Atrial Fibrillation After Patent Foramen Ovale Closure: Incidence, Pathophysiology, and Management

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.

New-onset atrial fibrillation after percutaneous patent foramen ovale closure: a meta-analysis

BACKGROUND

The exact incidence and predictors of new-onset atrial fibrillation (AF) after percutaneous closure of patent foramen ovale (PFO) are unknown.

OBJECTIVE

We sought to find post-procedural AF incidence rates and differences due to different screening strategies and devices.

METHODS

A systematic search was conducted in Cochrane, MEDLINE and EMBASE. Controlled trials fulfilling the inclusion criteria were included into this meta-analysis. The incidence of new-onset AF was the primary outcome. Further parameters were surveillance strategy, device type, AF treatment and neurological events. New AF was determined as early onset within one month after implantation and late thereafter.

RESULTS

8 controlled trials and 16 cohort studies were eligible for quantitative analysis. 7643 patients received percutaneous PFO closure after cryptogenic stroke or transient ischaemic attack, 117 with other indications, whereas 1792 patients formed the control group. Meta-analysis of controlled trials showed an AF incidence of 5.1% in the interventional and 1.6% in the conservative arm, respectively (OR 3.17, 95% CI 1.46-6.86, P = 0.03, I2 = 55%). 4.7% received high-quality surveillance strategy with Holter-ECG or Loop recorder whereby AF incidence was overall higher compared to the low-quality group with 12-lead ECG only (3.3-15% vs. 0.2-4.3%). Heterogeneous results on time of AF onset were found, limited by different follow-up strategies. CardioSEAL and Starflex seemed to have higher AF incidences in early and late onset with 4.5% and 4.2%, respectively.

CONCLUSION

Percutaneous PFO closure led to higher AF post-procedural incidence compared to the conservative strategy. Heterogeneity in surveillance and follow-up strategy limited the generalizability.

TRIAL REGISTRATION

Registered on PROSPERO (CRD42022359945).

Patent Foramen Ovale and Cryptogenic Stroke: Integrated Management

Patent foramen ovale (PFO) is a common cardiac abnormality with a prevalence of 25% in the general population. PFO has been associated with the paradoxical embolism causing cryptogenic stroke and systemic embolization. Results from clinical trials, meta-analyses, and position papers support percutaneous PFO device closure (PPFOC), especially if interatrial septal aneurysms coexist and in the presence of large shunts in young patients. Remarkably, accurately evaluating patients to refer to the closure strategy is extremely important. However, the selection of patients for PFO closure is still not so clear. The aim of this review is to update and clarify which patients should be considered for closure treatment.

Atrial Fibrillation Following Patent Foramen Ovale Closure: Systematic Review and Meta-Analysis of Observational Studies and Clinical Trials

[Figure: see text].

Current Dataset for Patent Foramen Ovale Closure in Cryptogenic Stroke: Randomized Clinical Trials and Observational Studies

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.

PFO "angioplasty": The preparation of a very stiff and long tunnel for device closure

INTRODUCTION

Patent foramen ovale (PFO) closure is a widely performed procedure. Understanding the anatomy is mandatory in order to perform the procedure successfully. The degree of overlap between the septum primum and secundum is called the tunnel. In particular, long and stiff tunnels may prevent the correct positioning of devices that have a fixed distance between the right and left atrial discs.

PATIENTS AND METHODS

We evaluated retrospectively 361 patients with PFO closure between January 2012 and June 2014 in our institution and were treated due to previous history of ischemic stroke. By TEE, the overlap between septum primum and secundum is usually better seen on the bicaval view that is obtained at 75-90° midesophageal views. Tunnel length and PFO opening were measured. Twelve subjects (median age 35 years; range 30-58 years; three females) showed a long (median 22 mm; range 15-32 mm) and rigid tunnel (median opening 2 mm; range 1-4 mm).

RESULTS

Angioplasty of the tunnel was performed by using peripheral angioplasty balloons with a length ranging from 4 to 8 cm and a diameter between 8 and 12 mm. After angioplasty, the tunnel appeared shorter (12 mm; range 8-16 mm) and less rigid (median opening 8 mm; range 7-12 mm). The following devices were implanted: 25 mm Amplatzer PFO occluder in three patients; 25 mm Gore septal occluder in nine subjects. Median fluoroscopy time was 8 min (range 6-10 min). No complications occurred. At a median follow-up of 12 months (range 2-18 months), no problems occurred and all subjects but one (trivial residual shunting) showed a complete closure.

CONCLUSIONS

Angioplasty of a PFO rigid and stiff tunnel is a feasible and safe option. © 2016 Wiley Periodicals, Inc.

Multidisciplinary Assessment in Optimising Results of Percutaneous Patent Foramen Ovale Closure

BACKGROUND

Percutaneous patent foramen ovale (PFO) closure is a therapeutic option to prevent recurrent cerebral ischaemia in patients with cryptogenic stroke and transient cerebral ischaemia (TIA). The apparent lack of benefit seen in previous randomised trials has, in part, reflected inclusion of patients with alternate mechanisms of stroke. The role of formal neurology involvement in accurately delineating the likely aetiology of stroke or TIA is crucial in appropriate identification of patients for device closure. Furthermore, as the benefits of device closure may accrue over time, long-term follow-up is essential to define the role of device closure in management of presumed cryptogenic stroke.

METHODS

We retrospectively reviewed our experience with percutaneous PFO device closure since 2005. All subjects who underwent PFO closure at John Hunter and Lake Macquarie Private Hospitals were included in the study. All patients referred for device closure following cryptogenic stroke or TIA had first undergone formal neurology review with appropriate imaging and exclusion of paroxysmal atrial arrhythmia. Patients with a history of transient ischaemic attack (TIA) are frequently referred to a specialised clinic, aimed to identify patients with conditions not referable to cerebral ischaemia, with investigations initiated by the specialist clinic to elucidate an underlying aetiology. Outcome data was derived from the Hunter New England Area Local Health District Cardiac and Stroke Outcomes Unit, in addition to review of the medical record. The Cardiac and Stroke Outcomes Unit prospectively identified all patients presenting with stroke, TIA and atrial fibrillation.

RESULTS

One hundred and twelve consecutive patients undergoing percutaneous patent foramen ovale closure between 2005 and 2015 were identified. The average age was 42.7 years and 57 (50.9%) patients were male. Cryptogenic stroke (68.8%) and transient cerebral ischaemia (23.2%) were the most common indications for PFO closure, with the Amplatzer device used in 83 cases (74.1%). Early residual shunting was visible in seven patients (6.3%), however on follow-up agitated saline study only two patients had residual shunt (1.8%). The annual risk of recurrent stroke or TIA was 0.21%.

CONCLUSIONS

Percutaneous patent foramen ovale closure can be performed safely and effectively in patients with paradoxical embolism. In selected patients, following appropriate multidisciplinary specialist pre-procedural assessment, excellent long-term results with low incidence of recurrent events may be achieved.

Transcatheter patent foramen ovale closure versus medical therapy for cryptogenic stroke: a meta-analysis of randomized clinical trials

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.

A novel technique to remove a right atrial thrombotic mass attached to a patent foramen ovale (PFO) closure device

Any percutaneously implanted foreign device carries the potential risk of thrombus formation. If a thrombus is detected after device implantation during follow-up, in most cases anticoagulation therapy is sufficient to resolve the thrombus. If the anticoagulation concept fails, surgery has been the only alternative option to remove thrombotic masses. This case of a patient with a large thrombus formation attached to a PFO closure device who denied surgery demonstrates that mechanical percutaneous clot retrieval is feasible with the AngioVac aspiration system (Vortex Medical, Inc., Norwell, MA). © 2013 Wiley Periodicals, Inc.