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Transcatheter patent foramen ovale closure versus standard medical therapy for prevention of recurrent stroke: Updated Meta-analysis with an importance on shunt size

Published:August 23, 2018DOI:https://doi.org/10.1016/j.ejim.2018.08.009
      Presence of patent foramen ovale (PFO) has been associated with increased risk of cryptogenic stroke [
      • Kernan W.N.
      • Ovbiagele B.
      • Black H.R.
      • Bravata D.M.
      • Chimowitz M.I.
      • Ezekowitz M.D.
      • et al.
      Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: A guideline for healthcare professionals from the American Heart Association/American Stroke Association.
      ]. PFO is present in about 25% of the general adult population but is found in upto 40% of patients with cryptogenic stroke [
      • Kernan W.N.
      • Ovbiagele B.
      • Black H.R.
      • Bravata D.M.
      • Chimowitz M.I.
      • Ezekowitz M.D.
      • et al.
      Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: A guideline for healthcare professionals from the American Heart Association/American Stroke Association.
      ]. Three previously published randomized controlled trials (RCTs) did not demonstrate the superiority of transcatheter PFO closure over standard medical therapy (SMT) [
      • Furlan A.J.
      • Reisman M.
      • Massaro J.
      • Mauri L.
      • Adams H.
      • Albers G.W.
      • et al.
      Closure or medical therapy for cryptogenic stroke with patent foramen ovale.
      ,
      • Carroll J.D.
      • Saver J.L.
      • Thaler D.E.
      • Smalling R.W.
      • Berry S.
      • MacDonald L.A.
      • et al.
      Closure of patent foramen ovale versus medical therapy after cryptogenic stroke.
      ,
      • Meier B.
      • Kalesan B.
      • Mattle H.P.
      • Khattab A.A.
      • Hildick-Smith D.
      • Dudek D.
      • et al.
      Percutaneous closure of patent foramen ovale in cryptogenic embolism.
      ]. Recently, long-term outcomes of a previously negative RCT (RESPECT trial) and three other RCTs have shown a benefit of PFO closure in the terms of reduction in the recurrent strokes compared to SMT [
      • Saver J.L.
      • Carroll J.D.
      • Thaler D.E.
      • Smalling R.W.
      • MacDonald L.A.
      • Marks D.S.
      • et al.
      Long-term outcomes of patent foramen ovale closure or medical therapy after stroke.
      ,
      • Mas J.L.
      • Derumeaux G.
      • Guillon B.
      • Massardier E.
      • Hosseini H.
      • Mechtouff L.
      • et al.
      Patent foramen ovale closure or anticoagulation vs. antiplatelets after stroke.
      ,
      • Sondergaard L.
      • Kasner S.E.
      • Rhodes J.F.
      • Andersen G.
      • Iversen H.K.
      • Nielsen-Kudsk J.E.
      • et al.
      Patent foramen ovale closure or antiplatelet therapy for cryptogenic stroke.
      ,
      • Lee P.H.
      • Song J.K.
      • Kim J.S.
      • Heo R.
      • Lee S.
      • Kim D.H.
      • et al.
      Cryptogenic stroke and high-risk patent foramen ovale: The DEFENSE-PFO trial.
      ]. However, current guidelines do not recommend the PFO closure in the patients with cryptogenic stroke and PFO [
      • Kernan W.N.
      • Ovbiagele B.
      • Black H.R.
      • Bravata D.M.
      • Chimowitz M.I.
      • Ezekowitz M.D.
      • et al.
      Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: A guideline for healthcare professionals from the American Heart Association/American Stroke Association.
      ,
      • Whitlock R.P.
      • Sun J.C.
      • Fremes S.E.
      • Rubens F.D.
      • Teoh K.H.
      Antithrombotic and thrombolytic therapy for valvular disease: Antithrombotic therapy and prevention of thrombosis, 9th ed: American college of chest physicians evidence-based clinical practice guidelines.
      ,
      • Messe S.R.
      • Gronseth G.
      • Kent D.M.
      • Kizer J.R.
      • Homma S.
      • Rosterman L.
      • et al.
      Practice advisory: Recurrent stroke with patent foramen ovale (update of practice parameter): Report of the guideline development, dissemination, and implementation subcommittee of the American Academy of Neurology.
      ]. Hence, we performed an updated meta-analysis of all the RCTs of PFO closure and cryptogenic stroke by including a recent DEFENCE-PFO trial by Lee et al. [
      • Lee P.H.
      • Song J.K.
      • Kim J.S.
      • Heo R.
      • Lee S.
      • Kim D.H.
      • et al.
      Cryptogenic stroke and high-risk patent foramen ovale: The DEFENSE-PFO trial.
      ].

      Keywords

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