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Closure of patent foramen ovale for cryptogenic stroke patients: an updated systematic review and meta-analysis of randomized trials

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Abstract

Objective

This systematic review and meta-analysis was performed to investigate the efficacy and safety of transcatheter device closure (TDC) plus anti-thrombotic drugs over medical management alone for patients with cryptogenic stroke and patent foramen oval.

Methods

PubMed, Embase and Cochrane Library database were searched for randomized controlled clinical trials (RCTs). The primary endpoint is the composite of stroke and transient ischemic attack. The secondary endpoints are all-cause mortality, total serious adverse events, atrial fibrillation and bleeding.

Results

Five RCTs with a total of 3440 participants were included. TDC significantly decreased the risk of primary endpoint when compared to medical therapy alone (RR 0.54, 95% CI 0.43–0.69). Further subgroup analyses showed that patients with male gender and with substantial shunt size of foramen ovale significantly benefited from TDC as compared to those with female gender and with no substantial shunt size of foramen oval separately. Moreover, TDC was superior to medical therapy with anti-platelet drug alone (not with anti-coagulation). On the other hand, the incidence of atrial fibrillation was higher in TDC group (RR 4.49, 95% CI 2.02–9.97), with the risk of other adverse events equivalent between the two groups.

Conclusions

TDC plus anti-thrombotic drugs is superior than medical therapy alone for secondary prevention of stroke, especially for those with male gender and with substantial shunt size of foramen ovale. Though it may increase the risk of postoperative atrial fibrillation, it would not bring higher risk of all-cause mortality, total adverse events and bleeding.

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Acknowledgements

This study was supported by National Natural Science Foundation of China (No. 81671051 to ZHZ, Nos. 81571249 and 81771382 to ZTZ).

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Author notes

  1. Xuan Niu and Guang Ou-Yang contributed equally to this article.

Authors and Affiliations

  1. Department of Neurology, Renmin Hospital of Wuhan University, Wuhan, 430060, China

    Xuan Niu, Zhen-tao Zhang & Zhao-hui Zhang

  2. Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, 430060, China

    Guang Ou-Yang & Shu-lan Huang

  3. Department of Neurosurgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China

    Peng-fei Yan

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  1. Xuan Niu
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Correspondence to Zhao-hui Zhang.

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Niu, X., Ou-Yang, G., Yan, Pf. et al. Closure of patent foramen ovale for cryptogenic stroke patients: an updated systematic review and meta-analysis of randomized trials. J Neurol 265, 1259–1268 (2018). https://doi.org/10.1007/s00415-018-8766-2

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  • DOI: https://doi.org/10.1007/s00415-018-8766-2

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