What are the best next steps for a 62-year-old patient with a small patent foramen ovale (PFO) noted on transesophageal echocardiogram (TEE)?

Management of Small Patent Foramen Ovale in a 62-Year-Old Patient

For a 62-year-old patient with an incidentally found small PFO on TEE, clinical observation with no specific intervention is recommended as the best next step.

Assessment and Risk Stratification

The management of a small PFO in a 62-year-old patient depends primarily on clinical context and risk factors:

Key Considerations:

• Age is a critical factor: At 62 years, the patient exceeds the age threshold (60 years) for which PFO closure has demonstrated benefit 1
• Absence of stroke history: The guidelines specifically recommend against intervention for incidentally found PFOs without history of cryptogenic stroke 1
• Small size: Small PFOs carry lower risk than those with large shunts or associated atrial septal aneurysms

Management Algorithm

1. Determine if the PFO is symptomatic or incidental

   • If incidental finding (no history of stroke/TIA): Clinical observation only
   • If found after cryptogenic stroke/TIA: Proceed to step 2

2. For patients with history of cryptogenic stroke/TIA:

   • Age assessment:
     • If ≤60 years: Consider PFO closure evaluation
     • If >60 years (like this patient): Medical therapy only (antiplatelet therapy) 1

3. Monitoring recommendations for incidental PFO:

   • Routine surveillance imaging is rated "Rarely Appropriate" 1
   • No specific follow-up echocardiography is required for incidental small PFO

Evidence-Based Rationale

The 2018 Canadian Stroke Best Practice Recommendations clearly state that PFO closure is not recommended for patients with stroke or TIA who are aged >60 years 1. For patients without stroke history, intervention is even less indicated.

The 2020 ACC/AHA Appropriate Use Criteria specifically rates routine surveillance of an asymptomatic patient with PFO using TTE or TEE as "Rarely Appropriate" 1.

Common Pitfalls to Avoid

1. Overtreatment: Avoid unnecessary closure procedures for incidental PFOs, especially in patients >60 years

2. Unnecessary monitoring: Routine surveillance imaging is not recommended for asymptomatic PFOs 1

3. Misattribution of symptoms: Be cautious about attributing non-specific symptoms to an incidental PFO without strong evidence

4. Overlooking other etiologies: In older adults, other stroke risk factors (hypertension, atrial fibrillation, carotid disease) are more likely causes of cerebrovascular events than PFO

Special Considerations

If the patient has other indications for anticoagulation (such as atrial fibrillation), those should be managed according to their respective guidelines, independent of the PFO finding.

For this 62-year-old patient with an incidentally discovered small PFO on TEE, reassurance and clinical observation without specific intervention or routine imaging follow-up is the most appropriate management strategy.