Multiple paradoxical embolisms caused by central venous catheter thrombus passing through a patent foramen ovale: A case report

BACKGROUND To date,this is the first case of a paradoxical embolism(PDE)that concurrently manifested in the coronary and lower limb arteries and was secondary to a central venous catheter(CVC)thrombus via a patent foramen ovale(PFO).CASE SUMMARY Here,we report a case of simultaneous coronary and lower limb artery embolism in a PFO patient carrier of a CVC.The patient presented to the hospital with acute chest pain and lower limb fatigue.Doppler ultrasound showed a large thrombus in the right internal jugular vein,precisely at the tip of the CVC.Transthoracic and transesophageal echocardiography confirmed the existence of a PFO,with inducible right-to-left shunting by the Valsalva maneuver.The patient was administered an extended course of anticoagulation therapy,and then the CVC was successfully removed.Percutaneous PFO closure was not undertaken.There was no recurrence during follow-up.CONCLUSION Thus,CVC-associated thrombosis is a potential source for multiple PDE in PFO patients.

Total colectomy in a colon cancer patient with patent foramen ovale:a case of surgical and anesthetic challenges

A patent foramen ovale(PFO)is a clinical condition linked to ischemic stroke,aura migraine,and other pathologies.Current medical consensus posits that PFO closure may mitigate the risk of recurrent strokes.This case report details the management of a 61-year-old female diagnosed with colon cancer for one month.Preoperative transthoracic echocardiography indicated a potential left-to-right shunt through the foramen ovale and mild regurgitation of both the mitral and aortic valves.The patient’s history revealed previous left-sided migraines,and a review of her medical records disclosed multifocal cerebral infarctions identified by a head CT.A pulmonary artery computed tomography angiography suggested embolization in the anterior branch of the right upper pulmonary artery and several branches of the right lower lung’s posterior and lateral basilar artery,along with thickening of the trunk canals of the pulmonary arteries.After a thorough assessment and extensive consultation with the surgical team,the procedure was transitioned from a laparoscopic radical resection to an open total colectomy.Anesthesia induction required careful avoidance of hypoxia,breath-holding,and coughing.Vigilant management of respiratory and circulatory functions was crucial during periods prone to intraoperative embolism formation.Postoperatively,attention was given to the stabilization of respiratory and circulatory functions during extubation,ensuring adequate sputum suction to prevent choking and close monitoring of breathing to avert airway obstruction post-extubation.Additionally,the patient was closely monitored for postoperative nausea and vomiting,a high-risk condition for this patient cohort.Strategies were implemented to minimize the risk of right-to-left shunting,ensuring the patient’s vital signs remained stable throughout the perioperative period.The patient was discharged safely after a 10-day recovery.For patients with cancer and PFO,comprehensive risk assessment and meticulous safety management are paramount.This case confirms the patient’s history of patent foramen ovale through the association between some atypical symptoms such as migraine,pulmonary embolism and cerebral infarction,which provides guidance for the management of anesthesia in the perioperative period,offering significant clinical implications.

Safety and Efficacy of Biodegradable Patent Foramen Ovale Occluder in Patients with Migraine:A Clinical Trial

Background:Transcatheter closure of patent foramen ovale(PFO)has been widely accepted as a highly effective way to treat high-risk PFO-related diseases.However,traditional non-degradable occluders made of metal alloys will permanently exist in the body,resulting in thrombosis,valve damage,hemolysis,arrhythmia,or other complications.The biodegradable PFO occluder developed by Shanghai Mallow Medical Instrument Co.,Ltd.,China can be fully absorbed and degrade into nontoxic ingredients,reducing postoperative complications.Objectives:To study the safety and efficacy of biodegradable PFO occluders in treating PFO.Methods:This single-center clinical trial collected 30 patients treated with a biodegradable PFO occluder.The follow-up period lasted 12 months to analyze the echocardiographic characteristics and headache relief through HIT-6 scores.Results:The immediate success rate was 100%,with no intraoperative severe occlusion-related complications.The contrast transcranial Doppler(cTCD)at 12 months showed that all patients’right-to-left shunts(RLS)were grade I or 0 with no serious postoperative complications,indicating the overall success rate was 100%.The biodegradable PFO occluder mostly degraded six months after the occlusion.Conclusion:PFO closure with a Mallow biodegradable occluder is safe and effective and has no severe complications.

Platypnea-Orthodeoxia Syndrome in an Elderly Patient Treated with Percutaneous Patent Foramen Ovale Closure: Report of a Case and Review of the Literature

Introduction: Platypnea-Orthodeoxia syndrome is characterized by dyspnea and hypoxia in the upright position, usually improving in the supine position. Two components are required: an interatrial or intrapulmonary shunt, and a functional component. Diagnosis is made by contrast ultrasonography. We report a case of Platypnea-Orthodeoxia syndrome revealed by positional dyspnea in an 87-year-old patient. The aim of this study is to describe the clinical, therapeutic and evolutionary profile of this syndrome. Case Presentation: This is an 87-year-old patient with a history of pulmonary embolism (PE) and stroke. He was seen for dyspnea and desaturation in orthostatism, revealing a patent foramen ovale (PFO). Progression was favorable after closure of the PFO. Conclusion: Platypnea-Orthodeoxia syndrome may be presented as simple exertional dyspnea. The clinician should check for improvement in symptoms and/or oxygenation during decubitus. Definitive treatment consists of percutaneous closure of the shunt.

Novel way of patent foramen ovale detection and percutaneous closure by intracardiac echocardiography:A case report

BACKGROUND Patent foramen ovale(PFO)is the most common congenital heart disease and is associated with several diseases,including stroke and migraine.PFO diagnosis involves transoesophageal echocardiography,transthoracic echocardiography,and transcranial Doppler.Recent studies have shown that intracardiac echocardiography(ICE)can be used to diagnose and guide percutaneous transcatheter closure.CASE SUMMARY A 70-year-old male presented with paroxysmal dizziness and limb weakness for the past 3 mo.Magnetic resonance imaging revealed a history of stroke,and a bubble test revealed the presence of PFO.The patient was then transferred to our hospital for PFO closure.Under ICE guidance,the separation of the septum primum and septum secundum was unclear;we then used a Swartz catheter to confirm PFO by applying physical pressure on the right part of the atrial septum without using any contrast.The ICE continuously and clearly guided the procedure.CONCLUSION ICE can guide PFO closure in patients with a history of stroke.When PFO is not evident under ICE,a Swartz catheter can be used.

Evaluation of right-to-left shunt on contrast-enhanced transcranial Doppler in patent foramen ovale-related cryptogenic stroke: Research based on imaging

BACKGROUND Cardiogenic embolism caused by patent foramen ovale(PFO)is a common etiology of cryptogenic stroke(CS),particularly in young and middle-aged patients.Studies about right-to-left shunt(RLS)detection using contrast-enhanced transcranial Doppler(c-TCD)are numerous.According to the time phase and number of microbubbles detected on c-TCD,RLS can be classified and graded.We hypothesized that the characteristics of an infarction lesion on diffusion-weighted imaging differs when combining the type and grade of RLS on c-TCD in patients with PFO-related CS.AIM To explore the characteristics of infarction lesions on diffusion-weighted imaging when combining the RLS type and grade determined by c-TCD.METHODS We retrospectively evaluated CS patients from August 2015 to December 2019 at a tertiary hospital.In total,111 PFO-related CS patients were divided according to whether RLS was permanent(microbubbles detected both at resting state and after the Valsalva maneuver)or latent(microbubbles detected only after the Valsalva maneuver)on c-TCD.Each group was subdivided into small,mild and large RLS according to the grade of shunt on c-TCD.A normal control group was composed of 33 patients who suffered from simple dizziness.Intragroup and intergroup differences were analyzed in terms of clinical,laboratory and diffusion-weighted imaging lesion characteristics.The correlation between RLS grade evaluated by c-TCD and size of PFO determined by transesophageal echocardiography were also analyzed.RESULTS In 111 patients with PFO-related CS,68 had permanent RLS and 43 had latent RLS.Clinical characteristics and laboratory tests were not significantly different among the permanent RLS,latent RLS and normal control groups.The proportion of patients with multiple territory lesions in the permanent RLS group(50%)was larger than that in the latent RLS group(27.91%;P=0.021).Posterior circulation was more likely to be affected in the latent RLS group than in the permanent RLS group(30.23%vs 8.82%,P=0.004).Permanent-large and latent-large RLS were both more likely to be related to multiple(P_(trend)=0.017 and 0.009,respectively),small(P_(trend)=0.035 and 0.006,respectively)and cortical(P_(trend)=0.031 and 0.033,respectively)lesions.The grade of RLS evaluated by c-TCD was correlated to the size of PFO determined by transesophageal echocardiography(r=0.758,P<0.001).CONCLUSION Distribution of the infarct suggested the possible type of RLS.Multiple,small and cortical infarcts suggest large RLS induced by a large PFO.

Thrombus straddling a patent foramen ovale and pulmonary embolism:A case report

BACKGROUND Venous thromboembolism is a common vascular syndrome presenting as deep vein thrombosis and/or pulmonary embolism.Thrombus has the possibility of migrating into the left circulation via patent foramen ovale in certain extreme circumstances.Thrombus straddling a patent foramen ovale is a direct evidence of this scenario.However,the confirmed cases of thrombus in transit are still rare.CASE SUMMARY A 32-year-old man suffered from recurrent syncope and intermittent dyspnea for 1 wk.Transthoracic echocardiography confirmed a thrombus straddling the patent foramen ovale,and thrombi were also found in the bilateral pulmonary artery by computed tomography.The man underwent inferior vena cava filter placement and thrombolysis with alteplase.Echocardiography showed the absence of thrombi in both the right atrium and left atrium 2 d after hospitalization.The man was discharged to home on warfarin without any complications 2 wk later.CONCLUSION Scrutinizing intracardiac thrombi provides measurable value in pulmonary embolism as closure of patent foramen ovale may be considered in certain patients.Early intervention plays a critical role in thrombus straddling a patent foramen ovale.A sedentary lifestyle may predispose young adults to thromboembolism,even if there are no other risk factors.

Left atrial dysfunction in elderly patients with patent foramen ovale and atrial septal aneurysm

Objective Recently it has been suggested that, in patients with large patent foramen ovale （PFO） and atrial septal aneurysms （ASA）, a certain amount of left atrial （LA） dysfunction may be active as an alternate mechanism promoting arterial embolism. Following this hypothesis, elderly patients, being more susceptible to atrial chambers stiffness, should present a more severe LA dysfunction profile. We sought to evaluate the grade of LA dysfunction in elderly patients submitted to transcatheter PFO closure. Methods We retrospectively enrolled 28 consecutive patients with previous stroke （mean age 674-12.5 years, 18 females） referred to our centre for catheter-based PFO closure after recurrent stroke. Baseline values of LA passive and active emptying, LA conduit function, LA ejection fraction, and spontaneous echocontrast （SEC） in the LA and LA appendage were compared with those of 50 atrial fibrillation patients, as well as a sex/age/cardiac risk matched population of 70 healthy controls. Results Pre-closure elderly subjects demonstrated significantly greater reservoir function as well as passive and active emptying, with reduced conduit function and LA ejection fraction, when compared to healthy and younger patients. After closure in elderly patients, LAparameters did not return completely to the levels of healthy patients, whereas LA dysfunction in younger subjects returned normal. Conclusions This study suggests that elderly patients have more severe LA dysfunction than younger patients, which affects the LA remodelling after closure.

Patent foramen ovale closure in non-lacunar cryptogenic ischemic stroke:where are we now?

Patent foram ovale(PFO)is the most common anatomical cause of an interarterial shunt.It is usually asymptomatic but may cause paradoxical embolism and is a risk factor for non-lacunar cryptogenic cerebral ischemia in young adults.Although the first clinical trials did not show a significant superiority of PFO closure in the secondary prevention of cerebral ischemia as compared with standard antithrombotic treatment,six subsequent randomized clinical trials(CLOSURE I,PC Trial,RESPECT,CLOSE,REDUCE,and DEFENSE-PFO)performed in a sample of cryptogenic stroke in patients aged 60 years or younger provided evidence of a significant reduction of recurrent cerebral ischemia after percutaneous PFO closure.However,the use of percutaneous PFO closure cannot be generalized to the entire population of patients with cerebral ischemia and PFO,but it is indicated in highly selected patients with non-lacunar cryptogenic cerebral infarction with a large right-to-left shunt,an atrial septal aneurysm and no evidence of atrial fibrillation,as well as in association with antithrombotic treatment for an optimal secondary prevention of cerebral ischemia.

Should we consider patent foramen ovale and secundum atrial septal defect as different steps of a single anatomo-clinical continuum？

1 Introduction Isolated atrial septal defects （ASD） represent 7% of all cardiac anomalies and can present at any age. Adolescents and adults with simple congenital heart disease such as isolated atrial septal defects are more likely to reach adult age without being diagnosed. Secundum ASD （sASD） is by far the most common type, occurring in 1/1500 live births, with 65% to 75% involving females, On the other hand, patent foramen ovale （PFO） represents an endemic variant in the normal population with a prevalence of 25%-27%. These two entities appear so different that is difficult to fred a conjunction ring： nevertheless we use the same philosophy for the treatment, Indeed, device-based closure has been proved to be effective in both settings.

Ischemic Stroke Due to Paradoxical Embolism in a Patient with Patent Foramen Ovale, Bilateral Distal Deep Vein Thrombosis and Platypnea-Orthodeoxia Syndrome: A Case Report

Patent foramen ovale (PFO) is a common congenital cardiac defect. It is usually asymptomatic, but it can be associated with relevant clinical manifestations such as cryptogenic stroke and platypnea-orthodeoxia syndrome. We present the case of a patient with hemodynamically significant carotid artery stenosis who underwent endarterectomy for a transient ischemic attack (TIA). After surgery, the patient presented an ischemic stroke due to M2 occlusion treated with mechanical thrombectomy. During hospitalization, a distal bilateral deep vein thrombosis was found. The patient developed respiratory failure due to a massive right-to-left shunt through a large PFO (platypnea-orthodeoxia syndrome). These findings are consistent with the hypothesis that the TIA and the subsequential ischemic stroke were related to paradoxical embolism rather than atherothromboembolism. The aim of our case report is to raise awareness of the possible complications of such a common finding as PFO.

Platypnea-orthodeoxia syndrome in a patient with a pre-existing patent foramen ovale successfully treated with an atrial septal occluder

Platypnea orthodeoxia syndrome is associated with dyspnea and arterial oxygen desamration accentuated by an upright posture. It can be secondary to an intracardiac shunt. We report a case of platypnea-orthodeoxia syndrome （POS） in a 58-year old male patient who had a pre-existing patent foramen ovale （PFO） and substantial pulmonary pathologies. He was successfully treated by percutaneous transcatheter closure of the PFO. Our case highlights the importance of recognition of this rare syndrome in patients who present with unexplained hy- poxia for whom transcatheter closure of the interatrial shunt can be safely carded out.

Patent foramen ovale in an old patient with ischemic stroke following carotid surgery

Post-procedural strokes have been observed in 0.5-2.7% of patients after carotid endarterectomy （CEA）. They are frequently due to carotid embolism or thrombosis of the operated artery. lntracerebral haemorrhages and technical difficulties are less common underlying factors.

Percutaneous Closure of Patent Foramen Ovale in a Patient with Mirror-Image Dextrocardia and Situs Inversus

A 26-year-old patient with mirror-image dextrocardia and situs inversus experienced a transient ischemic attack.We suspected that a patent foramen ovale was the reason.A Cardi-O-Fix occluder was used to close the patent foramen ovale with a mirror-reversed rotation of the radiologic views.During the 18-month follow-up,no symptoms of the transient ischemic attack appeared again.

Diameters and form of skull base foramen ovale measured by three-dimensional spiral CT thin-slice scan in healthy adults

BACKGROUND： The accurate measurements of various data of the bone diameters of foramen ovale of living person can change the methods of puncturing trigeminal gasserian ganglion via foramen ovale for treating trifacial neuralgia from the experience of puncture operator only to puncture by taking the objective data of measurement as the evidence, which is good for improving the accuracy of puncturing trigeminal ganglion and reducing side effects. OBJECTIVE ： To observe the forms of foramen ovales in healthy adults displayed by volume rendering and multi-planar reconstruction after three-dimensional spiral CT thin-slice scan of skull base, and measure the longitudinal diameter and transverse diameter. DESIGN ： A repetitive observation and measurement SETTINGS ： Department of Neurosurgery and Department of Medical Imaging, Foshan Hospital of Traditional Chinese Medicine. PARTICIPANTS： Fifty healthy adults （100 sides）, who were examined with three-dimensional spiral CT scan, were randomly selected from the Department of Medical Imaging, Foshan Hospital of Traditional Chinese Medicine from January 2005 to January 2006, including 26 males and 24 females, aged 25-68 years with an average of 48 years old. They were all informed and agreed with the examination. METHODS ： The subjects were examined with the Philips 16-slice spiral CT-Mx 8000 IDT CT apparatus （Philips Company, Holland）, the scanning ranged from 2 cm below the canthomeatal line to the level of suprasellar cistem. The width of collimator was 0.75 mm, pitch was 0.663; tube current was 350 mA, voltage was 120 kV, resolution was 512×512 matrix; slice thickness of reconstruction was 1 mm, and interval was 0.5 mm. After the three-dimensional spiral CT thin-slice scan of skull base, the image post-processing techniques including volume rendering and multi-planar reconstruction were applied to observe the forms of foramen ovales, and measure the size, longitudinal diameter and transverse diameter of the foramen ovales. The figures of the foramen ovales were drawn with mouse along the boundary of bone porous margin and soft tissue. According to the indications, the diameters were measured with computer to observe the forms of foramen ovales. MAIN OUTCOME MEASURES ： The longitudinal diameter, transverse diameter and form of foramen ovales were observed. RESULTS： All the 50 healthy adults （100 sides） were involved in the analysis of results. （1） It was observed in the volume rendering images that foramen ovales had four forms of oval shape （77 sides）, kidney shape （12 sides）, round shape （7 sides）, ribbon shape （4 sides）. （2） The longitudinal diameters of left and right foramen ovales were （7.67±1.32） and （7.98±1.45） mm, and the transverse diameters were （4.04±0.83）, （4.09±1.07） mm; There was no obvious difference between left and right longitudinal diameters （t = 1.63, P = 0.11 ）, and left and right transverse diameters were close （t = 0.45, P= 0.65）. CONCLUSION ： The non-invasive techniques of volume rendering and multi-planar reconstruction after three-dimensional spiral CT thin-slice scan can clearly display the formand size of foramen ovale in healthy adults.

Transcatheter closure for decompression sickness with a patent foramen ovale:A case report

A patent foramen ovale is one of the predisposing factors of neurotic decompression sickness.Transcatheter closure of a patent foramen ovale is effective in the secondary prevention of decompression sickness associated with intracardiac shunt.The size of the umbrella should not be limited to the diagnosis of a patent foramen ovale or an atrial septal defect but should be determined by the supporting force of the soft margin of the atrial septum.The surgical method of patent foramen ovale closure is the same as that of the closure of an atrial septal defect,but the closure umbrella of a patent foramen ovale is different from that of the closure umbrella of an atrial septal defect.The size of the umbrella of the right atrium is larger than that of the left atrium,and it is better to close the atrial septum.

Value of TCD foaming Test in Screening Patent Foramen Ovale in Migraine Patients and Efficacy of PFO Occlusion

Objective:To explore the effect of TCD foaming test in screening patent foramen ovale in migraine patients,as well as in the treatment effect.Methods:From September 2019 to August 2020,236 patients with migraine and 362 patients with normal physical examination were treated in our hospital.According to the random number table method,60 patients with migraine were selected as the observation group,and 60 patients with normal physical examination were selected as the control group.48 cases of PFO were confirmed by TCD foaming test Among the patients with migraine,36 patients received interventional occlusion therapy.The therapeutic effect and VAS score of the two groups were analyzed.Results:Through TCD foaming test,the proportion of PFO in the observation group was 80%,and that in the control group was 13.33%.The proportion of PFO in the observation group was significantly higher than that in the control group,and the difference was statistically significant(χ^(2)=53.5714,P<0.01);The symptoms disappeared in 30 patients and improved in 4 patients;Among the 36 patients who received interventional occlusion therapy,the VAS score of patients before and after the operation was significantly changed,and the proportion of patients whose pain disappeared after the operation was 83.33%,which was significantly lower than that before the operation,and the difference was comparable(χ^(2)=51.4286,P<0.01).Conclusion:TCD foaming test for PFO screening has strong applicability,not only safe and convenient,will not cause trauma to patients,and through interventional occlusion treatment,can significantly improve the clinical symptoms of migraine patients and cure patients.

Patent foramen ovale closure reduces recurrent stroke risk in cryptogenic stroke:A systematic review and metaanalysis of randomized controlled trials

AIM To investigate if patent foramen ovale(PFO) closure device reduces the risk of recurrent stroke in patients with cryptogenic stroke.METHODS We searched five databases-Pub Med,EMBASE,Cochrane,CINAHL and Web-of-Science and clinicaltrials.gov from January 2000 to September 2017 for randomized trials comparing PFO closure to medical therapy in cryptogenic stroke.Heterogeneity was determined using Cochrane's Q statistics.Random effects model was used.RESULTS Five randomized controlled trials with 3440 patients were included in the analysis.Mean follow-up was 50 ± 20 mo.PFO closure was associated with a 41% reduction in incidence of recurrent strokes when compared to medical therapy alone in patients with cryptogenic stroke [risk ratio(RR): 0.59,95%CI: 0.40-0.87,P = 0.008].Atrial fibrillation was higher with device closure when compared to medical therapy alone(RR: 4.97,95%CI: 2.22-11.11,P < 0.001).There was no difference between the two groups with respect to all-cause mortality,major bleeding or adverse events.CONCLUSION PFO device closure in appropriately selected patients with moderate to severe right-to-left shunt and/or atrial septal aneurysm shows benefit with respect to recurrent strokes,particularly in younger patients.Further studies are essential to evaluate the impact of higher incidence of atrial fibrillation seen with the PFO closure device on long-term mortality and stroke rates.

Clinical relevance of atrial septal aneurysm and patent foramen ovale with migraine

AIM To test the potential association between atrial septal aneurysm(ASA) and migraine in patent foramen ovale(PFO) closure patients through an observational, singlecenter, case-controlled study.METHODS We studied a total of 450 migraineurs who had rightto-left shunts and underwent PFO closure in a retrospective single-center non-randomized registry from February 2012 to October 2016 on the condition that they were aged 18-45 years old. Migraine was diagnosed according to the International Classification of Headache Disorders, 3^(rd) edition and evaluated using the Headache Impact Test-6(HIT-6). All patients underwent preoperative transesophageal echocardiography, contrast transthoracic echocardiography, and computed tomography or magnetic resonance imaging examinations, with subsequent fluoroscopy-guided PFO closure. Based on whether they have ASA or not, the patients were divided into two groups: A(PFO with ASA, n = 80) and B(PFO without ASA, n = 370). Baseline characteristics and procedural and follow-up data were reviewed. RESULTS Compared to group B, group A had an increased frequency of ischemic lesions(11.3% vs 6.2%, P = 0.038) and migraine with aura(32.5% vs 21.1%, P = 0.040). The PFO size was significantly larger in group A(P = 0.007). There was no significant difference in HIT-6 scores between the two groups before and at the oneyear follow-up after the PFO closure [61(9) vs 63(9), P = 0.227; 36(13) vs 36(10), P = 0.706].CONCLUSION Despite its small sample size, our study suggests that the prevalence of ASA in PFO with migraine patients is associated with ischemic stroke, larger PFO size, and migraine with aura.

Who benefits from percutaneous closure of patent foramen ovale vs medical therapy for stroke prevention? In-depth and updated metaanalysis of randomized trials

BACKGROUND A few randomized clinical trials(RCT) and their meta-analyses have found patent foramen ovale closure(PFOC) to be beneficial in prevention of stroke compared to medical therapy. Whether the benefit is extended across all groups of patients remains unclear.AIM To evaluate the efficacy and safety of PFOC vs medical therapy in different groups of patients presenting with stroke, we performed this meta-analysis of RCTs.METHODS Electronic search of PubMed, EMBASE, Cochrane Central, CINAHL and ProQuest Central and manual search were performed from inception through September 2018 for RCTs. Ischemic stroke(IS), transient ischemic attack(TIA), a composite of IS, TIA and systemic embolism(SE), mortality, major bleeding,atrial fibrillation(AF) and procedural complications were the major outcomes.Random-effects model was used to perform analyses.RESULTS Meta-analysis of 6 RCTs including 3560 patients showed that the PFOC,compared to medical therapy reduced the risk of IS [odds ratio: 0.34; 95%confidence interval: 0.15-0.78; P = 0.01] and the composite of IS, TIA and SE [0.55(0.32-0.93); P = 0.02] and increased the AF risk [4.79(2.35-9.77); P < 0.0001]. No statistical difference was observed in the risk of TIA [0.86(0.54-1.38); P = 0.54],mortality [0.74(0.28-1.93); P = 0.53] and major bleeding [0.81(0.42-1.56); P = 0.53]between two strategies. Subgroup analyses showed that compared to medical therapy, PFOC reduced the risk of stroke in persons who were males, ≤ 45 years of age and had large shunt or atrial septal aneurysm.CONCLUSION In certain groups of patients presenting with stroke, PFOC is beneficial in preventing future stroke compared to medical therapy.