Page 78 - BH-3-3

Brain & Heart Updates on the treatment of PFO

Table 1. Indications to PFO closure according to published guidance papers
Guideline Diagnosis Patient selection Age
ESO 2024 6 PFO-associated cryptogenic PASCAL classification: possible 18 – 60 years old
stroke or probable
SCAI 2022 5 PFO-associated stroke RoPE score ≥7 18 – 60 years old
AHA/ASAs 2021 4 Non-lacunar ESUS High-risk PFO anatomy <60 years old
AAN 2020 3 Embolic appearing ESUS Ruling-out other mechanisms <60 years old (if <30 years old only in single, small and
of stroke deep infarct without any risk factor for small vessel disease)
Canadian Best Practice Non-lacunar stroke/TIA with Neurologist expert in stroke 18 – 60 years old
Recommendation 2017 2 diagnostic imaging or cortical identifying PFO as most likely
symptoms cause
Note: Modified from ref . Copyright © 2025 Europa Group. Reprinted with permission of Europa Group.
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Abbreviations: AAN: American Association of Neurology; AHA: American Heart Association; ASAs: American Stroke Association; ESO: European
stroke organization; PFO: Patent (persistent) foramen ovale; RoPE: ROPE: Risk of paradoxical embolism; SCAI: Society for Cardiac Angiography and
Interventions; TIA: Transient ischemic attack.

Table 2. Indications to PFO closure according to consensus and position statements
Scientific Type of statement Diagnosis Patient selection Age
body
ESO 2024 guidelines (expert PFO-associated cryptogenic stroke PASCAL classification: >60 years old
consensus statement) 6 possible-probable+clinical judgment
ESO 2024 guidelines (expert PFO-associated cryptogenic stroke High-risk PFO anatomy <18 years old
consensus statement) 6
ESO 2024 guidelines (expert PFO-associated cryptogenic stroke PASCAL classification; unlikely with other 18 – 60 years
consensus statement) 6 high-risk factors for clinical causality old
EAPCI/ Intersocietal position PFO-related left thromboembolism High-risk PFO anatomy and clinical 18 – 65 years
ESO/ESC statement 2018 1 (stroke/TIA or systemic) evaluation old
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Note: Modified from ref . Copyright © 2025 Europa Group. Reprinted with permission of Europa Group.
Abbreviations: EAPCI: European association of percutaneous cardiac interventions; ESC: European Society of Cardiology; ESO: European Stroke
Organization; PFO: Patent (persistent) Foramen Ovale; TIA: Transient ischemic attack.
risk features (e.g., large PFO/shunt or associated enrolled in ongoing registries or randomized studies
atrial septal aneurysm) with non-cardiac risk factors to further refine clinical strategies.
assessed using the ROPE score. It stratifies patients The SCAI 2022 guidelines suggest closure plus medical
into three categories of causal relatedness: unlikely, therapy also in patients >60 years old and in those having
possible, and probable (Figure 1). an indication to lifelong anticoagulation if they had a
(iv) Patients classified as “unlikely” by PASCAL previous PFO-associated stroke. 5
classification should generally receive medical therapy
unless strong evidence of a causal relationship is 3.2. Desaturation syndromes
suggested by specific combinations of clinical or The role of PFO in platypnea-orthodeoxia and other
anatomical factors outlined in Table 3. unexplained arterial desaturation syndromes, including
Additionally, in line with the 2018 European position exercise-induced desaturation, is often straightforward.
paper and subsequent expert consensus statements, PFO In such cases, a significant right-to-left shunt through
closure may be considered in the following scenarios: the PFO is associated with arterial oxygen desaturation,
5,10
(i) Patients <18 years: Based on anatomical high-risk making PFO closure the standard treatment. These cases
features. frequently involve anatomical abnormalities of the atrial
(ii) Patients >60 years: Based on anatomical risk factors septum, which can render closure technically challenging.
and clinical judgment, considering (a) combinations When the shunt is less pronounced, other contributing
of factors listed in Table 3, and (b) comprehensive factors such as pulmonary embolism, parenchymal lung
assessments as described in the 2024 ESC consensus diseases, intrapulmonary shunts, or severe pulmonary
on ESUS. Where feasible, these patients should be hypertension must be evaluated. In these instances,
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Volume 3 Issue 3 (2025) 3 doi: 10.36922/bh.8133