Stroke/prevention and control

IJCS

Editorial

To Close or not to Close PFOs in Cryptogenic Stroke, an Evolving Question

Alex Felix et al. Monica Luiza de Alcantara

A matter of intense debate in the last decades, the ideal strategy for secondary prevention in patients with cryptogenic stroke and patent foramen ovale (PFO) is not yet clearly defined. PFOs are prevalent in the general population and can be found in up to 40% of patients with cryptogenic stroke. Although in some cases of cryptogenic stroke PFO might be just an innocent bystander, paradoxical embolism is a well-known potential causative mechanism, especially in patients with concomitant deep venous thrombosis, whereby PFO closure may represent an effective measure to avoid recurrences. Even among patients with PFO, phenotypical heterogeneity may also determine percutaneous treatment suitability and directly impact on results, whereas the presence of large shunts, atrial septal aneurysm or associated complex septal defects must also be taken into account.

In the past years, several evidence-based guidelines and expert consensus on the management of patients with PFO and prevention of recurrent stroke have been published by international scientific societies, including a position paper sponsored by the European Association of Percutaneous Cardiovascular Interventions (EAPCI), with the participation of eight European scientific societies. A recent guideline by the American Academy of Neurology (AAN) was published online last April.

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IJCS

Original Article

The Role of Patent Foramen Ovale Closure in the Secondary Prevention of Cryptogenic Stroke: a Meta-Analysis Report

Sónia P. Pinto Pereira et al. Alzira Nunes Cristina Santos Scott E Kasner José P. L Nunes

Abstract

Background:

Patent foramen ovale (PFO) closure has been compared to medical therapy for secondary prevention of recurrent cryptogenic stroke.

Objectives:

To produce an updated meta-analysis including only data from the primary analyses of clinical trials and to evaluate the role of PFO closure in the secondary prevention of recurrent stroke.

Methods:

Search in Medline (PubMed) and in ISI Web of Knowledge. Parameters under analysis and meta-analyses were: stroke, transient ischemic attack (TIA) and atrial fibrillation (AF). Comprehensive Meta-analysis Software V.2.0 (Biostat) was used. Random-effects analyses were carried out. A level of significance of 5% was used.

Results:

In this study six, randomized trials enrolling 3,750 patients were included. Unlike other published meta-analyses on the same topic, in this case, only clinical trial data, and not follow-up data, were used. PFO closure, as compared with medical therapy alone, demonstrated superiority in reducing the rate of recurrent stroke (risk ratio with PFO closure vs. medical therapy, 0.37; 95% confidence interval [CI], 0.17 to 0.78; p = 0.01). PFO closure did not offer a significant benefit in prevention of TIA (risk ratio with PFO closure vs. medical therapy, 0.96; 95% CI, 0.64 to 1.44; p = 0.85). Among patients assigned to closure group, an increased risk of atrial fibrillation was seen (risk ratio with PFO closure vs. medical therapy, 4.64; 95% CI, 2.38 to 9.01; p < 0.01).

Conclusions:

In patients with cryptogenic stroke who had a patent foramen ovale, a protective effect of closure was seen concerning the risk of recurrent stroke, but not regarding the prevention of TIA.