DOI: 10.1177/23969873231197564 ISSN:

Long-term risk of recurrent cerebrovascular events after patent foramen ovale closure: Results from a real-world stroke cohort

Markus Kneihsl, Susanna Horner, Isra Hatab, Nora Schöngrundner, Diether Kramer, Gabor Toth-Gayor, Gernot Grangl, Gerit Wünsch, Simon Fandler-Höfler, Melanie Haidegger, Natalie Berger, Sai Veeranki, Urs Fischer, Christian Enzinger, Thomas Gattringer
  • Cardiology and Cardiovascular Medicine
  • Neurology (clinical)


Patent foramen ovale (PFO)-closure is recommended for stroke prevention in selected patients with suspected PFO-associated stroke. However, studies on cerebrovascular event recurrence after PFO-closure are limited by relatively short follow-up periods and information on the underlying aetiology of recurrent events is scarce.

Patients and methods:

All consecutive patients with a cerebral ischaemic event and PFO-closure at the University Hospital Graz were prospectively identified from 2004 to 2021. Indication for PFO-closure was based on a neurological-cardiological PFO board decision. Patients underwent standardized clinical and echocardiographic follow-up 6 months after PFO-closure. Recurrent cerebrovascular events were assessed via electronical health records.


PFO-closure was performed in 515 patients (median age: 49 years; Amplatzer PFO occluder: 42%). Over a median follow-up of 11 years (range: 2–18 years, 5141 total patient-years), recurrent ischaemic cerebrovascular events were observed in 34 patients (ischaemic stroke: n = 22, TIA: n = 12) and associated with age, hyperlipidaemia and smoking in multivariable analysis ( p < 0.05 each). Large artery atherosclerosis and small vessel disease were the most frequent aetiologies of recurrent stroke/TIA (27% and 24% respectively), and only two events were related to atrial fibrillation (AF). Recurrent ischaemic cerebrovascular event rates and incident AF were comparable in patients treated with different PFO occluders ( p > 0.1).

Discussion and conclusion:

In this long-term follow-up-study of patients with a cerebral ischaemic event who had received PFO-closure with different devices, rates of recurrent stroke/TIA were low and largely related to large artery atherosclerosis and small vessel disease. Thorough vascular risk factor control seems crucial for secondary stroke prevention in patients treated for PFO-related stroke.

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