What is the next best treatment plan for a 58-year-old male with a past medical history of Coronary Artery Disease (CAD) status post Coronary Artery Bypass Grafting (CABG) x 4, who has a Patent Foramen Ovale (PFO) with moderate right-to-left shunting by agitated saline, as seen on Transesophageal Echocardiogram (TEE)?

From the Guidelines

For a 58-year-old male with a history of coronary artery disease (CAD) status post coronary artery bypass grafting (CABG) x4 who has been diagnosed with a patent foramen ovale (PFO) with moderate right-to-left shunting on transesophageal echocardiography (TEE), the next best treatment plan would be PFO closure via percutaneous transcatheter device placement, as recommended by the most recent guidelines 1. This procedure involves placing a closure device across the PFO to prevent further shunting between the right and left atria. Prior to the procedure, the patient should continue his current cardiac medications, including antiplatelet therapy (likely aspirin 81mg daily) as suggested by the guidelines for patients with a history of CABG 1. Following the procedure, dual antiplatelet therapy with aspirin 81mg daily and clopidogrel 75mg daily would typically be recommended for 1-6 months, followed by aspirin alone indefinitely, in line with the recommendations for patients with CAD status post CABG 1. The patient should also receive antibiotic prophylaxis at the time of the procedure. PFO closure is recommended in this case because the moderate right-to-left shunting increases the risk of paradoxical embolism, which could lead to stroke or other systemic embolic events. This risk is particularly concerning given the patient's age and existing cardiovascular disease. The procedure has shown superior outcomes compared to medical therapy alone in preventing recurrent stroke in patients with PFO and cryptogenic stroke, with a relatively low complication rate. Key considerations in the management of this patient include:

• The patient's history of CAD and CABG, which influences the choice of antiplatelet therapy 1
• The presence of moderate right-to-left shunting, which increases the risk of paradoxical embolism and supports the decision for PFO closure 1
• The need for careful management of antiplatelet therapy to balance the risk of bleeding and ischemic events, as outlined in the guidelines for patients with CAD 1

From the Research

Patient Profile

• 58-year-old male with a past medical history of Coronary Artery Disease (CAD) status post Coronary Artery Bypass Grafting (CABG) x 4
• Diagnosed with Patent Foramen Ovale (PFO) with moderate right to left shunting by agitated saline, seen on Transesophageal Echocardiography (TEE)

Treatment Considerations

• The patient's history of CABG x 4 indicates a high risk of future ischemic events 2
• Antiplatelet therapy is crucial for secondary prevention of coronary artery disease, with aspirin being the cornerstone of treatment 3
• The use of dual antiplatelet therapy, such as combining aspirin with a P2Y12 inhibitor (e.g., clopidogrel, prasugrel, or ticagrelor), may be beneficial in certain patient groups, including those with acute coronary syndrome 3
• However, the addition of anticoagulant therapy to antiplatelet therapy may increase the risk of major bleeding, with little to no benefit in preventing ischemic events 4

Management of PFO

• The presence of a PFO with moderate right to left shunting may increase the risk of paradoxical embolism and stroke
• However, there is limited evidence to guide the management of PFO in patients with a history of CABG and CAD
• Further evaluation and consideration of the patient's individual risk factors and clinical context are necessary to determine the best course of treatment for the PFO

Next Steps

• Consultation with a cardiologist or cardiothoracic surgeon to discuss the patient's individual risk factors and determine the best course of treatment for the PFO
• Consideration of the patient's current antiplatelet and anticoagulant therapy, and potential adjustments to minimize the risk of bleeding and maximize the prevention of ischemic events 2, 3, 4