Diagnosis and Management of Patent Foramen Ovale for Stroke Prevention: An Australian and New Zealand Consensus Statement Developed by a Modified Nominal Group Approach
ANZ multi-society consensus · 2026 · Australia
Source and licence
- Authors
- Brian R Chambers, Lauren M Sanders, Amanda Gilligan et al.
- Title
- Diagnosis and Management of Patent Foramen Ovale for Stroke Prevention: An Australian and New Zealand Consensus Statement Developed by a Modified Nominal Group Approach
- Journal
- The Medical Journal of Australia, 2026
- Licence
- CC BY 4.0
- Changes
- Verbatim excerpts; formatting adapted
Full text retrieved 2026-10-27 from Europe PMC · PMC13172030
Licence statement of the original publication
This is an open access article under the terms of the http://creativecommons.org/licenses/by/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.
This page reproduces excerpts of the original publication; the original is authoritative. It has not been reviewed by a physician, does not state a recommendation of Medelix and does not replace medical advice. The guideline may have been updated since.
Open the original publication →Full text on Europe PMC
Recommendations
Verbatim, with grade of recommendation or strength of consensus where given.
Patient selection
- Recommendation 1Patients aged ≤ 60 years with cryptogenic stroke should undergo screening for PFOGrade a: A1
- Recommendation 2Patients aged > 60 years with embolic stroke of undetermined source, absence of vascular risk factors and no atrial fibrillation detected on prolonged monitoring may be considered for PFO screeningGrade a: B1
Diagnostic investigations
- Recommendation 3The historical gold standard for PFO detection is TOE, but this is not the preferred screening investigation for PFO detectionGrade a: A1
- Recommendation 4A TCD bubble study should be considered as a first‐line screening investigation for PFO detectionGrade a: B1
- Recommendation 5Where TCD is not available, TTE with bubble study is an alternative screening investigation, although it has lower sensitivity for PFO detectionGrade a: B1
- Recommendation 6In patients with a positive TCD bubble study under consideration for percutaneous PFO closure, the presence of PFO should be confirmed by TOE. TOE will also reveal high‐risk features for stroke recurrence, including large PFO and associated atrial septal aneurysmGrade a: A1
Treatment decisions
- Recommendation 7A high RoPE score alone does not predict benefit from PFO closure and should therefore not be the principal basis of treatment decision‐making.Grade a: B1
- Recommendation 8The PASCAL classification system combines the RoPE score and high‐risk PFO features and should be incorporated into decision‐making for PFO closureGrade a: B1
- Recommendation 9Spontaneous right‐to‐left shunt and high‐grade right‐to‐left shunt with the Valsalva manoeuvre detected by TCD bubble study are predictors of increased stroke recurrence risk and should be incorporated into treatment decision‐makingGrade a: B1
- Recommendation 10Patients with PFO‐associated stroke and high‐risk features for stroke recurrence should be considered for PFO closure.Grade a: B1
- Recommendation 11PFO closure decisions should be made by a multidisciplinary heart–brain team that includes a stroke physician and a structural heart cardiologistGrade a: GPP
- Recommendation 12In patients with PFO‐associated stroke, other factors, including concurrent deep vein thrombosis and pulmonary embolism, and demonstration of thrombophilia, should also be considered in treatment decision‐makingGrade a: GPP
Abstract
Introduction: Patent foramen ovale (PFO) is implicated in 25%–50% of cryptogenic strokes in patients aged < 60 years. Recent clinical trials demonstrated the benefit of PFO closure in selected patients. However, there is considerable variability in Australian and New Zealand clinical practice regarding investigation and management approaches. A multidisciplinary consensus group comprising stroke neurologists and an interventional cardiologist from major centres employed a modified nominal group technique to develop evidence‐based recommendations for standardising PFO‐associated stroke management.
Main Recommendations: Twelve recommendations were developed across three domains.
For patient selection: Universal PFO screening for cryptogenic stroke patients aged ≤ 60 years, with selective screening for patients aged > 60 years with embolic stroke of undetermined source, absent vascular risk factors and excluded atrial fibrillation.
For diagnostic investigations: Transcranial Doppler (TCD) bubble study as preferred first‐line screening where available, with transthoracic echocardiography as an alternative when TCD is unavailable and transoesophageal echocardiography for confirmation before closure consideration.
For treatment decisions: Incorporation of the PFO‐Associated Stroke Causal Likelihood (PASCAL) classification system rather than the Risk of Paradoxical Embolism (RoPE) score alone, consideration of TCD grading results for risk stratification and mandatory multidisciplinary heart–brain team evaluation for all closure decisions.
Changes in Management as a Result of This Consensus Statement: These recommendations will standardise practice through enhanced TCD service provision, structured heart–brain team development and evidence‐based patient selection using the PASCAL classification. The emphasis on TCD as first‐line screening represents a departure from traditional transthoracic echocardiography‐based approaches. Implementation will improve patient outcomes through appropriate intervention in suitable candidates while avoiding unnecessary procedures in those unlikely to benefit, thereby promoting equitable access to optimal PFO management across Australia and New Zealand.
Contents of the original publication
The section headings of the original.
- Introduction
- Methods
- Recommendations
- Patient Selection for PFO Testing
- PFO Screening in Patients Aged ≤ 60 Years
- PFO Screening in Patients Aged > 60 Years
- Diagnostic Investigations
- Treatment Decisions
- Areas of Uncertainty
- Limitations
- Conclusion
- Supporting information
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