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PFO Assessment for Closure — EECC MCQ

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ModerateCardiac ImagingPFO Assessment for ClosureEECC

A 42-year-old man with cryptogenic stroke and a patent foramen ovale (PFO) detected on TOE with a bubble study undergoes assessment for PFO closure. Which anatomical feature on imaging most strongly supports the association between the PFO and the stroke?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: E — Large PFO with an atrial septal aneurysm (ASA) and significant right-to-left shunt at rest

The CLOSE, RESPECT, and DEFENSE-PFO trials demonstrated that PFO closure reduces recurrent stroke in carefully selected patients with cryptogenic stroke. Features that strengthen the PFO-stroke association and favour closure include: large PFO (tunnel length), presence of an atrial septal aneurysm (ASA, defined as >10 mm septal excursion), significant right-to-left shunt (especially at rest, not just with Valsalva), and high RoPE score. A small PFO with minimal shunt may be an incidental finding (PFOs are present in ~25% of the general population). PFO closure is recommended (Class I) when these high-risk features are present in patients aged 18-65 with cryptogenic stroke after exclusion of other causes.

Reference: ESC Position Paper on PFO Closure; NICE IPG472