Elevated risk of recurrent stroke in females after patent foramen ovale closure for cryptogenic stroke:A 4-year retrospective cohort study

To investigate the effect of gender on prognosis after transcatheter patent foramen ovale (PFO) closure in patients with cerebral infarction or transient ischemic attack.

A retrospective cohort study was conducted involving patients with cerebral infarction or transient ischemic attack (TIA) who underwent PFO closure at our hospital between January 2013 and December 2023. The patients were grouped by gender, and related data were collected, including age, comorbidities, Risk of Paradoxical Embolism (RoPE) score, laboratory results, findings of transthoracic/transesophageal echocardiography (TTE/TEE), and post-procedural complications, such as device-related thrombosis (DRT), recurrent stroke, bleeding, and atrial fibrillation (AF).

A total of 112 patients were enrolled, including 59 males and 53 females, at a mean age of 42.47±12.35 years. The females had significantly higher preoperative RoPE score than the males (6.6±1.4 vs 6.0±1.5, P=0.046), and a statistical difference was observed in the distribution of infarction sites between them (Chi-square=10.25, P=0.006), indicating that the males were prone to posterior circulation infarction. Intraoperative transthoracic echocardiography revealed a greater distance from the PFO to the aortic root in the females (9.3±2.4 mm vs 7.6±2.0 mm, P<0.001). During a median follow-up of 4 years, the male group had 1 case of myocardial infarction, 1 cerebral hemorrhage, 1 paroxysmal AF, 2 gingival bleeding episodes, and 1 skin ecchymosis. In the female group, 1 case experienced pulmonary embolism, 1 paroxysmal atrial fibrillation, 3 gingival bleeding episodes, 2 skin ecchymoses, 2 recurrent cerebral infarctions, and 2 recurrent TIAs. There was no statistical difference in overall adverse events between gender (P=0.291). Although the females had higher rates of recurrent cerebral infarction and TIA, this difference lacked statistical significance (P=0.222). Multivariate Cox regression analysis indicated that after adjusting for various potential confounding factors, such as RoPE score, age, hypertension, coronary heart disease, and other factors, gender was not an independent predictor of composite endpoint events after surgery.

Gender does not significantly affect overall prognosis after PFO closure in patients with cerebral infarction or TIA. However, females showed a trend toward higher rates of recurrent cerebral infarction and TIA.