Patent Foramen Ovale Closure in Stroke and the PASCAL Classification System

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.