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Clinical Review State of the Art Review

Advances in the management of cardioembolic stroke associated with patent foramen ovale

BMJ 2022; 376 doi: (Published 09 February 2022) Cite this as: BMJ 2022;376:e063161
  1. Brian Mac Grory, assistant professor1 2,
  2. E Magnus Ohman, professor of medicine2 3,
  3. Wuwei Feng, professor of neurology1,
  4. Ying Xian, professor of neurology and medicine4,
  5. Shadi Yaghi, associate professor of neurology5,
  6. Hooman Kamel, associate professor of neurology6,
  7. Michael E Reznik, assistant professor of neurology5
  1. 1Department of Neurology, Duke University School of Medicine, Durham, NC, USA
  2. 2Duke Clinical Research Institute, Durham, NC, USA
  3. 3Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
  4. 4Department of Neurology, UT Southwestern Medical Center, Dallas, TX, USA
  5. 5Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI, USA
  6. 6Department of Neurology, Weill Cornell Medicine, New York, NY, USA
  1. Correspondence to: B Mac Grory brian.macgrory{at}


Patent foramen ovale (PFO) describes a valve in the interatrial septum that permits shunting of blood or thrombotic material between the atria. PFOs are present in approximately 25% of the healthy population and are not associated with any pathology in the vast majority of cases. However, comparisons between patients with stroke and healthy controls suggest that PFOs may be causative of stroke in certain patients whose stroke is otherwise cryptogenic. Options for the diagnosis of PFO include transthoracic echocardiography, transesophageal echocardiography, and transcranial Doppler ultrasonography. PFOs associated with an interatrial septal aneurysm seem to be more strongly linked to risk of recurrent stroke. Therapeutic options for secondary stroke prevention in the setting of a PFO include antiplatelet therapy, anticoagulation, and percutaneous device closure. Recent randomized clinical trials suggest that percutaneous closure reduces the subsequent risk of stroke in appropriately selected patients, with a large relative benefit but small absolute benefit. Referral for percutaneous PFO closure should therefore be considered in certain patients after a multidisciplinary, patient centered discussion. Areas for future study include structural biomarkers to aid in determining the role of PFO closure in older people with possible PFO associated stroke, the role of direct oral anticoagulants, and very long term outcomes after device closure.


  • Series explanation: State of the Art Reviews are commissioned on the basis of their relevance to academics and specialists in the US and internationally. For this reason they are written predominantly by US authors

  • Contributors: All listed authors satisfy all four ICMJE authorship criteria. BMG conceived and designed the work, drafted the manuscript, and revised it for critically important intellectual content. EMO, WF, YX, SY, and HK made substantial contributions to the design of the work and revised it for critically important intellectual content. MER conceived and designed the work and revised it for critically important intellectual content. BMG, EMO, WF, YX, SY, HK, and MER provided final approval of the version to be published and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. BMG is the guarantor.

  • Competing interests: We have read and understood the BMJ policy on declaration of interests and declare the following interests: none.

  • Provenance and peer review: Commissioned; externally peer reviewed.

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