Percutaneous Closure Versus Medical Treatment in Stroke Patients With Patent Foramen Ovale: A Systematic Review and Meta-analysis

Ann Intern Med. 2018 Mar 6;168(5):343-350. doi: 10.7326/M17-3033. Epub 2018 Jan 9.


Background: New evidence emerged recently regarding the percutaneous closure of patent foramen ovale (PFO) to prevent recurrent stroke in patients with cryptogenic stroke.

Purpose: To compare risks for recurrent cerebrovascular events in adults with PFO and cryptogenic stroke who underwent PFO closure versus those who received medical therapy alone.

Data sources: PubMed, Scopus, and Google Scholar from 1 December 2004 through 14 September 2017; references of eligible studies; relevant scientific session abstracts; and cardiology Web sites.

Study selection: Randomized controlled trials, published in English, that compared PFO closure using a currently available device with medical treatment alone and that reported, at minimum, the rates of stroke or transient ischemic attack (TIA) or of new-onset atrial fibrillation (AF) or atrial flutter (AFL).

Data extraction: 2 investigators independently extracted study data and assessed study quality.

Data synthesis: 4 of 5 trials comparing PFO closure with medical therapy used commercially available devices. These 4 trials, involving 2531 patients, found that PFO closure reduced the risk for the main outcome of stroke or TIA (risk difference [RD], -0.029 [95% CI, -0.050 to -0.007]) and increased the risk for new-onset AF or AFL (RD, 0.033 [CI, 0.012 to 0.054]). The beneficial effect of PFO closure was associated with larger interatrial shunts (P = 0.034).

Limitation: Trials were not double-blind, and inclusion criteria were heterogeneous.

Conclusion: Compared with medical treatment, PFO closure prevents recurrent stroke and TIA but increases the incidence of AF or AFL in PFO carriers with cryptogenic stroke.

Primary funding source: Italian Ministry of Education, University and Research (MIUR). (PROSPERO: CRD42017074686).

Publication types

  • Meta-Analysis
  • Research Support, Non-U.S. Gov't
  • Systematic Review

MeSH terms

  • Foramen Ovale, Patent / complications*
  • Foramen Ovale, Patent / therapy*
  • Humans
  • Randomized Controlled Trials as Topic
  • Recurrence
  • Risk Assessment
  • Secondary Prevention / methods*
  • Septal Occluder Device
  • Stroke / etiology*
  • Stroke / prevention & control*