Meta-Analysis
Copyright ©The Author(s) 2018. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Cardiol. Jun 26, 2018; 10(6): 41-48
Published online Jun 26, 2018. doi: 10.4330/wjc.v10.i6.41
Patent foramen ovale closure reduces recurrent stroke risk in cryptogenic stroke: A systematic review and meta-analysis of randomized controlled trials
Mahesh Anantha-Narayanan, Dixitha Anugula, Gladwin Das
Mahesh Anantha-Narayanan, Gladwin Das, Division of Cardiovascular Disease, Department of Medicine, University of Minnesota, Minneapolis, MN 55455, United States
Dixitha Anugula, Division of Cardiology, CHI Health Creighton University Medical Center, Omaha, NE 68124, United States
Author contributions: All authors contributed to the manuscript.
Conflict-of-interest statement: No potential conflicts of interest relevant to this article were reported.
PRISMA 2009 Checklist statement: The manuscript was prepared and revised according to the PRISMA 2009 Checklist.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Mahesh Anantha-Narayanan, MD, Academic Fellow, Doctor, Division of Cardiovascular Diseases, Department of Medicine, University of Minnesota, Mayo Mail Code 508, 420 Delaware St SE, Minneapolis, MN 55455, United States. manantha@umn.edu
Telephone: +1-612-6262451 Fax: +1-612-6264411
Received: January 31, 2018
Peer-review started: January 31, 2018
First decision: February 27, 2018
Revised: March 1, 2018
Accepted: March 18, 2018
Article in press: March 18, 2018
Published online: June 26, 2018
Processing time: 146 Days and 7 Hours
ARTICLE HIGHLIGHTS
Research background

Cryptogenic stroke accounts for one-fourth of the ischemic strokes and the presumed mechanism is venous thromboembolisms entering systemic circulation via patent foramen ovale (PFO). Percutaneous device closure of PFO has been shown to reduce stroke rates but there is lack of evidence on whether percutaneous closure of PFO is better when compared to medical therapy with antiplatelet and/or anticoagulation. Previously published randomized controlled trials (RCTs) comparing PFO closure to medical therapy lacked appropriate patient selection and had large dropout rates at follow up. Based on this available data, the American Association of Neurology (AAN) guidelines recommended against PFO device closure

Research motivation

Though current guidelines do not support PFO device closure, two recently published RCTs showed reduction in incidence of recurrent strokes with PFO closure in appropriately selected patient population with cryptogenic stroke. We therefore performed a systematic review and meta-analysis to evaluate if PFO closure is superior to medical therapy alone including all published RCTs to date.

Research objectives

The purpose of the study is to analyze if PFO closure device is superior to medical therapy alone to prevent recurrent strokes in appropriately selected patient population with cryptogenic stroke.

Research methods

We searched five databases for studies comparing PFO device closure to medical therapy in patients with cryptogenic stroke. To qualify for inclusion, trials must have a randomized design, include patients > 18 years of age and compare PFO closure to medical therapy in patients with cryptogenic stroke. We obtained a total of five randomized controlled trials for inclusion and performed a meta-analysis. Our primary outcome was incidence of recurrent ischemic stroke. We also looked at secondary outcomes including incidence of atrial fibrillation, all-cause mortality, major bleeding and adverse events.

Research results

PFO device closure in appropriately selected patient population with cryptogenic stroke is superior to medical therapy alone in reducing incidence of recurrent strokes. There was no difference between the PFO device closure and the medical therapy groups in terms of overall mortality, major bleeding and adverse events but there was a significant increase in incidence of atrial fibrillation in the closure device group.

Research conclusions

Our current meta-analysis including all published randomized controlled trials comparing PFO closure device to medical therapy alone supports PFO device closure in appropriately selected patient population. PFO closure in younger patients with moderate to large PFO and with atrial septal aneurysm is clearly associated with reduction in incidence of recurrent strokes without increasing mortality, major bleeding or adverse events. There is an increase in atrial fibrillation with PFO closure compared to medical therapy alone but this was mostly in the immediate post-operative period.

Research perspectives

From this meta-analysis, it could be seen that PFO closure device reduces risk of recurrent stroke in appropriately selected patient population with cryptogenic stroke. PFO closure is associated with increase in atrial fibrillation but this could likely be an organic phenomenon related to atrial irritation from the device itself. Further studies are essential to address whether this increase in atrial fibrillation rates with PFO closure device is associated with adverse outcomes on long term follow up.