Device Closure of Patent Foramen Ovale After Stroke: Pooled Analysis of Completed Randomized Trials

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• 作者：David M. Kent ; MD^a ; ^b ; ^{dkent1@tuftsmedicalcenter.org" class="auth_mail" title="E-mail the corresponding author} ; Issa J. Dahabreh ; MD^a ; ^c ; ^d ; ^e ; Robin Ruthazer ; MPH^a ; Anthony J. Furlan ; MD^f ; Mark Reisman ; MD^g ; John D. Carroll ; MD^h ; Jeffrey L. Saver ; MDⁱ ; Richard W. Smalling ; MD ; PhD^j ; Peter Jü ; ni ; MD^k ; ^l ; Heinrich P. Mattle ; MD^m ; Bernhard Meier ; MDⁿ ; David E. Thaler ; MD^b
• 关键词：cryptogenic stroke ; meta-analysis ; transient ischemic attack
• 刊名：Journal of the American College of Cardiology
• 出版年：2016
• 出版时间：1 March 2016
• 年：2016
• 卷：67
• 期：8
• 页码：907-917
• 全文大小：1337 K

文摘

The comparative effectiveness of percutaneous closure of patent foramen ovale (PFO) plus medical therapy versus medical therapy alone for cryptogenic stroke is uncertain.

Objectives

The authors performed the first pooled analysis of individual participant data from completed randomized trials comparing PFO closure versus medical therapy in patients with cryptogenic stroke.

Methods

The analysis included data on 2 devices (STARFlex [umbrella occluder] [NMT Medical, Inc., Boston, Massachusetts] and Amplatzer PFO Occluder [disc occluder] [AGA Medical/St. Jude Medical, St. Paul, Minnesota]) evaluated in 3 trials. The primary composite outcome was stroke, transient ischemic attack, or death; the secondary outcome was stroke. We used log-rank tests and unadjusted and covariate-adjusted Cox regression models to compare device closure versus medical therapy.

Results

Among 2,303 patients, closure was not significantly associated with the primary composite outcome. The difference became significant after covariate adjustment (hazard ratio [HR]: 0.68; p = 0.049). For the outcome of stroke, all comparisons were statistically significant, with unadjusted and adjusted HRs of 0.58 (p = 0.043) and 0.58 (p = 0.044), respectively. In analyses limited to the 2 disc occluder device trials, the effect of closure was not significant for the composite outcome, but was for the stroke outcome (unadjusted HR: 0.39; p = 0.013). Subgroup analyses did not identify significant heterogeneity of treatment effects. Atrial fibrillation was more common among closure patients.

Conclusions

Among patients with PFO and cryptogenic stroke, closure reduced recurrent stroke and had a statistically significant effect on the composite of stroke, transient ischemic attack, and death in adjusted but not unadjusted analyses.