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CONTEXT The role of percutaneous closure of patent foramen oval (PFO) in patients with cryptogenic stroke has been very controversial for years due to a lack of clear evidence. OBJECTIVE Systematic review and meta analysis of the effect of percutaneous PFO closure for secondary prevention of cryptogenic strokes as compared to best medical therapy (BMT). DATA SOURCES Trials were identified through a literature search until 28 May 2013. STUDY SELECTION Controlled clinical trials (randomised and non randomised) comparing percutaneous PFO closure with BMT. DATA EXTRACTION AND SYNTHESIS Main end point of interest was stroke. A random effects model was used to calculate the pooled relative risks (RR) with 95 CIs. RESULTS A total of 14 studies (three randomised controlled trials (RCT) and 11 non randomised observational studies (non RCT)) and a total of 4335 patients were included for this analysis. There was no significant treatment effect of PFO closure regarding stroke among the RCT (RR 0.66 95 CI 0.37 to 1.19 p=0.171). However among non RCT stroke was reduced (RR 0.37 95 CI 0.20 to 0.67 p

In about 30% of patients undergoing coronary revascularisation by planned percutaneous coronary intervention (PCI), the procedure itself results in periprocedural myocardial necrosis.1 This form of PCI-related myocardial injury, which is often clinically silent, can be detected as an increase in serum cardiac enzymes above the 99th centile upper reference limit.2 Periprocedural myocardial necrosis following PCI, as measured by raised levels of serum troponin, has been shown to be associated with higher major adverse cardiac events (MACE), with a twofold and threefold increased risk of overall death and subsequent myocardial infarction, respectively.3 MACE are further amplified in the 15% of patients who experience periprocedural myocardial infarction (PMI) during the PCI procedure (termed type 4a myocardial infarction and defined as an elevation of cardiac biomarkers more than three times the 99th centile upper reference limit).2 The cause of PMI during PCI is multifactorial and includes distal coronary artery embolisation, side-branch occlusion, coronary dissection, occlusion of collaterals and epicardial or microvascular spasm (see figure 1).1 PMI following PCI can be visualised using cardiac MRI as discrete areas of late gadolinium enhancement, the extent of which correlates with the increase in serum cardiac enzymes.4 A wide variety of factors confer greater susceptibility to PMI during PCI. …

The Authors’ reply We thank Chen et al 1 for their feedback on our paper2 and we fully agree with most of their comments. Instent restenosis continues to be a problem even though the risk has been massively reduced by drug coating of stents.3 A significant proportion of patients had contraindications for drug-eluting stents (DES). Regarding the short-term and long-term follow-up data available for the PACCOCATH trial, we generally …

We thank Dr Ammirati and his colleagues for their very valuable comments on our paper.1 We agree with their interpretation, the low incidence of non-fatal strokes in the medical arm (