Atrial fibrillation (AF) is a recognized complication following percutaneous closure of a patent foramen ovale (PFO), with reported incidences of up to 30% during the first month. However, its true frequency remains uncertain due to the lack of continuous monitoring prior to the intervention.
This prospective cohort study aimed to determine the true incidence and timing of AF onset after PFO closure, using continuous implantable cardiac monitoring (ICM) before and after the procedure. The primary endpoint was detection of the first AF episode lasting >30 seconds at 30 days and at one year after closure. Secondary endpoints included the clinical and therapeutic characteristics of these episodes: symptoms, need for antiarrhythmic treatment or anticoagulation, and event duration.
Researchers included a total of 126 consecutive patients (mean age 57.2±11.5 years; 38.9% women) treated at Toulouse University Hospital between January 2015 and November 2022. Inclusion criteria were high-risk PFO (≥25 microbubbles on contrast echocardiography, atrial septal aneurysm with >15 mm excursion, or PFO width >2 mm) associated with a cryptogenic embolic event. Patients with AF detected on pre-implantation ICM or without post-procedural monitoring were excluded. The most commonly used closure devices were the Amplatzer PFO Occluder (60.3%) and the Amplatzer Cribriform Septal Occluder (34.1%); the left disc was ≤25 mm in 84.1% of cases.
Patients were monitored using ICM for a median of 8.6 months (interquartile range [IQR] 6.5–11.7) before closure, confirming the absence of pre-existing AF. Reveal devices (Medtronic) were used in 86.5% of cases. Post-procedural follow-up had a median duration of 5.8 months (IQR 3.3–11.3).
During the first year, 32 patients (27.6%; 95% confidence interval [CI]: 20.1–37.1) experienced AF; in 24 cases, the onset (19.3%; 95% CI: 13.4–27.4) occurred within the first 30 days. The median time to the first episode was 20.5 days (IQR 15.5–44.0). All episodes were paroxysmal; 56.3% lasted less than one hour. Only 15.6% were symptomatic, and a similar proportion required antiarrhythmic therapy, while 78.1% required oral anticoagulation.
Most episodes occurred within the first month, supporting the hypothesis of a mechanism related to device-induced atrial irritation or stretch. However, 25% occurred beyond 30 days despite exclusion of prior AF, suggesting a possible late device-related effect on the atrium.
Early and late atrial fibrillation episodes after PFO closure: clinical and therapeutic implications
In this cohort with comprehensive pre- and post-closure monitoring, the true incidence of post-procedural AF was high (19.3% at 30 days and 27.6% at one year), although mostly asymptomatic and paroxysmal. The findings question the need for routine antiarrhythmic therapy—potentially reserving it for symptomatic cases—and highlight the importance of prolonged monitoring to identify late episodes potentially induced by the device.
Original Title: Atrial fibrillation following patent foramen ovale closure: a cohort study with continuous implantable cardiac monitoring.
Reference: Paul Gautier, MD, MSc; et al. EuroIntervention 2025;21:e1–e3. DOI: 10.4244/EIJ-D-25-00603. Toulouse University Hospital, Francia.
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