What is the management of a patient with patent foramen ovale (PFO) grade 3 presenting with an acute cerebrovascular accident (CVA)?

Management of PFO Grade 3 Presenting with Acute CVA

For patients with a grade 3 patent foramen ovale (PFO) presenting with acute cerebrovascular accident (CVA), PFO closure plus antiplatelet therapy is strongly recommended as the optimal management strategy to prevent recurrent stroke.

Initial Management

1. Acute phase management:

   • Standard acute ischemic stroke care protocols
   • Neurological assessment and stabilization
   • Brain imaging (CT/MRI) to confirm ischemic stroke and rule out hemorrhage

2. Diagnostic workup:

   • Confirm PFO with transesophageal echocardiography (TEE) with bubble study
   • Assess PFO characteristics (size, shunt magnitude, associated atrial septal aneurysm)
   • Complete evaluation to exclude other stroke etiologies (carotid imaging, cardiac rhythm monitoring, hypercoagulability testing)

Definitive Management Algorithm

Step 1: Evaluate patient characteristics

• Age ≤60 years: Proceed to Step 2
• Age >60 years: Consider medical therapy alone (antiplatelet or anticoagulation) as PFO is less likely to be causative

Step 2: Assess for high-risk PFO features

• Grade 3 PFO (large shunt)
• Presence of atrial septal aneurysm
• Evidence of right-to-left shunting without Valsalva

Step 3: Treatment decision

For most patients with high-risk PFO features:

• PFO closure plus antiplatelet therapy 1
  • Percutaneous device closure (typically Amplatzer PFO Occluder or similar device)
  • Post-closure antiplatelet therapy (typically aspirin 81-325mg daily)
  • Reduces absolute stroke risk by 8.7% over 5 years compared to antiplatelet therapy alone 1

For patients with contraindications to PFO closure:

• Anticoagulation therapy (preferred over antiplatelet therapy) 1
  • Direct oral anticoagulants (DOACs) or warfarin (INR 2-3)
  • May decrease ischemic stroke by 7.1% absolute risk reduction over 5 years compared to antiplatelet therapy 1

For patients with contraindications to both PFO closure and anticoagulation:

• Antiplatelet therapy
  • Aspirin 81-325mg daily or clopidogrel 75mg daily

Procedural Considerations for PFO Closure

• Procedure performed under local anesthesia with moderate sedation or general anesthesia
• Catheter-based approach via femoral vein (or alternative access if needed)
• Procedure duration typically under 2 hours
• Hospital stay usually one day or less 1
• Post-procedure antiplatelet therapy (typically aspirin) continued long-term

Important Considerations and Caveats

1. Timing of closure: Typically performed after the acute phase of stroke (2-4 weeks) when risk of hemorrhagic transformation is low 1

2. Potential complications of PFO closure:

   • Device-related adverse events (3.6% absolute risk) 1
   • Increased risk of atrial fibrillation (1.8% absolute risk increase) 1
   • Most procedure-related complications do not result in long-term disability

3. Anticoagulation considerations:

   • Increases risk of major bleeding (1.2% absolute risk increase over 5 years) 1
   • May be preferred in patients with concomitant hypercoagulable states or venous thrombosis 2

4. Special situations:

   • For patients with both PFO and pulmonary embolism, consider PFO closure to prevent paradoxical embolism 1, 3
   • Presence of PFO in patients with massive PE increases risk of death (RR 2.4), ischemic stroke (RR 5.9), and peripheral arterial embolism (RR 15) 1

Follow-up Recommendations

• Clinical follow-up at 1 month, 6 months, and annually thereafter
• Echocardiography at 3-6 months post-closure to confirm device position and absence of residual shunt
• Continue risk factor modification (blood pressure control, lipid management, smoking cessation)
• Antiplatelet therapy continued indefinitely post-closure in most cases

The evidence strongly supports PFO closure plus antiplatelet therapy for patients with high-risk PFO features presenting with cryptogenic stroke, particularly in those ≤60 years of age, as this approach significantly reduces the risk of recurrent stroke compared to medical therapy alone 1, 2.