Management of Atrial Septal Aneurysm and Patent Foramen Ovale
Primary Recommendation
For patients under 60 years old with cryptogenic stroke and both PFO and atrial septal aneurysm, PFO closure plus antiplatelet therapy is strongly recommended over antiplatelet therapy alone. 1
Risk Stratification: Who Needs Intervention?
The presence of both an atrial septal aneurysm (>10mm excursion) and PFO significantly increases stroke risk compared to either condition alone 1:
- PFO + atrial septal aneurysm in patients <55 years: OR 15.59 for ischemic stroke 1
- Atrial septal aneurysm alone: OR 6.14 for ischemic stroke 1
- PFO alone: OR 3.1 for ischemic stroke 1
Key point: Atrial septal aneurysm is a marker of increased embolic risk and often associated with septal fenestrations 1
Diagnostic Approach
Initial Detection
- Transthoracic echocardiography with color Doppler can identify PFO by visualizing flow between atria 2
- Perform Valsalva maneuver during bubble study to increase sensitivity by transiently raising right atrial pressure 1, 2
Definitive Assessment
- Transesophageal echocardiography (TEE) has higher sensitivity than transthoracic imaging and is recommended in younger adults with unexplained cerebrovascular events 1, 2
- TEE is mandatory when PFO closure is planned for detailed visualization of atrial septal anatomy 1, 2
- Assess shunt size: microbubbles entering left atrium within 3 cardiac cycles after right atrial opacification indicates large shunt 1
Treatment Algorithm by Clinical Scenario
Scenario 1: Age <60 Years with Cryptogenic Stroke
If anticoagulation is contraindicated or declined:
- Strong recommendation: PFO closure + antiplatelet therapy versus antiplatelet therapy alone 1
- This applies when extensive workup excludes other stroke etiologies 1
If all treatment options are acceptable:
- Weak recommendation: PFO closure + antiplatelet therapy over anticoagulation 1
- Weak recommendation: Anticoagulation over antiplatelet therapy alone if closure is contraindicated/declined 1
Evidence supporting closure in this population:
- The CLOSE trial showed 0% stroke recurrence with PFO closure versus 6.0% with antiplatelet therapy alone (NNT=20 over 5 years) 1
- Benefit was driven by patients with atrial septal aneurysm or substantial shunt size 1
Scenario 2: Age >60 Years
Recommendation: Antiplatelet therapy alone 2
- PFO closure is not recommended in patients over 60 years 1
- The PFO is more likely incidental rather than causal in this age group 1
Scenario 3: PFO Without Prior Stroke
Recommendation: Antiplatelet therapy is reasonable 1
- Insufficient data to recommend PFO closure for primary prevention 1
PFO Closure Procedural Details
Patient Selection Criteria
Procedure Characteristics
- Takes under 2 hours 1, 2
- In-hospital stay typically 1 day 1, 2
- Most activities resumed within days, full recovery within weeks 1, 2
Complications to Monitor
- Device-related adverse events: 5.9% procedural complications 1, 3
- Atrial fibrillation: 4.6% in closure group versus 0.9% in medical therapy group 1, 3
- Most cases are transient and do not recur during follow-up 1
- Thrombus formation: Rare but requires antithrombotic therapy if detected 4
Medical Therapy Specifications
Post-Closure Antiplatelet Regimen
- Dual antiplatelet therapy (aspirin + clopidogrel) initially 5
- Transition to long-term single antiplatelet therapy 1
- Duration may be indefinite or discontinued months after closure depending on individual factors 1
Antiplatelet Therapy Alone (When Closure Not Performed)
Anticoagulation (When Indicated)
- Warfarin with target INR 2.0-3.0 2
- Direct oral anticoagulants may be used 1
- Not recommended for PFO-associated stroke unless indicated for other medical reasons (e.g., atrial fibrillation) 6
Follow-Up Monitoring
Post-Closure Surveillance
- Contrast-enhanced TEE at 1 month and 6 months 7
- Additional TEE every 6-12 months if incomplete closure 7
- Definite closure confirmed by at least two consecutive TEE studies 7
Long-Term Outcomes
- Recurrence rate of thromboembolic events: 0.7% per patient year after closure 7
- No relation between residual shunting and recurrent events in long-term follow-up 7
Critical Pitfalls to Avoid
Do not close PFO in:
- Patients >60 years old 1, 2
- Patients where PFO is likely incidental (other clear stroke etiology identified) 1
- Patients requiring chronic anticoagulation for other indications 1
Do not rely on:
- Estimating PFO size based solely on contrast amount in left atrium—this is unreliable 1
- Transthoracic echo alone for procedural planning—TEE is mandatory 1, 2
Monitor closely for: