Should I have percutaneous closure of a patent foramen ovale?

PFO Closure for Cryptogenic Stroke Prevention

If you are under 60 years old and have had a cryptogenic stroke with a patent foramen ovale (PFO) after extensive workup excluding other causes, you should undergo percutaneous PFO closure followed by antiplatelet therapy rather than medical therapy alone.

Clinical Decision Algorithm

The decision to close your PFO depends on three critical factors:

1. Age and Stroke Type

• Under 60 years old with cryptogenic ischemic stroke after thorough evaluation: Strong indication for closure 1
• Over 60 years old: Benefits are less certain; fewer cryptogenic strokes are caused by paradoxical emboli in this age group, and procedural risks may be higher 1

2. Treatment Options Available

If all options are acceptable to you:

• PFO closure plus antiplatelet therapy is weakly recommended over anticoagulation therapy 1
• This means closure is probably better, but the evidence isn't overwhelming when comparing to anticoagulation

If anticoagulation is contraindicated or you decline it:

• PFO closure plus antiplatelet therapy receives a strong recommendation over antiplatelet therapy alone 1
• This is the clearest evidence: closure significantly reduces stroke recurrence with high-quality evidence 1

If PFO closure is contraindicated or you decline it:

• Anticoagulation therapy is weakly recommended over antiplatelet therapy alone 1

3. Risk Stratification Factors

Your candidacy for closure should be evaluated based on:

• PFO anatomical features: Large shunt size, atrial septal aneurysm, and tunnel characteristics increase the likelihood that your PFO caused the stroke 2, 3
• Traditional vascular risk factors: Absence of diabetes, hypertension, and hyperlipidemia makes PFO more likely as the culprit 1
• PASCAL classification system: This should be used (rather than RoPE score alone) to determine causal likelihood 2

Evidence Quality and Stroke Reduction

The evidence supporting PFO closure is high quality for stroke prevention 1. Meta-analyses demonstrate that closure devices significantly reduce recurrent ischemic stroke risk (hazard ratio 0.29) compared to medical therapy 4. The benefit is substantial enough that most patients will prioritize this stroke reduction over potential complications 1.

Procedural Considerations

What to expect:

• Procedure duration: Under 2 hours
• Hospital stay: Typically 1 day
• Recovery: Most activities resumed within days; full recovery within weeks 1

Risks to discuss:

• Atrial fibrillation/flutter: Increased risk (approximately 5% vs. 1% with medical therapy) 1
  • Important caveat: When using the Amplatzer device specifically, this increased risk of atrial arrhythmias may not occur 4
• Device-related adverse events: Occur but are infrequent with modern devices 1
• Major bleeding: Actually decreased compared to anticoagulation therapy 1

Common Pitfalls to Avoid

1. Don't pursue closure without comprehensive stroke workup: Other stroke etiologies must be thoroughly excluded first 1
2. Don't assume all PFOs need closure: Incidentally discovered PFOs without clinical events should be managed conservatively 5
3. Don't ignore age limits: The evidence strongly supports closure in patients under 60; benefits are uncertain and risks higher in older patients 1
4. Don't skip multidisciplinary evaluation: A "heart-brain team" approach is mandatory for optimal patient selection 2

Diagnostic Workup Required

Before closure consideration:

• First-line screening: Transcranial Doppler (TCD) bubble study where available 2
• Alternative screening: Transthoracic echocardiography if TCD unavailable 2
• Pre-closure confirmation: Transesophageal echocardiography to characterize anatomy 2, 6
• Shunt grading: TCD results should be incorporated into risk stratification 2

Strength of Recommendation

The 2018 BMJ guideline provides the most direct guidance: strong recommendation for PFO closure plus antiplatelet therapy versus antiplatelet therapy alone when anticoagulation is not an option 1. This is based on substantial stroke reduction benefits that outweigh procedural risks for appropriately selected patients under 60 years old with cryptogenic stroke.

The evidence is less strong (weak recommendation) when comparing closure to anticoagulation, meaning both are reasonable options if you can tolerate anticoagulation 1. However, closure avoids long-term bleeding risks associated with anticoagulants 1.