Patent foramen ovale and stroke: More closure to closure but concerns remain-a review

A patent foramen ovale (PFO) is a persistent opening between the right and the left atrium that fails to close spontaneously after birth. An estimated 25% of all adults harbor this condition making it the commonest congenital cardiac anomaly in the general population. Presence of a PFO has long been implicated in causing strokes in the young even though it does not produce any cardiopulmonary hemodynamic perturbations. Patient management has traditionally relied on prophylaxis with antiplatelet medications or occasionally anticoagulants. Good quality evidence supporting surgical or mechanical closure of PFOs following a stroke had been lacking. Publication of 3 new randomized controlled trials in a recent edition of the New England Journal of Medicine is expected to reinforce calls for closing PFOs with percutaneous closure devices in stroke patients. While these trials provide answers to important questions in stroke prevention, it also raises concerns about injudicious extrapolation of these results and indiscriminate use of these devices in practice. The aim of this article is to review the background, pathophysiology and current level of evidence for secondary stroke prevention from PFO and highlight some pitfalls in management.