Patent foramen ovale: when is intervention warranted?

In our desire to bring harmony to understanding of unexplained pathologies, we tend to relate commonly occurring entities and attempt to demonstrate meaningful association or causality. The foramen ovale is a universally present structure in utero, remaining patent in a substantial proportion of live births and through adulthood. In its commonness, it has been associated with many disease states and claims of causal inference. As we review the current state of best practice concerning patent foramen ovale (PFO) based on recent randomized controlled trials and practice guidelines, we are reminded that the human body, despite its medical frailties, remains an incredibly efficient machine; a decision to permanently alter its workings should demand knowledge gleaned from substantiated experience and validated data. Presently, no indications exist for PFO closure, whether via a transcatheter or surgical approach, within existing medical care guidelines. Recent randomized controlled trials examining reduction of risk for secondary prevention of stroke and/or transient ischemic attack and for elimination of migraine have underscored the message to restrain the temptation to intervene on a PFO; adversity appears to increase without accrued benefit from such an intervention.