Evidence for patent foramen ovale (PFO) closure has been controversial, as was reflected in the guidelines published by AHA/ASA in 2014. Prior to 2014, three randomized controlled trials compared PFO closure and medical management. Evidence of PFO closure was lacking however PFO closure was being performed in both trial settings and non-trial settings.

We analyzed the Nationwide Inpatient sample (NIS) from 2008 to 2014. Ischemic stroke (IS) patients with primary diagnosis using ICD 9 codes were selected along with secondary diagnosis of PFO/ ASD (ICD 9 code: 745.5). Further we selected the patients who underwent the PFO closure procedure using ICD 9 procedure codes: 35.51 and 35.52.  We evaluated the rate of PFO closure, characteristics of patients receiving closure and evolution of trend during that time period at the national level.

Total number of patients admitted over 7 years in US with Ischemic stroke associated with PFO was 77964. Only a minority of patients [n=1487 (1.9%)] received PFO closure and about half were females (50.2%). Majority of treatments (70%) were performed in teaching hospital setting. Patients who underwent PFO closure were younger, mean age 55.3 years (± SD 16.6) years versus 61.4 years (± SD 16.7) (p< 0.001) in patent who did not receive closure. Medical comorbidities were significantly lower in group receiving treatment (Congestive heart failure 0.9% vs. 7.6%, hypertension 55% vs. 64.6%, atrial fibrillation 6.9% vs. 11.6%) but no difference was noted in deep venous thrombosis, pulmonary embolism and diabetes mellitus.

We noted a significant downward trend of PFO closure at the national level and at teaching hospitals over 7 years (see graph 1)

National database demonstrated that only a minority of patients received PFO closure in setting of ischemic stroke and overall a downward trend was noted over the years in setting of negative randomized trials.