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Impact on daily clinical practice of the latest evidence on percutaneous closure of patent foramen ovale after cryptogenic stroke: a single-center experience

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Abstract

Introduction and objectives

At the end of 2017, three clinical trials demonstrated that, in selected patients, percutaneous closure of patent foramen ovale (PFO) after cryptogenic stroke (CS) reduces the risk of recurrence. Our aim was to determine the impact of these findings on routine clinical practice in a tertiary hospital.

Methods

Patients with CS and percutaneous closure of PFO during 2001–2020 were included. The clinical characteristics of the patient and the anatomical characteristics of the foramen were analyzed. Based on both, the closure indications were classified into three groups according to the latest European recommendations and were analyzed in two periods, before and after the publication date of the clinical trials.

Results

A total of 293 patients were included. The mean age was 49 ± 11 years, and 15% were older than 60 years. The median RoPE score was 6 [p25–75, 5–7] and 75% had complex anatomy (CA). After the publication of the studies, the frequency of CA and the mean age of the patients were significantly higher (89% vs. 69% p < 0.0005 and 51 ± 11 vs. 48 ± 11 years, p = 0.02, respectively), and the RoPE score, significantly lower (5 [5–7] versus 6 [5–7], p = 0.02). Inadequate closure indications were significantly reduced (8% vs. 18%, p = 0.02).

Conclusion

After the publication of clinical trials that have shown benefit of PFO closure after CS, the number of inappropriate indications for closure has decreased significantly in our institution, with a higher percentage of CA, despite a clinical profile suggestive of lower causal probability of PFO.

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Abbreviations

CA:

Complex anatomy

CS:

Cryptogenic stroke

ISA:

Interatrial septal aneurysm

PFO:

Patent foramen ovale

TEE:

Transesophageal echocardiogram

References

  1. Mas JL, Derumeaux G, Guillon B, Massardier E, Hosseini H, Mechtouff L, Arquizan C, Béjot Y, Vuillier F, Detante O, Guidoux C, Canaple S, Vaduva C, Nequatre-Ponchelle N, Sibon I, Garnier P, Ferrier A, Timsit S, Robinet-Borgomano E, Sablot D, Lacour JC, Zuber M, Favrole P, Pinel, JF, Apoil M, Reiner P, Lefebvre C, Guérin P, Piot C, Rossi R, Dubois-Randé JL, Eicher JC, Meneveau N, Lusson JR, Bertrand B, Schleich JM, Godart F, Thambo JB, Leborgne L, Michel P, Pierard L, Turc G, Barthelet M, Charles-Nelson A, Weimar C, Moulin T, Juliard JM, Chatellier G; for the CLOSE Investigators (2017) Patent foramen ovale closure or anticoagulation vs. antiplatelets after stroke. N Engl J Med 377:1011–1021.

  2. Søndergaard L, Kasner SE, Rhodes JF, Andersen G, Iversen HK, Nielsen-Kudsk JE, Settergren M, Sjöstrand C, Roine RO, Hildick-Smith D, Spence JD, Thomassen L; Gore REDUCE Clinical Study Investigators (2017) Patent foramen ovale closure or antiplatelet therapy for cryptogenic stroke. N Engl J Med 377:1033–1042.

  3. Saver JL, Carroll JD, Thaler DE, Smalling RW, MacDonald LA, Marks DS, and Tirschwell DL for the RESPECT Investigators. Long-term outcomes of patent foramen ovale closure or medical therapy after stroke. N Engl J Med. 2017;377:1022–1032.

  4. Furlan AJ, Reisman M, Massaro J, Mauri L, Adams H, Albers GW, Felberg R, Herrmann H, Kar S, Landzberg M, Raizner A, Wechsler L; for the CLOSURE I Investigators (2012) Closure or medical therapy for cryptogenic stroke with patent foramen ovale. N Engl J Med 366:991–999.

  5. Carroll JD, Saver JL, Thaler DE, Smalling RW, Berry S, MacDonald LA, Marks DS, Tirschwell DL; for the RESPECT Investigator (2013) Closure of patent foramen ovale versus medical therapy after cryptogenic stroke. N Engl J Med 368:1092–1100

  6. Meier BB, Kalesan B, Mattle HP, Khattab AA, Hildick-Smith D, Dudek D, Andersen G, Ibrahim R, Schuler G, Walton AS, Wahl A, Windecker S, Jüni P; for the PC Trial Investigators (2013) Percutaneous closure of patent foramen ovale in cryptogenic embolism. N Engl J Med 368:1083–1091.

  7. Pristipino C, Sievert H, D’Ascenzo F, Mas JL, Meier B, Scacciatella P, Hildick-Smith D, Gaita F, Toni D, Kyrle P, Thomson J, Derumeaux G, Onorato E, Sibbing D, Germonpré P, Berti S, Chessa M, Bedogni F, Dudek D, Hornung M, Zamorano J (2019) European position paper on the management of patients with patent foramen ovale. General approach and left circulation thromboembolism. EuroIntervention 14:1389–1402

  8. Adams HP Jr, Bendixen BH, Kappelle LJ et al (1993) Classification of subtype of acute ischemic stroke: definitions for use in a multicenter clinical trial: TOAST: Trial of Org 10172 in Acute Stroke Treatment. Stroke 24:35–41

    Article  Google Scholar 

  9. Kent DM, Ruthazer R, Weimar C, Mas JL, Serena J, Homma J, Di Angelantonio E, Di Tullio MR, Lutz JS, V Elkind MS, Griffith J, Jaigobin C, Mattle HP, Michel P, Mono ML, Nedeltchev K, Papetti F, Thaler DE (2013) An index to identify stroke-related vs incidental patent foramen ovale in cryptogenic stroke. Neurology 81:619–25.

  10. Kent DM, Thaler DE; RoPE Study Investigators (2011) The risk of paradoxical embolism (RoPE) study: developing risk models for application to ongoing randomized trials of percutaneous patent foramen ovale closure for cryptogenic stroke. Trials 12:185

  11. Kent DM, Saver JL, Ruthazer R, Furlan AJ, Reisman M, Carroll JD, Smalling RW, Jüni P, Mattle HP, Meier B, Thaler DE (2020) Risk of Paradoxical Embolism (RoPE)-estimated attributable fraction correlates with the benefit of patent foramen ovale closure: an analysis of 3 trials. Stroke 51:3119–3123

    Article  Google Scholar 

  12. Morais LA, De Sousa L, Fiarresga A, Martins JD, Timóteo AT, Monteiro AV, Soares C, Agapito A, Pinto F, Ferreira RC (2018) RoPE score as a predictor of recurrent ischemic events after percutaneous patent foramen ovale closure. Heart J 59:1327–1332

    Google Scholar 

  13. Di Tullio M, Sacco RL, Venketasubramanian N, Sherman D, Mohr JP, Homma S (1993) Comparison of diagnostic techniques for the detection of a patent foramen ovale in stroke patients. Stroke 24:1020–1024

    Article  Google Scholar 

  14. Mügge A, Daniel WG, Angermann C, Spes C, Khandheria BK, Kronzon I, Freedberg RS, Keren A, Denning K, Engberding R, Sutherland GR, Vered Z, Erbel R, Visser CA, Lindert O, Hausmann D, Wenzlaff P (1995) Atrial septal aneurysm in adult patients. A multicenter study using transthoracic and transesophageal echocardiography. Circulation 91:2785–92

  15. Angeli S, Del Sette M, Beelke M et al (2001) Transcranial Doppler in the diagnosis of cardiac patent foramen ovale. Neurol Sci 22:353–356

    Article  CAS  Google Scholar 

  16. Giannandrea D, Padiglioni C, Eusebi P, Mengoni A, Romoli M, Galati F, Vecchio A, Cenciarelli S, Ricci S, Consoli D (2020) Clinical RoPE (cRoPE) score predicts patent foramen ovale detection among stroke patients: a multicenter observational study. Neurol Sci 41(11):3227–3233. https://doi.org/10.1007/s10072-020-04386-6

    Article  PubMed  Google Scholar 

  17. Scacciatella P, Jorfida M, Biava LM, Meynet I, Zema D, D’Ascenzo F, Pristipino C, Cerrato P, Giustetto C, Gaita F (2019) Insertable cardiac monitor detection of silent atrial fibrillation in candidates for percutaneous patent foramen ovale closure. J Cardiovasc Med 20:290–296

    Article  Google Scholar 

  18. Jorfida M, Antolini M, Cerrato E, Caprioli MG, Castagno D, Garrone P, Budano C, Cerrato P, Gaita F (2016) Cryptogenic ischemic stroke and prevalence of asymptomatic atrial fibrillation: a prospective study. J Cardiovasc Med 17:863–869

    Article  Google Scholar 

  19. Lu Y, Diao SS, Huang SJ, et al (2021) Insertable cardiac monitors for detection of atrial fibrillation after cryptogenic stroke: a meta-analysis. Neurol Sci

  20. Wintzer-Wehekinda J, Alperia A, Houdeb C, Côtéb JM, Vala Dd, Côtéa M, Rodés-Cabaul J (2020) Cierre percutáneo del foramen oval permeable en pacientes mayores de 60 años con ictus criptogénico. Rev Esp Cardiol 73:219–224

  21. Registro Español de Hemodinámica y Cardiología Intervencionista. XXVIII Informe Oficial de la Sección de Hemodinámica y Cardiología Intervencionista de la Sociedad Española de Cardiología (1990–2018).

  22. Messé SR, Gronseth GS, Kent DM, Kizer JR, Homma S, Rosterman L, Carroll JD, Ishida K, Sangha N, Kasner SE (2020) Practice advisory update summary: patent foramen ovale and secondary stroke prevention: report of the Guideline Subcommittee of the American Academy of Neurology. Neurology 94:876–885

    Article  Google Scholar 

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Authors and Affiliations

  1. Cardiology Service, Reina Sofia University Hospital, Avenue Menendez Pidal s/n, 14004, Cordoba, Spain

    Lucia Carnero Montoro, Martin Ruiz Ortiz, Nick Paredes Hurtado, Monica Delgado Ortega, Ana Rodriguez Almodovar, Jose María Segura Saint-Gerons, Francisco Mazuelos Bellido, Miguel Angel Romero Moreno, Manuel Pan Alvarez-Ossorio & Maria Dolores Mesa Rubio

  2. Neurology Service, Reina Sofia University Hospital, Cordoba, Spain

    Juan Jose Ochoa Sepulveda & Roberto Valverde Moyano

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  1. Lucia Carnero Montoro
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  2. Martin Ruiz Ortiz
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Correspondence to Lucia Carnero Montoro.

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Montoro, L.C., Ortiz, M.R., Hurtado, N.P. et al. Impact on daily clinical practice of the latest evidence on percutaneous closure of patent foramen ovale after cryptogenic stroke: a single-center experience. Neurol Sci 43, 1865–1871 (2022). https://doi.org/10.1007/s10072-021-05524-4

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