Cardiac Catheterization Before PFO Closure
Cardiac catheterization is not routinely indicated before patent foramen ovale (PFO) closure in most patients. Based on current guidelines, diagnostic cardiac catheterization should only be performed when non-invasive imaging methods fail to provide complete diagnostic information needed for clinical decision-making 1.
Evaluation Before PFO Closure
Standard Pre-Closure Assessment
- Echocardiography is the primary diagnostic tool:
- Transthoracic echocardiography (TTE) with contrast during Valsalva maneuver
- Transesophageal echocardiography (TEE) to confirm PFO anatomy and characteristics
- Assessment of right-to-left shunt severity
- Evaluation of associated features (atrial septal aneurysm, Eustachian valve, etc.)
When Cardiac Catheterization May Be Considered
Cardiac catheterization before PFO closure should be limited to specific scenarios:
Suspected pulmonary hypertension that cannot be adequately assessed by non-invasive methods 1
- Measurement of pulmonary artery pressures
- Assessment of pulmonary vascular resistance
- Evaluation of reversibility of pulmonary hypertension
Complex cardiac anatomy where non-invasive imaging yields incomplete information 1
- Congenital heart disease with PFO
- Unusual septal anatomy requiring detailed assessment
Coronary artery evaluation in patients with:
- Suspected coronary anomalies
- Risk factors for coronary artery disease requiring assessment
Risk-Benefit Analysis
Risks of Cardiac Catheterization
- Vascular injury/perforations
- Cardiac perforation
- Arrhythmias (including atrial fibrillation)
- Stroke
- Contrast-induced nephropathy
- Radiation exposure
- Allergic reactions to contrast
Benefits of Avoiding Unnecessary Catheterization
- Reduced procedural complications
- Lower healthcare costs
- Shorter hospital stays
- Avoidance of contrast exposure
Special Considerations
High-Risk PFO Features
PFOs with the following characteristics may warrant more detailed evaluation, but not necessarily cardiac catheterization 2:
- Long-tunnel PFO (≥10 mm)
- Atrial septal aneurysm
- Prominent Eustachian valve or Chiari's network
- Large right-to-left shunt
- Low-angle PFO
Patient Selection for PFO Closure
The Canadian Stroke Best Practice Recommendations 1 indicate PFO closure should be considered for carefully selected patients who meet all these criteria:
- Age 18-60 years
- Non-lacunar embolic ischemic stroke confirmed by imaging
- PFO determined to be the most likely cause after thorough evaluation
Conclusion
For most patients undergoing PFO closure for cryptogenic stroke, a comprehensive non-invasive evaluation with echocardiography (TTE and TEE) is sufficient. Cardiac catheterization should be reserved for specific cases where additional hemodynamic or anatomic information is essential for clinical decision-making and cannot be obtained through non-invasive methods.