AAN Practice Advisory on PFO Closure After Stroke

The American Academy of Neurology (AAN) has released a practice advisory concluding that poststroke surgical closure of a patent foramen ovale (PFO) may be recommended for some individuals. This practice advisory is endorsed by American Heart Association/American Stroke Association, the Society for Cardiovascular Angiography and Interventions and the European Academy of Neurology.

The practice advisory recommends PFO closure for people less than age 60 with PFO who have had a stroke and have no higher-risk potential causes of a secondary stroke. 

Study author Steven R. Messé, MD, of the Perelman School of Medicine at the University of Pennsylvania, and a Fellow of the American Academy of Neurology noted “. . .while there is generally a very low risk of stroke in patients with PFO, in younger people who have had a stroke without any other possible causes identified, closing the PFO may reduce the risk of having another stroke better than medication alone.”

Previous guidance from the AAN stated there was not enough evidence to recommend routine PFO closure after stroke. The new updated advisory takes note of newer studies reporting PFO closure with anticoagulant treatment reduces the risk of secondary stroke within 5 years by 3.4% more than anticoagulants alone. 
The practice advisory also recommends that stroke specialists first rule out nonPFO causes of stroke and that PFO closure be done only if other potential causes of ischemic stroke are not found in someone with PFO. The potential risks of PFO include procedural complications (3.9%) and increased risk of atrial fibrillation (.33% per year). 

For individuals who have a history of stroke and PFO in whom PFO closure is contraindicated, medical treatment alone with aspirin, antiplatelet, or anticoagulant drugs is still recommended