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Richard A. Krasuski, MD; Stephen A. Hart, BS; Drew Allen, DO; Athar Qureshi, MD; Gosta Pettersson, MD; Penny L. Houghtaling, MS; Lillian H. Batizy, MS; Eugene Blackstone, MD

JAMA. 2009;302(3):290-297.

Context  A recent survey suggested that cardiothoracic surgeons may alter planned procedures to repair incidentally discovered patent foramen ovale (PFO). How frequently this occurs and the impact on outcomes remain unknown.

Objective  To measure the frequency of incidentally discovered PFO closure during cardiothoracic surgery and determine its perioperative and long-term impact.

Design, Setting, and Patients  We reviewed the intraoperative transesophageal echocardiograms of 13 092 patients without prior diagnosis of PFO or atrial septal defect undergoing surgery at the Cleveland Clinic, Cleveland, Ohio, from 1995 through 2006. Postoperative outcomes were prospectively collected until discharge.

Main Outcome Measures  All-cause hospital mortality and stroke were predetermined primary outcomes; length of hospital stay, length of intensive care unit stay, and time on cardiopulmonary bypass were secondary outcomes.

Results  Intraoperative PFO was diagnosed in 2277 patients in the study population (17%), and risk factors for stroke were similar in patients with and without PFO. After propensity matching was performed with the comparator groups, patients with PFO demonstrated similar rates of in-hospital death (3.4% vs 2.6%, P = .11) and postoperative stroke (2.3% vs 2.3%, P = .84). Surgical closure was performed in 639 PFO patients (28%), and surgeons were more likely to close defects in patients who were younger (mean [SD] age, 61.1 [14] vs 64.4 [13] years; P < .001), were undergoing mitral or tricuspid valve surgery (51% vs 32%, P < .001), or had history of transient ischemic attack or stroke (16% vs 10%, P < .001). Patients with repaired PFO demonstrated a 2.47-times greater odds (95% confidence interval, 1.02-6.00) of having a postoperative stroke compared with those with unrepaired PFO (2.8% vs 1.2%, P = .04). Long-term analysis demonstrated that PFO repair was associated with no survival difference (P = .12).

Conclusions  Incidental PFO is common in patients undergoing cardiothoracic surgery but is not associated with increased perioperative morbidity or mortality. Surgical closure appears unrelated to long-term survival and may increase postoperative stroke risk.

Author Affiliations: Section of Clinical Cardiology, Department of Cardiovascular Medicine (Dr Krasuski and Mr Hart); Cleveland Clinic Lerner College of Medicine of Case Western Reserve University (Mr Hart); and Departments of Internal Medicine (Dr Allen), Pediatric Cardiology (Dr Qureshi), Quantitative Health Sciences (Mss Houghtaling and Batizy and Dr Blackstone), and Cardiothoracic Surgery (Drs Pettersson and Blackstone), Cleveland Clinic, Cleveland, Ohio.

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