Long-term benefits and risks in patients after persistent foramen ovale closure: a contemporary approach to guide clinical decision making.

Persistent foramen ovale (PFO) is a congenital heart disease which represents 80% of atrial septal defects. It is a remnant of fetal circulation that functions in postnatal conditions as a transient interatrial right­to­­left shunt of variable magnitude. Persistent foramen ovale may be implicated in the pathogenesis of several medical conditions, such as cryptogenic stroke, cryptogenic left circulation thromboembolism, migraine syndromes, and decompression sickness. The most frequent indication for PFO closure remains PFO­associated left circulation thromboembolism. In select patients, PFO closure reduces stroke recurrence in comparison with medical therapy after more than 3 years of follow­up on average, especially in patients with a high risk of recurrence. While in PFO­associated left circulation embolism, there is now conclusive evidence on the growing benefit of PFO closure in long­term follow­up, in many other clinical conditions, the degree of certainty of the results is deceiving. In this paper, we will review the benefits and risks that one can expect in the long term after percutaneous PFO closure in various clinical scenarios in order to facilitate therapeutic decision making.