PFO closure in ischemic stroke: insights from a single-center real-world cohort

Indications for patent foramen ovale (PFO) closure after ischemic stroke are primarily guided by the Risk of Paradoxical Embolism (RoPE) score and the PFO-associated Stroke Causal Likelihood Classification (PASCAL). Their application in routine care, however, is not well characterized. This study describes real-world management of patients with PFO presenting with ischemic stroke or transient ischemic attack (TIA). TIA cases were included to reflect clinical practice but are interpreted descriptively, as PFO closure is not guideline-supported after TIA alone. As a secondary aim, the "Age, Stroke Severity (NIHSS >5) to Find AF" (AS5F) score was explored for atrial fibrillation (AF) risk assessment.

This retrospective single-center study included consecutive patients with ischemic stroke or TIA and PFO treated at the University Medical Centre Mainz (2015-2022). TIA was defined clinically by symptom resolution within 24 h due to inconsistent MRI availability. Follow-up was performed via standardized telephone interviews ≥12 months after the index event. Subgroup analyses compared patients by PFO closure status, AF diagnosis, recurrent ischemic events, and age ≥60 years.

Among 188 patients, 62 underwent PFO closure. These patients were younger, had fewer cardiovascular risk factors, and more often exhibited embolic PFO features (PASCAL). The RoPE score was higher in the closure group (6.0 ± 1.7 vs. 4.1 ± 1.5; p < 0.001). The AS5F score was lower in closure patients but higher in those with AF (p < 0.001). In patients ≥60 years, higher AS5F scores were associated with AF (cut-off 3.8; p = 0.026). Despite greater comorbidity, over half of patients with recurrent events remained classified as cryptogenic.

These findings reflect real-world decision-making in PFO-associated stroke and highlight limitations of score-based approaches. While RoPE and PASCAL remain central, structured AF risk assessment may provide additional value, particularly in older patients. The high rate of cryptogenic recurrence suggests that the role of PFO may be underestimated in clinical practice. Given the moderate sample size, especially in elderly patients, these results should be considered exploratory and hypothesis-generating.