Optimizing patient selection for patent foramen ovale closure after stroke: The CRISP-PFO score

Although patent foramen ovale (PFO) transcatheter closure lowers recurrent cryptogenic stroke (CS), identifying patients who benefit most remains challenging. We developed, validated and assessed the diagnostic performance of a new scoring system to predict high-risk PFO patients who may benefit from PFO transcatheter closure in secondary prevention.

The CRISP-PFO score was derived from 936 PFO patients with a RoPE score ≥7, enrolled in a single-center prospective registry from March 2003 to March 2025. The score was derived from 624 patients and validated in 312 patients. Significant baseline variables (p < 0.1) from univariable logistic regression were entered into a multivariable model. Model performance was assessed via receiving operating curves and calibration slope. Patients were stratified into low-, intermediate-, and high-risk groups.

In the derivation cohort, multivariate analysis identified four independent predictors of CS: permanent right-to-left shunt (2 points), ischemic brain lesions (2 points), an antero-posterior left atrial (LA) diameter ≥43 mm (1 point), and atrial septal aneurysm (1 point). Based on these factors, patients were stratified into low (0-2 points), intermediate (3-4 points), and high (5-6 points) risk categories, with event rates increasing across these groups (p<0.001). The CRISP-PFO score demonstrated strong diagnostic performance, with an AUC of 0.80-0.81, C-statistics of 0.78-0.79, and Hosmer-Lemeshow p-values of 0.44-0.47 in the derivation and validation cohorts, respectively.

The CRISP-PFO score is a novel and straightforward tool that accurately identifies PFO patients at high risk for CS who may benefit from transcatheter PFO closure.