Supraventricular Arrhythmia Following Patent Foramen Ovale Percutaneous Closure.

Supraventricular Arrhythmia Following Patent Foramen Ovale Percutaneous Closure.

Guedeney P, Laredo M, Zeitouni M, Hauguel-Moreau M, Wallet T, Elegamandji B, Alamowitch S, Crozier S, Sabben C, Deltour S, Obadia M, Benyounes N, Collet JP, Rouanet S, Hammoudi N, Silvain J, Montalescot G. JACC Cardiovasc Interv. 2022 Nov 28;15(22):2315-2322. doi: 10.1016/j.jcin.2022.07.044. Epub 2022 Aug 22.PMID: 36008269

Dr Wendy Whiteside

Commentary from Dr. Wendy Whiteside (Ann Arbor, MI, USA), section editor of Congenital Heart
Disease Interventions Journal Watch:

Atrial arrythmias are cited among the most common complications post PFO closure. Published randomized controlled studies have reported an overall low rate (1.7-7.4%) of new atrial fibrillation (AF) after PFO closure, however this rate is based on patient reported symptomatic episodes, so the true incidence is unclear.  Guedeney et al present a single-center prospective cohort study to determine the incidence, timing, and determinants of supraventricular arrhythmias following PFO closure in adults using a standardized rhythm monitoring protocol in all their PFO patients between June 2018 to October 2021 at their center in Paris, France. Most patients received Amplatzer or Occlutech occlude devices.

A total of 225 patients were included. Patients were excluded if they had a prior supraventricular arrhythmia. Patients were separated into two groups—the high-risk group for AF (age >55 yr, associated cardiovascular risk factors, prior palpitations, or documented supraventricular ectopic activity) received an implantable loop recorder (ILR), and all other patients received a 4-week external loop recorder (ELR). The primary endpoint was incidence of AF, atrial flutter, or supraventricular tachycardia (SVT) lasting >30 seconds within 28 days of PFO closure procedure. 

The primary endpoint occurred in 47/225 patients (20.9%) including 13 (9.9%) with ELR and 24 (28.9%) of high-risk patients with ILR at a median of 14 days (IQR 6.5-19 days) after the procedure.  Only 4 more cases of supraventricular arrhythmia were diagnosed beyond 28 days (53-455 days). Just over half of patients reported symptoms. Antiarrhythmic agents were started in 60.8% of patients, primarily those with symptoms. Cardioversion (electrical or chemical) or ablation were 13 patients total with about 25% of patients requiring unplanned medical visits of hospital admissions.  By stepwise multivariate logistics regression, independent risk factors for the primary endpoint included older age (adjusted OR 1.67 per 10-year increase), diameter of left atrial disk >25 mm (adjusted OR 2.67) and male sex (adjusted OR 4.78). Patients with arrhythmias did not have a higher risk for cerebrovascular events in follow-up.

This study therefore uncovered many patients, many of whom may be asymptomatic, with atrial arrhythmias post-PFO closure, particularly in high-risk populations suggesting our prior numbers were grossly underestimated. These events occur soon after device placement and with few recurrences beyond 1-month post-procedure.  One hypothesis for these atrial arrhythmias is device-related atrial irritation.  The finding of larger diameter left atrial disk and temporal association with the procedure/device placement are indirect evidence of these arrythmias being procedure related.  This then begs the question of whether ASD closure may also have higher rates of occult atrial arrhythmia that is undetected.  ASD closure is often performed in younger patients who do not have the same risk factors for AF as the population in these PFO trials/studies however devices used are often larger relative to atrial size in these smaller patients. The question remains; however, does it matter, particularly if many events are asymptomatic and self-limited?  This study was not powered to evaluate the clinical consequences and management of these events and so this question cannot be answered at this time. There are ongoing trials to assess benefit of medical therapy to prevent atrial arrhythmias after PFO closure, which may help to evaluate the clinical benefit of such practices.