Net clinical benefit of PFO closure versus medical treatment in patients with cryptogenic stroke: A systematic review and meta-analysis

Risk of ischemic stroke in patients with pulmonary embolism and patent foramen ovale: A systematic review and meta-analysis

OBJECTIVE

Patients with acute pulmonary hypertension during an acute pulmonary embolism (PE) can develop stroke due to paradoxical embolism in the presence of a patent foramen ovale (PFO). We evaluated the current evidence regarding the risk of ischemic stroke and mortality in patients with PE and a PFO.

METHODS

We performed a systematic review and meta-analysis of studies found on PubMed, the Cochrane Library, Embase, SCOPUS, and the BVS portal. We included full-length reports, prospective observational cohorts, and clinical trials of adult patients (aged ≥18 years) diagnosed with PE and investigating the presence of PFO and new ischemic brain injuries. This study is registered with PROSPERO (CRD42023467133).

RESULTS

The initial search identified 1398 articles. After applying exclusion criteria, only 8 articles remained, including a total of 1197 individuals with PE, among whom PFO was identified in 318 patients. Ischemic stroke occurred in 62/318 (19.5 %) individuals in the PFO group and in 40/879 (4.5 %) individuals in the non-PFO group. The prevalence of ischemic stroke in the PFO group was higher than in the non-PFO group in all eight studies. The meta-analysis showed that PFO was significantly associated with ischemic stroke in patients with PE compared to those without PFO (odds ratio 5.36, 95 % CI 3.20-8.99, p < 0.00001; I² = 0 %). Three studies also reported higher mortality in the PFO group.

CONCLUSION

Patent foramen ovale is a common condition in patients with acute PE and is associated with a higher incidence of ischemic stroke and increased mortality.

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.