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Canadian Journal of Cardiology

Risk of Perioperative Stroke in Patients With Patent Foramen Ovale: A Systematic Review and Meta-analysis

Published:March 02, 2022DOI:https://doi.org/10.1016/j.cjca.2022.02.026

      Abstract

      Background

      Patent foramen ovale (PFO) is a common congenital cardiac abnormality. Risk of stroke increases perioperatively, but the association of PFO with perioperative stroke risk remains unclear. We conducted a systematic review to inform the risk of perioperative stroke in patients with PFO undergoing surgery.

      Methods

      Embase, MEDLINE, and Cochrane databases were searched from inception to January 2020. We described methods used for establishing PFO and perioperative stroke diagnosis. We conducted meta-analyses to obtain pooled estimates for risk of stroke in patients with and without PFO in different surgical populations.

      Results

      Ten articles with a total of 20,858,011 patients met the eligibility criteria. Prevalence of PFO ranged from 0.06% to 1.4% based on International Classification of Diseases (ICD)–code diagnosis and from 10.4% to 40.4% based on echocardiography diagnosis. Perioperative stroke was observed in 0% to 25% of patients with PFO, and 0% to 16.7% without PFO. Studies that used echocardiography to diagnose PFO found no association between PFO and perioperative stroke. Studies that used ICD codes found strong association but were highly heterogeneous. PFO was not associated with a risk of perioperative stroke in cardiac and transplantation surgeries. While the adjusted odds ratios for stroke were substantial for orthopaedic, general, genitourinary, neurologic, and thoracic surgeries (with PFO status established based on ICD codes), data heterogeneity and quality of data create significant uncertainty.

      Conclusions

      In conclusion, PFO is likely a risk factor for perioperative stroke in selected types of surgeries. However, this is based on very low-quality evidence. Rigorous prospective studies are needed to further investigate this relationship.

      Résumé

      Contexte

      Le foramen ovale perméable (FOP) est une anomalie cardiaque congénitale courante. Le risque d’accident vasculaire cérébral (AVC) augmente au cours de la période périopératoire. Toutefois, l’association entre le FOP et le risque d'AVC dans ce contexte reste incertaine. Nous avons réalisé une revue systématique afin d’objectiver le risque d'AVC périopératoire chez les patients qui présentent un FOP.

      Méthodologie

      Des recherches ont été effectuées dans les bases de données Embase, MEDLINE et Cochrane. La période ciblée allait de la date de leur création jusqu’au mois de janvier 2020. Les méthodes utilisées pour poser le diagnostic de FOP et d'AVC périopératoire ont été caractérisées. Des méta-analyses nous ont permis d’obtenir des estimations globales du risque d'AVC chez les patients ayant ou non un FOP dans différents contextes chirurgicaux.

      Résultats

      Dix articles, portant sur 20 858 011 patients en tout, répondaient aux critères d’inclusion. La prévalence du FOP allait de 0,06 à 1,4 % d’après les codes diagnostiques de la Classification internationale des maladies (CIM) et de 10,4 à 40,4 % d’après les résultats des examens échocardiographiques diagnostiques. Un AVC périopératoire a été noté chez 0 à 25 % des patients ayant un FOP et chez 0 à 16,7 % des patients n’en ayant pas. Les études où l’échocardiographie a servi à poser le diagnostic de FOP n’ont révélé aucune association entre le FOP et les AVC périopératoires. Les études où les codes CIM avaient été utilisés mettaient en lumière une forte association, mais étaient très hétérogènes. Le FOP n’était pas associé à un risque d'AVC périopératoire dans le contexte d’interventions chirurgicales cardiaques et de greffes. Les rapports de cotes ajustés pour l'AVC étaient élevés dans le cas des interventions chirurgicales orthopédiques, générales, génito-urinaires, neurologiques et thoraciques (la présence d’un FOP ayant été établie sur la base des codes CIM), mais l’hétérogénéité et la qualité des données créent une grande incertitude.

      Conclusions

      Le FOP constitue probablement un facteur de risque d'AVC périopératoire dans certains contextes chirurgicaux. Ce constat repose toutefois sur des données probantes de très faible qualité. Des études prospectives rigoureuses devront donc être menées pour approfondir la question.
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      References

        • Hagen P.T.
        • Scholz D.G.
        • Edwards W.D.
        Incidence and size of patent foramen ovale during the first 10 decades of life: an autopsy study of 965 normal hearts.
        Mayo Clin Proc. 1984; 59: 17-20
        • Michel P.
        • Villablanca P.A.
        • Ranka S.
        • et al.
        Patent foramen ovale and risk of cryptogenic stroke—analysis of outcomes and perioperative implications.
        J Cardiothorac Vasc Anesth. 2020; 34: 819-826
        • Zier L.S.
        • Sievert H.
        • Mahadevan V.S.
        To close or not to close: contemporary indications for patent foramen ovale closure.
        Exp Rev Cardiovasc Ther. 2016; 14: 1235-1244
        • Collado F.M.S.
        • Poulin M.F.
        • Murphy J.J.
        • et al.
        Patent foramen ovale closure for stroke prevention and other disorders.
        J Am Heart Assoc. 2018; 7e007146
        • Lamy C.
        • Giannesini C.
        • Zuber M.
        • et al.
        Clinical and imaging findings in cryptogenic stroke patients with and without patent foramen ovale: the PFO-ASA study.
        Stroke. 2002; 33: 706-711
        • Morais L.A.
        • Sousa L.
        • Fiarresga A.
        • et al.
        RoPE score as a predictor of recurrent ischemic events after percutaneous patent foramen ovale closure.
        Int Heart J. 2018; 59: 1327-1332
        • Nedeltchev K.
        • Arnold M.
        • Wahl A.
        • et al.
        Outcome of patients with cryptogenic stroke and patent foramen ovale.
        J Neurol Neurosurg Psychiatry. 2002; 72: 347-350
        • Sukernik M.R.
        • Bennett-Guerrero E.
        The incidental finding of a patent foramen ovale during cardiac surgery: should it always be repaired? A core review.
        Anesth Analg. 2007; 105: 602-610
        • Alkhouli M.
        • Sievert H.
        • Holmes D.R.
        Patent foramen ovale closure for secondary stroke prevention.
        Eur Heart J. 2019; 40: 2339-2350
        • Mashour G.A.
        • Moore L.E.
        • Lele A.V.
        • Robicsek S.A.
        • Gelb A.W.
        Perioperative care of patients at high risk for stroke during or after non-cardiac, non-neurologic surgery: consensus statement from the Society for Neuroscience in Anesthesiology and Critical Care.
        J Neurosurg Anesthesiol. 2014; 26
        • Al-Hader R.
        • Al-Robaidi K.
        • Jovin T.
        • et al.
        The incidence of perioperative stroke: estimate using state and national databases and systematic review.
        J Stroke. 2019; 21: 290-301
        • Salazar J.D.
        • Wityk R.J.
        • Grega M.A.
        • et al.
        Stroke after cardiac surgery: short- and long-term outcomes.
        Ann Thorac Surg. 2001; 72: 1195-1201
        • Devereaux P.J.
        • Yang H.
        • Yusuf S.
        • et al.
        • POISE Study Group
        Effects of extended-release metoprolol succinate in patients undergoing noncardiac surgery (POISE trial): a randomised controlled trial.
        Lancet. 2008; 371: 1839-1847
        • Gaudino M.
        • Benesch C.
        • Bakaeen F.
        • et al.
        American Heart Association Council on Cardiovascular Surgery and Anesthesia; Stroke Council; Council on Cardiovascular and Stroke Nursing. Considerations for reduction of risk of perioperative stroke in adult patients undergoing cardiac and thoracic aortic operations: a scientific statement from the American Heart Association.
        Circulation. 2020; 142: e193-e209
        • NeuroVISION Investigators
        Perioperative covert stroke in patients undergoing noncardiac surgery (NeuroVISION): a prospective cohort study.
        Lancet. 2019; 394: 1022-1029
        • Page M.J.
        • McKenzie J.E.
        • Bossuyt P.M.
        • et al.
        The PRISMA 2020 statement: an updated guideline for reporting systematic reviews.
        BMJ. 2021; 372: n71
        • Covidence
        Better systematic review management.
        (Available at:)
        • Moola S.M.Z.
        • Tufanaru C.
        • Aromataris E.
        • et al.
        Systematic reviews of etiology and risk.
        in: Aromataris E. Munn Z. JBI Manual for Evidence Synthesis. Joanna Briggs Institute, 2020 (Available at:) (Accessed June 10, 2022)
        • Higgins J.P.
        • Thompson S.G.
        • Deeks J.J.
        • Altman D.G.
        Measuring inconsistency in meta-analyses.
        BMJ. 2003; 327: 557-560
        • R Core Team
        R: a language and environment for statistical computing.
        R Foundation for Statistical Computing, 2020
        • Higgins J.P.
        • Thompson S.G.
        Quantifying heterogeneity in a meta-analysis.
        Stat Med. 2002; 21: 1539-1558
        • Engelhardt M.
        • Folkers W.
        • Brenke C.
        • et al.
        Neurosurgical operations with the patient in sitting position: analysis of risk factors using transcranial Doppler sonography.
        Br J Anaesth. 2006; 96: 467-472
        • Patel R.
        • Stygall J.
        • Harrington J.
        • Newman S.
        • Haddad F.
        Intra-operative cerebral microembolisation during primary hybrid total hip arthroplasty compared with primary hip resurfacing.
        Acta Orthop Belg. 2009; 75: 671-677
        • Patel R.V.
        • Stygall J.
        • Harrington J.
        • Newman S.P.
        • Haddad F.S.
        Cerebral microembolization during primary total hip arthroplasty and neuropsychologic outcome: a pilot study.
        Clin Orthop Relat Res. 2010; 468: 1621-1629
        • Friedrich S.
        • Ng P.Y.
        • Platzbecker K.
        • et al.
        Patent foramen ovale and long-term risk of ischaemic stroke after surgery.
        Eur Heart J. 2019; 40: 914-924
        • Floyd T.F.
        • Shah P.N.
        • Price C.C.
        • et al.
        Clinically silent cerebral ischemic events after cardiac surgery: their incidence, regional vascular occurrence, and procedural dependence.
        Ann Thorac Surg. 2006; 81: 2160-2166
        • Krasuski R.A.
        • Hart S.A.
        • Allen D.
        • et al.
        Prevalence and repair of intraoperatively diagnosed patent foramen ovale and association with perioperative outcomes and long-term survival.
        JAMA. 2009; 302: 290-297
        • Werlang M.E.
        • Palmer W.C.
        • Boyd E.A.
        • et al.
        Patent foramen ovale in liver transplant recipients does not negatively impact short-term outcomes.
        Clin Transplant. 2016; 30: 26-32
        • Perfetti D.C.
        • Chughtai M.
        • Boylan M.R.
        • et al.
        Atrial septal defect increases the risk for stroke after total hip arthroplasty.
        J Arthroplasty. 2017; 32: 3152-3156
        • Gai N.
        • Lavi R.
        • Jones P.M.
        • et al.
        The use of point-of-care ultrasound to diagnose patent foramen ovale in elective hip and knee arthroplasty patients and its association with postoperative delirium.
        Can J Anaesth. 2018; 65: 619-626
        • Gertsvolf N.
        • Andersen E.
        • Othman T.
        • et al.
        Patent foramen ovale and neurologic events in patients undergoing liver transplantation.
        Cardiovasc Revasc Med. 2018; 19: 53-55
        • Hess N.R.
        • Esper S.A.
        • Awori Hayanga J.W.
        • et al.
        Patent foramen ovale repair at the time of double lung transplantation: necessary or not?.
        Clin Transplant. 2018; e13201
        • Ng P.Y.
        • Ng A.K.
        • Subramaniam B.
        • et al.
        Association of preoperatively diagnosed patent foramen ovale with perioperative ischemic stroke.
        JAMA. 2018; 319: 452-462
        • Smilowitz N.R.
        • Subashchandran V.
        • Berger J.S.
        Atrial septal defect and the risk of ischemic stroke in the perioperative period of noncardiac surgery.
        Am J Cardiol. 2019; 124: 1120-1124
        • Villablanca P.A.
        • Lemor A.
        • So C.Y.
        • et al.
        Increased risk of perioperative ischemic stroke in patients who undergo noncardiac surgery with preexisting atrial septal defect or patent foramen ovale.
        J Cardiothorac Vasc Anesth. 2020; 34: 2060-2068
        • Duceppe E.
        • Parlow J.
        • MacDonald P.
        • et al.
        Canadian Cardiovascular Society guidelines on perioperative cardiac risk assessment and management for patients who undergo noncardiac surgery.
        Can J Cardioly. 2017; 33: 17-32
        • Kristensen S.D.
        • Knuuti J.
        • Saraste A.
        • et al.
        2014 ESC/ESA guidelines on noncardiac surgery: cardiovascular assessment and management: the Joint Task Force on Noncardiac Surgery: Cardiovascular Assessment and Management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA).
        Eur Heart J. 2014; 35: 2383-2431
        • Mehdi Z.
        • Birns J.
        • Partridge J.
        • Bhalla A.
        • Dhesi J.
        Perioperative management of adult patients with a history of stroke or transient ischaemic attack undergoing elective noncardiac surgery.
        Clin Med. 2016; 16: 535-540
        • Meissner I.
        • Whisnant J.P.
        • Khandheria B.K.
        • et al.
        Prevalence of potential risk factors for stroke assessed by transesophageal echocardiography and carotid ultrasonography: the SPARC study.
        Mayo Clin Proc. 1999; 74: 862-869
        • Smilowitz N.R.
        • Gupta N.
        • Ramakrishna H.
        • et al.
        Perioperative major adverse cardiovascular and cerebrovascular events associated with noncardiac surgery.
        JAMA Cardiol. 2017; 2: 181-187
        • Benesch C.
        • Glance L.G.
        • Derdeyn C.P.
        • et al.
        American Heart Association Stroke Council; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology; Council on Epidemiology and Prevention. Perioperative neurological evaluation and management to lower the risk of acute stroke in patients undergoing noncardiac, nonneurological surgery: a scientific statement from the American Heart Association/American Stroke Association.
        Circulation. 2021; 143: e923-e926
        • di Tullio M.R.
        • Sacco R.L.
        • Sciacca R.R.
        • Jin Z.
        • Homma S.
        Patent foramen ovale and the risk of ischemic stroke in a multiethnic population.
        J Am Coll Cardiol. 2007; 49: 797-802
        • Meissner I.
        • Khandheria B.K.
        • Heit J.A.
        • et al.
        Patent foramen ovale: innocent or guilty? Evidence from a prospective population-based study.
        J Am Coll Cardiol. 2006; 47: 440-445
        • Elgendy A.Y.
        • Saver J.L.
        • Amin Z.
        • et al.
        Proposal for updated nomenclature and classification of potential causative mechanism in patent foramen ovale-associated stroke.
        JAMA Neurol. 2020; 77: 878-886
        • Pristipino C.
        • Anzola G.P.
        • Ballerini L.
        • et al.
        Management of patients with patent foramen ovale and cryptogenic stroke: a collaborative, multidisciplinary, position paper.
        Catheter Cardiovasc Interv. 2013; 82: e38-e51