Diagnosis and Management of Patent Foramen Ovale for Stroke Prevention: An Australian and New Zealand Consensus Statement Developed by a Modified Nominal Group Approach.

Abstract

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. 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. 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.