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Updated: Nov 25, 2025
Closure of a Patent Foramen Ovale PFO: An Intervention Sequence
Published on: December 23, 2022
Cryptogenic stroke and patent foramen ovale (abridged and translated version)
Hans-Christoph Diener1, Armin Grau2, Stephan Baldus3
1German Society of Neurology, Stuttgart, Germany.
Insights
Interventional patent foramen ovale (PFO) closure is recommended for cryptogenic stroke patients aged 16-60 with significant shunts. For those refusing closure, antiplatelet therapy is advised over anticoagulation for secondary stroke prevention.
Area of Science:
- Cardiology
- Neurology
- Interventional Cardiology
Background:
- Patent foramen ovale (PFO) is a potential cause of cryptogenic ischemic stroke.
- Patient selection and treatment strategies for PFO-related stroke remain areas of clinical interest.
Purpose of the Study:
- To provide guideline-based recommendations for the interventional closure of PFO in patients with cryptogenic ischemic stroke.
- To outline secondary prevention strategies for patients with PFO and cryptogenic stroke who decline PFO closure.
Main Methods:
- Guideline abridgement and translation from established neurological society recommendations.
- Review of diagnostic work-up, patient selection criteria, and therapeutic options.
Main Results:
- Interventional PFO closure is indicated for patients aged 16-60 with cryptogenic ischemic stroke and moderate-to-extensive right-to-left shunt.
- For patients declining PFO closure, antiplatelet therapy (aspirin or clopidogrel) is recommended over oral anticoagulation for secondary prevention.
Conclusions:
- PFO closure is a viable option for select cryptogenic stroke patients, balancing risks and benefits.
- Antiplatelet therapy is the standard of care for secondary prevention in PFO patients who reject closure, given lack of evidence for anticoagulation superiority.
Abstract:
Interventional patent foramen ovale (PFO) closure should be performed in patients aged 16 to 60 years (after extensive neurological and cardiological diagnostic work-up) with a history of cryptogenic ischaemic stroke and patent foramen ovale, with moderate or extensive right-to-left shunt. In patients with cryptogenic ischaemic stroke and patent foramen ovale, who reject a PFO closure, there is no evidence of superiority of oral anticoagulation over antiplatelet therapy. Therefore, secondary prevention should be performed with aspirin or clopidogrel. Atrial fibrillation, pericardial tamponade, and pulmonary embolism are reported complications during and after implantation of an occluder. However, these events are so rare that they should not influence the recommendation for implantation. This article is an abridged and translated version of the guideline published in Nervenarzt: Diener, HC., für die Deutsche Gesellschaft für Neurologie (DGN), Grau, A.J. et al. Nervenarzt (2018) 89: 1143. 10.1007/s00115-018-0609-y.
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