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Is closure of patent foramen ovale to prevent ischaemic stroke ever justified? Robert A Henderson,1 Philip M W Bath2 1

Trent Cardiac Centre, City Hospital Campus, Nottingham University Hospitals, Nottingham NG5 1PB, UK 2 University of Nottingham, Stroke Trials Unit, City Hospital Campus, Nottingham University Hospitals, Nottingham Correspondence to: R A Henderson [email protected] Cite this as: BMJ 2013;347:f6193 doi: 10.1136/bmj.f6193

This is one of a series of occasional articles that highlight areas of practice where management lacks convincing supporting evidence. The series adviser is David Tovey, editor in chief, the Cochrane Library. To suggest a topic, please email us at [email protected].

bmj.com Previous articles in this series ЖЖHow should we manage fear of falling in older adults living in the community? (BMJ 2013;346:f2933) ЖЖShould inpatient hyperglycaemia be treated? (BMJ 2013;346:f134) ЖЖDoes routine oxygen supplementation in patients with acute stroke improve outcome? (BMJ 2012;345:e6976) ЖЖDoes gluten sensitivity in the absence of coeliac disease exist? (BMJ 2012;345:e7907) ЖЖDoes mindfulness based cognitive therapy prevent relapse of depression? (BMJ 2012;345:e7194)

The foramen ovale is a tunnel in the interatrial septum of the fetal heart that allows oxygenated placental blood to bypass the lungs and flow into the systemic circulation. At birth, inflation of the lungs causes physiological closure of the foramen, and in most people the interatrial communication seals completely over time. In around a quarter of the population, however, incomplete closure of the foramen results in a persistent (or patent) foramen ovale that provides a potential route for bloodborne material from the venous circulation to enter the systemic circulation. Case reports of thrombus straddling a patent foramen ovale confirm that material from the venous circulation can pass through the interatrial communication and cause systemic embolism to the brain and other organs,1 but the frequency and clinical relevance of this phenomenon are controversial. Case-control studies to assess whether patent foramen ovale is more common in people with stroke are confounded by selection and case ascertainment biases and have produced conflicting results. Nevertheless, metaanalyses of these studies support an association between a patent foramen ovale and stroke without an identifiable cause (“cryptogenic stroke”), especially in young patients (age

Is closure of patent foramen ovale to prevent ischaemic stroke ever justified?

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