Patent foramen ovale PFO closure has been shown to reduce the risk of stroke in patients with recurrent stroke. However, the majority of existing clinical studies in this field excluded patients over the age of 60 years. Data in older patients is limited and since the population ages and stroke remains a major cause of death and morbidity, randomized clinical trials are needed to better assess the benefit of PFO closure in this elderly population. Therefore, this study proposal sought to determine the efficacy of PFO closure for the prevention of recurrent stroke in older patients with PFO and cryptogenic stroke.

Background and importance Consistent with studies performed in younger patient cohorts, older patients suffering a cryptogenic stroke exhibit a much higher prevalence of patent foramen ovale (PFO) compared to their stroke of known origin counterparts. Several studies have provided promising preliminary data regarding PFO closure in older patients with cryptogenic stroke, with very low stroke recurrence rates at mid- to long-term follow-up. Several randomized trials have shown the beneficial effects of PFO closure vs. medical treatment in patients younger than 60 years with cryptogenic stroke and PFO. Current observational data suggest similar or even more marked effects on stroke recurrence prevention of PFO closure in older patients and would support the design of a randomized trial to provide definite evidence in this field. Therefore, the objective of the present study is to evaluate the efficacy of transcatheter PFO closure for preventing recurrent ischemic stroke (nonlacunar) events in patients >60 years diagnosed with a cryptogenic stroke and PFO.

Inclusion Criteria:

• Cryptogenic stroke
• Age >60 years
• Right-to-left shunt as evaluated by echocardiography (TEE).

Exclusion Criteria:

-≤60 year-old

• Lacunar (small vessel) stroke.
• Permanent or paroxysmal atrial fibrillation/flutter (clinically apparent or detected by continuous ECG monitoring).
• Need for chronic anticoagulation therapy.
• Any contraindication for antiplatelet therapy (aspirin, clopidogrel, ticagrelor).
• Presence of extracranial or intracranial atherosclerosis causing ≥50% luminal --stenosis in arteries supplying the area of ischemia.
• Presence of complex atheroma plaques at the ascending aorta-aortic arch (≥4-mm-thick, ulcerated or containing mobile thrombi) as evaluated by TEE.
• Presence of intracardiac thrombus as evaluated by TEE.
• Uncontrolled hypertension (systemic pressure values >160/90 mmHg despite optimal medical treatment).
• History of myocardial infarction or coronary intervention. (percutaneous coronary intervention, coronary artery bypass graft).
• History of prior valve surgery or transcatheter valve repair.
• Presence of deep venous thrombosis at the time of index stroke as evaluated by Doppler ultrasonography.
• Left ventricular ejection fraction <50% as evaluated by TTE.
• Significant (moderate or severe) valvular disease as evaluated by echocardiography.
• History of congestive heart failure.
• Severe chronic kidney dysfunction defined an estimated glomerular filtration rate <30 ml/min/m2 or need for dialysis.
• Isolated ASD or ASD associated with PFO but with a hemodynamically significant left-to-right shunt requiring closure.
• Other specific cause of stroke identified (eg, arteritis, dissection, migraine/vasospasm, and drug abuse).
• Prior surgical or endovascular treatments of PFO or ASD.
• Rheumatic heart disease.
• Left atrial enlargement defined as a left atrial diameter >41 mm in men and ≥39 mm in women.
• Presence of high burden of premature atrial contractions (>500 per 24 hrs) as evaluated by continuous ECG monitoring.
• Follow-up impossible or expected poor compliance.
• Active cancer.
• Presence of an inferior vena cava filter.
• Severe pulmonary artery hypertension (systolic pulmonary pressure >60 mmHg).
• Functional dependency as measured by a modified Rankin Scale score >3 (unable to attend to own bodily needs without assistance and unable to walk unassisted).
• Any medical condition determining a life expectancy <2 years.
• Participation in another randomized study.
• Failure to provide signed informed consent.