Management of patent foramen ovale-associated stroke: a review of closure vs. medical therapy

Abstract

Patent foramen ovale (PFO) is prevalent in approximately 25% of the general population and the incidence reaches up to 50% among patients with cryptogenic stroke (CS). Extensive research indicates that PFO is linked to paradoxical embolism, leading to CS, embolic stroke of undetermined source, and systemic embolization. Percutaneous PFO closure (PPFOC) has been a promising approach to prevent recurrent ischemic stroke, particularly in selected CS patients under 60 years with a high-risk PFO. Despite advancements, unresolved issues persist. In this review, we provide an updated overview of the diagnosis of high-risk PFOs and summarize recent insights into whether closure or medical therapy alone is effective for reducing recurrent ischemic stroke in CS patients with PFOs. Additionally, we present the current evidence about the safety and effectiveness of PFO percutaneous closure in elderly CS patients. Lastly, we discuss the incidence and the management of atrial fibrillation after PFO closure to guide clinicians in their decision making. Emphasizing the importance of comprehensive assessment, we advocate for a close multidisciplinary collaboration, including neurologists and cardiologists, to avoid unnecessary closure and associated complications in CS patients with a PFO.