Patent foramen ovale and stroke: from diagnosis to treatment—a clinical practice review

Patent foramen ovale (PFO) is present in 25% of the general population. However, its prevalence increases to 50–60% in young cryptogenic stroke patients. Early randomized trials of PFO closure shows no significant improvement in future stroke risk, largely owing to suboptimal patient selection and limited power. With careful case selection and longer follow-up time, PFO closure has been shown to improve future stroke events in multiple landmark trials. Therefore, current practice of PFO closure in young stroke patients emphasizes on diagnostic workup and risk stratification, to better classify which PFOs are likely contributing to the stroke etiology. The PFO-associated stroke causal likelihood (PASCAL) risk stratification system combines patient underlying demographics with PFO anatomy to determine the PFO-stroke causal relationship. It has been shown to be effective in distinguishing patients who are likely to benefit from PFO closure. In borderline cases, a heart-brain team approach is advocated to further identify patients whose stroke is likely caused by PFO. Current success rate of PFO closure is nearly 100% with high safety profile. Careful device sizing and selection minimizes residual shunt. Atrial fibrillation after PFO closure is mostly transient and occurs in the first 3 months after the procedure. Anticoagulation is generally not necessary. Future studies should focus on bioresorbable or suture-based device would further improve outcome, and whether PFO closure could benefit elderly cryptogenic stroke patients after comprehensive evaluation.