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Patent foramen ovale

Key sources
The following summarized guidelines for the evaluation and management of patent foramen ovale are prepared by our editorial team based on guidelines from the Society for Cardiovascular Angiography and Interventions (SCAI 2022), the European Society of Cardiology (ESC 2021; 2019), the American Heart Association (AHA/ASA 2021), the American Academy of Neurology (AAN 2020), the British Medical Journal (BMJ 2018), and the American College of Chest Physicians (ACCP 2012).
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Guidelines

1.Screening and diagnosis

Indications for screening: do not obtain primary screening for PFO on a routine basis in divers and/or aircrews.
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2.Diagnostic investigations

Diagnostic imaging: combine different diagnostic techniques to achieve maximal accuracy in PFO diagnosis.
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  • Evaluation of hypoxemia

  • Evaluation of left circulation thromboembolism

  • Evaluation of decompression sickness

  • Pre-closure evaluation

3.Medical management

General principles
Ensure interdisciplinary assessment and decision-making in patients with PFO, taking into account an estimation of the individual probability of a causal role of the PFO in the clinical picture and the risk of recurrence. Take into account clinical, anatomical and imaging characteristics during individual risk stratification. Document shared decision-making in an open, individualized, informed consent.
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Use decision aids and narrative tools to enhance patient involvement.
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  • Antithrombotic therapy

4.Surgical interventions

Indications for closure, patients with prior stroke, SCAI: perform PFO closure over antiplatelet therapy alone in 18-60 years old patients with a prior PFO-associated stroke.
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  • Indications for closure (patients with no history of stroke)

5.Specific circumstances

Pregnant patients: do not screen for PFO in unselected healthy, asymptomatic females planning a pregnancy or during a normal pregnancy.
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  • Patients with Ebstein anomaly

  • Patients undergoing non-cardiac surgery

6.Patient education

General counseling
As per ESC 2021 guidelines:
Do not advise any restrictions on conventional altitude flights for any patient when the PFO is an incidental finding.
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Provide counseling by an experienced diving physician in recreational divers, according to the context, size of shunt and the individual's compliance/preferences, when the PFO is an incidental finding.
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7.Preventative measures

Secondary prevention of decompression sickness: provide secondary prevention primarily aiming at suppressing venous gaseous emboli production up to possible permanent cessation of the activity, regardless of the presence of a PFO.
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8.Follow-up and surveillance

Serial imaging assessment
Consider obtaining the following to acquire comparable data:
TTE before hospital discharge
contrast-enhanced transcranial Doppler at least once beyond 6 months to assess effective PFO closure and thereafter, if residual shunt persists, annually until closure
contrast-enhanced TEE or TTE in case of severe residual shunt at contrast-enhanced transcranial Doppler or recurrent events or symptoms during follow-up
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Insufficient evidence regarding the value of residual shunt after percutaneous closure.
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  • Post-closure antiplatelet therapy

  • Post-closure antibiotic prophylaxis