Are yearly echocardiograms (echos) necessary after patent foramen ovale (PFO) closure?

Yearly Echocardiograms After PFO Closure

Routine yearly echocardiograms are not necessary after patent foramen ovale (PFO) closure in asymptomatic patients with successful device placement and no residual shunt.

Evidence-Based Surveillance Recommendations

The 2020 ACC/AHA/ASE multimodality imaging guidelines explicitly address post-PFO closure surveillance and provide clear direction 1:

• Routine surveillance of an asymptomatic patient with a PFO using transthoracic echocardiography (TTE) or transesophageal echocardiography (TEE) was rated "Rarely Appropriate" 1
• This recommendation applies specifically to patients without complications or significant residual findings 1

Appropriate Post-Closure Imaging Timeline

Based on the atrial septal defect (ASD) device closure protocols (which serve as the closest analog for PFO closure), the guideline-supported surveillance schedule is 1:

• 1 month post-procedure: TTE is appropriate to assess device position and residual shunt 1
• 3-6 months post-procedure: TTE is appropriate for routine surveillance 1
• 1 year post-procedure: TTE is appropriate 1
• Beyond 1 year: Routine surveillance every 2-5 years is appropriate (not annually) in asymptomatic patients with no or mild sequelae 1

Clinical Context from Research Evidence

Long-term outcome data support limited surveillance needs 2:

• In a study of 201 patients followed for a median of 12 years post-PFO closure, residual shunt was observed in only 3.3% at follow-up echocardiography 2
• The stroke recurrence rate was extremely low (0.08 strokes per 100 patient-years) 2
• Echocardiographic examinations were performed at 1-6 month follow-up, with no indication for annual surveillance thereafter 2

When to Perform Imaging Beyond Routine Schedule

Echocardiography should be performed outside the routine schedule only if 1:

• New symptoms develop (stroke, TIA, palpitations, dyspnea)
• Clinical examination suggests complications (new murmur, signs of device erosion)
• Significant residual shunt was present at initial follow-up
• Associated complications exist (arrhythmias, valvular dysfunction, pulmonary hypertension)

Key Clinical Pitfalls to Avoid

• Do not confuse PFO closure surveillance with ASD closure surveillance: While the guidelines use ASD as a framework, they explicitly state that routine PFO surveillance is "rarely appropriate" 1
• Avoid reflexive annual imaging: The evidence does not support yearly echocardiograms in uncomplicated cases 1, 2
• Focus on clinical assessment: Annual clinical follow-up with history and physical examination is more appropriate than routine imaging 2

Practical Algorithm for Post-PFO Closure Follow-Up

For asymptomatic patients with successful closure:

1. TTE at 1 month to confirm device position and assess for residual shunt 1
2. TTE at 3-6 months for routine surveillance 1
3. TTE at 1 year 1
4. Clinical follow-up annually; imaging only if symptoms develop or every 2-5 years if desired 1, 2

For patients with complications (residual shunt, arrhythmias, valve dysfunction):

• TTE every 3-12 months as clinically indicated 1

This approach prioritizes patient outcomes by avoiding unnecessary testing while maintaining appropriate surveillance for the small percentage of patients who develop complications.