PFO Closure, Oral Anticoagulants or Antiplatelet Therapy After PFO-associated Stroke in Patients Aged 60 to 80 Years
- Conditions
- Cryptogenic Ischemic StrokePatent Foramen Ovale
- Interventions
- Drug: Oral Anticoagulant, Direct-ActingProcedure: Transcatheter PFO closureDrug: Antiplatelet therapy
- Registration Number
- NCT05387954
- Lead Sponsor
- Assistance Publique - Hôpitaux de Paris
- Brief Summary
To assess whether PFO closure plus antiplatelet therapy is superior to antiplatelet therapy alone and whether oral anticoagulant therapy is superior to antiplatelet therapy to prevent stroke recurrence in patients aged 60 to 80 years with a PFO with large shunt (\> 20 microbubbles) or a PFO associated with an ASA (\> 10 mm), and an otherwise unexplained ischemic stroke.
- Detailed Description
The CLOSE trial (NCT00562289, NEJM 2017) has unambiguously demonstrated the superiority of patent foramen ovale (PFO) closure over antiplatelet therapy alone in patients aged up to 60 years with a PFO associated with an atrial septal aneurysm (ASA) or a large right-to-left shunt (so-called "high-risk PFO"), and an otherwise unexplained ischemic stroke. Oral anticoagulant therapy is also a logical approach assuming that PFO-related strokes are due to paradoxical embolism which implies a venous source of embolism, or to direct embolization of a thrombus formed at the atrial level. The CLOSE trial also suggested that oral anticoagulants might reduce stroke recurrence compared to aspirin.
There is accumulating evidence that presence of a PFO is significantly associated with cryptogenic stroke in patients over 60 years. Cryptogenic ischemic strokes represent about one third of all ischemic strokes in patients older than 60 years. However, the optimal therapeutic strategy in patients older than 60 years with a PFO and an otherwise unexplained ischemic stroke is unknown, because these patients were excluded from randomized trials.
The hypothesis tested in this trial is that transcatheter PFO closure plus long-term antiplatelet therapy is superior to antiplatelet therapy alone and that oral anticoagulant therapy is superior to antiplatelet therapy to prevent recurrent stroke in patients aged 60 to 80 years who have a high-risk PFO and a recent otherwise unexplained ischemic stroke.
Recruitment & Eligibility
- Status
- RECRUITING
- Sex
- All
- Target Recruitment
- 792
-
Man or woman aged 60 to 80 years.
-
Recent (≤ 6 months) ischemic stroke confirmed by cerebral imaging regardless of symptom duration.
-
Absence of a more probable cause of stroke than PFO after a standardized etiological work-up (see addenda).
-
Presence of a PFO with at least 1 of the 2 following characteristics:
- PFO with large shunt > 20 microbubbles appearing in the left atrium during at least one of the 3 cardiac cycles after opacification of the right atrium, detected spontaneously or during provocative manoeuvers, on contrast transthoracic (TTE) or transoesophageal (TOE) echocardiography. The diagnosis of PFO by contrast TEE must be confirmed by contrast TOE showing a right-to-left passage of the contrast material across the PFO.
- PFO with ASA on transoesophageal echocardiography: excursion >10 mm
-
Affiliation to a French Health Insurance system. Informed consent.
- Life expectancy < 4 years.
- Contraindication to both experimental treatments (PFO closure, oral anticoagulant therapy) or to the reference treatment (antiplatelet therapy) (see paragraph 20.5).
- Indication to long-term anticoagulant therapy.
- mRS >= 3.
- Presence of other medical conditions that would lead to inability to complete the study or interfere with the assessment of outcomes.
- Previous surgical or transcatheter treatment of PFO or ASA. Expected impossible follow-up or poor compliance.
- Patient unable to understand the informed consent form. Patient under tutorship, curatorship, or legal protection.
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- PARALLEL
- Arm && Interventions
Group Intervention Description Oral anticoagulants, Direct-Acting Oral Anticoagulant, Direct-Acting Apixaban (5mg twice a day) OR Dabigatran (150 mg twice a day) OR Rivaroxaban (20 mg once a day) PFO closure Transcatheter PFO closure PFO closure followed by dual antiplatelet therapy (aspirin 75 mg/d + clopidogrel 75 mg/d) for 3 months, then by single antiplatelet therapy by aspirin or clopidogrel PFO closure Antiplatelet therapy PFO closure followed by dual antiplatelet therapy (aspirin 75 mg/d + clopidogrel 75 mg/d) for 3 months, then by single antiplatelet therapy by aspirin or clopidogrel Antiplatelet therapy Antiplatelet therapy Aspirin OR clopidogrel
- Primary Outcome Measures
Name Time Method Time to recurrent stroke (ischemic or hemorrhagic fatal or non-fatal) From date of randomization until the date of first recurrent stroke, assessed from up to 4 years (for the last patient included) to up to 8 years (for the first patient included) Stroke: sudden onset of focal neurological symptoms related to a disturbance of the cerebral circulation.
Ischemic stroke : at least one of the following criteria:
* Sudden onset of focal neurological symptoms with the presence of cerebral infarction in the appropriate territory on brain imaging (CT or MRI), regardless of the duration of symptoms (less than or more than 24 hours).
* Sudden onset of focal neurological symptoms lasting more than 24 hours, with no apparent cause other than cerebral ischemia.
Intracerebral hemorrhage: sudden onset of focal neurological symptoms with the presence of cerebral hemorrhage in the appropriate territory on brain imaging (CT or MRI), regardless of the duration of symptoms (less than or more than 24 hours) and regardless of the cause of the hemorrhage (spontaneous or secondary to trauma, tumour or another cause).
Unknown type of stroke : the type of stroke cannot be determined with certainty and the symptoms last more than 24 hours.
- Secondary Outcome Measures
Name Time Method Time to disabling stroke From date of randomization until the date of first recurrent disabling stroke, assessed from up to 4 years (for the last patient included) to up to 8 years (for the first patient included) mRS score greater than or equal to 3, with an increase of at least 2 points compared to the last mRS score before the stroke.
Time to ischemic stroke From date of randomization until the date of first recurrent ischemic stroke, assessed from up to 4 years (for the last patient included) to up to 8 years (for the first patient included) At least one of the following criteria:
* Sudden onset of focal neurological symptoms with the presence of cerebral infarction in the appropriate territory on brain imaging (CT or MRI), regardless of the duration of symptoms (less than or more than 24 hours).
* Sudden onset of focal neurological symptoms lasting more than 24 hours, with no apparent cause other than cerebral ischemia.Time to ischemic stroke or systemic embolism From date of randomization until the date of first recurrent ischemic stroke or systemic embolism, assessed from up to 4 years (for the last patient included) to up to 8 years (for the first patient included) Clinical features related to embolism usually affecting a limb, mesenteric, splenic, or renal artery. The diagnosis of embolism must be confirmed by appropriate investigations.
Time to all-cause mortality From date of randomization until the date of death, assessed from up to 4 years (for the last patient included) to up to 8 years (for the first patient included) Vascular (see definition) or nonvascular death: death due to a documented non-vascular cause (infection, cancer, accident, suicide, etc.).
Proportion of success of device implantation, of the procedure and of PFO closure, 6 months after PFO closure * Success of device implantation: deployment of the device in the appropriate place and removal of the placement system.
* Success of the procedure: successful implantation with no complications before the patient's discharge.
* Success of PFO closure: success of the procedure with no residual shunt or minimal residual shunt on echocardiography performed 6 months after the procedure.Proportion of fatal, life-threatening or major procedure- or device-related complications Within 4 weeks following the procedure (PFO closure) Life-threatening
* Cardiac perforation with tamponade requiring emergency drainage.
* Cerebral air embolism responsible for acute neurological disorders
* Embolization of the device.
* Life-threatening hematoma at the puncture site or retroperitoneal.
* Complications of general anesthesia or TOE requiring intensive care and/or surgical operation.
Major
* Hemorrhage at the puncture site or retroperitoneal requiring transfusion or surgery.
* Arteriovenous fistula, pseudoaneurysm requiring surgery.
* Peripheral nerve lesion with disabling neurological deficit persisting \> 1 month.
* Cardiac arrhythmias (particularly AF) during catheterization or post-procedure requiring treatment \>= 1 month.
* Infective endocarditis.
* Asymptomatic late thrombosis of the device.
* Any device-related complication requiring surgery.
* Any other complication related to the transcatheter treatment or anesthesia, considered to be major by the investigator.Incremental cost-utility ratio at 4 years (ICUR) Within 48 months after randomization The incremental cost-utility ratio (ICUR) will be calculated as difference in costs (between groups)/difference in QALYs (Quality-Adjusted Life Year) between groups.
The QALYs will be constructed with the EuroQoL-5D (EQ-5D) questionnaire and value setsTime to transient ischemic attack, From date of randomization until the date of first transient ischemic attack, assessed from up to 4 years (for the last patient included) to up to 8 years (for the first patient included) Sudden onset of neurological symptoms, presumed to be ischemic, resolving in less than 24 hours, clearly attributable to focal involvement of the central nervous system (or of the eye) with no signs of a corresponding recent cerebral infarction on brain imaging. The diagnosis of TIA will be confirmed by a neurologist, considering clinical data and brain imaging (MRI with diffusion sequence is recommended).
Time to vascular death From date of randomization until the date of vascular death, assessed from up to 4 years (for the last patient included) to up to 8 years (for the first patient included) * death related to a cardiac or vascular cause.
* death due to hemorrhage.
* death due to pulmonary embolism.
* sudden death: death occurring in less than 24 hours, unexpectedly in a subject in apparent good health and whose condition was stable or was improving.
* death with no documented non-vascular cause.
* fatal stroke: death occurring within 30 days of a stroke (ischemic or hemorrhagic).Quality of life score Every 6 months after randomization or up to 4 years (for the last patient included) to up to 8 years (for the first patient included)] Measured by using the European Quality Of Life (EQ-5D) auto-questionnaire. The digits for the five dimensions are combined into a 5-digit number that describes the patient's health state. The visual analogue scale (VAS) records the patient's self-rated health on a vertical axis from 0 (worst health) to 100 (best health)
Time to ischemic stroke recurrence according to the presence of a residual shunt From date of PFO closure until the date of first ischemic stroke recurrence, assessed from up to 4 years (for the last patient included) to up to 8 years (for the first patient included), according to the presence of residual shunt] From control echocardiography after PFO closure to the end of the patient's follow-up
Time to fatal, life-threatening or major hemorrhage, including intracerebral and Intracranial hemorrhage From date of randomization until the date of first fatal,life-threatening or major hemorrhage,including intracerebral and Intracranial hemorrhage,assessed from up to 4 years(for the last patient included) to up to 8 years(for the first patient included) Life-threatening
* Fatal hemorrhage.
* Drop in hemoglobin by ≥ 5 g/dL (or drop in hematocrit by 15% or more in absolute value)
* Symptomatic intracranial hemorrhage (confirmed by appropriate investigations, classified as cerebral hemorrhage, subarachnoid hemorrhage and subdural hematoma).
* Transfusion ≥ 4 units of packed cells (or equivalent of whole blood)\*.
Major
* Transfusion ≤ 3 units of packed cells (or equivalent of whole blood)\*.
* Requiring hospitalization (or prolonging hospitalization).
* Requiring surgical treatment.
* Intraocular hemorrhage with significant loss of vision.
* Other hemorrhage responsible for significant disability according to the investigator.Time to new-onset atrial fibrillation From date of randomization until the date of new-onset atrial fibrillation, assessed from up to 4 years (for the last patient included) to up to 8 years (for the first patient included)] Atrial fibrillation lasting at least 30 seconds
Costs Within 48 months after randomization Costs will be estimated from the viewpoint of the healthcare system (hospital admission, transportation, study interventions, emergency room visit without admission,consultations,imaging)
Trial Locations
- Locations (41)
Fondation Adolphe de Rothschild
🇫🇷Paris, France
CH Perpignan
🇫🇷Perpignan, France
CHU La Milétrie
🇫🇷Poitiers, France
Hôpital Novo
🇫🇷Pontoise, France
CHU Rennes-Hôpital Pontchaillou
🇫🇷Rennes, France
CHU Rouen-Hôpital Charles-Nicolle
🇫🇷Rouen, France
CH Yves Le Foll
🇫🇷Saint Brieuc, France
CHU Nantes-Hôpital Nord Laennec
🇫🇷Saint Herblain, France
CHU Amiens
🇫🇷Amiens, France
CH Arras
🇫🇷Arras, France
CHU Jean Minjoz
🇫🇷Besançon, France
CHU Bordeaux - GH Pellegrin
🇫🇷Bordeaux, France
CHRU La Cavale Blanche
🇫🇷Brest, France
HCL-Groupement Hospitalier Lyon Est
🇫🇷Bron, France
CHU Côte de Nacre
🇫🇷Caen, France
CHU Clermont Ferrand
🇫🇷Clermont-Ferrand, France
CH Sud Francilien
🇫🇷Corbeil-Essonnes, France
Hôpital Henri Mondor
🇫🇷Créteil, France
CHU Dijon-Hôpital François Mitterrand
🇫🇷Dijon, France
CH Grenoble-Site Nord
🇫🇷Grenoble, France
GPE Hospitalier La Rochelle-Ré-Aunis
🇫🇷La Rochelle, France
CH Versailles-Hôpital Mignot
🇫🇷Le Chesnay, France
CHU Bicêtre
🇫🇷Le Kremlin-Bicetre, France
CHRU Lille-Hôpital Salengro
🇫🇷Lille, France
Hôpital de la Timone
🇫🇷Marseille, France
Grand Hôpital de l'Est Francilien
🇫🇷Meaux, France
Hôpital Gui de Chauliac
🇫🇷Montpellier, France
CHRU Nancy-Hôpital central
🇫🇷Nancy, France
CHU de Nice-Hôpital Pasteur
🇫🇷Nice, France
CHU Carémeau
🇫🇷Nîmes, France
CH Orsay
🇫🇷Orsay, France
APHP Hôpital Lariboisière
🇫🇷Paris, France
Hôpital Pitié Salpêtrière
🇫🇷Paris, France
GHU Paris Psychiatrie et Neurosciences
🇫🇷Paris, France
Groupe Hospitalier Paris Saint-Joseph
🇫🇷Paris, France
APHP Hôpital Bichat
🇫🇷Paris, France
CHU Saint-Etienne-Hôpital Nord
🇫🇷Saint-Priest en Jarez, France
Hôpital Hautepierre
🇫🇷Strasbourg, France
Hôpital Foch
🇫🇷Suresnes, France
CHU Toulouse-Hôpital Pierre Paul Riquet
🇫🇷Toulouse, France
CHRU Tours- Hôpital Bretonneau
🇫🇷Tours, France