New-onset atrial fibrillation after percutaneous patent foramen ovale closure: a meta-analysis

Abstract

Background The exact incidence and predictors of new-onset atrial fibrillation (AF) after percutaneous closure of patent foramen ovale (PFO) are unknown. Objective We sought to find post-procedural AF incidence rates and differences due to different screening strategies and devices. Methods A systematic search was conducted in Cochrane, MEDLINE and EMBASE. Controlled trials fulfilling the inclusion criteria were included into this meta-analysis. The incidence of new-onset AF was the primary outcome. Further parameters were surveillance strategy, device type, AF treatment and neurological events. New AF was determined as early onset within one month after implantation and late thereafter. Results 8 controlled trials and 16 cohort studies were eligible for quantitative analysis. 7643 patients received percutaneous PFO closure after cryptogenic stroke or transient ischaemic attack, 117 with other indications, whereas 1792 patients formed the control group. Meta-analysis of controlled trials showed an AF incidence of 5.1% in the interventional and 1.6% in the conservative arm, respectively (OR 3.17, 95% CI 1.46–6.86, P = 0.03, I2 = 55%). 4.7% received high-quality surveillance strategy with Holter-ECG or Loop recorder whereby AF incidence was overall higher compared to the low-quality group with 12-lead ECG only (3.3–15% vs. 0.2–4.3%). Heterogeneous results on time of AF onset were found, limited by different follow-up strategies. CardioSEAL and Starflex seemed to have higher AF incidences in early and late onset with 4.5% and 4.2%, respectively. Conclusion Percutaneous PFO closure led to higher AF post-procedural incidence compared to the conservative strategy. Heterogeneity in surveillance and follow-up strategy limited the generalizability. Trial Registration Registered on PROSPERO (CRD42022359945). Graphical abstract

Temporal alterations in P-wave electrocardiographic metrics post patent foramen ovale closure: a retrospective study

“…The lack of consensus about recurrent CVEs and AF occurring after PFO closure, and the detection of different incidences in follow-ups with ECG, Holter, and event recorder, make it necessary to use simpler and common parameters. [4][5][6] The electrocardiographic parameters related to PW characteristics-specifically PWmax, PWmin, PWdis, PWPT, and PWPTF -provide valuable insights into their potential associations with AF. 25 These parameters serve as important markers of atrial electrophysiology, offering a window into the underlying substrate that may contribute to the initiation and maintenance of AF.…”

“…However, some large-scale studies have observed an increase in atrial tachycardias postclosure when compared to patients undergoing medical monitoring. 4 While this rate was observed to be 4-6% in follow-ups of symptomatic patients and ambulatory Holter analyses, it was reported to be much higher in intracardiac recording studies. Among these atrial tachycardias, atrial fibrillation (AF) is of particular importance.…”

Atrial Fibrillation After Patent Foramen Ovale Closure: Incidence, Pathophysiology, and Management

“…The incidence was between 3.3% and 15% in high‐quality screening studies, between 0.4% and 10.3% in opportunistic studies, and between 0.2% and 4.3% in low‐quality screening studies. 28 Surely, the prospective, multicenter, observational cohort study in France will exact more safe conclusions, by monitoring 250 patients with intracardiac monitoring 2 months before and 24 months after PFO closure. 29 Although the precise incidence of AF following PFO closure remains elusive, our efforts to delineate this phenomenon are encapsulated in Figure 2 .…”

“… 38 This theory could probably explain why the incidence of AF was higher after the placement of first‐generation, more bulky devices, such as the STARFlex device. 28 , 39 Finally, it has been hypothesized that the interatrial conduction, largely via the Bachmann bundle lying in the roof of the atrium at the superior margin of the fossa ovalis, may be compromised by device placement. This is reflected in the finding of an increased P ‐wave duration index after closure and may provide further substrate for arrhythmogenesis.…”

“… 58 According to a recent, comprehensive systematic review and meta‐analysis, which included 24 studies and 7643 patients treated with PFO closure, the reported incidence was significantly lower (0.0008%); only 4 studies reported a total of 6 patients with ischemic events after detected AF events. 28 More specifically, 3 of them were reported in the CLOSURE I trial, and in 2 of these cases, the patients had device‐related thrombus detected by transesophageal echocardiogram. 54 Another case was diagnosed with transient ischemic attack after stopping antiplatelet therapy 3 years after the procedure and experienced an AF event 20 days after closure.…”