New evidence suggests that closure of a
patent foramen ovale (PFO) plus medical
therapy (MT; antiplatelet or anticoagulation) is superior to MT alone to prevent recurrent
cryptogenic stroke. We performed a meta-analysis of randomized controlled trials that compared PFO closure plus MT with MT alone in patients with
cryptogenic stroke. The efficacy end points were recurrent
stroke, transient
ischemia attack, and death. The safety end points were major
bleeding and newly detected
atrial fibrillation. Trials were pooled using random effects and fixed effects models. A trial sequential analysis was performed to assess if the current evidence is sufficient. Risk ratios (RR) were calculated for pooled estimates of risk. Five randomized controlled trials (3,440 patients) were included. Mean follow-up was 4.1 years. PFO closure reduced the risk of recurrent
stroke by 58% (RR 0.42, 95% CI 0.20 to 0.91, p = 0.03). The number needed to treat was 38. The cumulative Z-line crossed the trial sequential boundary, suggesting there is adequate evidence to conclude that PFO closure reduces the risk of recurrent
stroke by 60%. PFO closure did not reduce the risk of transient
ischemia attack (RR 0.78, 95% CI 0.53 to 1.15, p = 0.21), mortality (RR 0.74, 95% CI 0.35 to 1.60, p = 0.45), or major
bleeding (RR 0.96, 95% CI 0.42 to 2.20, p = 0.93); it did increase the risk of
atrial fibrillation (RR 4.69, 95% CI 2.17 to 10.12, p <0.0001).