Ultrasound, The First College of Clinical Medical Sciences, China Three Gorges University, Yichang, Hubei Province, China
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Mazzucco S, Li L, Rothwell PM. Prognosis of Cryptogenic Stroke With Patent Foramen Ovale at Older Ages and Implications for Trials: A Population-Based Study and Systematic Review. JAMA Neurol 2021; 77:1279-1287. [PMID: 32628255 PMCID: PMC7550974 DOI: 10.1001/jamaneurol.2020.1948] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Importance Patent foramen ovale (PFO) closure may prevent recurrent stroke after cryptogenic transient ischemic attack (TIA) or stroke (TIA/stroke) in patients aged 60 years or younger. Patent foramen ovale is associated with cryptogenic stroke in the older population, but risk of recurrence is unknown. Data on prognosis of patients receiving medical treatment at older ages (≥60 years) are essential to justify trials of PFO closure. Objective To examine the age-specific risk of recurrence in patients with cryptogenic TIA/stroke with PFO. Design, Setting, and Participants A prospective study was nested in the population-based Oxford Vascular Study between September 1, 2014, and March 31, 2019, with face-to-face follow-up for 5 years. A total of 416 consecutive patients with a diagnosis of cryptogenic TIA or nondisabling stroke, screened for PFO at a rapid-access TIA/stroke clinic, were included. A systematic review and meta-analysis of cohort studies reporting on ischemic stroke recurrence after cryptogenic TIA/stroke in patients with PFO who were receiving medical therapy alone, or with PFO vs no-PFO was conducted. Sample size calculation for future trials on PFO closure was performed for patients aged 60 years or older. Exposures Patent foramen ovale and age as modifiers of risk of recurrent stroke after cryptogenic TIA/stroke in patients receiving only medical therapy. Main Outcomes and Measures Risk of ischemic stroke recurrence in patients with cryptogenic TIA/stroke and PFO receiving medical therapy only, and in patients with vs without PFO, stratified by age (<65 vs ≥65 years), as well as sample-size calculation for future trials of PFO closure in patients aged 60 years or older. Results Among the 153 Oxford Vascular Study patients with PFO (mean [SD] age, 66.7 [13.7] years; 80 [52.3%] men), recurrent ischemic stroke risk (2.05 per 100 patient-years) was similar to the pooled estimate from a systematic review of 23 other studies (9 trials and 14 observational studies) (2.00 per 100 patient-years; 95% CI, 1.55-2.58). However, there was heterogeneity between studies (P < .001 for heterogeneity), owing mainly to risk increasing with mean cohort age (meta-regression: R2 = 0.31; P = .003). In the pooled analysis of 4 studies including patients with or without PFO, increased risk of stroke recurrence with PFO was seen only at age 65 years or older (odds ratio, 2.5; 95% CI, 1.4-4.2; P = .001 for difference; P = .39 for heterogeneity). The pooled ischemic stroke risk was 3.27 per 100 patient-years (95% CI, 2.59-4.13) in 4 cohorts with mean age 60 years or older. Assuming the more conservative 2.0 per 100 patient-years ischemic stroke risk in the PFO nonclosure arms of future trials in patients aged 60 years or older, projected sample sizes were 1080 per arm for 80% power to detect a 33% relative risk reduction. Conclusions and Relevance The findings of this study suggest that age is a determinant of risk of ischemic stroke after cryptogenic TIA/stroke in patients with PFO, such that trials of PFO closure at older ages are justified; however, projected sample sizes are large.
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Affiliation(s)
- Sara Mazzucco
- Wolfson Centre for Prevention of Stroke and Dementia, University of Oxford, Oxford, United Kingdom
| | - Linxin Li
- Wolfson Centre for Prevention of Stroke and Dementia, University of Oxford, Oxford, United Kingdom
| | - Peter M Rothwell
- Wolfson Centre for Prevention of Stroke and Dementia, University of Oxford, Oxford, United Kingdom
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Xu L, Pan X, Zhou C, Li J, Wang F. Long-term efficacy after closure of patent foramen ovale for ischemic neurological events in young adults: A systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e18675. [PMID: 31914059 PMCID: PMC6959863 DOI: 10.1097/md.0000000000018675] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The efficacy of patent foramen ovale (PFO) closure remains controversial, and it is unclear which patient groups are best benefited. We performed this meta-analysis to clarify the efficacy of PFO closure of younger patients for prevention of recurrent ischemic neurological events. METHODS We systematically searched for studies of PFO closure for younger patients under the age of 55, and pooled available data on PFO closure of younger vs older patients and on PFO closure of younger patients vs medical therapy. The primary endpoints were the composite outcome of recurrent ischemic neurological events [stroke and/or transient ischemic attack (TIA)]. The secondary endpoints included recurrent stroke, TIA, atrial fibrillation (AF) and bleeding events. We calculated the odds ratios (OR) and 95% confidence interval (CI) using fixed-effect and random-effect models. RESULTS Three randomized controlled trials (RCT) and 13 observational studies were eligible. Compared with older patients undergoing PFO closure, younger patients undergoing closure had a lower risk of composite outcome (OR: 0.40, 95% CI: 0.28 to .56; P < .001) and AF (OR: 0.25, 95% CI: 0.10-0.61; P = .003). Compared with medical therapy, PFO closure of younger patients reduced the risk of composite outcome (OR: 0.50, 95% CI: 0.33-0.75; P<.001); there was no statistical difference in total complications of AF and bleeding events (OR: 2.15, 95% CI: 0.15-30.37; P = .57). Separate analysis of stroke and TIA showed that PFO closure in younger patients was more effective in preventing stroke (OR: 0.45, 95% CI: 0.28-0.72; P < .001) and TIA (OR: 0.35, 95% CI: 0.21-0.58); P < .001) compared with older patients. Compared with medical therapy, PFO closure of younger patients reduced the risk of stroke (OR: 0.26, 95% CI: 0.13-0.51; P < .001); but there was no difference in the risk of TIA (OR: 1.07, 95% CI: 0.16-7.01; P = .94). CONCLUSIONS Compared with PFO closure of older patients and medical therapy, PFO closure of younger patients can benefit more for the prevention of recurrent ischemic neurological events. Our results indicate that PFO closure is the best treatment strategy for younger patients under the age of 55.
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Affiliation(s)
- Liang Xu
- Department of Ultrasound, The First College of Clinical Medical Sciences, China Three Gorges University
| | - Xuemei Pan
- Department of Ultrasound, The Third People's Hospital of Yichang City, Yichang, Hubei Province, China
| | - Chang Zhou
- Department of Ultrasound, The First College of Clinical Medical Sciences, China Three Gorges University
| | - Jie Li
- Department of Ultrasound, The First College of Clinical Medical Sciences, China Three Gorges University
| | - Fangyuan Wang
- Department of Ultrasound, The First College of Clinical Medical Sciences, China Three Gorges University
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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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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 2018; 6:2178. [PMID: 30271571 PMCID: PMC6137413 DOI: 10.12688/f1000research.13444.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/17/2018] [Indexed: 11/20/2022] 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;
I2: 15%). It also reduced stroke (RR: 0.50, 95% CI: 0.35-0.73, P < 0.0001;
I2: 32%) despite increasing the risk of atrial fibrillation/flutter (RR: 1.90, 95% CI: 1.23-2.93, P < 0.01;
I2: 43%). However, it did not reduce transient ischemic accident events (0.75; 95% CI: 0.51-1.10, P = 0.14;
I2: 0%), all-cause bleeding (RR: 0.89; 95% CI: 0.44-1.78, P = 0.74;
I2: 51%) or gastrointestinal complications (RR: 0.92; 95% CI: 0.32-2.70, P = 0.88;
I2: 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
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Patent foramen ovale closure versus medical therapy for cryptogenic stroke: An updated meta-analysis. J Neurol Sci 2018; 390:139-149. [DOI: 10.1016/j.jns.2018.04.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 04/02/2018] [Accepted: 04/18/2018] [Indexed: 11/19/2022]
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Palaiodimos L, Kokkinidis DG, Faillace RT, Foley TR, Dangas GD, Price MJ, Mastoris I. Percutaneous closure of patent foramen ovale vs. medical treatment for patients with history of cryptogenic stroke: A systematic review and meta-analysis of randomized controlled trials. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2018; 19:852-858. [PMID: 29576519 DOI: 10.1016/j.carrev.2018.02.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 02/04/2018] [Accepted: 02/23/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Patients with history of cryptogenic stroke are more likely to have a patent foramen ovale (PFO) and should be managed with antithrombotic agents, while the alternative option is percutaneous closure of PFOs. Our aim was to perform a meta-analysis of randomized controlled trials (RCTs) comparing percutaneous closure vs. medical treatment for patients with PFO and prior cryptogenic stroke. METHODS Medline, Scopus and Cochrane databases were reviewed. A random-effect model meta-analysis was used and I-square was utilized to assess the heterogeneity. New ischemic stroke was defined as the primary endpoint. A sensitivity analysis was performed for Amplatzer device. Subgroup analyses were performed for different patient and PFO characteristics for the composite endpoints as defined by the included RCTs. RESULTS In total of 3440 patients were included in this meta-analysis. Closure devices were superior to medical therapy for prevention of recurrent ischemic strokes (HR = 0.29; CI: 0.02-0.56), but were associated with increased risk of new onset of atrial fibrillation (AF) and atrial flutter (RR = 4.67; CI: 2.22-9.81). However, in the sensitivity analysis for Amplatzer device, there was no difference between the two groups in new onset of atrial arrhythmias. Closure devices were superior across all different subgroups when compared to medical treatment with the exception of patients with a small shunt. CONCLUSION This meta-analysis shows that closure devices for patients with PFO and history of cryptogenic stroke can significantly decrease the risk of a new ischemic stroke. The use of Amplatzer device was not associated with increased risk of newly diagnosed atrial arrhythmias.
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Affiliation(s)
- Leonidas Palaiodimos
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States.
| | - Damianos G Kokkinidis
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Robert T Faillace
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States
| | - T Raymond Foley
- Cardiac Catheterization Laboratory, Division of Cardiovascular Diseases, Scripps Clinic, La Jolla, CA, United States
| | - George D Dangas
- The Zena and Michael A. Wiener Cardiovascular Institute, The Icahn School of Medicine at Mount Sinai, NY, New York, United States
| | - Matthew J Price
- Cardiac Catheterization Laboratory, Division of Cardiovascular Diseases, Scripps Clinic, La Jolla, CA, United States
| | - Ioannis Mastoris
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States
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Zhang XL, Kang LN, Wang L, Xu B. Percutaneous closure versus medical therapy for stroke with patent foramen Ovale: a systematic review and meta-analysis. BMC Cardiovasc Disord 2018; 18:45. [PMID: 29499641 PMCID: PMC5834900 DOI: 10.1186/s12872-018-0780-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 02/22/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Patent foramen ovale (PFO) closure has emerged as a secondary prevention option in patients with PFO and cryptogenic stroke. However, the comparative efficacy and safety of percutaneous closure and medical therapy in patients with cryptogenic stroke and PFO remain unclear. METHODS Randomized controlled trials (RCTs) and comparative observational studies that compared PFO closure against medical therapy, each with a minimal of 20 patients in the closure arm and 1-year follow-up were included. RESULTS We analyzed 6961 patients from 20 studies (5 RCTs and 15 observational studies) with a median follow-up of 3.1 years. Moderate-quality evidence showed that PFO closure was associated with a significantly lower incidence of the composite outcome of ischemic stroke, transient ischemic attack (TIA), or all-cause death (odds ratio [OR]: 0.57; 95% confidence interval [CI]: 0.38 to 0.85; P = 0.006), mainly driven by lower incidence of stroke (OR: 0.39; 95% CI: 0.24 to 0.63; P < 0.001). The numbers needed to treat were 43 and 39 for the composite outcome and recurrent ischemic stroke respectively. PFO closure increased the risks for atrial fibrillation or atrial flutter (OR: 5.74; 95% CI: 3.08 to 10.70; P < 0.001; high-quality evidence) and pulmonary embolism (OR: 3.03; 95% CI: 1.06 to 8.63; P = 0.038; moderate-quality evidence), with the numbers needed to harm being 30 and 143 respectively. The risks for TIA, all-cause death, and major bleeding were not statistically different. Analyses limited to RCTs showed similar findings, as did a series of other subgroup analyses. CONCLUSION In conclusion, PFO closure reduced the incidences of stroke and the composite outcome of ischemic stroke, TIA, or all-cause death, but increased risks for atrial fibrillation or atrial flutter and pulmonary embolism compared with medical therapy.
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Affiliation(s)
- Xin-Lin Zhang
- Department of Cardiology, Affiliated Drum Tower Hospital, Nanjing University School of Medicine, 321 Zhongshan Road, Nanjing, 210008, China
| | - Li-Na Kang
- Department of Cardiology, Affiliated Drum Tower Hospital, Nanjing University School of Medicine, 321 Zhongshan Road, Nanjing, 210008, China
| | - Lian Wang
- Department of Cardiology, Affiliated Drum Tower Hospital, Nanjing University School of Medicine, 321 Zhongshan Road, Nanjing, 210008, China
| | - Biao Xu
- Department of Cardiology, Affiliated Drum Tower Hospital, Nanjing University School of Medicine, 321 Zhongshan Road, Nanjing, 210008, China.
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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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Odunukan OW, Price MJ. Current Dataset for Patent Foramen Ovale Closure in Cryptogenic Stroke: Randomized Clinical Trials and Observational Studies. Interv Cardiol Clin 2017; 6:525-538. [PMID: 28886843 DOI: 10.1016/j.iccl.2017.05.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Approximately one-third of all strokes have no apparent cause. A patent foramen ovale (PFO) is present in as many as 60% of these patients with cryptogenic strokes, which is significantly more frequent than that of the general population. The presumed biologic mechanisms of ischemic stroke in the setting of a PFO are paradoxic embolism from the peripheral venous system through this interatrial shunt or embolism from in situ thrombosis. In this review, the authors summarize and critically assess the contemporary studies evaluating the efficacy and safety of PFO closure for prevention of recurrent cryptogenic strokes.
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Affiliation(s)
- Olufunso W Odunukan
- Division of Cardiovascular Diseases, Scripps Clinic, 9898 Genesee Avenue, La Jolla, CA 92037, USA.
| | - Matthew J Price
- Division of Cardiovascular Diseases, Scripps Clinic, 9898 Genesee Avenue, La Jolla, CA 92037, USA
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