PFO Closure: Indications and Outcomes

Patient Case Overview

  • Patient Details: 46-year-old male with an embolic stroke of uncertain source.

  • Neurological Review: Cortical stroke with thorough examination revealing no obvious source for the stroke, except for a potential patent foramen ovale (PFO).

  • Initial Testing: A Transesophageal Echocardiogram (TEE) with bubble injection shows a significant presence of bubbles in the left atrium (50 to 100 bubbles). 90 Day rhythm monitoring was negative for atrial fibrillation.

  • Outcome: 25mm Gore Cardioform device implanted

Key Considerations for Treatment

  • Antiplatelet Therapy vs. Closure:

    • ACC/AHA Guidelines 2021: it is reasonable to percutaneously close PFO in patients who meet each of the following criteria: age 18 to 60 years, non-lacunar stroke, no other identified cause, and high risk PFO features (large strength, more benefit than small shunt)

  • Neurologist's Queries:

    • Is it ischemic?

    • Does it match a large vessel embolus?

      • Keep in mind: Lacunar strokes are most often small and central, and due to small vessel disease. Large vessel ischemic strokes are most often thromboembolic.

    • Has an arterial source been excluded?

    • Has another intracardiac source been excluded?

    • Has subclinical atrial fibrillation been excluded?

    • Any evidence of underlying thrombophilia?

      • Venus thrombophilia testing: lupus anticoagulant, prothrombin mutation 2021, factor V Leiden, APL

  • Common Pitfalls in PFO Diagnosis

    • Sedation for TEE can inhibit patient’s ability to properly perform Valsalva maneuver. therefore, it is recommended to obtain a non-sedated bubble study if not seen with sedated TEE.

    • Localization of of shunting

    • For those with platypnea (dyspnea in the upright position), many patients won’t volunteer that they are more dyspneic in upright position and less specifically asked

    • Also consider orthodeoxia, arterial desaturation in the upright position

      • Those with orthodeoxia and platypnea generally see immediate relief with device closure. These symptoms are therefore a class one indication for PFO device closure in multiple guideline documents.

Post Operative Complications

  • Postop AF is relatively common (transient AF, flutter, or SVT noted in 21% of patients)

    • Median onset two weeks; Occurrences are rare after 30 days

    • Only half of patients are symptomatic

    • Half of patients only had a single episode

    • If AF occurs, it is recommended to initiate DOAC for 1-2 months, then re-monitor to discontinue

Additional Considerations

  • There is no clear need for PFO closure for most patients with pacemaker leads

  • There are currently studies investigating the impact of PFO closure on those with migraines. So far, data has yielded that there may be some reduction in migraine days, however, guidelines do not currently recommend closure.

  • PFO increases the chance of decompression illness 2 to 5 fold for scuba divers. However, a fivefold absolute risk increase equals 0.25%, which is still very low. Therefore, PFO closure is not recommended for most sport divers unless decompression illness has occurred in the presence of a PFO (in which case closure has been shown to reduce reoccurrence)