Stroke or transient ischemic attack in patients with transvenous pacemaker or defibrillator and echocardiographically detected patent foramen ovale.

Abstract

BACKGROUND:

A patent foramen ovale (PFO) may permit arterial embolization of thrombi that accumulate on the leads of cardiac implantable electronic devices in the right-sided cardiac chambers. We sought to determine whether a PFO increases the risk of stroke/transient ischemic attack (TIA) in patients with endocardial leads.

METHODS AND RESULTS:

We retrospectively evaluated all patients who had endocardial leads implanted between January 1, 2000, and October 25, 2010, at Mayo Clinic Rochester. Echocardiography was used to establish definite PFO and non-PFO cohorts. The primary end point of stroke/TIA consistent with a cardioembolic etiology and the secondary end point of mortality during postimplantation follow-up were compared in PFO versus non-PFO patients with the use of Cox proportional hazards models. We analyzed 6075 patients (364 with PFO) followed for a mean 4.7 ± 3.1 years. The primary end point of stroke/TIA was met in 30/364 (8.2%) PFO versus 117/5711 (2.0%) non-PFO patients (hazard ratio, 3.49; 95% confidence interval, 2.33-5.25; P<0.0001). The association of PFO with stroke/TIA remained significant after multivariable adjustment for age, sex, history of stroke/TIA, atrial fibrillation, and baseline aspirin/warfarin use (hazard ratio, 3.30; 95% confidence interval, 2.19-4.96; P<0.0001). There was no significant difference in all-cause mortality between PFO and non-PFO patients (hazard ratio, 0.91; 95% confidence interval, 0.77-1.07; P=0.25).

CONCLUSIONS:

In patients with endocardial leads, the presence of a PFO on routine echocardiography is associated with a substantially increased risk of embolic stroke/TIA. This finding suggests a role of screening for PFOs in patients who require cardiac implantable electronic devices; if a PFO is detected, PFO closure, anticoagulation, or nonvascular lead placement may be considered.

• Authors: Christopher V DeSimone, Paul A Friedman, Amit Noheria, Nikhil A Patel, Daniel C DeSimone, Sami Bdeir, Christopher A Aakre, Vaibhav R Vaidya, Joshua P Slusser, David O Hodge, Michael J Ackerman, Alejandro A Rabinstein, Samuel J Asirvatham
• Journal: Circulation (Circulation) Vol. 128 Issue 13 Pg. 1433-41 (Sep 24 2013) ISSN: 1524-4539 [Electronic] United States
• PMID: 23946264 (Publication Type: Journal Article, Research Support, Non-U.S. Gov't)

Topics

• Aged
• Aged, 80 and over
• Cohort Studies
• Defibrillators, Implantable
• Echocardiography, Transesophageal
• Female
• Follow-Up Studies
• Foramen Ovale, Patent (diagnostic imaging, epidemiology, therapy)
• Humans
• Ischemic Attack, Transient (diagnostic imaging, epidemiology)
• Male
• Middle Aged
• Pacemaker, Artificial
• Retrospective Studies
• Stroke (diagnostic imaging, epidemiology)
• Survival Rate (trends)