Patent Foramen Ovale, Old Patients, and Atrial Fibrillation

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J Stroke. 2023;25(3):325-326
Publication date (electronic) : 2023 September 26
doi :
Department of Neurology, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
Correspondence: Jong S. Kim Department of Neurology, Gangneung Asan Hospital, University of Ulsan College of Medicine, 38 Bangdong-gil, Gangneung 25440, Korea Tel: +82-33-610-4196 E-mail:
Received 2023 September 14; Revised 2023 September 14; Accepted 2023 September 14.

A couple of years ago, the author and colleagues published a subgroup analysis of Device Closure Versus Medical Therapy for Cryptogenic Stroke Patients With High-Risk Patent Foramen Ovale (DEFENSE-PFO) study, which included the patients with old (≥60 yrs) age [1]. We found that the two-year risk of ischemic stroke or transient ischemic attack in old patients was substantially higher than in the young counterparts (24.6% vs. 5.8%). Accordingly, the benefit of patent foramen ovale (PFO) closure was more significant in old patients than in young ones. However, the result should be cautiously interpreted because the number of patients was small [2]. The question of PFO closure benefit in old patients is still ongoing [3].

In this issue of the Journal of Stroke, Farjat-Pasos et al. [4] published a review containing updated information on this issue. Due to the absence of evidence from randomized trials, the authors could not make any firm conclusions, but they summarized the relevant facts. As compared to young stroke patients with PFO, old patients with PFO more often (1) exhibit high-risk PFO anatomical features, (2) have concomitant vascular-related risk factors that may increase the risk of paradoxical embolism, and (3) present a higher incidence of future PFO-related ischemic events. It was also noted that old age was not associated with an increased risk of complications associated with PFO closure. Thus, all these findings support the PFO closure in old patients as long as the PFO has high-risk characteristics and other stroke etiologies, such as atrial fibrillation (AF), were excluded after thorough investigations. However, some studies showed that newonset AFs were observed more frequently in older patients than younger ones. Therefore, the “close or not” decision in old patients should be made after an intense discussion based on these facts among the neurologist, cardiologist, and patient [3] until ongoing randomized trials provide more definitive insights into the role of PFO closure in the old population.

Another paper by Baik et al. [5] is also worth reading. They performed transthoracic echocardiography and transesophageal echocardiography in patients with both AF and PFO and measured various indices, including the left atrial appendage emptying velocity (LAAV). They found that left atrium/left atrial appendage (LA/LAA) thrombus or spontaneous echo-contrast (SEC) was less frequent in patients with PFO than in those without (37.2% vs. 50.3%, P=0.007). PFO was independently associated with the lower prevalence of LA/LAA thrombus or SEC (adjusted odds ratio 0.64, 95% confidence interval 0.43–0.93, P=0.021). They also found that LAAV was significantly higher in patients with PFO than in those without PFO (35.0 [21.8–53.0] cm/s vs. 27.6 [18.3–46.5] cm/s, P=0.005). These results suggest that PFO may be associated with a lower prevalence of LA/LAA thrombus or SEC in stroke patients with AF and that higher LAAV may mediate this relationship in patients with PFO. Although the cause-effect relationship remains uncertain, this observation suggests the beneficial role of PFO in reducing LA/LAA thrombosis in patients with AF. These interesting findings raise another question. Nowadays, with intensive etiology work-ups, patients with both AF and PFO are increasingly recognized. Given the paper by Baik et al. [5], we are currently unsure whether PFO is an enemy or friend in patients with AF. If such patients develop a stroke, should we close the PFO or not?


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Conflicts of interest

The author has no financial conflicts of interest.


1. Kwon H, Lee PH, Song JK, Kwon SU, Kang DW, Kim JS. Patent foramen ovale closure in old stroke patients: a subgroup analysis of the DEFENSE-PFO Trial. J Stroke 2021;23:289–292.
2. Kim JS, Hong KS. Patent foramen ovale closure: opportunity closed in old patients? J Stroke 2021;23:147–148.
3. Kim JS, Thijs V, Yudi M, Toyoda K, Shiozawa M, Zening J, et al. Establishment of the heart and brain team for patent foramen ovale closure in stroke patients: an expert opinion. J Stroke 2022;24:345–351.
4. Farjat-Pasos JI, Chamorro A, Lanthier S, Robichaud M, Mengi S, Houde C, et al. Cerebrovascular events in older patients with patent foramen ovale: current status and future perspectives. J Stroke 2023;25:338–349.
5. Baik M, Shim CY, Gwak SY, Kim YD, Nam HS, Jeon S, et al. Patent foramen ovale may decrease the risk of left atrial thrombosis in stroke patients with atrial fibrillation. J Stroke 2023;25:417–420.

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