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Should we close PFOs?

P foramen ovale (PFO) has the potential for right-to-left shunt, paradoxical embolization and, therefore, ischemic stroke.[1] Additionally, studies have shown that prevalence of PFO in patients with cryptogenic stroke is significantly higher compared to the normal population.[1,2] The association between PFO and increased risk for cryptogenic ischemic stroke is stronger in patients who are younger than 55 years old.[3,4] When there is a coexistent atrial septal aneurysm, the association between PFO and increased risk for ischemic stroke may be stronger.[3,4] Cramer and co-workers[5] have found that young adults with cryptogenic ischemic stroke are more likely to have both PFO and pelvic deep venous thrombosis. Considering these studies, there is strong evidence that young people with PFO are more prone to have ischemic stroke. However, currently, we cannot conclude that closing PFO in patients who have ischemic stroke is clearly beneficial, as evidence from recently-conducted studies reveals no clear benefit of doing so in these patients.[6-8] It is known, then, that PFO has a cause-effect relation with ischemic stroke, while PFO closure has no clear benefit. There may be several mechanisms to explain this discrepancy.