Advances and ongoing controversies in patent foramen ovale closure and cryptogenic stroke: a 2025 review

Abstract

Cryptogenic stroke accounts for roughly one-third of all ischemic strokes, with patent foramen ovale (PFO) playing a significant role in many of these cases due to paradoxical embolism. Percutaneous PFO closure techniques have advanced significantly over the last decade, as randomized controlled trials showed lower recurrence rates in selected patients. However, as of 2025, there are ongoing debates over patient selection, particularly in older people, the comparative efficacy of anticoagulation, and long-term hazards like device-related atrial fibrillation. This review aimed to summarize the evidence from recent clinical trials, meta-analyses, and guidelines, focusing on advances in device technology, risk-stratification tools such as the Risk of Paradoxical Embolism (RoPE) score and the PFO-Associated Stroke Causal Likelihood (PASCAL) classification, and unresolved debates about procedural safety and generalizability. This review underlined the need for interdisciplinary neurocardiology teams and future research objectives in optimizing outcomes in this diverse group. Recent 2025 studies emphasized the necessity of long-term follow-up in determining closure efficacy, with meta-analyses indicating lasting benefits but highlighting heterogeneity in real-world implementations. Furthermore, new research on bioresorbable devices and AI-assisted diagnostics promises to solve present constraints in patient selection and procedural hazards.