Pulmonary arteriovenous malformation and cryptogenic stroke / 国际脑血管病杂志

The relationship between pulmonary arteriovenous malformations (PAVMs) and stroke remains unclear. With the development of imaging technology, studies shows that PAVMs are an important cause of cryptogenic stroke (CS). Most PAVMs are not diagnosed until the onset of stroke. The main pathogenesis of PAVMs-related CS is paradoxical embolism and increased blood viscosity caused by iron deficiency anemia. Antiplatelet therapy and interventional therapy may have a preventive effect on recurrent stroke in such patients. This article summarizes the pathophysiological mechanism, diagnosis and treatment of PAVMs-related CS, hoping to provide new ideas for the diagnosis and treatment of CS.

Papel do Ecocardiograma na Avaliação do Septo Interatrial e Pesquisa de Forame Oval Patente como Fonte Emboligênica / The Role of Echocardiography in the Assessment of the Interatrial Septum and Patent Foramen Ovale as an Emboligenic Source

Resumo A comunicação do septo atrial (CIA) representa, aproximadamente, de 6%-10% dos defeitos cardíacos congênitos, com incidência de 1 em 1.500 nascidos vivos.1 Forame oval patente (FOP) é mais comum e está presente em mais de 20%-25% dos adultos.2 Síndromes clínicas associadas a CIA e FOP são variáveis, com implicações abrangendo a medicina pediátrica e adulta, neurologia e cirurgia. O interesse adicional na anatomia do septo interatrial (SIA) aumentou substancialmente nas últimas duas décadas, com evolução simultânea dos procedimentos percutâneos envolvendo cardiopatia estrutural do lado esquerdo e procedimentos eletrofisiológicos. Idealmente, essas intervenções baseadas em cateter requerem rota direta para o átrio esquerdo (AE) através do SIA, necessitando completo entendimento de sua anatomia. Atualmente, tecnologias de imagem sofisticadas e não invasivas como ecocardiografia transesofágica bidimensional (ETE 2D) e tridimensional (ETE 3D), ressonância cardíaca (RMC) e tomografia computadorizada (TC) passaram por um extraordinário desenvolvimento tecnológico, fornecendo detalhes anatômicos das estruturas cardíacas visualizadas em formato 2D e 3D e são essenciais para diagnóstico e tratamento de pacientes com doenças cardíacas. A avaliação da anatomia e anormalidades do SIA, portanto, requer abordagem padronizada e sistemática, integrando modalidades diagnósticas e fornecendo avaliação adequada e uniforme para terapias cirúrgicas e transcateter.

Abstract Atrial septal defects (ASD) account for approximately 6%-10% of congenital heart defects, with an incidence of 1 in 1,500 live births.1 Patent foramen ovale (PFO) is more common and is present in more than 20%-25% of adults.2 Clinical syndromes associated with ASD and PFO are variable, and their implications are targeted by pediatric and adult medicine, neurology, and surgery. Additional interest in the anatomy of the interatrial septum (IAS) has increased substantially over the last two decades. Additionally, percutaneous procedures involving left-sided structural heart disease and electrophysiological procedures have evolved considerably. Ideally, these catheter-based interventions require a direct route to the left atrium (LA) through the IAS, with a full understanding of its anatomy. Also, sophisticated and noninvasive imaging technologies such as two-dimensional transesophageal echocardiography (2D-TEE) and three-dimensional transesophageal echocardiography (3D-TEE), cardiac magnetic resonance imaging (CMR), and computed tomography (CT) have evolved considerably, providing anatomical details of cardiac structures visualized in 2D and 3D format and being key for the diagnosis and treatment of patients with heart diseases. Therefore, assessing the anatomy of the IAS and any abnormalities requires a standardized and systematic approach, integrating diagnostic modalities and enabling adequate and consistent evaluation for both surgical and transcatheter therapies.

Diagnostic analysis of cTTE for patent foramen ovale and the value of combined NLR monitoring in predicting cryptogenic stroke / 中国医师杂志

Objective:To investigate the diagnostic value of transthoracic echocardiographic contrast-enhanced ultrasound (cTTE) in patent foramen ovale (PFO) and the value of combined neutrophil to lymphocyte ratio (NLR) in predicting cryptogenic stroke.Methods:A total of 120 suspected PFO patients admitted to the Affiliated Hospital of Jining Medical College from January 2021 to December 2021 were selected and examined by cTTE and transesophageal echocardiography (TEE) to analyze the diagnostic value of cTTE in PFO. The clinical data and cTTE parameters of PFO patients with and without cryptogenic stroke were analyzed.Results:A total of 69 patients with PFO were confirmed. Among the 69 patients, 23 patients with cryptogenic stroke and 46 patients without cryptogenic stroke were confirmed by magnetic resonance imaging (MRI). The value of cTTE in the diagnosis of PFO was high: the sensitivity, accuracy and negative predictive value of cTTE under Valsalva motion in the diagnosis of PFO were 95.65%, 91.67% and 93.62%, respectively, which were significantly higher than that of cTTE at rest (all P<0.05). The NLR, the proportion of large shunt of PFO right to left shunt (PFO-RLS), the inlet width of patent foramen ovale (PFO) and the outlet width of PFO in patients with PFO complicated with cryptogenic stroke were (3.01±0.89), 43.48%(10/23), (2.54±0.65)mm and (1.51±0.35)mm, respectively, which were significantly higher than those in patients without cryptogenic stroke (all P<0.05). Logistic regression analysis showed that NLR and the degree of PFO-RLS shunt were the influencing factors of patients with PFO complicated with cryptogenic stroke (both P<0.05). The area under the Receiver operating characteristic (ROC) curve predicted by NLR combined with PFO-RLS shunt was 0.905, which was significantly higher than that predicted by NLR and PFO-RLS shunt alone (all P<0.05). Conclusions:cTTE has a good value in the diagnosis of PFO, and cTTE combined with NLR has a certain application value in predicting PFO complicated with cryptogenic stroke.

Patent foramen ovale in patients with cryptogenic stroke: evaluation and secondary prevention / 国际脑血管病杂志

Cryptogenic stroke (CS) is a type of stroke that can not find the exact cause after using the standard clinical examination procedure of stroke. In recent years, many studies have shown that patent foramen ovale (PFO) is closely associated with CS, and its main pathogenesis is paradoxical embolism. In clinical practice, ultrasound is often used for PFO screening. In the context of PFO, the secondary prevention of CS includes drug therapy and PFO closure, but the choice of treatment is still controversial. Screening and evaluation of possible PFO will help to develop secondary prevention strategies for patients with CS, especially those who can benefit from PFO closure.

Embolic stroke of undetermined source: potential etiology and secondary prevention / 国际脑血管病杂志

The source of the emboli of embolic stroke of undetermined source (ESUS) is still unclear, and the effect of antithrombotic therapy is also different. The recurrence rate of stroke in patients with ESUS is higher, and antiplatelet therapy is still a commonly used secondary prevention scheme. This article reviews the potential causes, pathogenesis and secondary prevention of ESUS.

Paradoxical brain embolism and pulmonary embolism due to a deep femoral venous aneurysm and patent foramen ovale: a case report / 中华神经科杂志

The cases of paradoxical brain embolism (PBE) due to venous aneurysms and patent foramen ovale (PFO) are extremely scarce, with only 5 cases caused by popliteal venous aneurysm reported in the literature to date, while PBE caused by deep femoral venous aneurysm (DFVA) and PFO has not been reported. Herein, an unusual case of PBE in a 15-year-old girl with PFO who still had cerebral infarction and pulmonary embolism after transcatheter closure was present. She was finally diagnosed as PFO with DFVA by angiography. Furthermore, clinical characteristics of 6 cases were summarized to improve the clinicians′ recognition of the rare risk factor of stroke-venous aneurysms of the lower extremity deep veins.

Analysis of influencing factors in migraine combined with patent foramen ovale / 中国医师进修杂志

Objective:To investigate the influencing factors of headache degree in migraine patients with patent foramen ovale (PFO).Methods:The clinical data of 124 migraine patients with PFO from January 2013 to June 2019 in Dalian Central Hospital Affiliated to Dalian Medical University were retrospectively analyzed. The right-to-left shunt of PFO was assessed by contrast-enhanced transcranial Doppler (c-TCD); the diameter of PFO, length of PFO tunnel and the presence of atrial septal aneurysm (ASA) were detected by transesophageal echocardiography (TEE); the degree of migraine was assessed by headache impact test-6 (HIT-6) scale. The relations between right-to-left shunt volume of PFO, diameter of PFO and degree of migraine were analyzed by Goodman-Kruskal γ test; the relations between the length of PFO tunnel, ASA and degree of migraine were analyzed by Spearman rank correlation analysis.Results:Among the 124 migraine patients with PFO, the c-TCD test result showed that small shunt volume was in 20 cases, medium shunt volume in 31 cases, and large shunt volume in 73 cases. The TEE test result showed that small foramen ovale in 76 cases, medium foramen ovale in 47 cases, and large foramen ovale in 1 case; long tunnel in 57 cases, and short tunnel in 67 cases; without ASA in 91 cases, and with ASA in 33 cases. The HIT-6 score result showed that some influence in 9 cases, significantly influence in 22 cases, and serious influence in 93 cases. The Goodman-Kruskal γ test result showed that right-to-left shunt volume of PFO and diameter of PFO were positive correlation with degree of migraine ( γ = 0.66, P<0.01; γ = 0.38, P<0.05). The Spearman rank correlation analysis result showed that ASA was positive correlation with degree of migraine ( r = 0.18, P<0.05), while the length of PFO tunnel was negative correlation with degree of migraine ( r = -0.23, P<0.05). Conclusions:The right to left shunt amount of PFO, diameter of PFO and the presence of ASA are positive correlation with degree of migraine, while the length of PFO tunnel is negative correlation with degree of migraine.

Risk factors for cryptogenic stroke in patients with patent foramen ovale / 国际脑血管病杂志

Objective:To investigate the potential risk factors for cryptogenic stroke (CS) in patients with patent foramen ovale (PFO).Methods:Patients underwent PFO closure in the Department of Cardiovascular Surgery, the Second Hospital of Hebei Medical University from June 2018 to December 2021 were enrolled retrospectively. Transesophageal echocardiography was used to evaluate the morphological characteristics of foramen ovale and right-to-left shunt (RLS). Multivariate logistic regression analysis was used to determine the independent risk factors for CS in patients with PFO. Results:A total of 203 patients with PFO were enrolled. Their age was 41.9±14.3, and 116 patients (57.1%) were male. There were 102 patients in CS group and 101 patients in non-stroke group. The age, body mass index, systolic blood pressure and diastolic blood pressure, and the constituent ratios of male, hypertension, diabetes, hyperlipidemia and smoking of the CS group were significant higher than those of the non-stroke group (all P<0.05). The PFO channel of the CS group was longer, wider and more combined with resting RLS (all P<0.05). Multivariate logistic regression analysis showed that systolic blood pressure (odds ratio [ OR] 1.065, 95% confidence interval [ CI] 1.022-1.111; P=0.003), PFO length ( OR 1.124, 95% CI 1.004-1.258; P=0.043) and resting RLS ( OR 5.449, 95% CI 2.283-13.004; P<0.001) were the independent risk factors for CS in patients with PFO. Conclusion:Systolic blood pressure, PFO length and the presence of resting RLS are the independent risk factors for CS in patients with PFO.

Comparison of right-to-left shunt characteristics in cryptogenic embolic ischemic stroke and non-cardioembolic ischemic stroke / Comparação das características do shunt direita-esquerda em pacientes com AVC isquêmico criptogênio e AVC não cardioembólico

Abstract Background: Patent foramen ovale (PFO) has been considered a potential mechanism of embolic stroke of undetermined origin. Objective: The aim of the present study was to identify the features of the right-to-left shunt (RLS) in patients with undetermined embolic ischemic stroke and compare them with those of patients with non-cardioembolic ischemic stroke. Methods: A retrospective study was conducted with 168 patients with stroke and RLS separated into the following two groups: the undetermined embolic stroke group (UES group) and non-cardioembolic stroke group (NCES group). All patients were assessed by transcranial Doppler to evaluate the presence and quantification of microembolic signals (MES) at rest and under Valsalva maneuver. Results: Of all patients evaluated in the current study, 96 were included in the UES group and 72 in the NCES group. In the UES group, 65 patients had RLS with ≥10 MES (67.7%), which was higher than that observed in the NCES group (51.4%, p=0.038). According to the moment of the cardiac cycle, 75 patients (78.1%) in the UES group had a positive test at rest compared to 42 (58.3%) in the NCES group (p=0.007). Conclusions: The current study demonstrated that almost 70% of patients with undetermined embolic stroke and PFO presented a large RLS and more than 75% had RLS at rest. These findings suggest that the size of the shunt should be taken into account when evaluating whether PFO could be a possible mechanism underlying cryptogenic stroke.

RESUMO Antecedentes: Uma das potenciais fontes embólicas no acidente vascular cerebral (AVC) de origem indeterminada é o forame oval patente (FOP). Objetivo: O objetivo do presente estudo foi identificar as características do shunt direita-esquerda em paciente com AVC de etiologia indeterminada, presumidamente embólica, e comparar tais características com pacientes apresentando AVC por outras causas não embólicas. Métodos: Trata-se de um estudo retrospectivo com 168 pacientes com AVC e forame oval patente, separados em dois grupos: AVC embólico de etiologia indeterminada e AVC por outras causas não embólicas. Todos os pacientes foram submetidos a Doppler transcraniano, para avaliar a presença de shunt direita-esquerda por meio do teste de embolia paradoxal. Além da quantificação de microbolhas, também foi avaliada a presença de shunt em repouso e sob manobra de Valsalva. Resultado: Do total, 96 pacientes foram incluídos no primeiro grupo (AVC indeterminado) e 72, no segundo grupo (AVC não embólico). No primeiro grupo, 65 pacientes exibiram shunt com passagem de mais de 10 microbolhas (67,5%), enquanto no segundo grupo isso aconteceu em 51,4% (p=0,038) dos casos. Além disso, 75 pacientes (78,1%) do primeiro grupo tiveram teste positivo ao repouso, comparados com 42 pacientes (58,3%) no segundo grupo (p=0,007). Conclusão: O presente estudo demonstrou que até 70% dos pacientes com AVC de etiologia indeterminada e forame oval apresentaram shunts maiores; em mais de 75%, houve passagem de microbolhas ao repouso. Esses achados sugerem que as características do shunt, como quantidade de microbolhas e passagem ao repouso, devem ser levadas em consideração na avaliação do FOP como possível mecanismo subjacente ao AVC.

Central retinal artery occlusion associated with patent foramen ovale: a case report and literature review / Oclusão da artéria central da retina associada ao forame oval patente: relato de caso e revisão de literatura

ABSTRACT Patent foramen ovale might cause cryptogenic strokes, including retinal artery occlusion. Herein, we describe a previously healthy young man who presented with central retinal artery occlusion in the setting of patent foramen ovale and explore the need for transesophageal echocardiogram for its diagnosis. Cardiovascular workup and neuroimaging were unremarkable. Transthoracic echocardiogram bubble study revealed a right to left atrial shunt and subsequent transesophageal echocardiogram disclosed patent foramen ovale. This congenital cardiac anomaly was the likely conduit for a thrombo-embolic central retinal artery occlusion. We identified seven patients with patent foramen ovale associated with central retinal artery occlusion in the literature. Transthoracic echocardiogram was diagnostic in only one patient (14.3%), whereas transesophageal echocardiogram was required to reveal patent foramen ovale in the remaining six (85.7%). Our case and the previous reports support the link between central retinal artery occlusion and patent foramen ovale. Therefore, providers should consider the more sensitive transesophageal echocardiogram during the initial evaluation of young patients without immediately identifiable causes of retinal artery occlusion.

RESUMO O forame oval patente pode estar associado a derrames criptogênicos que incluem a oclusão da artéria retiniana. Descrevemos aqui um jovem previamente saudável que apresentou oclusão da artéria central da retina associada ao forame oval patente, sendo considerado portanto, a necessidade de um ecocardiograma transesofágico para seu diagnóstico. A avaliação cardiovascular e a neuroimagem não foram significativas. O estudo da bolha no ecocardiograma transtorácico revelou um shunt atrial direito-esquerdo e o ecocardiograma transesofágico subsequente revelou um forame oval patente. Esta anomalia cardíaca congênita foi o provável conduíte para uma oclusão tromboembólica da artéria central retiniana Na literatura, foram identificadossete pacientes com forame oval patente associado à oclusão da artéria central retiniana. O ecocardiograma transtorácico diagnosticou apenas um paciente (14,3%), enquanto o ecocardiograma transesofágico foi necessário para revelar o forame oval patente nos seis casos restantes (85,7%). Nosso caso e relatos anteriores suportam a ligação entre a oclusão da artéria central retiniana e o forame oval patente. Os profissionais devem considerar, como sendo mais sensível, o ecocardiograma transesofágico na avaliação inicial de pacientes jovens sem causas imediatamente identificáveis de oclusões da artéria retiniana.

Ultrasonic examination and management of adult atrial septal aneurysm / 中华健康管理学杂志

Objective:To explore the ultrasonography and classification management strategy for adult atrial septal aneurysm (ASA).Methods:Of 138 patients diagnosed with ASA by the transthoracic echocardiography (TTE), in No.83 Army Hospital and No.988 Hospital of Joint Logistic Support Force from January 2015 to October 2019, 103 underwent the transesophageal echocardiography (TEE), and all were examined by the right heart contrast transthoracic echocardiography (cTTE). According to the semi-quantitative method, the shunt was graded, classified, and managed through follow-up or surgical treatment.Results:In the resting state, among 138 patients, 26 cases were detected by TTE as ASA with patent foramen ovale (PFO), showing left-to-right shunt. Among 112 patients with no shunt detected by TTE, 103 cases underwent TEE, of whom 44 cases had PFO and left-to-right shunt. The detection rate of PFO shunt by TEE was significantly higher than that of TTE (42.72% vs 18.84%, P<0.001). Out of the 138 patients who underwent cTTE, 96 cases had different degrees of right-to-left shunt. According to the semi-quantitative standard, there were 15 cases of grade Ⅰ, 28 cases of grade Ⅱ, and 53 cases of grade Ⅲ. The detection rate of cTTE was significantly higher than that of TTE and TEE (69.56% vs 18.84% and 42.72%, both P<0.001). Among these 96 patients with right-to-left shunt detected by cTTE, 52 cases (54.17%) were clinically diagnosed as cryptogenic stroke, with right-to-left shunt in 6 cases of grade Ⅰ, 12 cases of grade Ⅱ, and 34 cases of grade Ⅲ. The number of new infarcts in patients with grade Ⅱ or Ⅲ shunts who received PFO closure via catheter was significantly lower than that of patients who did not receive closure therapy (0 vs 27.27%, P=0.011). Conclusion:ASA combined with PFO and right-to-left shunts were detected more frequently by ultrasonography combined with cTTE in adults, this helps to formulate a reasonable management strategy.

Cryptogenic stroke in patients with patent foramen ovale: potential mechanisms and prevention strategies / 国际脑血管病杂志

Patent foramen ovale (PFO) is a congenital heart disease that occurs in about 25% of healthy adults. In recent years, more and more studies have shown that PFO is closely associated with cryptogenic stroke (CS). Although it is currently believed that paradoxical embolism is one of the main mechanisms of the pathogenesis of CS, but the exact mechanism is still controversial. In addition, the treatment of CS in patients with PFO is also the focus of controversy. Recent clinical trials have shown that PFO occlusion is significantly better than drug therapy alone in preventing stroke recurrence, especially for patients with a large right-to-left shunt and atrial septal tumor. This article reviews the potential mechanisms and prevention strategies of CS in patients with PFO.

The Role of Patent Foramen Ovale Closure in the Secondary Prevention of Cryptogenic Stroke: a Meta-Analysis Report

Abstract Background: Patent foramen ovale (PFO) closure has been compared to medical therapy for secondary prevention of recurrent cryptogenic stroke. Objectives: To produce an updated meta-analysis including only data from the primary analyses of clinical trials and to evaluate the role of PFO closure in the secondary prevention of recurrent stroke. Methods: Search in Medline (PubMed) and in ISI Web of Knowledge. Parameters under analysis and meta-analyses were: stroke, transient ischemic attack (TIA) and atrial fibrillation (AF). Comprehensive Meta-analysis Software V.2.0 (Biostat) was used. Random-effects analyses were carried out. A level of significance of 5% was used. Results: In this study six, randomized trials enrolling 3,750 patients were included. Unlike other published meta-analyses on the same topic, in this case, only clinical trial data, and not follow-up data, were used. PFO closure, as compared with medical therapy alone, demonstrated superiority in reducing the rate of recurrent stroke (risk ratio with PFO closure vs. medical therapy, 0.37; 95% confidence interval [CI], 0.17 to 0.78; p = 0.01). PFO closure did not offer a significant benefit in prevention of TIA (risk ratio with PFO closure vs. medical therapy, 0.96; 95% CI, 0.64 to 1.44; p = 0.85). Among patients assigned to closure group, an increased risk of atrial fibrillation was seen (risk ratio with PFO closure vs. medical therapy, 4.64; 95% CI, 2.38 to 9.01; p < 0.01). Conclusions: In patients with cryptogenic stroke who had a patent foramen ovale, a protective effect of closure was seen concerning the risk of recurrent stroke, but not regarding the prevention of TIA.

Hipoxemia recurrente y formen oval permeable. Unidad diagnóstica fácilmente inadvertida. Caso clínico / Recurrent hypoxemia secondary to a patent foramen ovale. Report of one case

Patent foramen ovale (PFO) is a prevalent congenital septal atrial defect usually without pathological significance. In certain pathogenic situations, PFO can trigger episodes of recurrent hypoxemia, a specific condition known as platipnea-orthodeoxia syndrome (POS). We report a 73 years old female presenting with dyspnea and low arterial oxygen saturation. On admission the patient had a hemoglobin saturation of 81% and an arterial oxygen partial pressure of 50 mmHg. After breathing 100% a 17% arterial-venous shunt was found (normal: less than 12%). A transesophageal echocardiogram and a cardiac catheterization showed the presence of a PFO. A percutaneous closure was performed.

Foramen oval permeable e ictus criptogénico

El foramen oval permeable es un defecto estructural cardíaco frecuente en la población general. Su importancia clínica radica principalmente en su asociación con el ictus criptogénico, que ha sido descrita en varios estudios. La evidencia es controvertida y para definir el mejor tratamiento en cada caso es necesario individualizar su rol en el ictus criptogénico y el riesgo de recurrencia del mismo.

Summary: The patent foramen ovale is a common structural heart defect in the general population. Its clinical magnitude lies in its association with cryptogenic stroke, which has been described in several studies. The evidence is controversial and to define the best treatment choice in each case, it is necessary to identify its role in the cryptogenic stroke and the risk of its recurrence.

O forame oval patente é um defeito cardíaco estrutural comum na população geral. A magnitude clínica deste achado reside na sua associação com o acidente vascular cerebral criptogênico, que tem sido descrito em vários estudos. A evidência é controversa e para definir a melhor escolha de tratamento em cada caso, é necessário identificar o seu papel no acidente vascular cerebral criptogênico e o risco de sua recorrência.

Trombo a través de foramen oval permeable: embolia paradojal cerebral y factores de alto riesgo de recurrencia. Caso clínico / Paradoxical embolism due to a persistent patent foramen ovale: report of one case

Abstract: Patent Foramen Ovale (PFO) is one of the most frequent congenital defects in adults. Its prevalence in middle-aged adults is close to 25-30% and may cause paradoxical embolic phenomena. We report a 45 years old male admitted for an ischemic stroke with an occlusion of the left terminal internal carotid artery. A thrombectomy was performed. Searching for possible sources of emboli, a patent foramen ovale was detected in an echocardiography, with an hypoechogenic examination image passing through it. Anticoagulant therapy was started and the patient had an uneventful evolution.

Updated meta-analysis on the closure of patent foramen ovale in reduction of stroke rates: the defense-pfo trial does not change the scenario

Abstract Objective: We aimed to analyze whether patent foramen ovale (PFO) closure reduces the risk of stroke, assessing also some safety outcomes after the publication of a new trial. Introduction: The clinical benefit of closing a PFO has been an open question, so it is necessary to review the current state of published medical data in regards to this subject. Methods: MEDLINE, EMBASE, CENTRAL/CCTR, SciELO, LILACS, Google Scholar and reference lists of relevant articles were used to search for randomized controlled trials (RCTs) that reported any of the following outcomes: stroke, death, major bleeding or atrial fibrillation. Six studies fulfilled our eligibility criteria and included 3560 patients (1889 for PFO closure and 1671 for medical therapy. Results: The risk ration (RR) for stroke in the "closure" group compared with the "medical therapy" showed a statistically significant difference between the groups, favouring the "closure" group (RR 0.366; 95%CI 0.171-0.782, P=0.010). There was no statistically significant difference between the groups regarding the safety outcomes, death and major bleeding, but we observed an increase in the risk of atrial fibrillation in the "closure" group (RR 4.131; 95%CI 2.293-7.443, P<0.001). We also observed that the larger the proportion of effective closure, the lower the risk of stroke. Conclusion: This meta-analysis found that stroke rates are lower with percutaneously implanted device closure than with medical therapy alone, being these rates modulated by the rates of hypertension, atrial septal aneurysm and effective closure. The publication of a new trial did not change the scenario in the medical literature.