What is the next step in managing a 48-year-old patient with an echocardiogram (ECHO) showing an ejection fraction (EF) of 51%, a suspected patent foramen ovale (PFO) visualized by agitated saline imaging, and currently on Aspirin (ASA) 81 mg daily and Atorvastatin (Lipitor) 40 mg daily?

Management of Patent Foramen Ovale Detected by Agitated Saline Imaging

The next step for this 48-year-old patient with a suspected patent foramen ovale (PFO) visualized by agitated saline imaging should be a transesophageal echocardiography (TEE) to confirm the diagnosis and characterize the PFO anatomy in detail.

Diagnostic Confirmation and Risk Assessment

• Transthoracic echocardiography with agitated saline has identified a suspected PFO, but transesophageal echocardiography (TEE) has higher sensitivity for PFO detection and is recommended for detailed visualization of atrial septal anatomy 1
• TEE will help determine important characteristics that affect management decisions:
  • Size of the PFO shunt (small vs. moderate/large)
  • Presence of atrial septal aneurysm (defined as >10mm excursion from centerline during cardiac cycle)
  • Other potential cardiac sources of embolism 1

Current Medical Management

• The patient is already appropriately managed with:
  • Aspirin 81mg daily (appropriate antiplatelet therapy for PFO) 1
  • Atorvastatin 40mg daily (appropriate for cardiovascular risk reduction)

Risk Stratification Considerations

• PFO is common (present in 25-30% of adults) and often clinically silent 2
• Risk factors that would increase concern for paradoxical embolism include:
  • History of cryptogenic stroke or TIA
  • Presence of atrial septal aneurysm (increases embolic risk)
  • Large shunt size
  • Evidence of deep vein thrombosis 1

Management Algorithm Based on Clinical Context

If No History of Stroke/TIA (Incidental Finding):

• For asymptomatic PFO with no history of stroke/TIA:
  • Continue current medical therapy (ASA 81mg daily)
  • No anticoagulation is recommended for asymptomatic PFO 1
  • PFO closure is not indicated for asymptomatic patients 2

If History of Cryptogenic Stroke/TIA:

• If the patient has had a cryptogenic stroke or TIA:
  • Complete workup to rule out other causes of stroke
  • Consider PFO closure if:
    • Age <60 years
    • PFO with moderate to large shunt
    • Presence of atrial septal aneurysm 3, 4
  • PFO closure plus antiplatelet therapy has been shown to reduce recurrent stroke risk compared to antiplatelet therapy alone (risk difference -87 per 1000 patients over 5 years) 3

If Evidence of Paradoxical Embolism:

• If there is evidence of paradoxical embolism (thrombus trapped within PFO):
  • Surgical embolectomy may be considered (Class IIb; Level of Evidence C) 1
  • Anticoagulation therapy may be indicated 1

Special Considerations

• If the patient is a diver or has occupational exposure to pressure changes:
  • PFO increases risk of decompression illness
  • PFO closure may be considered if the patient cannot avoid high-risk activities 5

Potential Complications and Monitoring

• If PFO closure is eventually performed, be aware of potential complications:
  • Increased risk of persistent atrial fibrillation
  • Device-related adverse events 3
  • Need for continued antiplatelet therapy post-closure

Key Pitfalls to Avoid

• Avoid assuming all PFOs require closure - most incidental PFOs can be managed conservatively 2
• Avoid attributing all stroke symptoms to PFO without thorough evaluation for other causes 1
• Don't underestimate the importance of shunt size and atrial septal aneurysm in risk stratification 1
• Remember that PFO closure has specific indications and is not beneficial for all patients with PFO 1