Can a patient with a Patent Foramen Ovale (PFO) undergo surgery?

Can a Patient with a Patent Foramen Ovale (PFO) Undergo Surgery?

Yes, a patient with a PFO can safely undergo surgery, as PFO is not a contraindication to surgical procedures. 1 The presence of a PFO requires specific perioperative considerations but does not preclude surgical intervention.

Key Perioperative Considerations

Preoperative Assessment

• Evaluate the clinical context of the PFO: Determine whether the patient has a history of paradoxical embolism, cryptogenic stroke, or other PFO-related complications, as these may influence perioperative management strategies 2

• Assess thromboembolic risk: Patients with documented systemic embolism from paradoxical embolism may require oral anticoagulation perioperatively 2

• Consider right-to-left shunt severity: The degree of shunting through the PFO may impact decisions about anesthetic management and monitoring 3

Specific Surgical Scenarios

Cardiac Surgery with Concurrent PFO:

• If the patient requires cardiac surgery for another indication (e.g., tricuspid valve repair), PFO closure should be performed surgically at the time of the primary procedure 2
• This represents a Class I recommendation from the European Society of Cardiology guidelines 2

Non-Cardiac Surgery:

• Standard surgical procedures can proceed safely in patients with PFO 1
• The primary concern is preventing paradoxical embolism during periods of increased venous thrombosis risk 3

Perioperative Management Strategy

Antithrombotic Therapy:

• For patients with PFO and history of paradoxical embolism or atrial fibrillation, oral anticoagulation is recommended 2
• In patients with increased thromboembolic risk or right-to-left shunt, oral anticoagulation may be considered perioperatively 2
• Standard antiplatelet therapy is reasonable for most PFO patients without specific high-risk features 2

Anesthetic Considerations:

• Avoid conditions that increase right atrial pressure (which could exacerbate right-to-left shunting), such as excessive positive pressure ventilation or Valsalva maneuvers 3
• Maintain adequate hydration and avoid hypovolemia to minimize shunt fraction 4
• Consider air embolism precautions, as PFO provides a pathway for paradoxical air embolism 4

Special Populations Requiring Enhanced Vigilance

High-Risk Scenarios:

• Patients with massive or submassive pulmonary embolism and PFO face significantly elevated mortality risk (2.4-fold increased risk of death, 5.9-fold increased risk of ischemic stroke) and may require more aggressive intervention 1
• Older patients (≥45 years) with PFO and cryptogenic stroke history have higher recurrence rates (35% vs 0% in younger patients) and warrant closer monitoring 5

Common Pitfalls to Avoid

• Do not delay necessary surgery solely due to PFO presence: PFO is not a surgical contraindication 1
• Do not overlook the opportunity for concurrent PFO closure: When performing cardiac surgery, address the PFO if clinically indicated 2
• Do not assume all PFOs carry equal risk: Risk stratification based on shunt size, associated atrial septal aneurysm, and patient history is essential 3, 6
• Avoid inadequate DVT prophylaxis: Standard or enhanced thromboprophylaxis is critical given the paradoxical embolism risk 1

Postoperative Management

• Continue appropriate antithrombotic therapy based on individual risk assessment 2
• Maintain vigilance for neurological symptoms that could indicate paradoxical embolism 1
• Consider PFO closure evaluation at 3-6 months post-surgery if the patient experienced complications potentially related to the PFO 1