Atrial Fibrillation After Patent Foramen Ovale Closure: Incidence, Pathophysiology, and Management

Abstract

This comprehensive review explores the incidence, pathophysiology, and management of atrial fibrillation (AF) following percutaneous closure of patent foramen ovale (PFO). Although AF is considered a common adverse event post PFO closure, its incidence, estimated at <5%, varies based on monitoring methods. The review delves into the challenging task of precisely estimating AF incidence, given subclinical AF and diverse diagnostic approaches. Notably, a temporal pattern emerges, with peak incidence around the 14th day after closure and a subsequent decline after the 45th day, mimicking general population AF trends. The pathophysiological mechanisms behind post PFO closure AF remain elusive, with proposed factors including local irritation, device-related interference, tissue stretch, and nickel hypersensitivity. Management considerations encompass rhythm control, with flecainide showing promise, and anticoagulation tailored to individual risk profiles. The authors advocate for a personalized approach, weighing factors like age, comorbidities, and device characteristics. Notably, postclosure AF is generally considered benign, often resolving spontaneously within 45 days, minimizing thromboembolic risks. Further studies are required to refine understanding and provide evidence-based guidelines.

Keywords: arrhythmias; occlusion; patent foramen ovale; review.

Figure 1. Incidence of atrial fibrillation (AF) occurring after patent foramen ovale closure, as it has been reported in meta‐analyses published from 2013 to 2023.

Figure 2. Incidence of atrial fibrillation (AF) occurring after patent foramen ovale closure during the first 2 years after the procedure.

Figure 3. Possible pathophysiological mechanisms explaining the development of atrial fibrillation after patent foramen ovale closure.

Device implantation could cause local irritation, tissue stretch, and interference because of the metallic component of the device. Local irritation could also cause oxidative stress and local inflammation, processes in which nickel hypersensitivity may play a role. Dotted line shows that it is a hypothetical mechanism, with low evidence.

Figure 4. Risk factors for developing atrial fibrillation after patent foramen ovale (PFO) closure.

LA indicates left atrial; and RoPE, Risk of Paradoxical Embolism.

Figure 5. Classification of atrial fibrillation (AF) as primary or secondary after patent foramen ovale (PFO) closure.

Created with data from Elgendy et al⁵⁸ SR indicates sinus rhythm.

Figure 6. Transeptal puncture using only fluoroscopic guidance for atrial fibrillation ablation in a patient with a patent foramen ovale occluder.

From the personal archive of Dr Tsiachris.

Figure 7. Summary of incidence, risk factors, pathophysiology, severity, and management of atrial fibrillation (AF) occurring after patent foramen ovale (PFO) closure.