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As a cardiologist give me an infor mation about pfo

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"patent foramen ovale" AND closure

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2025 SCAI guideline patent foramen ovale closure patient information

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PMID: 40683784

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SCAI guidelines management patent foramen ovale 2022 recommendations closure 18 60 stroke

PFO means patent foramen ovale. It is a small flap-like opening between the upper chambers of the heart, the right and left atria.

What it means

Before birth, this opening normally allows blood to bypass the lungs. It usually seals shortly after birth. In about 1 in 4 adults, it remains partly open. A PFO is not the same as an atrial septal defect (ASD): a PFO is usually a flap that can open transiently, rather than a fixed hole.
Most people with a PFO:
  • Have no symptoms
  • Have normal heart function
  • Never require treatment
Textbook data estimate PFO in about 25% of adults, with no shunt at rest in many people. Fuster and Hurst's The Heart, p. 813.

Why can a PFO matter?

Normally, a clot from the leg veins travels to the lungs. If right-sided pressure temporarily rises, such as while coughing, straining, or during a Valsalva maneuver, a clot can potentially pass through a PFO into the arterial circulation. This is called paradoxical embolism and may cause a stroke.
A PFO is considered more relevant when someone has had an otherwise unexplained ischemic stroke, particularly at a younger age and with:
  • No clear alternative stroke mechanism
  • Evidence of a large right-to-left shunt
  • An atrial septal aneurysm or very mobile atrial septum
  • Deep-vein thrombosis or pulmonary embolism
  • Stroke occurring around prolonged immobility, recent surgery, long travel, or straining
However, finding a PFO after a stroke does not automatically mean it caused the stroke, because PFOs are common in the general population. Fuster and Hurst's The Heart, p. 813.

How it is diagnosed

Common tests include:
  1. Transthoracic echocardiography with agitated-saline “bubble” study
  2. Transesophageal echocardiography (TEE), which provides more detailed anatomy and helps assess shunt size and atrial septal aneurysm
  3. Sometimes transcranial Doppler bubble testing, which detects a right-to-left shunt but does not show the PFO anatomy directly.

When is PFO closure considered?

Closure is not recommended simply because a PFO is found incidentally.
The strongest evidence supports closure in carefully selected patients who:
  • Are generally 18 to 60 years old
  • Have had a PFO-associated ischemic stroke
  • Have undergone a thorough evaluation that finds no better stroke cause
  • Can safely undergo a catheter procedure
The SCAI guideline recommends closure rather than antiplatelet treatment alone in this selected 18-60 group; a higher RoPE score can indicate that the PFO is more likely related to the stroke. See the SCAI PFO guideline.
For people over 60, the decision is more individualized because atrial fibrillation, aortic plaque, and vascular disease become more common alternative sources of stroke.
Closure may also be considered in rare circumstances such as:
  • Platypnea-orthodeoxia syndrome: low oxygen levels that worsen upright and improve when lying down
  • Some cases of systemic embolism after other sources have been excluded

What does closure involve?

PFO closure is usually a minimally invasive catheter procedure:
  • A catheter is passed through a vein in the groin.
  • A small double-disc device is placed across the PFO.
  • The device becomes covered by the body’s own tissue over time.
  • Antiplatelet medication is commonly prescribed for a period afterward, but the exact regimen is individualized by the treating cardiologist.

Benefits and risks

In appropriately selected patients with prior cryptogenic stroke, closure reduces recurrent ischemic stroke compared with medical therapy. A recent systematic review found lower recurrent stroke/TIA rates but a higher risk of atrial fibrillation after closure. Recent meta-analysis, PMID 40683784.
Potential risks include:
  • New atrial fibrillation or flutter, often early after the procedure
  • Bleeding or vascular complications at the groin site
  • Device-related clot, device embolization, or residual leak, all uncommon
  • Rare erosion or infection

PFO and migraine or scuba diving

  • Migraine: Routine PFO closure is not recommended solely to treat migraine.
  • Scuba diving: A PFO can contribute to certain decompression illness scenarios, but routine screening or closure is not recommended for most divers. This requires individualized assessment by a diving-medicine and structural-heart team.

When to seek urgent care

Seek emergency evaluation immediately for possible stroke symptoms: facial drooping, arm or leg weakness/numbness, speech difficulty, sudden severe imbalance, visual loss, or a sudden severe headache. Do not wait to arrange an outpatient PFO evaluation.
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