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Brain & Heart Updates on the treatment of PFO

clinical syndromes, including decompression sickness specific risk factors, clinical presentation, and
(DCS), arterial desaturation syndromes such as platypnea- multidisciplinary input to optimize outcomes. A summary
orthodeoxia, and migraine with aura, particularly in of these recommendations is presented in Tables 1 and 2.
refractory cases. These associations have expanded the Other conditions linked to PFO have also been
scope of PFO research and fueled updates in clinical addressed in these guidelines. The management of DCS in
guidelines and consensus statements, which now address divers was detailed in the 2015 South Pacific Underwater
a broader spectrum of conditions and patient subgroups. Medicine Society and the United Kingdom Sports Diving
Over the past decade, advancements in clinical research, Medical Committee consensus statements, and reinforced
9
procedural techniques, and device development have by the 2021 European position paper, which recommends
further refined patient selection, procedural techniques, closure in select cases following evaluation by both diving
and risk stratification. This paper aims to provide a and cardiac specialists. 10
comprehensive review of the latest updates in PFO closure
guidelines and consensus papers, incorporating new Migraine with aura is acknowledged in the 2019 AAN
3
insights into its role in managing associated syndromes. document and the 2021 European paper as a potential
By synthesizing these developments, we seek to guide indication for PFO closure, particularly in refractory cases,
clinicians in translating evidence into practice, optimizing though the evidence remains debated. 10
patient outcomes, and addressing remaining gaps in the Additionally, the 2021 European paper highlight
evidence. severe arterial desaturation syndromes, such as platypnea-
orthodeoxia, as indications for closure when strongly
2. Cornerstones in guidance papers associated with PFO. 10
Since the landmark evidence in 2017 – 2018 confirming 3. A practical state of the art of indications
PFO’s role in cryptogenic stroke, several key guidance
papers and consensus documents have addressed PFO- 3.1. PFO-associated stroke
associated syndromes. The 2018 European position paper, Since the 2018 European position paper, guidance documents
developed by eight multidisciplinary societies, was the first from major societies have consistently emphasized
to outline comprehensive management and indications for personalized decision-making based on a multidisciplinary
PFO closure. Other guidance includes the 2017 Canadian assessment of the patient’s risk-benefit profile. 1
1
Best Practice Recommendations on stroke at large, the
2
American Academy of Neurology (AAN) expert consensus The 2024 ESC consensus statement on embolic
document, the 2020 American Heart Association/ strokes of undetermined source (ESUS) introduced a
3
American Stroke Association guidelines, the Society for multiparametric assessment method to evaluate the causal
4
Cardiovascular Angiography and Interventions (SCAI) probability of different conditions associated with stroke.
5
2022 guidelines. These documents consistently recommend This framework provides an objective basis for decision-
PFO closure as a primary option for patients under 60 – making in this complex context. 6
65 years with cryptogenic stroke, emphasizing the use Current indications for PFO closure plus antiplatelet
of objective tools like the risk of paradoxical embolism therapy in cryptogenic stroke have largely remained
(ROPE) score in conjunction with clinical judgment. For unchanged in Europe since 2018, with the recent
patients over 65 years, percutaneous closure is considered introduction of the PASCAL classification to enhance risk
after a detailed evaluation of potential alternative etiologies. stratification in the last 2024 guidelines. These indications
6
The most recent update is the 2024 European Stroke prioritize carefully selected patients where a causal
Organisation Guidelines, which integrate findings from relationship between the PFO and the stroke is likely, as
6
the 2021 patient-level meta-analysis of randomized trials. determined by the following criteria:
7
These guidelines reaffirm PFO closure in cryptogenic stroke (i) Age: Between 18 and 60 years.
patients aged 18 – 60 years and introduce the PASCAL (ii) Exclusion of other stroke causes: Primarily atrial
fibrillation (AF)—For patients above 55 – 60 years of
classification for refined risk stratification. They also age, if AF is not detected with short-term monitoring,
support closure for patients over 60 after individualized long-term monitoring (preferably with an implantable
evaluation and update diagnostic recommendations from loop recorder) is recommended. For those under 55 –
earlier guidance, confirming the 2018 European position 60 years with low AF risk, short-term monitoring may
paper’s conclusions.
suffice.
Collectively, these guidance documents emphasize (iii) PASCAL classification: “Possible” or “Probable”—The
personalized decision-making, incorporating patient- PASCAL classification integrates anatomical high-

Volume 3 Issue 3 (2025) 2 doi: 10.36922/bh.8133