History Of Cryptogenic Stroke Research Articles

Evaluating cost-effectiveness of PFO management strategies: closure with Cardioform vs. Amplatzer, and treatment with medical therapy alone, for secondary stroke prevention

Aim The aim of this study was to evaluate the cost-effectiveness of patent foramen ovale (PFO) closure using CARDIOFORM Septal Occluders versus AMPLATZER Septal Occluders, as well as compared to Medical Therapy Alone, from a payor perspective in the United States. Methods An economic evaluation compared the value of CARDIOFORM, AMPLATZER, and Medical Therapy Alone. A Markov model simulated a cohort of 1,000 individuals with PFO and a history of cryptogenic stroke, with baseline demographic and clinical characteristics reflecting individuals enrolled in the REDUCE and RESPECT trials over a five-year time horizon. The costs and health consequences associated with complications and adverse events, including recurrent stroke, were compared over a time horizon of 5 years. Results PFO closure using CARDIOFORM was economically dominant, providing both cost-savings and improved effectiveness compared to closure with AMPLATZER. It resulted in an estimated savings of over $1.3 million, an additional 24.8 quality-adjusted life-years (QALYs) gained, and 28 strokes avoided in a cohort of 1,000 patients. When compared to Medical Therapy Alone, closure with CARDIOFORM was found to be cost-effective, with an incremental cost-effectiveness ratio (ICER) of $36,697 per QALY gained. Sensitivity and scenario analysis showed the model findings to be highly robust across reasonable changes to baseline input values and assumptions. Conclusions The results of this analysis suggest that PFO closure using the CARDIOFORM Septal Occluder is the most cost-effective treatment strategy for patients with a PFO-associated stroke, particularly compared to AMPLATZER where it resulted in both cost-saving and improved patient outcomes.

Applicability of Percutaneous Occlusion with Double Disc Prosthesis for Correction of Patent Foramen Ovale

Objective: To discuss the applicability of percutaneous occlusion with a double-disk prosthesis to correct patent foramen ovale. Methodology: Integrative review of the literature carried out in the Virtual Health Library (VHL), Google Scholar and PubMed databases, using the Health Sciences (DeCS) descriptors: “Prosthesis design”, “Patent foramen ovale” and “Cardiac catheterization ” combined with each other by the Boolean operator AND. Results: Patent foramen ovale (PFO) is a congenital condition characterized by non-healing of the foramen ovale after birth, which can lead to complications such as paradoxical embolism and cerebrovascular accidents. Percutaneous occlusion rates with double-disc prostheses have accompanied this increase in PFO detection, while the technique, which involves inserting a double-disc device into the foramen ovale to close it, has proven effective in preventing embolic events in patients with a history of cryptogenic stroke or other PFO-related manifestations. The approach of percutaneous occlusion with a double-disk prosthesis for PFO correction is, therefore, a valuable tool in the therapeutic arsenal to reduce the risk of embolic events in high-risk patients. Conclusion: Percutaneous occlusion with a double disc prosthesis is an effective approach to preventing embolic events in patients with patent foramen ovale. Its growth reflects technological advances and understanding of the risks of FOP.

Diagnostic yield of implantable loop recorders: results from the hellenic registry

ObjectiveImplantable loop recorders (ILRs) are increasingly being used for long-term cardiac monitoring in different clinical settings. The aim of this study was to investigate the real-world performance of ILRs—including the time to diagnosis—in unselected patients with different ILR indications. Methods and ResultsIn this multicenter, observational study, 871 patients with an indication of pre-syncope/syncope (61.9%), unexplained palpitations (10.4%), and atrial fibrillation (AF) detection with a history of cryptogenic stroke (CS) (27.7%) underwent ILR implantation. The median follow-up was 28.8 ± 12.9 months. In the presyncope/syncope group, 167 (31%) received a diagnosis established by the device. Kaplan-Meier estimates indicated that 16.9% of patients had a diagnosis at 6 months, and the proportion increased to 22.5% at 1 year. Of 91 patients with palpitations, 20 (22%) received a diagnosis based on the device. The diagnosis was established in 12.2% of patients at 6 months, and the proportion increased to 13.3% at 1 year. Among 241 patients with CS, 47 (19.5%) were diagnosed with AF. The diagnostic yield of the device was 10.4% at 6 months and 12.4% at 1 year. In all cases, oral anticoagulation was initiated. Overall, ILR diagnosis altered the therapeutic strategy in 26.1% of the presyncope/syncope group, 2.2% of the palpitations group, and 3.7% of the CS group in addition to oral anticoagulation initiation. ConclusionIn this real-world patient population, ILR determines diagnosis and initiates new therapeutic management for nearly one-fourth of patients. ILR implantation is valuable in the evaluation of patients with unexplained presyncope/syncope, CS, and palpitations.

Detection of atrial fibrillation using an implantable loop recorder in patients with previous cryptogenic stroke: the SPIDER-AF registry (Stroke Prevention by Increasing DEtection Rates of Atrial Fibrillation).

The use of implantable loop recorder (ILR) to detect atrial fibrillation (AF) in patients with a history of cryptogenic stroke (CS) has seldom been investigated in "real-world" settings. This study aimed to present the results of the Stroke Prevention by Increasing DEtection Rates of Atrial Fibrillation (SPIDER-AF) registry. SPIDER is a multicentric, observational registry, including 35 facilities all over Germany. It enrolled outpatients without AF history and with CS before ILR implantation. We included 500 patients (mean age 63.1 ± 12.7years), 304 (60.8%) were males, with previous stroke (72.6%) and TIA (27.4%). After inclusion, all were followed for at least 12months. AF was detected in 133(26.8%), 25.3% of patients with previous stroke and 29.9% with TIA (p = 0.30). AF was detected after a median of 121.5days (IQR 40.5-223.0). AF was primarily paroxysmal (95.7% after stroke, 100% after TIA). In 19.5% (n = 26) anticoagulation was not administered after AF detection. Mean CHA2DS2-VASc score (OR 1.22; CI 1.01-1.49; p = 0.037) and age > 70years (OR 0.41; CI 0.19-0.88; p = 0.0020) correlated with AF. Repeat cerebrovascular events at follow-up (28; 5.6%) correlated with AF (OR = 2.17; CI 1.00-4.72; p = 0.049). AF (p = 0.91) and recurrent events (p = 0.43) occurred similarly in females and males. In the context of cryptogenic strokes ILRs are a valuable tool for early detection of AF. In a real-world scenario, the anticoagulation therapy remains inadequate despite diagnosed AF in a relevant subset of patients requiring optimization of patient management.

New-onset heart failure symptoms caused by obstructive left atrial myxoma in a patient with a history of cryptogenic stroke two decades ago: a case report

New-onset heart failure symptoms caused by obstructive left atrial myxoma in a patient with a history of cryptogenic stroke two decades ago: a case report

The effect of rivaroxaban vs aspirin on stroke recurrence among patients with history of cryptogenic stroke and left atrial cardiomyopathy: An analytical cross-sectional study

Background: Stroke is defined as a lack of blood flow in the brain that can cause neurological deficits. Approximately 25% of all ischemic stroke patients are classified as cryptogenic strokes, most of which are caused by an embolic mechanism. Anticoagulant treatment with rivaroxaban may result in a lower risk of recurrent stroke than aspirin in patients with history of cryptogenic stroke and left atrial cardiomyopathy. Methods: In this cross-sectional study, we compared the efficacy and safety of rivaroxaban with aspirin for the prevention of recurrent stroke in patients with history of cryptogenic stroke and left atrial cardiomyopathy. Results: The results showed that assuming the other variables such as age, sex, hypertension, and diabetes be constant, stroke recurrence odds ratio in the Aspirin therapy was 11 times more than rivaroxaban therapy (OR=11.35, CI 95%: 1.39-113.08, P-value=0.038). Conclusion: Rivaroxaban was superior to aspirin with regard to the prevention of recurrent stroke among patients with history of cryptogenic stroke and left atrial cardiomyopathy.

STROKE RISK AND ORAL ANTICOAGULATION USE WITH EXTENDED CARDIAC MONITORING FOR ATRIAL FIBRILLATION VERSUS USUAL CARE: A SYSTEMATIC REVIEW AND META-ANALYSIS

Extended cardiac monitoring is used to detect atrial fibrillation (AF) in high-risk populations, including those with a history of cryptogenic stroke. Despite demonstrated effectiveness in AF detection, randomized trials have not clearly demonstrated a reduction in stroke and systemic embolism (SSE) or transient ischemic attack (TIA). We performed a systematic review and meta-analysis of randomized trials evaluating extended monitoring versus usual care on reduction of stroke/SSE and TIA (PROSPERO #CRD42021277611).

A new era in patent foramen ovale closure – a percutaneous suture-based ‘deviceless’ technique (NobleStitch®): Experience of a Portuguese center

IntroductionIn patients with cryptogenic stroke, one of the most frequently found abnormalities is patent foramen ovale (PFO). Percutaneous ‘deviceless’ systems based on surgical suture-mediated PFO closure have recently been introduced and show a favorable efficacy and safety profile with clear advantages. ObjectivesTo present procedural details of the technique and baseline characteristics of patients who underwent the procedure in our center. MethodsA single-center prospective observational registry was established between February 2020 and February 2021, to assess the safety, efficacy and possible advantages of a novel percutaneous PFO closure system (NobleStitch® EL). Patient and PFO characteristics as well as technical features were collected for analysis. ResultsTwenty-three patients were considered suitable for this technique after transesophageal echocardiography. Their mean age was 51 years and 69.5% were women. Most patients (91.3%) had a history of cryptogenic stroke. PFO closure with the NobleStitch® system was successfully performed in all patients. All procedures were performed under local anesthesia and fluoroscopic monitoring. The mean duration of the procedure was 52 min and median contrast dose used was 187 ml. Median radiation dose absorbed per patient was 61.5 Gy cm2. All patients were discharged asymptomatic 24 hours after the procedure with no peri- or postprocedural complications recorded. ConclusionSuture-mediated PFO closure represents a valid and safe alternative to traditional umbrella-like devices, and is feasible in the majority of PFO anatomies. Follow-up information, results of larger series and clinical trials may possibly validate this technique as the first choice for PFO closure.

Recurrent cerebrovascular events in patients with a history of cryptogenic stroke or transient ischemic attack and patent foramen ovale in a long‑term follow‑up.

Cryptogenic stroke may be associated with a patent foramen ovale (PFO). Both cardiovascular risk factors and transcatheter closure of PFO may have an impact on the risk of recurrent cerebrovascular events. The aim of the study was to assess the occurrence and risk factors of recurrent cerebrovascular events (rCVE) in patients with a history of cryptogenic stroke or transient ischemic attack (TIA) and PFO. Overall, 392 patients (median [interquartile range, IQR] age 39.5 [30-49] years, 64.3% women, 35.7% men) with a history of cryptogenic stroke / TIA and confirmed PFO underwent a long‑term follow‑up with a median (IQR) of 51.5 (35-65) months. The primary end point was defined as rCVE including stroke and TIA. During the follow‑up, 17 patients with a history of cryptogenic stroke / TIA and confirmed PFO (4.3%, 11 women, 6 men) developed rCVE. In a multivariable analysis, the Risk of Paradoxical Embolism (RoPE) score was associated with a lower risk of rCVE (odds ratio [OR], 0.61 per 1 point; 95% CI, 0.45-0.84; P = 0.002). The transcatheter closure of PFO did not have a significant impact on rCVE in the study population (P = 0.19). The occurrence of rCVE in the patients with cryptogenic stroke / TIA and PFO reached 4.3% regardless of a high percentage of patients who underwent the PFO closure. RoPE score was associated with a lower risk of rCVE in the study population.

Carotid Web Is an Under-recognized and Devastating Cause of Ischemic Stroke

Carotid web is a rare form of fibromuscular dysplasia that can result in embolic stroke. Misdiagnosis is common and can lead to catastrophic neurologic events. Reports in the literature are scarce, and management remains controversial. Carotid web was defined as single, shelf-like, linear projection in the carotid bulb causing a characteristic filling defect on computed tomography angiography (CTA) or angiography (Fig). Cases at a single institution with a high-volume stroke center were identified retrospectively. Between 2016 and 2020, a total of 38 webs were identified in 32 patients; 22 (69%) were women. Average age was 48 years; 23 (72%) were African American. Symptomatic patients (26/32; 81%) initially presented with stroke (23/26; 88%) or transient ischemic attack (3/26; 12%). Webs were found incidentally in 6 of 32 patients (19%). Notably, the degree of stenosis was less than 50% in all patients, none were diagnosed with carotid ultrasound examination, and 16 of the 26 (62%) symptomatic webs were missed on initial CTA or cerebral angiography. Web-associated thrombus was observed radiographically or grossly upon carotid exploration in 13 of 26 (50%) symptomatic patients (Fig). Seven patients (27%) had a history of cryptogenic stroke and presented with ipsilateral recurrence at an average interval of 28 months. All seven were on dual antiplatelet and statin therapy prior to recurrence; four were left with permanent deficits. Definitive treatment in symptomatic patients was with transfemoral stenting in 19 of 25 (76%) or endarterectomy in 6 of 25 (24%). After an average follow-up of 19 months, there has been no reported stroke or mortality following intervention. Six patients with asymptomatic webs have been managed with antiplatelet and statin therapy for an average of 20 months. As the largest experience reported to date, our series demonstrates that carotid web is often missed on carotid duplex imaging, CTA, and cerebral angiography, and that devastating neurologic events occur if treatment is delayed after initial, web-related stroke. Symptomatic patients warrant aggressive intervention, as recurrent stroke occurred in all who were managed with medical therapy alone after initial ipsilateral stroke. A high index of suspicion and rigorous review of imaging are essential for accurate diagnosis, especially in younger, African American women who present with cryptogenic stroke and minimal carotid stenosis.

Safety and efficacy of endovascular patent foramen ovale closure: the first results of a Russian multicenter study

Patent foramen ovale (PFO) is detectable in more than 25% of the adult population and is generally clinically insignificant. However, it can be a cause of paradoxical embolism in some cases. Randomized trials indicate that endovascular PFO closure in patients with a history of cryptogenic stroke is an effective method for the secondary prevention of catastrophic brain damage.Objective: to study the safety and efficiency of endovascular PFO closure in young patients with a history of cryptogenic stroke.Patients and methods. Sixty-two patients, including (22 males and 40 females) women, underwent percutaneous PFO closure in May 2018 to March 2020. The patients' mean age was 37.4±7.6 years. The inclusion criteria were a prior cryptogenic ischemic stroke lasting less than 12 months and PFO with a high risk for paradoxical embolism (PFO concurrent with atrial septal aneurysm or hypermobility; PFO, ≥2 mm size; the presence of the Chiari network and/or the Eustachian valve).Results and discussion. The technical success of the operation was achieved in all cases. In 50 (80.6%) patients, the right chamber of the heart was completely isolated from the left one in the first 3 months. During the first year, the atria were also completely isolated in 10 (16.1%) patients. A left-to-right shunt persisted in 2 (3.2%) patents 12 months later. Two patients were found to have main procedural complications: one had perioperative atrial fibrillation and the other had pseudoaneurysm formation at the puncture site.Conclusion. Endovascular PFO closure is a safe and effective operation for the secondary prevention of recurrent ischemic stroke. In our study, blood shunting through the PFO was stopped in 96.6% of patients at less than 6 months after surgery, which suggests that there is a rapid and effective reduction in the risk of paradoxical embolism.

Large Left Atrial Thrombus on Amplatzer Septal Occluder Secondary to Medication Nonadherence

Patent foramen ovale (PFO) is a common clinical entity that is encountered in 20-34% of the general population. In most individuals, this anatomical variation is asymptomatic and goes undetected throughout their lives or is only incidentally discovered on cardiac investigations. In situations when the conduit is large enough and when the right atrial pressure exceeds the left atrial pressure, right to left interatrial flow may occur in these individuals. This creates a channel for translocation of air or thrombi from the venous to the arterial circulation, a phenomenon known as paradoxical embolism. Approximately 25-40% of strokes and transient ischemic attacks in patients less than 60 years of age are classified as cryptogenic and studies have identified a higher prevalence (60%) of PFO in young adults with strokes of unidentifiable etiology. Recent trials have demonstrated utility of PFO closure with mechanical devices for secondary prevention of recurrent strokes in patients aged <60 years of age. The general consensus of post-operative management of PFO closure has been largely drawn from randomized controlled trials and comprises use of aspirin and clopidogrel for 6 months followed by use of aspirin alone for at least 5 years. We present a case of an incidentally discovered left intra-atrial thrombus attached to a PFO closure device in a 36-year-old female with a history of cryptogenic stroke three months after implantation.

CONTEMPORARY TRENDS AND OUTCOMES OF PATENT FORAMEN OVALE CLOSURE

Percutaneous patent foramen ovale (PFO) closure is an effective treatment for preventing stroke recurrence in patients with a history of cryptogenic stroke. However, comparative data between the two FDA-approved PFO closure devices is limited. This study aims to compare peri-procedural

Incidental finding of PFO during cardiac surgery and implications - A dilemma in decision making

Introduction Patent foramen ovale (PFO) is common finding during coronary artery bypass graft (CABG) surgery. There is lack of data to help guide treatment decisions regarding incidental findings of PFO during CABG surgery. Certainly, the benefit versus risk equation seems to be a reasonable approach on individualized basis. Methods 67 years old female with history of unstable angina, no other comorbidities and normal preoperative Echocardiogram underwent elective CABG. Intraoperative TOE showed good biventricular function, no significant valvular abnormality and moderate size PFO with left-right shunt. The PFO was not treated as the patient was asymptomatic preoperatively. Immediately in postoperative period the patient was hypoxic. CTPA showed basal atelectasis, TOE demonstrated pericardial collection and reversal of the flow across the PFO. Percutaneous closure of PFO was considered but deemed inappropriate due to lack of evidence. Following discharge patient was readmitted with shortness of breath. She underwent a complicated redo-sternotomy for surgical removal of pericardial collection and PFO closure. Injury to the RV due to adhesion required femoral cannulation and led to compartment syndrome. Peri-operative TOE demonstrated moderate PFO with significant right-left shunt. Failure of mechanical ventilation wean mandated another review by cardiology and decision to percutaneously close the PFO was agreed. PFO closure was followed by immediate drop in oxygen requirement and facilitated immediate extubation and wean from ventilation. Discussion There is no evidence to suggest incidental PFO in patients undergoing cardiac surgery is linked to morbidity or mortality, and no evidence to support closure. One study showed that change from a planned procedure to include PFO closure increased risk of postoperative stroke with no long-term survival benefit. PFOs in patients with history of cryptogenic stroke are known to be larger (>4 mm) with longer tunnels (>1 cm) and that size and history of paradoxical embolism are major factor behind the surgeon's decision to close PFO. Conclusion Lack of strong evidence has led to our patient's unanticipated complication and longer hospital stay. Closure of PFO in asymptomatic patient should be decided on individual basis. Stronger evidence and recommendations are necessary to prevent complications.

PMD24 - Cost Effectiveness Analysis of Percutaneous Patent Foramen Ovale (PFO) Closure in Patients with a History of Cryptogenic Stroke in Korea

Patent Foramen Ovale (PFO) is a congenital defect that constitutes a hole between the right and left upper chambers of the heart. It may contribute to the risk of ischemic stroke so the closure is considered as a secondary prevention in patients who had a cryptogenic stroke. The objective of this study is to examine cost effectiveness of PFO closure in the context of Korean healthcare system. A Markov model consisting of 4 health states (stable, post-minor recurrent stroke, post-moderate recurrent stroke, death) similar to Tirschwell et al. (HTAi 2017) was developed to assess cost effectiveness in patients selected for PFO closure based on RESPECT trial extended follow-up. The intervention cost and medication costs were obtained from the current fee schedule, drug prices, and statistical yearbook in the National Health Insurance (NHI). Severity distribution of recurrent stroke was set by expert opinion. Using these data, a cost effectiveness analyses of (1) PFO closure with antiplatelet therapy (intervention) versus (2) medical therapy alone (control) was assessed at 20 years post the intervention. Univariate sensitivity analyses and probabilistic sensitivity analysis (PSA) were performed. The analysis showed that the intervention has 3.2 million KRW more cost with 1.2 higher utility which corresponds to an ICER of 2.7 million KRW per QALY which is below the implicit Korean threshold of 25 million KRW. A sensitivity analysis on time horizon showed that discounted ICER reach the threshold in 4 years, i.e. net monetary benefit of intervention exceeds control in 4 years. The PSA result showed acceptability of intervention at the threshold was 96.4% compared to control. Though there might be uncertainties from foreign modeling, the current study suggests a careful selection of patients with cryptogenic stroke history and application of PFO closure may benefit the patients and the public payer in Korea.

Clinical impact of the alpha-galactosidase A gene single nucleotide polymorphism -10C>T: A single-center observational study.

Single nucleotide polymorphisms (SNPs) in the alpha-galactosidase A gene region (GLA) have been discussed as potential cause of symptoms and organ manifestations similarly to those seen in Fabry disease (FD). However, due to scarce data, clinical implications remain limited. The aim of the present study was to investigate the clinical impact of -10C>T SNP in the GLA.Prospective single-center observational study to determine the natural history and outcome of FD.Subjects initially referred to the Fabry Center for Interdisciplinary Therapy Würzburg (FAZIT) for management of suspected FD (11 women, 2 men, mean age 42 ± 10 years) who were tested negative for coding GLA mutations but positive for the noncoding -10C>T SNP underwent comprehensive characterization for therapy recommendation.All subjects reported at least 1 neurological, but no cardiac or renal symptoms. In 7 patients, pain of unknown etiology was reported and 3 patients had a history of cryptogenic stroke. In all patients, α-GAL activity was at a lower limit, ranging between 0.27 and 0.45 nmol/min per mg protein (reference: 0.4–1.0), while plasma Lyso-Gb3 levels remained normal (range 0.39 ± 0.33; reference: ≤0.9 ng/mL). For both hemizygous subjects investigated, brain magnetic resonance imaging revealed unspecific white matter lesions. One of these subjects had suffered from severe early-onset stroke, the other showed mild hypertrophic cardiomyopathy.Presence of isolated heterozygous -10C >T SNP is not associated with clinically relevant symptoms or organ manifestations as seen in FD. Respective polymorphisms might, however, play a role in modifying disease severity in FD. Great care has to be taken in respective subjects suspected to suffer from nonclassical FD in order to prevent unnecessary Fabry-specific therapy.

Patent Foramen Ovale and Cryptogenic Stroke or Transient Ischemic Attack: To Close or Not to Close? A Systematic Review and Meta-Analysis

Background: The optimal strategy of secondary stroke prevention in patients with patent foramen ovale (PFO) is controversial. This study was performed to evaluate the efficacy and safety of the device closure (DC) versus the medical therapy (MT) in patients with cryptogenic stroke or transient ischemic attack (TIA) and PFO. Summary: Randomized controlled trials with active and control groups receiving the DC plus MT and MT alone in patients with history of cryptogenic stroke/TIA and diagnosis of PFO were systematically searched. The main efficacy outcome was stroke recurrence. Subgroup-analyses were performed according to age, shunt size, and presence of atrial septal aneurysm (ASA). Safety endpoints included any serious adverse event (SAE), atrial fibrillation (AF), and major bleeding complications. Risk ratios (RRs) and hazard ratios (HRs) with 95% CIs were estimated. Five trials were included, involving 3,440 participants (DC = 1,829, MT = 1,611). There was a protective effect of closure in the risk of recurrent stroke (RR 0.43 [0.21–0.90]; p = 0.024; HR = 0.39 [0.19–0.83]; p = 0.014). The benefit of PFO closure was significant in patients with PFO associated with substantial right-to-left shunt or ASA. There were no differences in the risks of SAEs and major bleedings between the groups. The rate of new-onset AF was higher in the DC than in the MT arm (RR 4.46 [2.35–8.41]; p < 0.001). Successful device implantation and effective PFO closure were achieved in 96 and 91% of the patients respectively. Key Messages: In selected adult patients with PFO and history of cryptogenic stroke, the DC plus MT is more effective to prevent stroke recurrence and is associated with an increased risk of new-onset AF compared to the MT alone.

Reduced Stroke After Transcatheter Patent Foramen Ovale Closure: A Systematic Review and Meta-analysis

BackgroundRecent randomized control trials (RCTs) have suggested benefit with transcatheter patent foramen ovale (PFO) closure plus antiplatelet therapy over medical treatment alone for secondary stroke prevention. Material and MethodsData sources: we searched PubMed and Ovid MEDLINE from the inception until November 10, 2017 for RCTs comparing TPFO closure to medical therapy in patients with a PFO and a history of cryptogenic stroke. ResultsFive RCTs with 3,627 patients (TPFO closure = 1,829 versus medical therapy =1,798) were included. There was a decreased number of post-TPFO closure strokes compared to the medical therapy arm; 53 versus 80 strokes (odds ratio [OR] = 0.61, CI: 0.39-0.94, P = 0.03, I2 = 17%). Transient ischemic attacks occurred in 43 patients after TPFO closure versus 60 patients in the medical therapy group (OR = 0.80, CI: 0.53-1.19, P = 0.26, I2 = 0%). There was a higher incidence of atrial fibrillation in the TPFO closure group, which occurred in 75 patients, compared to 12 patients in the medical therapy group (OR = 5.23, CI: 2.17-12.59, P = 0.0002, I2 = 43%). There was a trend toward a decreased number of neuropsychiatric events in the TPFO closure closure group compared to the medical therapy group; 42 versus 67 neuropsychiatric events (OR = 0.71, CI: 0.48-1.06, P = 0.09, I2 = 0%). ConclusionsTPFO closure plus antiplatelet therapy is superior to medical therapy in patients with a PFO and cryptogenic stroke. PFO closure is associated with new-onset atrial fibrillation and a trend toward reduced neuropsychiatric events.

Percutaneous closure of patent foramen ovale vs. medical treatment for patients with history of cryptogenic stroke: A systematic review and meta-analysis of randomized controlled trials.

Patients with history of cryptogenic stroke are more likely to have a patent foramen ovale (PFO) and should be managed with antithrombotic agents, while the alternative option is percutaneous closure of PFOs. Our aim was to perform a meta-analysis of randomized controlled trials (RCTs) comparing percutaneous closure vs. medical treatment for patients with PFO and prior cryptogenic stroke. Medline, Scopus and Cochrane databases were reviewed. A random-effect model meta-analysis was used and I-square was utilized to assess the heterogeneity. New ischemic stroke was defined as the primary endpoint. A sensitivity analysis was performed for Amplatzer device. Subgroup analyses were performed for different patient and PFO characteristics for the composite endpoints as defined by the included RCTs. In total of 3440 patients were included in this meta-analysis. Closure devices were superior to medical therapy for prevention of recurrent ischemic strokes (HR = 0.29; CI: 0.02-0.56), but were associated with increased risk of new onset of atrial fibrillation (AF) and atrial flutter (RR = 4.67; CI: 2.22-9.81). However, in the sensitivity analysis for Amplatzer device, there was no difference between the two groups in new onset of atrial arrhythmias. Closure devices were superior across all different subgroups when compared to medical treatment with the exception of patients with a small shunt. This meta-analysis shows that closure devices for patients with PFO and history of cryptogenic stroke can significantly decrease the risk of a new ischemic stroke. The use of Amplatzer device was not associated with increased risk of newly diagnosed atrial arrhythmias.

Abstract TMP57: Left Atrial Dilatation: A Cohort Analysis With Strong Implications for Future Atrial Fibrillation and Stroke Monitoring

Introduction: Atrial fibrillation (AF) increases the risk of thromboembolism five-fold. Left atrial dilatation (LAD) is a known predictor of AF. It is necessary to better understand the association of LAD, AF and stroke to determine if screening with cardiac monitoring as a prevention measure for stroke is potentially warranted in patients with LAD and no history of cryptogenic stroke. Aim: To evaluate the high risk association of LAD on routine echocardiography with AF and stroke. Methods: A retrospective review of all patients with an echocardiogram performed within Henry Ford Health System from Mar 6th to Sept 6th 2016 was conducted. Patients were categorized based on the degree of LAD (mild, moderate and severe). Chi-squared tests and two-sample t-tests were used to compare characteristics and multivariate logistic regression analyses were done with AF and stroke as outcomes in two separate models adjusting for the exposure variables. Results: From a total of 8679 patients, 54% were female and 41% were African American. The mean age was 64.9 years (SD=16.9). Patients were divided into normal LA size (55%), mild LAD (15%), moderate LAD (12%) and severe LAD (18%). Patients with any LAD were older (70.7±15.0 vs 60.1±17.0 p&lt;0.001), had higher prevalence of AF (36% vs 11% p&lt;0.001), stroke (21% vs 16%, p&lt;0.001) and CHADS2Vasc scores (2.9 ± 1.9 vs 4.0± 1.9 p&lt;0.001). In multivariate analysis, AF was more common in any LAD compared to normal (OR 2.51 CI 2.15-2.93 p&lt;0.001). The odds of AF increased significantly with LAD severity (Mild 1.8, Moderate 2.0 and Severe 3.7). There was no significant association between LAD and stroke in the multivariate analyses (OR 0.97 CI 0.85-1.11, p=0.69). Female gender (OR 0.60, p&lt;0.001) and African American race (OR 0.54, p&lt;0.001) were protective against AF, although not against stroke which was increased in African Americans (OR 1.42, p&lt;0.001). Conclusion: Left atrial dilatation is commonly found on routine echocardiography and AF is established in only one-third of those patients. Structural LAD represents a significant marker for AF, although many patients with LAD are yet to be diagnosed with AF. Left atrial dilatation is an attractive high risk marker for occult AF that may warrant prolonged cardiac monitoring for primary identification of AF.