Atrial Septal Aneurysm, Shunt Size, Recurrent Stroke Risk in PFO Patients

May 05, 2020
Font Size
A
A
A
Authors:
Turc G, Lee JY, Brochet E, et al., on behalf of the CLOSE and DEFENSE-PFO Trial Investigators.
Citation:
Atrial Septal Aneurysm, Shunt Size, and Recurrent Stroke Risk in Patients With Patent Foramen Ovale. J Am Coll Cardiol 2020;75:2312-2320.
Summary By:
Mollie McDermott, MD, MS

Quick Takes

  • Results from previous studies suggest that large PFO and ASA may increase the risk of recurrent ischemic stroke in PFO patients.
  • In this pooled analysis of patient-level data, the presence of ASA but not large PFO was associated with an increased risk of recurrent ischemic stroke.
  • As such, patients with ASA may benefit more from PFO closure than those without ASA given a higher annual risk of recurrent ischemic stroke.

Study Questions:

In patients with recent patent foramen ovale (PFO)-related stroke, what is the effect of large PFO size and atrial septal aneurysm (ASA) on the risk of recurrent ischemic stroke?

Methods:

This is a pooled analysis of data from individual PFO patients enrolled in four trials (two observational and two randomized controlled studies) treated with either antiplatelet therapy or anticoagulation (no PFO closure). All patients underwent transthoracic and transesophageal echocardiography. ASA was defined as an interatrial septal excursion ≥10 mm, and a large PFO was defined by >30 bubbles in the left atrium within three cardiac cycles. The primary outcome was time to recurrent ischemic stroke.

Results:

A total of 898 patients were included in this study, with a mean age of 45.3 years: 263 (29.3%) received oral anticoagulation and 635 (70.7%) received antiplatelet therapy. Median follow-up was 3.8 (interquartile range, 2.6-5.5) years, over which time 47 (5.2%) patients had recurrent ischemic stroke. The incident rates of recurrent ischemic stroke per 100 person-years (with 95% confidence intervals) were as follows:

  • For the 397 (44%) patients without ASA and with large PFO: 0.6 (0.4-1.1)
  • For the 252 (28%) without ASA and without large PFO: 1.3 (0.7-2.3)
  • For the 178 (20%) patients with ASA and large PFO: 2.4 (1.6-3.8)
  • For the 71 (8%) patients with ASA and nonlarge PFO: 2.7 (1.3-5.5)

No interaction was observed between large PFO and ASA presence (p = 0.96).

Conclusions:

In this pooled analysis of patient-level data, the presence of ASA but not large PFO was associated with an increased risk of recurrent ischemic stroke in patients with recent PFO-related stroke. The annual risk of recurrent ischemic stroke in patients with ASA was approximately 2.5%. No synergistic effect between ASA presence and large PFO was observed.

Perspective:

Data from the present pooled analysis suggest that patients with ASA may benefit more from PFO closure than those without ASA, although additional data from randomized controlled PFO closure trials are needed to confirm this.

Clinical Topics: Anticoagulation Management, Congenital Heart Disease and Pediatric Cardiology, Noninvasive Imaging, Prevention, Congenital Heart Disease, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Imaging, CHD and Pediatrics and Quality Improvement, Echocardiography/Ultrasound

Keywords: Anticoagulants, Atrial Septum, Brain Ischemia, Echocardiography, Echocardiography, Transesophageal, Foramen Ovale, Patent, Heart Aneurysm, Heart Atria, Heart Defects, Congenital, Platelet Aggregation Inhibitors, Risk, Secondary Prevention, Stroke, Vascular Diseases


< Back to Listings