The patent foramen ovale does not spontaneously close in patients aged 60

Patent foramen ovale (PFO) closure for the prevention of recurrent stroke has travelled a long and winding road to acceptance. The first report of paradoxical embolism through a PFO was published in 1877, but it was not until the 1980s that PFOs were noted to be much more common in the setting of cryptogenic stroke1. Early randomised trials of PFO closure were disappointing – largely because the treatment was available outside clinical trials, and therefore, higher-risk patients were often offered PFO closure and only lower-risk individuals were randomised. More recent trials, however, with increased patient numbers and longer follow-up, have demonstrated the safety and efficacy of PFO closure for the prevention of recurrent stroke2.

PFO closure reduces the risk of stroke by preventing transit of venous thrombus. The clinical trials, aiming for clean data, restricted entrants to those under the age of 60. This strategy was vindicated when the trials were finally positive but has resulted in the disenfranchisement of patients over 60 with likely PFO-related stroke3. Funding bodies, possibly alarmed by the sheer prevalence of PFO, have...