What is the management approach for a patient with a patent foramen ovale (PFO)?

Management of Patent Foramen Ovale (PFO)

For patients with a patent foramen ovale (PFO), management should be based on clinical presentation, with PFO closure plus antiplatelet therapy strongly recommended for patients under 60 years with cryptogenic stroke when anticoagulation is contraindicated or declined. 1

Diagnosis and Assessment

• PFO is a communication between the right and left atrium, typically diagnosed by transthoracic echocardiography with observed flow between the left and right atrium by color Doppler ultrasonography 1
• Transesophageal echocardiography has higher sensitivity for PFO detection compared to transthoracic imaging and is recommended in younger adults with unexplained cerebrovascular events 1
• Sensitivity for PFO detection is increased by asking the patient to perform a Valsalva maneuver, which transiently increases right atrial pressure 1
• When PFO closure is planned, transesophageal echocardiography is recommended for detailed visualization of atrial septal anatomy 1

Management Algorithm Based on Clinical Presentation

1. Patients with Cryptogenic Stroke and PFO (Under 60 Years)

• For patients open to all options:

  • Weak recommendation for PFO closure plus antiplatelet therapy rather than anticoagulant therapy 1

• For patients with contraindications to anticoagulation:

  • Strong recommendation for PFO closure plus antiplatelet therapy versus antiplatelet therapy alone 1

• For patients in whom closure is contraindicated or declined:

  • Weak recommendation for anticoagulant therapy rather than antiplatelet therapy 1

• PFO closure has been shown to reduce stroke recurrence with a number needed to treat between 20 and 44 over five years 2

• The benefit of closure is particularly evident in patients with embolic-appearing strokes, large right-to-left shunts, or associated atrial septal aneurysm 3, 4

2. Patients with Massive or Submassive Pulmonary Embolism and PFO

• Consider screening for PFO with echocardiogram using agitated saline bubble study or transcranial Doppler for risk stratification 1
• Presence of PFO in patients with PE increases risk of death (relative risk 2.4), ischemic stroke (relative risk 5.9), and peripheral arterial embolism (relative risk 15) 1
• Patients with intracardiac shunt should be considered for aggressive therapeutic options, including catheter-based techniques or surgical embolectomy, particularly if intracardiac thrombus is identified 1

3. Patients Over 60 Years with PFO

• PFO closure is generally NOT recommended for patients over 60 years with cryptogenic stroke 5
• Antiplatelet therapy is recommended as first-line treatment rather than PFO closure 5
• In older patients, fewer cryptogenic strokes are caused by paradoxical emboli, so the benefits of PFO closure would be smaller and the harms potentially greater 1

Procedural Considerations for PFO Closure

• PFO closure procedure typically takes under 2 hours 1
• In-hospital stay is usually one day 1
• Most activities can be resumed within a few days, with full recovery within a few weeks 1
• Potential risks include:
  • Device-related adverse events (3.6% absolute risk) 1
  • Persistent atrial fibrillation (1.8% absolute risk increase) 5
  • Transient atrial fibrillation (1.2% absolute risk increase) 5

Medical Therapy Options

• Antiplatelet therapy options:

  • Aspirin (75-325 mg daily) 5
  • Clopidogrel (75 mg daily) if aspirin is not tolerated 5
  • Combination of aspirin and dipyridamole 5

• Anticoagulation therapy:

  • Consider if there are additional risk factors such as evidence of venous thrombosis, hypercoagulable state, or recurrent ischemic events despite antiplatelet therapy 5
  • Warfarin with target INR of 2.0-3.0 is recommended if anticoagulation is indicated 5
  • The efficacy of direct oral anticoagulants (DOACs) in this patient population compared to other medical therapy or mechanical closure has not yet been fully investigated 6

Special Considerations

• For patients with concurrent atrial fibrillation, anticoagulation would be indicated regardless of PFO status 5
• Patients with PFO should be advised to avoid activities that may increase right-to-left shunting (e.g., Valsalva maneuvers) 5
• Consider evaluation for deep vein thrombosis as a potential source of paradoxical embolism 5
• PFO closure for indications other than cryptogenic stroke (such as migraines, platypnea-orthodeoxia, or decompression illness) should be considered on a case-by-case basis as robust trials are still required 2, 7