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Updated: Jan 28, 2026

Closure of a Patent Foramen Ovale PFO: An Intervention Sequence
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Patent Foramen Ovale Closure in Stroke and the PASCAL Classification System.

Jeffrey L Saver1,2, David M Kent3, Scott E Kasner4

  • 1Comprehensive Stroke Center, David Geffen School of Medicine, University of California, Los Angeles.

JAMA Neurology
|January 26, 2026
PubMed
Summary
This summary is machine-generated.

The PASCAL classification system helps identify patients with patent foramen ovale (PFO) who benefit from PFO closure to prevent recurrent stroke. It accurately predicts net benefit for most patients, while identifying those likely to experience harm.

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Area of Science:

  • Cardiovascular Medicine
  • Neurology
  • Medical Diagnostics

Background:

  • Patent foramen ovale (PFO) closure reduces recurrent stroke but increases atrial fibrillation (AF) risk.
  • Optimal patient selection for PFO closure is crucial to maximize benefits and minimize harm.

Purpose of the Study:

  • To evaluate the PFO-Associated Stroke Causal Likelihood (PASCAL) classification system.
  • To determine if PASCAL accurately identifies patients who gain net benefit from PFO closure.

Main Methods:

  • Secondary analysis of individual participant data from 6 randomized trials (SCOPE consortium).
  • Included young and middle-aged adults with PFO and cryptogenic stroke.
  • Compared transcatheter PFO closure plus antithrombotic therapy versus antithrombotic therapy alone.

Main Results:

  • PASCAL classified 37% of patients as probable, 48.4% as possible, and 14.6% as unlikely for PFO-related stroke.
  • Patients classified as probable or possible PFO-related stroke experienced net benefit from closure (fewer strokes vs. increased AF).
  • Patients classified as unlikely PFO-related stroke experienced net harm (no stroke reduction, increased AF).

Conclusions:

  • The PASCAL classification system effectively distinguishes patients likely to benefit from PFO closure.
  • It identifies 4 out of 5 patients (probable/possible groups) who gain net benefit.
  • It identifies 1 out of 5 patients (unlikely group) who are at risk of net harm from closure.