Page 31 - Journal of Structural Heart Disease Volume 4, Issue 5

Original Scientific Article
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parisons of different treatment modalities are shown in Figure 2B. Plotting the posterior mean deviance of the individual data points in the inconsistency model against their posterior mean deviance in the consis- tency model suggested reasonable consistency be- tween direct and indirect evidence.
Discussion
The present study is a network meta-analysis com- paring three different strategies for recurrent stroke prevention in patients with PFO and cryptogenic stroke, namely, PFO closure, antiplatelet therapy and oral anticoagulation. The main finding of our study is that PFO closure is associated with significant reduc- tion in recurrent strokes when compared to antiplate- let therapy alone.
Trans catheter PFO closure has been compared to medical therapy in randomized trials to evaluate the benefit in recurrent stroke prevention in patients with cryptogenic strokes. In the CLOSURE I [6] and the PC [4] trials as well as the early results of the RESPECT tri- al, [9] there was no significant benefit of PFO closure over medical therapy. However, when PFO closure was compared to antiplatelet therapy alone in the REDUCE [7] and CLOSE [5] trials, there was significant reduction in recurrent stroke events in patients who underwent PFO closure. Hence, the inclusion of pa- tients on anticoagulation in the medical therapy arm might have contributed to the absence of difference between PFO closure and medical therapy.
A recent updated meta-analysis comparing PFO closure to medical therapy, whether antiplatelets or oral anticoagulation, PFO closure was associated with significant reduction in recurrent strokes. [16] In our study, however, we aimed to evaluate the benefit of PFO closure compared to antiplatelet therapy and oral anticoagulation separately. Based on the results
of our study, there is clear benefit of PFO closure over antiplatelet therapy alone. On the other hand, when compared to oral anticoagulation, the benefit of PFO closure is less evident and needs further investiga- tion.
There are limitations to our study that should be considered. There was marked heterogeneity be- tween the results of the trials. However, we used the more conservative random effect model for interpre- tation of the results. Another limitation is the exclu- sion of the PC trial as outcomes were not reported separately for patients on antiplatelets and patients on anticoagulation in that trial. A third limitation is that we were unable to perform subgroup analy- sis based on factors like age, atrial septal aneurysm and shunt size that might have an impact on recur- rent strokes. A fourth limitation is that the only out- come evaluated was recurrent strokes because there were no sufficient data on other outcomes that was stratified based on medical therapy used. Finally, the number of patients in the oral anticoagulation arm is small. Therefore, the results pertaining the use of an- ticoagulation should be taken with caution and more trials are needed to validate our findings.
In conclusion, when compared to antiplatelet therapy alone, PFO closure is an effective treatment strategy for recurrent stroke prevention in patients with PFO who had a cryptogenic stroke. This benefit was not statistically significant when PFO closure was compared with the use of oral anticoagulation.
Conflict of Interest
The authors have no conflict of interest relevant to this publication.
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References
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Journal of Structural Heart Disease, October 2018
Volume 4, Issue 5:222-227