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Background A Patent Foramen Ovale (PFO) is a communication between the two atria of the heart which is a normal variant but can be associated with cryptogenic stroke and paradoxical embolisation. 1 It is present in a quarter of the population. At the Queen Elizabeth Hospital Birmingham (QEHB), suitability for PFO closure in the setting of a cryptogenic stroke is determined via a multidisciplinary team (MDT) approach, and based on NHS England (NHSE) funding criteria.Aims This retrospective audit aims to measure current practice of PFO closure against the use of PFO Associated Stroke Causal Likelihood (PASCAL) classification without developing improvements, to determine whether patients with a cryptogenic stroke would benefit from PFO closure. The PASCAL classification has been recommended by the European Society of Cardiology, utilising a combination of the Risk of Paradoxical Embolisation score and predefined PFO characteristics, to help aid decision-making. 2Methods 90 consecutive patient records discussed at the QEHB PFO MDT over a 12-month period were reviewed. Electronic patient records were used to determine whether the MDT decisions aligned with recommendations based on the PASCAL classification. There were 13 patients[OG(C1] either without a confirmed stroke, lost to follow-up or had an undecided outcome regarding PFO closure, so were excluded from further analysis.Results PASCAL classified ‘Unlikely’ and PFO closed10PASCAL classified ‘Unlikely’ and PFO not closed5PASCAL classified ‘Possible’ and PFO closed23PASCAL classified ‘Possible’ and PFO not closed13PASCAL classified ‘Probable’ and PFO closed21PASCAL classified ‘Probable’ and PFO not closed5Conclusion MDT decision making is generally consistent with the PASCAL probability of PFO-related stroke with higher closure rates observed in patients classified as PASCAL ‘probable’ compared with ‘possible’ and ‘unlikely’. However, a notable proportion of those classified as PASCAL ‘unlikely’ underwent closure. This discordance between PASCAL classification and MDT decisions is likely to reflect the inclusion of additional patient-specific factors and other imaging findings within MDT discussions that are not wholly captured by structured risk scores, encompassing comorbidities, alternative thrombo-embolic risk factors, and infarct patterns. Therefore, the introduction of structured risk grading systems, such as the PASCAL and RoPE score into MDT meetings may improve the consistency of patient selection while also maintaining the use of specialist clinical judgement.References Zito C, Carerj S, Falanga G, Oreto G, Khandheria B. How to understand patent foramen ovale clinical significance: Part I. Journal of Cardiovascular Echography 2014;24(4):114.Caso V, Guillaume Turc, Abdul-Rahim AH, Castro P, Hussain S, Lal A, et al. European stroke organisation (ESO) guidelines on the diagnosis and management of patent foramen ovale (PFO) after stroke. European Stroke Journal 2024 May 16;