Case Report: Managing a patent foramen ovale complicated by severe left-sided heart failure and multiple...

The management of patent foramen ovale (PFO) in patients with concurrent severe left-sided heart failure (HF) and a high burden of pulmonary thromboembolism poses a therapeutic dilemma. This case report describes a tailored strategy that prioritizes left atrial unloading in such a complex scenario.

We present the case of a 31-year-old man with ischemic cardiomyopathy (left ventricular ejection fraction 30%-35%) and a history of multiple thromboembolic events. Extensive evaluation revealed a PFO with a left-to-right shunt, chronically elevated left atrial pressure (LAP), a massive left ventricular thrombus, and bilateral chronic pulmonary emboli. Contrary to the standard indication for closure to prevent paradoxical embolism, the patient underwent balloon dilation of the PFO to 6.5 mm, along with balloon pulmonary angioplasty (BPA), to treat the thromboembolic disease.

The patient experienced rapid symptom relief following the procedure. At the 1-month follow-up, his HF functional class improved from NYHA IV to II, with LVEF increasing to 46.6%. At the latest follow-up (33 months), the PFO remained patent, LAP had normalized (average E/e' 8.8), the ventricular thrombus had regressed, and no further thromboembolic events had occurred.

In patients with a PFO complicated by severe left-sided HF and elevated LAP, maintaining an interatrial shunt through balloon dilation, rather than performing PFO closure, can be a feasible and effective therapeutic strategy for improving hemodynamics and clinical status. This case highlights the necessity of individualized management in patients with complex cardiopulmonary disease.