Antithrombotic therapy in patients with patent foramen ovale (PFO), PFO closure, left ventricular mural thrombus, atrial thrombus, and catheter-related thrombosis

Abstract

Abstract A patent foramen ovale (PFO) can give rise to paradoxical embolism and ischaemic stroke. In patients younger than 60–65 years with PFO-related ischaemic stroke, the risk of recurrent stroke can be reduced by about 60% by transcatheter PFO closure, while continuing antiplatelet therapy. Clinical history, age, presence of risk factors for stroke, ischaemic brain infarct location, and PFO anatomy are key factors when determining the probability of an ischaemic stroke being causally linked to a PFO. Heart–brain team assessment should be integral in the decision-making process for PFO closure. Technical success of transcatheter PFO closure is very high, and the complication rate is low. Dual antiplatelet therapy (aspirin and clopidogrel) should be given for 1–6 months after PFO closure followed by single antiplatelet therapy for up to 5 years. Oral anticoagulation is recommended over antiplatelets in patients with a PFO-related ischaemic stroke not eligible for transcatheter PFO closure. Thrombus formation on the PFO-closure device is a rare complication after PFO closure. Management of device-related thrombosis is outlined. Left ventricular mural thrombus is a serious complication occurring in the setting of regional or global left ventricular dysfunction. It is most often seen in association with acute myocardial infarction. Addition of oral anticoagulation with vitamin K antagonists to aspirin is the historical treatment; however, newer observational studies suggest direct oral anticoagulants to be a safe and equally effective alternative. Thrombus formation in the right and left atria can occur in association with atrial fibrillation, mitral and tricuspid valve stenosis, inflammatory disorders, coagulopathy, cancer, or congenital heart disease and in the setting of thrombosis on intracardiac catheters or pacing leads. Diagnosis and management of atrial thrombi and catheter-related thrombosis are discussed.