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Updated: Jun 4, 2026
Closure of a Patent Foramen Ovale (PFO): An Intervention Sequence
Published on: December 23, 2022
Should a patent foramen ovale found incidentally during isolated coronary surgery be closed?
Tammy T H Lo1, Omar A Jarral, Alex R Shipolini
1Department of Cardiothoracic Surgery, The London Chest Hospital, Bonner Road, London E2 9JX, UK.
Insights
Closing an incidentally found patent foramen ovale (PFO) during coronary surgery is not recommended. Evidence shows closure increases stroke risk without improving long-term survival for cardiac surgery patients.
Area of Science:
- Cardiology
- Cardiovascular Surgery
- Neurosurgery
Background:
- Patent foramen ovale (PFO) is frequently discovered incidentally during cardiac surgery.
- The clinical significance and optimal management of incidental PFOs remain debated.
Purpose of the Study:
- To evaluate the evidence regarding the closure of incidentally found PFOs in patients undergoing isolated coronary artery surgery.
Main Methods:
- A systematic review of best-evidence articles was conducted.
- Analysis included a significant propensity-matched study of 2277 patients (639 closures) and a survey of 438 US cardiac surgeons.
Main Results:
- No evidence links incidental PFO to increased morbidity, mortality, or decreased survival in cardiac surgery patients.
- PFO closure was associated with a significantly higher risk of postoperative stroke and offered no long-term survival benefit.
- Surgeon decision-making on closure lacks consensus, considering factors like PFO size and embolism history.
Conclusions:
- Incidental PFO closure during coronary surgery is not supported by current evidence and may increase stroke risk.
- Further research and consensus are needed for managing incidental PFOs in this patient population.
Abstract:
A best evidence topic was written according to a structured protocol. The question addressed was whether incidentally found patent foramen ovale (PFO) during isolated coronary surgery should be closed. A total of 573 papers were found using the reported searches of which six represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. There is currently no evidence to suggest that incidental PFO in patients undergoing cardiac surgery is linked with increased morbidity, mortality or decreased long-term survival. The most significant study identified examined the outcomes of 2277 patients with incidentally found PFO during cardiac surgery of whom 639 underwent closure. After propensity matched analysis, the authors found closure was associated with a significantly higher risk of postoperative stroke with no advantage in terms of long-term survival. A recent survey of 438 cardiac surgeons from the USA showed no consensus on decision-making behind closure, but that factors taken in to account include PFO size, right atrial pressure and a history of paradoxical embolism. This is not surprising given that morphological research has confirmed that larger PFO size is indeed associated with cryptogenic stroke.
