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Patent foramen ovale closure versus medical therapy for prevention of recurrent cryptogenic embolism: updated meta-analysis of randomized clinical trials

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Abstract

Background

We performed an updated meta-analysis of all randomized-controlled trials (RCTs) comparing patent foramen ovale (PFO) closure with medical therapy for prevention of recurrent ischemic stroke.

Methods and results

We searched Medline, EMBASE, and Cochrane databases, and proceedings of international meetings for RCTs of patients with cryptogenic stroke and PFO comparing percutaneous PFO closure versus medical therapy for prevention of recurrent ischemic stroke. The primary outcome was a composite ischemic/embolic endpoint comprising stroke, transient ischemic attack (TIA), peripheral embolism, and early death in the intention-to-treat population. Secondary outcomes were all-cause death, stroke, TIA, atrial fibrillation (AF), and major bleeding. Of 3440 enrolled patients across five RCTs, 1829 were allocated to PFO closure and 1611 to medical therapy. The follow-up ranged from 2 to 5.9 years. PFO closure reduced the risk of the composite outcome [HR 0.52, (0.36–0.77); p < 0.01], and stroke, [HR 0.39, (0.19–0.83); p < 0.01], and increased the risk of AF [OR 3.75, (2.44–5.78); p < 0.01] as compared to medical therapy. NNT for stroke was 37 and NNH for AF 49, indicating a net clinical benefit of PFO closure. The meta-analysis had 95% power to detect a 50% relative risk reduction (RRR) in the primary outcome and 89% power to detect a 70% RRR in ischemic stroke. The risk of all-cause death (HR 1.08, p = 0.90), TIA [HR 0.73, (0.49–1.09); p = 0.12], and major bleeding [OR 0.97, (0.44–2.17); p = 0.95] was comparable between the groups.

Conclusions

Among patients with cryptogenic stroke and PFO, percutaneous closure of PFO is superior to medical therapy in preventing recurrent ischemic/embolic events and stroke but is associated with an increased risk of AF.

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Funding

No funding was used for this study.

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Author notes

  1. Brunilda Alushi  and Alexander Lauten have contributed equally to the work.

Authors and Affiliations

  1. Department of Cardiovascular Diseases, Campus Benjamin Franklin, Charite’-Universitätsmedizin Berlin, and German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany

    Brunilda Alushi, Alexander Lauten & Ulf Landmesser

  2. German Heart Center Munich, Technische Universität München, Munich, Germany

    Salvatore Cassese, Roisin Colleran, Stefanie Schüpke, Himanshu Rai, Heribert Schunkert & Adnan Kastrati

  3. DZHK, Partner Site Munich Heart Alliance, Munich, Germany

    Heribert Schunkert & Adnan Kastrati

  4. Department of Cardiology, Bern University Hospital, Bern, Switzerland

    Bernhard Meier

  5. Berlin Institute of Health (BIH), Berlin, Germany

    Ulf Landmesser

  6. Department of Cardiology, German Heart Centre, Munich, Lazarettstraße 36, Munich, Germany

    Adnan Kastrati

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  1. Brunilda Alushi
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Correspondence to Adnan Kastrati.

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Conflict of interest

Dr. Colleran reports a grant from the Irish Board for Training in Cardiovascular Medicine sponsored by MSD, outside the submitted work. Prof. Lauten reports grants from Edwards Lifesciences, grants from Abbott Vascular, outside the submitted work. Prof. Meier was principal investigator of the PC trial and reports personal fees from Abbott, during the conduction of the study and Co-primary investigator of the PC trial (more than 2 years ago). Prof. Landmesser reports grants from Edwards Lifesciences, grants and personal fees from Abbott, outside the submitted work. All other authors report no relationships relevant to the contents of this paper to disclose.

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Alushi, B., Lauten, A., Cassese, S. et al. Patent foramen ovale closure versus medical therapy for prevention of recurrent cryptogenic embolism: updated meta-analysis of randomized clinical trials. Clin Res Cardiol 107, 788–798 (2018). https://doi.org/10.1007/s00392-018-1246-y

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  • DOI: https://doi.org/10.1007/s00392-018-1246-y

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