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- Title
Residual Shunt After Patent Foramen Ovale Closure and Long-Term Stroke Recurrence: A Prospective Cohort Study.
- Authors
Deng, Wenjun; Yin, Shanye; McMullin, David; Inglessis-Azuaje, Ignacio; Elmariah, Sammy; Hung, Judy; Lo, Eng H.; Palacios, Igor F.; Buonanno, Ferdinando S.; Ning, MingMing
- Abstract
Background: Residual shunt is observed in up to 25% of patients after patent foramen ovale (PFO) closure, but its long-term influence on stroke recurrence currently is unknown. Objective: To investigate the association of residual shunt after PFO closure with the incidence of recurrent stroke and transient ischemic attack (TIA). Design: Prospective cohort study comparing stroke or TIA recurrence in patients with and without residual shunt after PFO closure. Setting: Single hospital center. Participants: 1078 consecutive patients (mean age, 49.3 years) with PFO-attributable cryptogenic stroke who were undergoing percutaneous PFO closure were followed for up to 11 years. Measurements: Residual shunt was evaluated by transthoracic echocardiography with saline contrast. Primary outcome was a composite of the first recurrent ischemic stroke or TIA after PFO closure. Results: Compared with complete closure, the presence of residual shunt after PFO closure was associated with an increased incidence of recurrent stroke or TIA: 2.32 versus 0.75 events per 100 patient-years (hazard ratio [HR], 3.05 [95% CI, 1.65 to 5.62]; P < 0.001). This result remained robust after adjustment for important covariates, namely age; study period; device; presence of atrial septal aneurysm, hypertension, hyperlipidemia, diabetes, hypercoagulability, or hypermobile septum; and medication use (HR, 3.01 [CI, 1.59 to 5.69]; P < 0.001). Further stratification based on shunt size revealed that moderate or large residual shunts were associated with a higher risk for stroke or TIA recurrence (HR, 4.50 [CI, 2.20 to 9.20]; P < 0.001); the result for small residual shunts was indeterminate (HR, 2.02 [CI, 0.87 to 4.69]; P = 0.102). Limitation: Nonrandomized study with potential unmeasured confounding. Conclusion: Among patients undergoing PFO closure to prevent future stroke, the presence of residual shunt, particularly a moderate or large residual shunt, was associated with an increased risk for stroke or TIA recurrence. Primary Funding Source: National Institutes of Health. Visual Abstract. Residual Shunt After PFO Closure and Long-Term Stroke Recurrence Recent evidence has demonstrated the efficacy of patent foramen ovale (PFO) closure in preventing recurrent stroke. Residual shunt, however, may be observed after percutaneous closure. This study evaluated the long-term association of residual shunt with recurrent neurologic events after percutaneous PFO closure. Recent evidence has demonstrated the efficacy of patent foramen ovale (PFO) closure in preventing recurrent stroke. Residual shunt, however, may be observed after percutaneous closure. This study evaluated the long-term association of residual shunt with recurrent neurologic events after percutaneous PFO closure.
- Subjects
NATIONAL Institutes of Health (U.S.); PATENT foramen ovale; TRANSIENT ischemic attack; STROKE; LONGITUDINAL method; COHORT analysis; CEREBROSPINAL fluid shunts
- Publication
Annals of Internal Medicine, 2020, Vol 172, Issue 11, p717
- ISSN
0003-4819
- Publication type
Article
- DOI
10.7326/M19-3583