Atrial septal defect and PFO — structured written assessment

SAQ 1 (10 marks)

Practice scenario. A 49-year-old woman has 2 years of exertional breathlessness and palpitations. She has fixed splitting of the second heart sound and a systolic pulmonary flow murmur; the ECG shows incomplete right bundle branch block and right-axis deviation.^[1] Transthoracic echocardiography shows a secundum ASD with RV enlargement and increased stroke volume, normal LV function with no LV disease, and a calculated systolic pulmonary artery pressure of 48 mmHg.^[1]

1. What further haemodynamic assessment does ESC 2020 require before deciding on closure, and why? (2)^[1]
2. Catheterisation shows PVR 2.4 WU, Qp:Qs 2.1 and a wedge pressure of 9 mmHg. Give the ESC recommendations for closure (ESC 2020 and the newer ESC/ERS 2022 row), with class and level, and the 2025 ACC/AHA row for her haemodynamics. (2)^[1][3][2]
3. Which closure method do ESC 2020 and ACC/AHA 2025 favour, with class and level, and which morphological criteria does ESC 2020 name? (2)^[1][2]
4. Give the ESC 2020 figures for complications and the antithrombotic therapy needed after a device. (2)^[1]
5. How should she be followed after device closure (ESC 2020), and what arrhythmia risk applies at her age? (2)^[1]

Model answers — SAQ 1

1. Invasive measurement of PVR is mandatory in patients with non-invasive signs of raised pulmonary artery pressure (ESC 2020, Class I, Level C) (1 mark).^[1] ESC 2020 requires cardiac catheterisation to determine PVR when the calculated systolic pulmonary artery pressure is over 40 mmHg, as here (1 mark).^[1]
2. ESC 2020: with RV volume overload and no PAH (invasive PVR under 3 WU) or LV disease, ASD closure is recommended regardless of symptoms (Class I, Level B); the newer ESC/ERS 2022 row for ASD with PVR under 3 WU, in patients with a pulmonary-to-systemic flow ratio over 1.5:1, also recommends shunt closure (Class I, Level C) (1 mark).^[1][3] ACC/AHA 2025: with Qp:Qs of 1.5 or more, RV dilation, PVR over 2 to under 5 Wood units and no significant LV disease, closure is reasonable to improve functional status (COR 2a, LOE B-R) (1 mark).^[2]
3. Device closure is the method of choice for secundum ASD when technically suitable (ESC 2020, Class I, Level C); ACC/AHA 2025 says transcatheter closure is usually preferred to surgery for an isolated secundum ASD, to reduce length of stay and recovery time (COR 1, LOE B-NR) (1 mark).^[1][2] ESC 2020: suitability depends on morphology, which includes a stretched diameter of 38 mm or less and a sufficient rim of 5 mm except towards the aorta; this is the case in about 80% of patients (1 mark).^[1]
4. Mortality cannot be assumed to be zero, but several studies reported none; serious complications occur in 1% or fewer; erosion of the atrial wall, anterior mitral leaflet or aorta, and thromboembolic events, appear very rare (1 mark).^[1] Antiplatelet therapy for at least 6 months, aspirin 75 mg once daily as the minimum (1 mark).^[1]
5. Regular follow-up for the first 2 years, then every 3–5 years depending on results, which ESC 2020 calls reasonable; repair at adult age, particularly over 40, calls for regular follow-up including evaluation in specialised ACHD centres (1 mark).^[1] ESC 2020: in patients who have ASD closure after age 40, the prevalence of atrial arrhythmias is up to 40–60%, and the potential incidence of late arrhythmias or adverse events after device closure still requires investigation (1 mark).^[1]

SAQ 2 (10 marks)

Practice scenario. A 42-year-old man has a nonlacunar, cortical ischaemic stroke. A thorough evaluation, including vascular imaging and cardiac monitoring, finds no cause apart from a PFO. He has no hypertension or diabetes, no prior stroke or TIA and does not smoke.^[6][7][9] TOE shows a large shunt (more than 20 bubbles in the left atrium) and an atrial septal aneurysm (more than 10 mm excursion).^[7]

1. Calculate his RoPE score from ESO 2024 Table 6 and classify him with PASCAL (Table 7). (2)^[7]
2. Give the AHA/ASA 2021 recommendation that applies, with COR and LOE, and who should make the decision. (2)^[6]
3. Give the ESO 2024 recommendation for his PASCAL group, with strength and quality, and the IPDMA result for patients with a large shunt plus an atrial septal aneurysm. (2)^[7]
4. What antiplatelet regimen does ESO 2024 suggest after closure, and on what basis? (2)^[7]
5. Name two harms of closure reported in the SCOPE IPDMA (ESO 2024) and the periprocedural complication rate from AHA/ASA 2021 for his age group. (2)^[7][6]

Model answers — SAQ 2

1. RoPE 8: one point each for no hypertension, no diabetes, no prior stroke or TIA, non-smoker and cortical infarct, plus 3 for age 40–49 (1 mark).^[7] PASCAL probable: high RoPE score (7 or more) plus a high-risk PFO feature (1 mark).^[7]
2. Age 18 to 60, nonlacunar ischaemic stroke of undetermined cause despite a thorough evaluation, PFO with high-risk anatomic features: it is reasonable to choose transcatheter closure plus long-term antiplatelet therapy over antiplatelet therapy alone (COR 2a, LOE B-R) (1 mark).^[6] The decision should be made jointly by the patient, a cardiologist and a neurologist, considering the probability that the PFO is causal (COR 1, LOE C-EO) (1 mark).^[6]
3. ESO 2024: with possible or probable PFO-related stroke by PASCAL at age 18–60, PFO closure in addition to antiplatelet therapy is recommended (strong for intervention, moderate-quality evidence) (1 mark).^[7] ESO 2024 reports that in the IPDMA, patients with a large shunt plus an atrial septal aneurysm benefited most: absolute risk reduction 5.5% at 2 years and 7.1% at 5 years, with a number needed to treat of 14 (1 mark).^[7]
4. After closure, dual antiplatelet therapy followed by single antiplatelet therapy to reduce the risk of recurrent stroke, an evidence-based PICO 5 suggestion with low-quality evidence, based on the protocol of available randomised trials (1 mark).^[7] The durations, dual antiplatelet therapy for 1–6 months and then single antiplatelet therapy long term, for at least 5 years after closure, are an expert consensus statement (vote 9/9) drawn from the protocol design of most positive randomised trials; ESO 2024 states that no evidence-based recommendation can be formulated on the duration of single antiplatelet therapy (1 mark).^[7]
5. Atrial fibrillation beyond day 45 (absolute increase 0.65% in the PASCAL probable group) and major bleeding, including access-site or retroperitoneal haemorrhage in 1% and pericardial tamponade in 0.17% (1 mark).^[7] AHA/ASA 2021 reports administrative claims data showing a 4.9% rate of serious periprocedural complications, including AF, in patients aged 60 or under (1 mark).^[6]