Management
➤ In patients being considered for PFO closure, clinicians should assess
for cardioembolic sources using TTE, followed by TEE assessment if
the first study does not identify a high-risk stroke mechanism. Studies
should use bubble contrast, with and without Valsalva maneuver, to
assess for right-to-left shunt and determine degree of shunting (B).
➤ In patients being considered for PFO closure, clinicians should
perform hypercoagulable studies that would be considered a
plausible high-risk stroke mechanism that would lead to a change
in management, such as requiring lifelong anticoagulation (e.g.,
persistent moderate- or high-titer antiphospholipid antibodies in a
younger patient with cryptogenic stroke)
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(B).
➤ In patients being considered for PFO closure, clinicians may use TCD
agitated saline contrast as a screening evaluation for right-to-left
shunt, but this does not obviate the need for TTE and TEE to rule out
alternative mechanisms of cardioembolism and confirm that right-to-
left shunting is intracardiac and transseptal (C).
➤ Before undergoing PFO closure, patients should be assessed by a
clinician with expertise in stroke to ensure that the PFO is the most
plausible mechanism of stroke (B).
➤ If a higher risk alternative mechanism of stroke is identified, clinicians
should not routinely recommend PFO closure (B).
➤ Before undergoing PFO closure, patients should be assessed by
a clinician with expertise in assessing the degree of shunting and
anatomical features of a PFO and performing PFO closure, to assess
whether the PFO is anatomically appropriate for closure, to ascertain
whether other factors are present that could modify the risk of the
procedure, and to address post-procedure management (B).
➤ In patients with a PFO detected after stroke and no other etiology
identified after a thorough evaluation, clinicians should counsel
patients that having a PFO is common, that it occurs in about 1 in 4
adults in the general population, that it is difficult to determine with
certainty whether their PFO caused their stroke, and that PFO closure
probably reduces recurrent stroke risk in select patients (B).
