Closure of Patent Foramen Ovale and Cryptogenic Stroke: Unresolved Issues

Risk of Ischemic Stroke After Patent Foramen Ovale Closure

BACKGROUND

Transcatheter patent foramen ovale (PFO) closure is the recommended treatment for patients age 18 to 60 years with cryptogenic stroke having a high probability of being PFO-related. Limited data exist on stroke recurrence after PFO closure outside clinical trials.

OBJECTIVES

The purpose of this study was to examine stroke recurrence after PFO closure in routine clinical practice.

METHODS

We used nationwide population-based Danish registries to conduct a cohort study of all patients with PFO closure during 2008 to 2021 (n = 1,162) and a birth year and sex-matched comparison cohort from the general population (n = 11,620). We calculated absolute and relative risks of ischemic stroke within 4 years after PFO closure. We used weighted Cox regression to estimate adjusted HRs of the association between PFO closure vs the general population and ischemic stroke.

RESULTS

The absolute risks of ischemic stroke in patients with PFO closure and in the general population, respectively, were 1.4% (95% CI: 0.8%-2.3%) and 0.1% (95% CI: 0.0%-0.1%) at 1 year, 1.4% (95% CI: 0.8%-2.3%) and 0.2% (95% CI: 0.2%-0.4%) at 2 years, 2.2% (95% CI: 1.3%-3.5%) and 0.4% (95% CI: 0.2%-0.5%) at 3 years, and 2.5% (95% CI: 1.5%-4.0%) and 0.4% (95% CI: 0.3%-0.6%) at 4 years. Thus, the absolute 4-year risk of ischemic stroke was 2.1% (95% CI: 0.9%-3.3%) higher in patients with PFO closure than in the general population, corresponding to an adjusted HR of 6.3 (95% CI: 3.1-12.6).

CONCLUSIONS

The 4-year risk of ischemic stroke after routine PFO closure for cryptogenic stroke was comparable to that observed in clinical trials, but remained higher than in the general population.

Long-term risk of atrial fibrillation or flutter after transcatheter patent foramen ovale closure: a nationwide Danish study

AIMS

Transcatheter closure of patent foramen ovale (PFO) is the recommended stroke prevention treatment in patients ≤60 years with cryptogenic ischemic stroke and PFO. Atrial fibrillation or flutter (AF) is a known potential procedure-related complication, but long-term risk of developing AF remains unknown. This paper studied the long-term risk of developing AF following PFO closure.

METHODS AND RESULTS

A Danish nationwide cohort study was conducted. During 2008-2020, this study identified a PFO closure cohort, a PFO diagnosis cohort without PFO closure, and a general population comparison cohort matched 10:1 to the PFO closure cohort on age and sex. The outcome was first-time AF diagnosis. Risk of AF and multivariable-adjusted hazard ratio (HR) of the association between PFO closure or PFO diagnosis and AF were calculated. A total of 817 patients with PFO closure, 1224 with PFO diagnosis, and 8170 matched individuals were identified. The 5 year risk of AF was 7.8% [95% confidence interval (CI): 5.5-10] in the PFO closure cohort, 3.1% (95% CI: 2.0-4.2) in the PFO diagnosis cohort, and 1.2% (95% CI: 0.8-1.6) in the matched cohort. The HR of AF comparing PFO closure with PFO diagnosis was 2.3 (95% CI: 1.3-4.0) within the first 3 months and 0.7 (95% CI: 0.3-1.7) thereafter. The HR of AF comparing PFO closure with the matched cohort was 51 (95% CI: 21-125) within the first 3 months and 2.5 (95% CI: 1.2-5.0) thereafter.

CONCLUSION

Patent foramen ovale closure was not associated with any substantial increased long-term risk of developing AF beyond the well-known procedure-related short-term risk.

Long-term outcome after closure of an atrial shunt in patients aged 60 years or older with ischemic stroke: A nationwide, registry-based, case-control study

Background

According to the current guidelines, evidence of the effects of transcatheter closure in patients aged ≥60 years with an atrial shunt and cryptogenic stroke is still limited.

Methods

Using Swedish health registries, patients aged ≥60 years who had previously developed a cryptogenic cerebrovascular event and undergone transcatheter closure were identified. Patients with atrial fibrillation were excluded, and the remaining patients were propensity score-matched with patients of the same age and risk profile who had only undergone medical treatment and with controls from the general population. They were then followed up until 2017 (mean period of 7.1 ± 3.9 years).

Results

In total, 100 patients of the intervention group were matched with 100 patients of the medical treatment group and with 100 controls and followed up. The hazard ratio for a recurrent ischemic stroke in the intervention group compared with the medical treatment group was 0.8 (95% confidence interval, 0.3-2.1), and that compared with the controls was 2.3 (95% confidence interval, 0.6-8.9). Atrial fibrillation occurred at the same rate in the two treatment groups (odds ratio, 0.8; 95% confidence interval, 0.4-1.7). However, patients in the intervention group developed vascular disease at a lower rate (odds ratio, 0.5; 95% confidence interval, 0.25-0.85).

Conclusions

Patients aged ≥60 years with cryptogenic stroke may undergo transcatheter closure of an atrial shunt after thorough screening for other potential causes of stroke. The incidence of vascular disease seems to be mitigated in these patients relative to medically treated patients.

Recurrent Stroke in a Young Patient with Embolic Stroke of Undetermined Source and Patent Foramen Ovale: Quo Vadis?

So far, there has been no generally accepted diagnostic and therapeutic algorithm for patients with embolic stroke of undetermined source (ESUS). As recent clinical trials on secondary stroke prevention in ESUS did not support the use of oral anticoagulation and the concept of ESUS comprises heterogeneous subgroups of patients, including a wide age range, concomitant patent foramen ovale (PFO), variable cardiovascular risk factors as well as a variable probability for atrial fibrillation (AF), an individualized clinical approach is needed. In this context, we here present a case of recurrent stroke in a young patient with ESUS and PFO. During treatment according to our Catch-up-ESUS registry study, prolonged cardiac monitoring diagnosed AF, and PFO closure was omitted.

Patent foramen ovale closure by using transesophageal echocardiography for cryptogenic stroke: single center experience in 132 consecutive patients

Background

Percutaneous closure of patent foramen ovale (PFO) is routinely performed using plain fluoroscopy in the catheter room. This method results in inevitable radiation damage, adverse effects of contrast agents on kidneys, and high cost. We performed PFO closure with a simplified and economical transesophageal echocardiography (TEE)-only guided approach in the operating room. This study aimed to investigate the feasibility, safety, and effectiveness of the percutaneous closure of PFO by only using TEE.

Methods

We reviewed the medical records of patients who underwent percutaneous PFO closure at our center from December 2013 to December 2017. A total of 132 patients with PFO and cryptogenic strokes underwent PFO closure by using cardi-O-fix PFO device under TEE guidance. The participants comprised 64 and 68 male and female patients, respectively. The mean age and body weight of the patients were 39.40 ± 13.22 years old (12–68 years old) and 65.42 ± 9.70 kg (40–95 kg), respectively. All patients only received aspirin (3–5 mg/kg body weight, oral administration) for 6 months. Contrast-enhanced transthoracic echocardiography (c-TTE) with Valsalva maneuver was performed during follow-up, and questionnaire surveys were obtained at 3, 6, and 12 months after the procedure.

Results

All (100%) patients were successfully closed. Follow-ups were conducted for 13 months to 48 months, with an average of 27 months. No severe complications were found during the follow-up period. Paroxysmal atrial fibrillation occurred in 4 patients within 3 months after the procedure. No recurrent stroke or death occurred in all patients during the follow-up period. Transient ischemic attack occurred in one patient 6 months after the procedure. Ten (7.6%) patients had a right-to-left shunt, as demonstrated by c-TTE at 12 months of follow-up. Among the 57 patients suffering from migraine, significant relief or resolution was reported by 42 (73.7%) patients.

Conclusion

TEE-only guided PFO closure was a safe, feasible, and effective method that did not require the use of X-rays and contrast agents.

[Closure of the patent foramen ovale (PFO) in cryptogenic stroke]

Autopsy studies and echocardiographic investigations have shown that around 20-25% of the healthy population have a patent foramen ovale (PFO). In patients younger than 55 years the risk of a cryptogenic stroke is increased in the presence of a PFO. The first three randomized studies could not demonstrate superiority of an interventional closure of a PFO compared to antithrombotic treatment in patients with cryptogenic stroke. The results of three recently published studies and the extension of an earlier study showed a superiority of an interventional closure of a PFO compared to stroke prevention with antiplatelet therapy in patients aged 18-60 years after a cryptogenic stroke; however, PFO closure was not superior to oral anticoagulation but anticoagulation is associated with an increased risk of bleeding. The implantation of a PFO occluder can be associated with transient atrial fibrillation in some patients. The collaboration of neurologists and cardiologists is essential in order to select patients who are most likely to benefit from a PFO closure.

Patent Foramen Ovale: Story Closed?

The optimal treatment strategy for secondary prevention in patients with cryptogenic stroke and patent foramen ovale (PFO) has been a matter of controversy for decades. After three randomized trials failed to show a benefit of closure with an excess of complications in the interventional arm, two large recent trials suggest a benefit with regard of preventing further ischemic strokes. With this discrepancy in results it is important to discuss recent trials in detail and evolve an informed clinical approach for daily practice.