A patent foramen ovale (PFO) is common and often harmless. In selected patients, however, it can play a relevant role in stroke, transient ischemic attack, migraine symptoms, or decompression illness in divers.
At CARDIOVASCULAR GLOBAL, PFO closure is evaluated individually. Decisions are never based on rigid checklists but on anatomy, clinical context, and patient-specific risk profiles.
Patients we frequently see
We routinely evaluate patients who were declined elsewhere or whose situation does not fit standard criteria, including:
– Patients after unsuccessful PFO closure attempts
– Patients with a residual shunt after PFO closure
– Patients rejected because of age despite otherwise reasonable indications
– Divers, including recreational divers
– Patients with migraine with or without aura
– Patients with competing stroke mechanisms where paradoxical embolism remains the most likely cause
– Patients with known or suspected nickel allergy or intolerance to implants
If you were told that PFO closure is not possible or not indicated, a structured second opinion may still be worthwhile.
When can PFO closure be considered
PFO closure may be considered when the PFO is likely to be clinically relevant, most commonly after an embolic stroke or transient ischemic attack without another clear cause.
Importantly, the presence of additional stroke mechanisms does not automatically exclude PFO closure if paradoxical embolism remains the most plausible explanation after careful review.
Primary PFO closure (before stroke or TIA)
In selected patients, PFO closure may also be considered as a preventive strategy before a stroke or transient ischemic attack has occurred. This applies only to carefully selected individuals with high-risk PFO anatomy, specific professional or lifestyle-related risk profiles, or other compelling clinical considerations. Such decisions require particularly careful evaluation and are never made routinely.
Closure techniques
Different anatomical situations and patient preferences require different closure strategies.
Device-based PFO closure
Device-based closure is the most established technique. Some devices contain nickel. While clinically relevant nickel reactions are uncommon, implantation of a nickel-containing device is generally considered contraindicated in patients with known nickel allergy. In such cases, alternative strategies should be discussed.
Suture-based PFO closure (no permanent implant)
Suture-based PFO closure aims to close the PFO without leaving a permanent implant in the heart. This option may be suitable in selected anatomical situations and is particularly relevant for patients with nickel allergy or concerns about permanent implants.
Bioresorbable PFO closure devices
Bioresorbable devices use a temporary occluder that is intended to resorb over time. They may be considered in selected patients with nickel allergy or in those who explicitly wish to avoid a permanent intracardiac implant.
Residual shunt and redo situations
A residual shunt after implantation of a conventional metal PFO device cannot be treated with a bioresorbable occluder.
In contrast, a residual shunt after suture-based PFO closure can, in selected cases, be closed using a bioresorbable device. This situation is particularly relevant in patients with nickel allergy.
Combined and future cardiac interventions
We also evaluate and coordinate patients who require additional left-heart interventions after PFO closure, including left atrial appendage closure, atrial fibrillation ablation, or transcatheter edge-to-edge repair (TEER), either sequentially or as part of an integrated treatment strategy.
Lifestyle considerations
If a relevant PFO has been identified, diving should be avoided until evaluation is completed and, if chosen, closure has been performed and confirmed. After successful closure and appropriate follow-up, diving is typically possible again with individualized recommendations.
Travel is usually possible as early as the next day after PFO closure, with specific instructions regarding hydration, mobility, medication adherence, and follow-up.
FAQ
Q: I was rejected elsewhere or told I am too old – should I still ask for an evaluation?
A: Yes. Age alone should not be the only criterion. We assess the overall clinical context and anatomy before making an individualized recommendation.
Q: What if my PFO closure elsewhere was unsuccessful or left a residual shunt?
A: We frequently evaluate such cases and discuss observation, medical therapy, or alternative interventional strategies.
Q: Do you offer metal-free alternatives?
A: Yes. Depending on anatomy and clinical context, suture-based or bioresorbable closure concepts may be considered.
If you are unsure whether PFO closure may be relevant in your situation, an individual consultation may help clarify your options.
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