What is the next step for a patient with a patent foramen ovale (PFO) who has suffered a stroke and developed deep vein thrombosis (DVT)?

Management of PFO with Concurrent Stroke and DVT

This patient requires immediate anticoagulation for at least 3 months to treat the DVT, followed by consideration for PFO closure after the acute thrombotic phase is managed. 1, 2

Immediate Priority: Anticoagulation Therapy

The presence of concurrent DVT with stroke and PFO represents a high-risk scenario for paradoxical embolism that fundamentally changes management from typical cryptogenic stroke. 2

Initiate therapeutic anticoagulation immediately:

• Bridge with unfractionated heparin or low-molecular-weight heparin while transitioning to warfarin 2, 3
• Target INR 2.0-3.0 3
• Minimum duration: 3 months for DVT treatment 3, 2
• The DVT requires treatment regardless of PFO management decisions 2

Why Anticoagulation Takes Priority

The American College of Chest Physicians explicitly states that evidence of venous thrombosis (DVT) together with systemic embolism and PFO "provides a strong indication for anticoagulation, and when technically feasible, closure of the PFO." 1 This is not a typical cryptogenic stroke scenario—the DVT provides a clear embolic source and mechanism. 2

Critical pitfall to avoid: Do not close the PFO acutely. The active thrombotic state is a relative contraindication to device placement. 2

Secondary Step: PFO Closure Consideration

After completing the initial 3-month anticoagulation course for DVT, PFO closure should be considered. 2

Criteria supporting PFO closure in this case:

• Age ≤60 years (per Canadian Stroke Best Practice guidelines) 1
• Confirmed embolic stroke on imaging 1
• Clear mechanism of paradoxical embolism (DVT + PFO + stroke) 1
• High-risk scenario with documented venous thrombosis 2

The American College of Chest Physicians provides a Grade 2C recommendation for PFO closure consideration in patients with cryptogenic stroke, DVT, and PFO after the acute thrombotic phase is managed. 2

Hypercoagulable Workup

Complete evaluation for underlying thrombophilia during the anticoagulation period:

• Test for antiphospholipid antibodies, Factor V Leiden, prothrombin 20210 mutation, protein C/S deficiency, antithrombin deficiency 3
• If hypercoagulable disorder identified: consider indefinite anticoagulation beyond initial 3 months 2, 3
• Patients with documented antiphospholipid antibodies or two or more thrombophilic conditions may require 12 months to indefinite anticoagulation 3

Treatment Algorithm Summary

1. Immediate (Day 1): Start therapeutic anticoagulation with heparin bridge to warfarin (INR 2.0-3.0) 2, 3
2. First 3 months: Continue anticoagulation for DVT treatment 2, 3
3. During anticoagulation: Complete hypercoagulable workup 2
4. After 3 months: Evaluate for PFO closure candidacy if no contraindications 2
5. Long-term: If hypercoagulable state identified, continue indefinite anticoagulation; if not, proceed with PFO closure plus antiplatelet therapy 1, 2

Why Not Discharge Without Treatment

Discharging without anticoagulation is contraindicated—the DVT alone mandates treatment for at least 3 months regardless of stroke or PFO considerations. 2, 3 The combination of DVT, PFO, and stroke increases risk 10-fold for death and 5-fold for arterial thromboembolism. 2

Why Not PFO Closure Plus Aspirin Alone

While PFO closure plus antiplatelet therapy is the standard for cryptogenic stroke with PFO in younger patients 1, the concurrent DVT changes this paradigm. The active venous thrombosis requires anticoagulation first, and attempting device closure during an active thrombotic state carries unacceptable procedural risk. 2