Abstract
Objectives: Concerns regarding the real efficacy of transcatheter patent foramen ovale (PFO) closure versus medical therapy in patients with cryptogenic stroke remained unresolved. We performed a meta-analysis using the randomized controlled trials on the efficacy and safety of transcatheter PFO closure in patients with cryptogenic stroke. Methods: Web of Science, EMBASE, PubMed, and the Cochrane Library were searched for relevant randomized controlled trials (RCTs). The primary outcome was recurrent stroke and transient-ischemic attack (TIA). Original data, hazard ratio (HR) with 95% confidence interval (95% CI) were abstracted to calculate a pooled effect size. Results: Our meta-analysis showed benefit with device closure when compared with medical therapy with an HR of 0.54 (95% CI: 0.39 - 0.74, P = 0.108) in the intention-to-treat cohort, 0.44 (95% CI: 0.24 - 0.82, P = 0.103) in the per-protocol populations, and 0.43 (95% CI: 0.31 - 0.60, P = 0.019) in the as-treated populations. There was a significantly higher incidence of new-onset atrial fibrillation in PFO closure patients (OR = 4.53, 95% CI: 2.58 - 7.97, P = 0.094). PFO Patients with an atrial septal aneurysm benefit from device closure (OR = 0.39, 95% CI: 0.22 - 0.69, P = 0.053). Patients with a substantial PFO shunt benefit the greatest with device closure with a pooled OR of 0.27 (95% CI: 0.14 - 0.56, P = 0.525). Conclusions: The meta-analysis concluded that PFO closure was associated with significantly lower risk of recurrent stroke in PFO patients with cryptogenic stroke than with medical therapy alone. The benefit of PFO closure was greater in patients with a substantial shunt and atrial septal aneurysm. PFO closure was associated with higher rates of new-onset atrial fibrillation.
Highlights
The patent foramen ovale (PFO) is a critical communication of the normal fetal circulation; it continues to remain patent after birth in up to 25% of adults [1]
Our meta-analysis showed benefit with device closure when compared with medical therapy with an hazard ratio (HR) of 0.54 in the intention-to-treat cohort, 0.44 in the per-protocol populations, and 0.43 in the as-treated populations
PFO Patients with an atrial septal aneurysm benefit from device closure (OR = 0.39, 95% confidence interval (95% CI): 0.22 - 0.69, P = 0.053)
Summary
The patent foramen ovale (PFO) is a critical communication of the normal fetal circulation; it continues to remain patent after birth in up to 25% of adults [1]. Epidemiologic study has found a significant association between PFO and cryptogenic stroke both in the younger and older patients [3] [4]. It was reported that the incidence of stroke recurrence in PFO patients after medical therapy within a four-year follow-up period was approximately 25% [5]. There has been a growing debate on whether percutaneous closure of PFO was to medical therapy. 3 recent randomized controlled trials have concluded that use of PFO closure devices was associated with a lower risk of recurrent stroke than that observed with medical treatment [14] [15] [16]. An update meta-analysis that involved the role of percutaneous PFO closure versus medical therapy in cryptogenic stroke is urgently warranted
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