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Open Access Highly Accessed Research article

Transcatheter patent foramen ovale closure versus medical therapy for cryptogenic stroke: a meta-analysis of randomized clinical trials

Irbaz Bin Riaz1, Abhijeet Dhoble2, Ahmad Mizyed2, Chiu-Hsieh Hsu3, Muhammad Husnain2, Justin Z Lee1, Kapildeo Lotun2 and Kwan S Lee2*

Author Affiliations

1 Department of Internal Medicine, University of Arizona, Tucson, AZ 85714, USA

2 Department of Cardiovascular Diseases, University of Arizona, 3950 S Country Club Road, Suite 200, Tucson, AZ 85714, USA

3 Department of Biostatistics, University of Arizona, Tucson, AZ 85714, USA

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BMC Cardiovascular Disorders 2013, 13:116  doi:10.1186/1471-2261-13-116

Published: 11 December 2013

Abstract

Background

There is an association between cryptogenic stroke and patent foramen ovale (PFO). The optimal treatment strategy for secondary prevention remains unclear. The purpose of this study was to analyze aggregate data examining the safety and efficacy of transcatheter device closure versus standard medical therapy in patients with PFO and cryptogenic stroke.

Methods

A search of published data identified 3 randomized clinical trials for inclusion. The primary outcome was a composite end-point of death, stroke and transient-ischemic attack (TIA). Pre-defined subgroup analysis was performed with respect to baseline characteristics including age, sex, atrial septal aneurysm and shunt size. Data was synthesized using a random effects model and results presented as hazard ratios (HRs) with 95% confidence intervals (CIs).

Results

A cohort of 2,303 patients with a history of cryptogenic stroke and PFO were randomized to device closure (n = 1150) and medical therapy (n = 1153). Mean follow-up was 2.5 years. Transcatheter closure was not superior to medical therapy in the secondary prevention of stroke or TIA in intention-to-treat analysis (HR: 0.66, 95% CI: 0.43 to 1.01; p = 0.056). However, the results were statistically significant using per-protocol analysis (HR: 0.64, 95% CI: 0.41 to 0.98; p = 0.043). Males had significant benefit with device closure (HR: 0.48, 95% CI: 0.24 to 0.96; p = 0.038).

Conclusions

In this meta-analysis, using intention-to-treat analysis, transcatheter device closure of PFO was not superior to standard medical therapy in the secondary prevention of cryptogenic stroke. Transcatheter closure was superior using per-protocol analysis.

Keywords:
Patent foramen ovale; Inter atrial shunt; Transcatheter closure; Cryptogenic stroke