Patent Foramen Ovale Closure in Old Stroke Patients: A Subgroup Analysis of the DEFENSE-PFO Trial

Kwon, Hyun Wook; Lee, Pil Hyung; Song, Jae-Kwan; Kwon, Sun U.; Kang, Dong‐Wha; Kim, Jong Seung

doi:10.5853/jos.2021.00647

Cited by 26 publications

(20 citation statements)

References 11 publications

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“…An analysis did not identify an interaction by age, dichotomized as greater or less than 60 years. 5 However, this post hoc analysis was underpowered and updated professional society guidelines identify age as a critical consideration, indicating more data are needed to clearly establish the role of PFO closure in older patients. 6 , 7 , 8 The different approaches to age may reflect varying interpretations of the literature or may suggest neurologists are generally more conservative in approaching PFO closure after stroke.…”

Section: Discussionmentioning

confidence: 99%

“…While most trials excluded older patients (aged >60 years), 1 , 2 , 3 one did not, in which approximately one fourth were at least aged 60 years. 4 , 5 Several professional societies have published updated guideline statements emphasizing the importance of patient selection for PFO closure, 6 , 7 , 8 , 9 but it remains unclear how this has been integrated into clinical practice. In 2005, a survey‐based study revealed that cardiologists were more likely than neurologists to recommend PFO closure in young patients with cryptogenic stroke with PFO.…”

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confidence: 99%

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Clinicians' Approach to Patent Foramen Ovale Closure after Stroke: Comparing Cardiologists and Neurologists

Khan

Fiorilli

Messé

et al. 2022

JAHA

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Background Evidence from randomized trials and updated professional society guidelines supports patent foramen ovale (PFO) closure after cryptogenic stroke in select patients. It is unclear how this has been integrated into real‐world practice, so we aimed to compare practice patterns between cardiologists and neurologists. Methods and Results In March of 2021, a survey of cardiologists and neurologists who work or previously trained at the University of Pennsylvania Health System assessed practice preferences with respect to PFO closure after stroke. Clinical vignettes isolated specific variables of interest and used a 5‐point Likert scale to assess the level of support for PFO closure. Stroke neurologists and interventional cardiologists were compared by Wilcoxon‐Mann–Whitney tests. Secondarily, Kruskal–Wallis tests compared stroke neurologists, general neurologists, interventional cardiologists, and general cardiologists. We received 106 responses from 182 survey recipients (31/31 stroke neurologists, 38/46 interventional cardiologists, 20/30 general neurologists, and 17/77 general cardiologists). A similar proportion of stroke neurologists and interventional cardiologists favored PFO closure in a young patient with cryptogenic stroke, 88% and 87%, respectively ( P =0.54). Interventionalists were more likely than stroke neurologists to support closure in the context of an alternative high‐risk stroke mechanism, 14% and 0%, respectively ( P =0.003). Stroke neurologists were more likely to oppose closure on the basis of older age ( P =0.01). Conclusions There are key differences between how neurologists and cardiologists approach PFO closure after stroke, particularly when interpreting the stroke etiology and when considering closure beyond the scope of prior trials; this underscores the importance of collaboration between cardiologists and neurologists.

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Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

Clinicians' Approach to Patent Foramen Ovale Closure after Stroke: Comparing Cardiologists and Neurologists

Khan

Fiorilli

Messé

et al. 2022

JAHA

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“…25,26 In a secondary analysis of the Device Closure Versus Medical Therapy for Cryptogenic Stroke Patients With High-Risk Patent Foramen Ovale (DEFENSE-PFO) trial that included older patients (≥60 years), 4 PFO closure was also effective in older patients, although the results were inconclusive due to the small number of events. 27,28 Second, PFO closure in stroke patients with other determined etiologies remains a matter of debate. A recent study suggested that PFO may be the actual cause of stroke in some patients with determined etiologies, especially in younger patients or those who belong to the probable PASCAL category.…”

Section: Discussionmentioning

confidence: 99%

“…Actually, a low RoPE score (e.g., old age) alone was identified as an independent predictor of recurrent ischemic cerebrovascular events [ 25 , 26 ]. In a secondary analysis of the Device Closure Versus Medical Therapy for Cryptogenic Stroke Patients With High-Risk Patent Foramen Ovale (DEFENSE-PFO) trial that included older patients (≥60 years) [ 4 ], PFO closure was also effective in older patients, although the results were inconclusive due to the small number of events [ 27 , 28 ].…”

Section: Discussionmentioning

confidence: 99%

Establishment of the Heart and Brain Team for Patent Foramen Ovale Closure in Stroke Patients: An Expert Opinion

et al. 2022

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The online 2021 Asian-Pacific Heart and Brain Summit was organized to present and discuss experiences within leading Asian-Pacific centers with regard to institutional heart and brain teams managing the diagnosis, treatment, and follow-up of cryptogenic stroke (CS) patients with patent foramen ovale (PFO). This manuscript presents a narrative review of presentations and discussions during the summit meeting. Percutaneous PFO closure is an established therapy for CS patients in whom PFO is considered to be causal. Guidelines and consensus statements emphasize the importance of multidisciplinary clinical decision-making regarding PFO closure with the involvement of several clinical specialties, including neurology, cardiology, and hematology. It is also recommended that the patient be closely involved in this process. The heart and brain team is a collaborative platform that facilitates such a multidisciplinary decision-making process and patient involvement. It also creates opportunities for education and evaluation of the healthcare provided to patients with CS. This review provides insights into the implementation, composition, organization, and operation of a heart and brain team. Methods and metrics are suggested to evaluate the team’s role. We suggest that an efficient heart and brain team can implement guideline-recommended multidisciplinary clinical decision-making with regard to PFO closure in CS patients and play an important role in the management of these patients.

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“…Yet, very recent data suggest that PFO closure may offer greater advantage at older ages, and have sparked debate within the scientific community. A subgroup analysis of the DEFENSE-PFO trial has shown that transcatheter PFO closure versus medical therapy alone was significantly more beneficial in terms of ischaemic event recurrence only in subjects aged ≥60 years, and even more so in those aged ≥70 years [ 24 ]. Along the same lines are the results of an age-focused meta-analysis by Mazzucco et al [ 25 ] on cohort studies involving patients with cryptogenic ischaemic events.…”

Section: Discussionmentioning

confidence: 99%

Ischaemic Stroke of the “Hand-Knob” Area Due to Paradoxical Cerebral Air Embolism after Central Venous Catheterization—A Doubly Rare Occurrence: A Case Report and an Overview of Pathophysiology, Diagnosis, and Treatment

et al. 2022

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Central venous catheters (CVCs) are increasingly used across specialties for invasive haemodynamic monitoring and for the delivery of fluids, medications, and nutritional support. Cerebral air embolism (CAE) is a rare but potentially fatal complication associated with the insertion, maintenance, and removal of CVCs. It can occur through different mechanisms, including the direct retrograde ascension of air into the cerebral veins and paradoxical embolism due to a right-to-left intracardiac or intrapulmonary shunt. The “hand-knob” area is the cortical region within the primary motor cortex that contains the representation of the hand. It is located in the superior precentral gyrus and is the site of less than 1% of all ischaemic strokes. We report here the case of a patient who experienced an ischaemic stroke of the right “hand-knob” area, due to paradoxical CAE through a previously undiagnosed patent foramen ovale (PFO), after the insertion of a catheter in the right internal jugular vein. We also provide an overview of the pathophysiology, diagnosis, and treatment of CAE. Suspecting CAE in the case of an acute neurological event occurring in close temporal relationship with central venous catheterization is paramount to allow the early recognition and treatment of this uncommon form of iatrogenic stroke.

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Patent Foramen Ovale Closure in Old Stroke Patients: A Subgroup Analysis of the DEFENSE-PFO Trial

Cited by 26 publications

References 11 publications

Clinicians' Approach to Patent Foramen Ovale Closure after Stroke: Comparing Cardiologists and Neurologists

Clinicians' Approach to Patent Foramen Ovale Closure after Stroke: Comparing Cardiologists and Neurologists

Establishment of the Heart and Brain Team for Patent Foramen Ovale Closure in Stroke Patients: An Expert Opinion

Ischaemic Stroke of the “Hand-Knob” Area Due to Paradoxical Cerebral Air Embolism after Central Venous Catheterization—A Doubly Rare Occurrence: A Case Report and an Overview of Pathophysiology, Diagnosis, and Treatment

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