If you’ve had a stroke due to an unknown cause, learn how you may be able to prevent another with the Amplatzer™ PFO Occluder.

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American and International Stroke Guidelines

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American and International Stroke Guidelines

The United States and countries across the globe have updated their stroke guidelines to include PFO closure. See below for brief summaries of the guidelines, as well as links to the full publications.

United States Guidelines1 – 2020

Experts from the American Academy of Neurology, or AAN, carefully reviewed the available evidence about secondary stroke prevention in patients with a patent foramen ovale, or PFO. Based on their review, they conclude the following:

  • Recent studies have shown that for some patients, particularly those younger than 60 years who have had a stroke thought to be caused by a PFO, closure of the PFO reduces the risk of having another stroke better than medical treatments alone.
  • Before recommending PFO closure in people who have had a stroke, it's important for doctors with expertise in stroke to rule out causes other than the PFO.
Practice Advisory Update: PFO and AAN Update: PFO and Secondary Stroke Prevention: Summary for Patients and their Families

Australian Guidelines2 - 2019

Published by the Stroke Foundation, the Australian guidelines strongly recommend that in ischaemic stroke patients aged <60 in whom a patent foramen ovale is considered the likely cause of stroke after thorough exclusion of other causes, percutaneous closure of the PFO is recommended.

The Clinical Guidelines for Stroke Management, Chapter 4 Secondary Prevention

German Guidelines3 - 2018

Physicians from cardiology, internal medicine and neurology joined together to publish new stroke guidelines related to PFO closure in patients with cryptogenic stroke. The guidelines state that interventional PFO closure should be performed in patients aged 16 to 60 years (after extensive neurological and cardiological diagnostic work-up) with a history of cryptogenic ischaemic stroke and patent foramen ovale, with moderate or extensive right-to-left shunt.

Cryptogenic Stroke and Patent Foramen Ovale (abridged and translated version)

Canadian Guidelines4 - 2017

The Heart and Stroke Foundation Canadian Stroke Best Practice Committees recommend the following:

Patent Foramen Ovale

For carefully-selected patients with a recent ischemic stroke or TIA attributed to a PFO, PFO device closure plus long-term antiplatelet therapy is recommended over long-term antithrombotic therapy alone, provided all the following criteria are met:

  1. Age 18–60 years;
  2. The diagnosis of the index stroke event is confirmed by imaging
  3. The patient has been evaluated by a neurologist or clinician with stroke expertise, and the PFO is felt to be the most likely cause for the index stroke event following a thorough etiological evaluation to exclude alternate etiologies.
Canadian Stroke Best Practice Recommendations: Secondary Prevention of Stroke, sixth edition practice guidelines, update 2017

Position Papers

In addition to guidelines, there have also been position papers and consensus statements published regarding PFO closure in patients with cryptogenic stroke.

Japanese Position Paper5 – 2019

The Japan Stroke Society, Japanese Circulation Society and Japanese Association of Cardiovascular Intervention and Therapeutics came together to review the evidence on PFO closure and recommend the following: PFO closure should be considered for patients younger than 60 years who have the diagnosis of a cryptogenic stroke and have a PFO. It is critical that the patient is able to take antithrombotic medication after device implantation.

Japanese Position Paper (Available in Japanese only)

European Position Paper6 - 2018

EuroIntervention published a European position paper regarding the management of patients with PFO. The paper was developed by eight scientific societies and international stroke experts.


“Position of our societies to perform percutaneous closure of PFO in carefully selected patients from 18 to 65 years with confirmed cryptogenic stroke, TIA or systemic embolism and estimated high probability of causal role of PFO as assessed by clinical, anatomic and imaging features.”

“The interventional procedure must be proposed to each patient evaluating the individual probability of benefit based on an assessment of both the role of the PFO in the thromboembolic event and the expected results and risks of a lifelong medical therapy.”

European Position Paper on the Management of Patients with Patent Foramen Ovale. General Approach and Left Circulation Thromboembolism
  1. Messé SR, Gronseth GS, Kent DM, Kize JR, Homma S, et al. Practice Advisory Update: Patent Foramen Ovale and Secondary Stroke Prevention. Neurology® 2020;94:1-10.
  2. Australian Stroke Foundation. Clinical Guidelines for Stroke Management. Chapter 4: Secondary Prevention.
  3. Diener et al. Neurological Research and Practice
  4. Wein et al, Canadian Stroke Best Practice Recommendations: Secondary Prevention of Stroke, Sixth Edition Practice Guidelines, Update 2017. International Journal of Stroke, 2017. DOI: 10.1177/1747493017743062
  5. The Japan Stroke Society, The Japanese Circulation Society, and Japanese Association of Cardiovascular Intervention and Therapeutics Guidance on Percutaneous Closure of Patent Foramen Ovale (PFO) in Cryptogenic Stroke Patients
  6. Pristipino et al. European Position paper on the management of patients with patent foramen ovale. Eurointervention 2018: Jaa-434 2018
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