What are the management and treatment options for a patient with a patent foramen ovale (PFO) and a large left patent ductus arteriosus (PDA) with predominantly left to right shunting?

Management of Patent Foramen Ovale and Patent Ductus Arteriosus with Left-to-Right Shunting

PDA closure is recommended for this patient with left atrial and left ventricular enlargement attributable to a large left PDA with predominantly left-to-right shunting. 1

Clinical Assessment and Diagnostic Findings

• The echocardiographic findings show a patent foramen ovale (PFO) with multiple fenestrations and predominantly left-to-right atrial shunting 1
• More significantly, there is a large left patent ductus arteriosus (PDA) with unrestrictive flow and predominantly left-to-right shunting 1
• The findings of dilated left atrium, mild left ventricular dilatation, and elevated right ventricular systolic pressure (RVSP = 77 mmHg + CVP) indicate hemodynamic consequences of the shunts 1
• The flattened systolic interventricular septum motion suggests right ventricular pressure overload, consistent with pulmonary hypertension 1

Management Approach for PDA

Indications for PDA Closure

• PDA closure is indicated when there is left atrial or left ventricular enlargement attributable to PDA with net left-to-right shunt, as seen in this patient 1
• The presence of dilated left cardiac chambers in this patient suggests significant volume overload that warrants intervention 1
• Closure is recommended to prevent further cardiac chamber enlargement, progression of pulmonary arterial hypertension (PAH), and development of pulmonary hypertension secondary to left heart failure 1

Closure Options

• Percutaneous device closure is the preferred first-line approach for PDA in adults due to good success rates and minimal complications 1
• Surgical closure is an alternative but potentially more hazardous in adults due to calcification and tissue friability in the area of the aortic isthmus and pulmonary artery 1
• The choice between percutaneous and surgical approaches should consider the PDA anatomy (size, shape) and the presence of other cardiac lesions requiring intervention 1

Special Considerations for Elevated Pulmonary Pressures

• The elevated RVSP (77 mmHg + CVP) indicates significant pulmonary hypertension 1
• Before proceeding with closure, cardiac catheterization is recommended to evaluate:
  • The degree of shunting (left-to-right vs. right-to-left)
  • Pulmonary vascular resistance (PVR)
  • Reactivity of the pulmonary vascular bed 1
• Even with elevated pulmonary pressure and PVR, closure may improve clinical status in patients with persistent left-to-right shunting and prevent further progression of PAH 1
• However, if PVR is greater than two-thirds systemic and there is net right-to-left shunting (Eisenmenger physiology), PDA closure is contraindicated due to high morbidity and mortality 1

Management of Patent Foramen Ovale

• The PFO with multiple fenestrations appears to be hemodynamically less significant than the PDA in this patient 1, 2
• Most PFOs with left-to-right shunting do not require specific intervention unless associated with paradoxical embolism or cryptogenic stroke 1
• After addressing the PDA, reassessment of the PFO's hemodynamic significance is recommended 2
• If the PFO remains hemodynamically significant after PDA closure, percutaneous device closure could be considered 1

Pulmonary Hypertension Management

• The elevated RVSP (77 mmHg + CVP) requires careful evaluation and management 1
• Pulmonary vasodilator therapy may be considered if pulmonary vascular reactivity testing shows reversibility 1
• Consultation with ACHD (Adult Congenital Heart Disease) and pulmonary hypertension specialists is important given the complexity of decision-making in this scenario 1
• After PDA closure, continued monitoring of pulmonary pressures is essential to assess for improvement or need for ongoing pulmonary hypertension therapy 1

Follow-up Recommendations

• Regular echocardiographic monitoring to assess:
  • Changes in cardiac chamber size
  • Pulmonary artery pressure
  • Ventricular function
  • Residual shunting after intervention 1
• Oxygen saturation measurements in both hands and feet to detect any differential cyanosis that might develop 1
• Exercise capacity assessment to evaluate functional improvement after intervention 1
• Long-term antiplatelet or anticoagulation therapy may be considered based on individual risk factors and the type of device used for closure 1

Potential Complications and Pitfalls

• Device embolization into pulmonary or systemic circulation during percutaneous closure 1
• Device obstruction to aortic or pulmonary flow 1
• Transient left ventricular systolic dysfunction following closure 1
• Hemolysis or recanalization after device placement 1
• Worsening right heart failure if closure is performed in a patient with fixed pulmonary hypertension 1
• Residual shunting requiring additional intervention 1