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Patent foramen ovale (PFO) closure - should yours be closed?

After a stroke with no obvious cause, a PFO changes the conversation. Closure or medication is a genuine decision, not a foregone conclusion - and it deserves a stroke neurologist and a structural cardiologist weighing your case together, with the trial evidence on the table.

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A radiographer guides a patient onto the bed of an advanced 3 Tesla MRI scanner in a London imaging suite

Indicative pricing

What the stroke-prevention pathway costs in the UK.

The assessment comes first and costs a fraction of the device.

In short

Full assessment: £1,100–£2,300. Closure, if recommended: £9,500–£14,500.

Stage Indicative range
Stroke-prevention assessment (neurology + cardiology reviews) £500–£900
Bubble-contrast echo with shunt grading £350–£650
Prolonged cardiac rhythm monitoring (7–14 days) £300–£700
PFO closure package (if recommended) £9,500–£14,500
Annual stroke-prevention review £250–£400

On the NHS, closure is commissioned for patients up to 60 whose cryptogenic stroke has been attributed to the PFO by a specialist MDT - the same criteria we apply. Private care buys speed through the work-up and choice of operator; it never changes whether closure is the right answer.

The problem

Two failure modes: closing too readily, and never discussing it at all.

Some patients are offered a device before the work-up is finished. Others are discharged on aspirin and never told closure existed. Both are failures of process.

  • Finish the search first

    Hidden atrial fibrillation mimics PFO stroke and needs anticoagulation, not a device. Prolonged rhythm monitoring before any closure decision is non-negotiable.

  • Put both specialists in the room

    Cardiology sees the anatomy; neurology sees the stroke. UK guidance requires the decision to be made jointly - and documented.

  • Give you the absolute numbers

    A halved relative risk sounds dramatic; one stroke prevented per 20–40 patients over five years is the honest framing. You decide with both in hand.

When it helps

When closure earns its place in stroke prevention.

The factors that push the decision towards a device - and the one red flag that outranks everything on this page.

  • A stroke with no cause found

    Scans clear, arteries clear, rhythm monitoring clear - and then a PFO turns up. Roughly one in three ischaemic strokes in younger adults ends up here.

  • You are under about 60

    The randomised trials that showed closure beats medication recruited patients aged 18–60. Age is central to whether the evidence applies to you.

  • A large shunt or septal aneurysm

    Big shunts and floppy, aneurysmal septa are the anatomies where the PFO is most plausibly guilty - and where closure showed the clearest benefit.

  • A high RoPE score

    The Risk of Paradoxical Embolism score estimates how likely your PFO caused your stroke. Younger age and no vascular risk factors push it higher.

  • A second event on medication

    Another stroke or TIA while taking your tablets properly changes the arithmetic sharply in favour of mechanical closure.

  • You want off long-term uncertainty

    Some patients choose closure for the durable risk reduction it offers over decades - a legitimate preference when the anatomy supports it.

  • Anticoagulation is a problem for you

    Where blood thinners are poorly tolerated, risky or incompatible with your work or sport, closure plus short-course antiplatelets is attractive.

  • Red flag: symptoms right now

    Face drooping, arm weakness, slurred speech - act FAST. That is a 999 call and a hyperacute stroke unit, never any kind of clinic booking.

Your options

Closure, tablets, or watchful review - the real choices.

Every route is a legitimate stroke-prevention strategy for the right patient. Here is what each involves, and what the evidence says about it.

  • Closure plus antiplatelets

    The trial-backed route for selected under-60s: device closure, dual antiplatelets for a few months, then aspirin. Roughly halves recurrent stroke risk versus medication alone in the pooled trials.

  • Antiplatelet therapy alone

    Aspirin or clopidogrel without a device. Absolute recurrence risk on tablets is low - around 1 percent per year - which is why closure is a genuine choice, not an automatic one.

  • Anticoagulation

    Warfarin or a DOAC - considered when there is another reason for it, such as a clotting disorder or venous thrombosis. Not routinely preferred over closure for PFO-attributed stroke.

  • The RoPE score conversation

    A 10-point score built from age, risk factors and infarct pattern. High scorers get most of closure’s benefit; low scorers may be closing an innocent bystander.

  • What the trials showed

    RESPECT (long-term), CLOSE and Gore REDUCE, all reported in 2017, showed fewer recurrent strokes with closure in selected patients - at the cost of more transient atrial fibrillation.

  • Who the trials did not answer

    Over-60s, small shunts with low RoPE scores, and migraine-only patients sit outside the evidence. For them, honest uncertainty is the truthful position.

  • Shared decision-making

    UK practice is a documented cardiology–neurology decision with you in the room. You should hear the absolute numbers, not just the relative ones.

  • Lifelong vascular care either way

    Blood pressure, cholesterol, smoking, exercise - closure addresses one mechanism only. The rest of stroke prevention continues regardless of the device.

Risks and benefits

The trade-offs, stated plainly.

A good closure decision is made with the absolute numbers in view - the benefit, the AF trade-off, and what closure cannot do.

  • The benefit, in absolute numbers

    In the trials, closure prevented roughly one recurrent stroke for every 20–40 patients treated over five years, compared with medication alone. Meaningful - and worth weighing calmly.

  • The main trade-off: atrial fibrillation

    Closure caused new, usually transient AF in about 2–5 percent of trial patients. Most episodes settled within weeks; a small number needed ongoing treatment.

  • Procedural risk is low

    Serious procedural complications - tamponade, device embolisation, major bleeding - each occur in well under 1 percent of cases in experienced structural units.

  • Medication does not stop on day one

    Dual antiplatelets run for 1–3 months after closure, then aspirin - often for years. Closure changes your drug burden; it does not eliminate it immediately.

  • Recurrence is not zero either way

    Closure reduces PFO-related recurrence; it cannot prevent strokes from other mechanisms. Any new neurological symptoms after closure still mean urgent assessment.

  • The device is permanent

    The occluder is a lifelong implant that tissue grows over within months. MRI scanning remains safe, and airport scanners are not a problem.

  • If you choose tablets instead

    That is a reasonable, evidence-supported decision - with annual review, because a further event or new evidence can change the balance later.

  • Driving and DVLA rules

    After a stroke or TIA, UK licence rules apply regardless of closure - usually one month off driving for a car licence, longer for professional licences. We flag the rules that apply to you.

  • Red flags after closure

    New palpitations that persist, chest pain, breathlessness, groin swelling or any FAST symptoms need the same-day team or A&E - never a wait for the routine follow-up.

Reading your MDT letter

Your decision letter in four parts. Read the last one first.

Whether the MDT recommends closure or medication, the letter you receive keeps to the same shape.

A UK consultant reviewing a stroke-prevention decision letter with a patient

A quiet reminder

Stroke letters carry heavy words lightly - we translate them for you.

If you would like us to talk you through the MDT reasoning and the numbers behind it, just ask.

  1. 01 Header

    The attribution decision

    The MDT’s reasoning: why your stroke was judged cryptogenic, your RoPE score, and why the PFO was - or was not - held responsible.

  2. 02 Technique

    What was done, if closure was chosen

    The device, the imaging guidance, and the immediate result - or, if you chose medication, the regime selected and the reasoning.

  3. 03 Findings

    Residual shunt and rhythm

    The follow-up bubble study result, and whether any atrial arrhythmia appeared on post-procedure monitoring.

  4. 04 Impression

    Your prevention plan from here

    Read this first: the tablet schedule and stop dates, blood pressure and cholesterol targets, driving guidance, and when your next review falls.

Recognised by major UK insurers

BupaAXA HealthVitalityAvivaWPACignaHealixBupaAXA HealthVitalityAvivaWPACignaHealixBupaAXA HealthVitalityAvivaWPACignaHealix

Where closure is recommended by an MDT after a qualifying stroke or TIA, UK insurers usually cover both the work-up and the procedure.

Frequently asked

Everything we get asked about the PFO closure decision.

Quick answers on cryptogenic stroke, the RoPE score, the evidence, age limits and cost.

  • My stroke was blamed on a PFO - does that mean closure is essential?

    No. It means closure is worth a structured discussion. For selected patients under about 60 with a genuinely cryptogenic stroke and a convincing shunt, the trials show closure roughly halves the risk of another stroke compared with tablets alone. But the risk on tablets is already low, so the absolute gain is modest - one stroke prevented per roughly 20–40 patients treated over five years. Some people weigh that and choose closure; others reasonably choose medication.

  • What is a cryptogenic stroke?

    A stroke where the standard work-up - brain imaging, artery imaging, heart-rhythm monitoring and blood tests - finds no clear cause. Only after that search is complete does a PFO become a plausible explanation, because a PFO can let a clot from the veins slip through to the brain. Attributing the stroke to the PFO before the work-up is finished is the mistake we exist to prevent.

  • What is the RoPE score and why does it matter?

    The Risk of Paradoxical Embolism score uses your age, vascular risk factors and stroke pattern to estimate the probability that your PFO actually caused your stroke. Younger patients without hypertension, diabetes or smoking history score higher - meaning their PFO is more likely to be guilty and closure more likely to help. A low score suggests the PFO may be an innocent bystander.

  • I am over 60 - can I still have my PFO closed?

    Sometimes, but the honest answer is that the randomised trials only recruited patients up to 60, so the evidence for benefit above that age is limited, and NHS commissioning follows the same cut-off. Over 60, other stroke causes - particularly hidden atrial fibrillation - become steadily more likely.

  • What does the stroke-prevention pathway cost privately?

    The assessment phase - neurology and cardiology consultations, bubble echo and prolonged rhythm monitoring - typically comes to £1,100–£2,300 depending on what you already have. If closure is recommended and you proceed, the procedure package is roughly £9,500–£14,500. If the MDT recommends tablets instead, you have spent a fraction of that and gained a properly documented decision.

  • Will closure stop me ever having another stroke?

    No, and anyone who implies otherwise is overselling. Closure addresses one mechanism - paradoxical embolism through the foramen. Strokes have many causes, so blood pressure control, cholesterol, not smoking and regular review remain essential for life. Think of closure as removing one specific risk from the list, not wiping the list clean.

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