Patent Foramen Ovale 2023: More Lights than Shadows

Dear Colleagues,

Patent foramen ovale (PFO) represents a benign common abnormality affecting up to 30% of the general population. Nevertheless, in some cases, the PFO can open widely, leading to the paradoxical shunting of blood or thrombotic material from the venous to arterial circulation, which is associated with stroke and systemic embolization. In fact, one-third of ischemic strokes are considered to be PFO-related, and the majority of them are thought to be caused by a paradoxical embolism via the PFO. Four recent randomized control trials have provided strong and objective evidence that percutaneous PFO closure with long-term antiplatelet therapy over antithrombotic therapy alone is associated with reduced rates of recurrent stroke. Remarkably, PFO can be associated with other pathologic conditions such as decompression illness, platypnea–orthodeoxia, migraine with aura, paradoxical coronary embolism, major orthopaedic surgery, posterior fossa neurosurgery, obstructive sleep apnea, and arterial deoxygenation, which have been defined as PFO-associated syndromes. Those patients need to be approached within a multidisciplinary framework, wherein shared decision making becomes essential.

Areas for future study include the role of new PFO closure devices, platelet hyperactivity in migraine aura patients with PFO, new markers to aid in the determination of the role of PFO closure in individual patients, the role of oral anticoagulants, particularly direct oral anticoagulants, the role of PFO in stroke occurring in patients older than 60 years old, the possible efficacy of primary prevention in selected populations, and very long-term outcomes after device closure. In addition, how close are we to PFO closure be a standard indication for selected aura migraine patients.

Prof. Dr. Eustaquio Maria Onorato
Dr. Christian Pristipino
Guest Editors

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• patent foramen ovale
• patent foramen ovale closure
• paradoxical embolism
• right-to-left shunt
• stroke
• cryptogenic stroke
• decompression illness
• migraine aura
• platypnea–orthodeoxia syndrome
• posterior fossa neurosurgery
• major orthopaedic surgery and paradoxical fat embolism