What is the best management for a Patent Foramen Ovale (PFO)?

From the Guidelines

The best management for Patent Foramen Ovale (PFO) is PFO device closure plus long-term antiplatelet therapy for carefully-selected patients with a recent ischemic stroke or TIA attributed to a PFO, as recommended by the most recent and highest quality study 1. This approach is supported by the latest evidence, which suggests that PFO closure plus antiplatelet therapy is superior to antiplatelet therapy alone for patients who have experienced a cryptogenic stroke and have a PFO. The following criteria should be met for PFO closure to be recommended:

• Age 18–60 years
• The diagnosis of the index stroke event is confirmed by imaging as a nonlacunar embolic ischemic stroke or a TIA with positive neuroimaging or cortical symptoms
• The patient has been evaluated by a neurologist or clinician with stroke expertise, and the PFO is felt to be the most likely cause for the index stroke event following a thorough etiological evaluation to exclude alternate etiologies. After PFO closure, 1–6 months of dual antiplatelet therapy (DAPT) is recommended, followed by single antiplatelet therapy (SAPT) for up to 5 years, as suggested by the study 1. The choice of antiplatelet drug type is empirical, and optimal antithrombotic treatment after PFO closure remains to be assessed. Some key points to consider when managing PFO include:
• Patient age and stroke risk factors
• PFO characteristics, such as size and presence of atrial septal aneurysm
• Patient preferences and discussion of the benefits and risks of each approach
• The need for individualized decision-making based on patient characteristics and risk versus benefit profile, as noted in the study 1.

From the Research

Best Management for PFO

The optimal management strategy for patients with patent foramen ovale (PFO) is a topic of ongoing debate. Several studies have investigated the efficacy and safety of different approaches, including device closure, medical therapy, and anticoagulation.

• Device Closure vs. Medical Therapy: A systematic review and meta-analysis published in 2018 2 found that device closure plus medical therapy was more effective in preventing stroke recurrence compared to medical therapy alone in patients with cryptogenic stroke or transient ischemic attack (TIA) and PFO.
• Catheter Closure: A study published in 2001 3 reported that catheter closure of PFO was a technically simple procedure with a low complication rate, and that the success rate had improved with the use of newer devices.
• Anticoagulation vs. Antiplatelet Therapy: A systematic review and meta-analysis published in 2020 4 found that anticoagulation conveyed no net benefit in preventing recurrent stroke compared to antiplatelet therapy in patients with PFO-related stroke, although anticoagulation may be beneficial in patients with a high RoPE score.
• Current Guidelines: A review article published in 2024 5 noted that current guidelines recommend closing a PFO in patients who have experienced a cryptogenic or cardioembolic stroke, have a high-risk PFO, and are aged between 16 and 60 years.
• Recurrent Stroke/TIA after PFO Closure: A cohort study published in 2025 6 found that the rate of recurrent stroke/TIA after PFO closure was comparable to findings in previous trials, and that pre-existing vascular risk factors and a hypercoagulable state were associated with recurrent ischemic stroke/TIA.

Key Findings

• Device closure plus medical therapy may be more effective in preventing stroke recurrence compared to medical therapy alone in patients with cryptogenic stroke or TIA and PFO.
• Catheter closure of PFO is a technically simple procedure with a low complication rate.
• Anticoagulation may not convey a net benefit in preventing recurrent stroke compared to antiplatelet therapy in patients with PFO-related stroke, although it may be beneficial in patients with a high RoPE score.
• Current guidelines recommend closing a PFO in patients who have experienced a cryptogenic or cardioembolic stroke, have a high-risk PFO, and are aged between 16 and 60 years.
• Pre-existing vascular risk factors and a hypercoagulable state are associated with recurrent ischemic stroke/TIA after PFO closure.