USA: Updated Guideline on PFO Management

The American Academy of Neurology (AAN) has released an updated guideline on the management of patients with a patent foramen ovale (PFO) with a history of stroke or TIA. The guideline, published in the journal JAMA, updates previous guidelines, incorporating recent data on the effect of PFO closure and antithrombotic and antiplatelet therapy on stroke risk.

Key Recommendations

• In patients being considered for PFO closure, clinicians should ensure that an appropriately thorough evaluation has been performed to rule out alternative mechanisms of stroke, as was performed in all positive PFO closure trials.
• In patients being considered for PFO closure, clinicians should obtain brain imaging to confirm stroke size and distribution, assessing for an embolic pattern or a lacunar infarct (typically involving a single deep perforator, <1.5 cm in diameter).
• In patients being considered for PFO closure, clinicians should obtain complete vascular imaging (MRA or CTA) of the cervical and intracranial vessels to look for dissection, vasculopathy, and atherosclerosis.
• In patients being considered for PFO closure, clinicians must perform a baseline ECG to look for atrial fibrillation.
• Select patients being considered for PFO closure thought to be at risk of atrial fibrillation should receive prolonged cardiac monitoring for at least 28 days (level B). Risk factors for atrial fibrillation include:
  • Age ≥50 years
  • Hypertension
  • Obesity
  • Sleep apnea
  • Enlarged left atrium
  • Elevated NT-proBNP
  • Frequent premature atrial contractions
  • Increased P-wave dispersion
  Recently published guidelines from the American Heart Association, American College of Cardiology, and Heart Rhythm Society recommend prolonged ECG monitoring following cryptogenic stroke for patients older than 40 years, although more research is needed to define the yield in unselected young patients and in patients with PFO.
• 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.
• 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).
• 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 cardio embolism and confirm that right-to-left shunting is intracardiac and transseptal.
• 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.
• If a higher risk alternative mechanism of stroke is identified, clinicians should not routinely recommend PFO closure.
• Before undergoing PFO closure, patients should be assessed by a clinician with expertise in assessing the degree of shunting and anatomic 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 postprocedure management.
• In patients with a PFO detected after stroke and no other etiology identified after a thorough evaluation, clinicians should counsel 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.