Supraventricular arrhythmias more common than thought after percutaneous PFO closure
Supraventricular arrhythmias may be underestimated in patients who have received percutaneous patent foramen ovale closure for stroke prevention, researchers reported at the European Society of Cardiology Congress.
“One of the most frequent complications following PFO percutaneous closure is atrial fibrillation, with an incidence that is between 1% and 7%, usually, below 6%,” Paul Guedeney, MD, from Sorbonne Université, ACTION study group, INSERM UMRS_1166 Institut de cardiologie, Pitié Salpêtrière (AP-HP), Paris, said during a presentation. “However, this incidence is mostly based on patient-reported symptomatic episodes, and not on systematic long-term cardiac monitoring. Consequently, the true incidence and timing of atrial fibrillation following PFO closure is actually unknown.”
For the study, which was simultaneously published in JACC: Cardiovascular Interventions, Guedeney and colleagues analyzed 225 patients (mean age, 52 years; 57% men) who underwent cardiac monitoring after percutaneous PFO closure (Amplatzer, Abbott; Occlutech, Occlutech) performed at a single center from June 2018 to October 2021.
Patients deemed at higher risk for AF due to age 55 years or older, associated CV risk factors, prior palpitations or documented supraventricular ectopic activity received an implantable loop recorder (Reveal XT, Medtronic; Reveal LINQ, Medtronic; Biomonitor III, Biotronik). Other patients received an external loop recorder for 4 weeks.
The primary endpoint was AF, atrial flutter or supraventricular tachycardia lasting at least 30 seconds within 28 days of the procedure.
In the total cohort, the primary endpoint occurred in 20.9% of patients. Among those who had an external loop recorder, 9.9% achieved the primary endpoint, whereas among those who had an implantable loop recorder, 28.9% achieved the primary endpoint, according to the researchers.
Median time between procedure and arrhythmia was 14 days, and approximately half of the patients who developed an arrhythmia were symptomatic, Guedeney and colleagues found.
In addition, 4.4% of patients had a periprocedural arrhythmia, Guedeney said during the presentation, and four patients with an implantable loop recorder had an arrhythmia detected after 28 days.
Predictors of the primary endpoint included older age (adjusted OR per 10 years = 1.67; 95% CI, 1.18-2.36), device left disc diameter of at least 25 mm (aOR = 2.67; 95% CI, 1.19-5.98) and male sex (aOR = 4.78; 95% CI, 1.96-11.66), according to the researchers.
“Using more than 28 days loop recorder monitoring, supraventricular arrhythmia was diagnosed in one patient out of five, suggesting that this postprocedural event has been, so far, underestimated,” Guedeney said during the presentation.
The ACTION study group is currently conducting the randomized multicenter AFLOAT study evaluating flecaine to prevent AF episodes after PFO closure.
In a related editorial in JACC: Cardiovascular Interventions, Suzanne J. Baron, MD, MSc, director of interventional cardiology research at Lahey Hospital and Medical Center in Burlington, Massachusetts, wrote that: “For those patients in whom the PFO closure procedure is the instigator for atrial fibrillation (and these data do suggest that the incidence is higher than previously recognized), it remains unclear what the clinical implications of these events are and how they should be handled. For patients with persistent or recurrent atrial fibrillation, anticoagulation and rhythm control as needed should obviously be pursued. However, for those patients with a single detected episode of periprocedural atrial fibrillation, be it 6 minutes, 6 hours or 16 hours, the prognosis and management pathway are less clear.
“While these issues may have seemed less pressing in the past, we now possess the knowledge of a documented occurrence of atrial fibrillation post-PFO procedure that is five times higher than previously thought,” Baron concluded. “As such, the time is now to engage in research endeavors to answer these and other questions regarding the management of the post-PFO closure patient with atrial arrhythmias, once thought to be uncommon, but which clearly are not so rare after all.”
References:
- Baron SJ. JACC Cardiovasc Interv. 2022;doi:10.1016/j.jcin.2022.08.022.
- Guedeney P, et al. JACC Cardiovasc Interv. 2022;doi:10.1016/j.jcin.2022.07.044.
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Guedeney P, et al. Abstract 80221. Presented at: European Society of Cardiology Congress; Aug. 26-29, 2022; Barcelona, Spain (hybrid meeting).
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