Antithrombotic treatment after transcatheter patent foramen ovale closure in patients with previous cryptogenic stroke

The safety and the efficacy of transcatheter patent foramen ovale (PFO) closure as a secondary prevention measure for patients that have experienced a cryptogenic stroke has been demonstrated in multiple randomized controlled trials. The recently published European guidelines recommend dual antiplatelet therapy (DAPT) for 3-6 months, tailored from aspirin or clopidogrel following the transcatheter PFO closure. However, the extent to which these recommendations are impleme nted in current clinical practice remains uncertain.

This analysis seeks to investigate prevailing trends in the duration and the customization of antithrombotic treatment following transcatheter PFO closure, as observed in contemporary clinical practice.

Consecutively treated patients undergoing transcatheter PFO closure at a tertiary hospital were included in our analysis. We scrutinized baseline demographic details, comorbidities, and pharmaceutical characteristics.

Data on post-closure antithrombotic treatment were available for 71 patients, who were predominantly female (60.6%) and had a mean age of 46.6±4.7 years. Hypertension, dyslipidemia, and diabetes mellitus were present in 22 (30%), 36 (50%), and 6 (8%) patients, respectively. Only one patient had a pre-existing diagnosis of coronary artery disease before the initial event. Following transcatheter PFO closure, all patients received antithrombotic therapy; only two did not receive any antiplatelet agent but were treated solely with a newer anticoagulant. Out of them, the first patient, due to known thrombophilia and high bleeding risk, received only apixaban following the hematologists' consultation. The second one developed atrial fibrillation during the hospitalization for the procedure; therefore, was anticoagulated with rivaroxaban. Consequently, at discharge, 69 patients (97%) were on antiplatelet treatment, 63 (91%) were on DAPT and the remaining six (9%) on a single antiplatelet agent (SAPT). More specifically, out of the patients that were treated with SAPT, one patient has received concomitantly aspirin and NOAC, two only aspirin and the last three were treated with clopidogrel due to aspirin intolerance. Forty-four patients (64%) were treated with DAPT for 3-6 months, two (3%) were treated for less than three months, and the remaining for more than six months. During a mean follow-up of 1,014 ± 462 days, we suspected that a recurrent stroke occurred in one patient, who was discharged with aspirin treatment, 38 months after the procedure.

While current guidelines recommend 3-6 months of DAPT after PFO closure, our analysis indicates that physicians generally adhere to these recommendations. Deviations from the guidelines are primarily attributed to specific patient clinical situations. Further studies are warranted to determine the optimal duration of antithrombotic treatment after PFO closure and enhance physician compliance with guidelines.