Table of contents
Patent foramen ovale
Guidelines
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 American Heart Association (AHA/ASA 2021), the European Society of Cardiology (ESC 2021,2019), the American Academy of Neurology (AAN 2020), the British Medical Journal (BMJ 2018), and the ...
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Screening and diagnosis
Diagnostic investigations
Diagnostic imaging: as per ESC 2019 guidelines, combine different diagnostic techniques to achieve maximal accuracy in PFO diagnosis.
A
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Evaluation of hypoxemia
Evaluation of left circulation thromboembolism
Evaluation of decompression sickness
Pre-closure evaluation
Medical management
General principles
As per ESC 2019 guidelines:
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.
B
Use decision aids and narrative tools to enhance patient involvement.
B
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Antithrombotic therapy
Surgical interventions
Indications for closure, patients with prior stroke: as per SCAI 2022 guidelines, perform PFO closure over antiplatelet therapy alone in 18-60 years old patients with a prior PFO-associated stroke.
B
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Indications for closure (patients with no history of stroke)
Specific circumstances
Pregnant patients: as per ESC 2021 guidelines, do not screen for PFO in unselected healthy, asymptomatic females planning a pregnancy or during a normal pregnancy.
D
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Patients with Ebstein anomaly
Patients undergoing non-cardiac surgery
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.
D
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.
B
Preventative measures
Follow-up and surveillance
Imaging follow-up
As per ESC 2019 guidelines:
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
C
Insufficient evidence regarding the value of residual shunt after percutaneous closure.
I
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Post-closure antiplatelet therapy
Post-closure antibiotic prophylaxis