➤ In patients younger than 60 years with a PFO and an embolic-
appearing infarct and no other mechanism of stroke identified,
clinicians may recommend closure following a discussion of
potential benefits (reduction of stroke recurrence) and risks
(procedural complication and atrial fibrillation) (C).
➤ Clinicians may inform patients that presence of a large shunt
probably is associated with benefit from closure. Conversely, there
probably is less likelihood of benefit in patients with a small shunt
or a non–embolic-appearing single, small, deep infarct, and it is
uncertain whether atrial septal aneurysm in the absence of a large
shunt influences the likelihood of benefitting from PFO closure (C).
➤ PFO closure may be offered in other populations, such as for
a patient who is 60–65 years old with a very limited degree of
traditional vascular risk factors (i.e., hypertension, diabetes,
hyperlipidemia, or smoking) and no other mechanism of stroke
detected following a thorough evaluation, including prolonged
monitoring for atrial fibrillation (C).
➤ PFO closure may be offered to younger patients (e.g., <30 years) with
a single, small, deep stroke (<1.5 cm), a large shunt, and absence
of any vascular risk factors that would lead to intrinsic small-vessel
disease such as hypertension, diabetes, or hyperlipidemia (C).
➤ In a patient for whom PFO closure is being considered, a shared
decision-making approach between clinicians and the patient
should be used, exploring how well the patient's attributes match
those included in the positive PFO closure trials and the patient's
preferences and concerns regarding risk of stroke recurrence and
risk of adverse events (B).
Recommendations Regarding Medical Therapy
➤ In patients who opt to receive medical therapy alone without PFO
closure, clinicians may recommend either an antiplatelet medication
such as aspirin or anticoagulation (using a vitamin K antagonist, a
direct thrombin inhibitor, or a factor Xa inhibitor) (C).
➤ In patients who would otherwise be considered good candidates
for PFO closure but require long-term anticoagulation because of
suspected or proven hypercoagulability (defined thrombophilia,
unprovoked deep venous thrombosis, or unprovoked pulmonary
embolism), clinicians should counsel the patient that the efficacy of
PFO closure in addition to anticoagulation cannot be confirmed or
refuted (B).
Management
