INTRODUCTION: Patent foramen ovale (PFO) is the most common congenital heart anomaly, and currently affects roughly 20–25% of adults worldwide. This defect allows direct blood flow between the right and left atria with interatrial shunting and increased risk of stroke due to paradoxical embolism. These potential complications are particularly concerning in patients undergoing liver transplant especially those with hepatopulmonary syndrome (HPS) and when using the piggyback operative technique. Two studies evaluated short-term outcomes including neurologic events in patients undergoing liver transplant surgery. Both reported no statistically significant difference in outcomes/neurologic events between patients with or without PFO undergoing transplant. The purpose of this case report is to discuss a patient with known PFO without closure who underwent liver transplantation, and suffered from an MRI-proven stroke and significant cardiopulmonary compromise. CASE DESCRIPTION/METHODS: A 60-year-old female with history of NASH cirrhosis, HPS, and atrial fibrillation with known, asymptomatic PFO as evidenced by interatrial shunting on transthoracic echocardiogram underwent liver transplant with uncomplicated surgery. However, her hospital course was complicated by pneumonia. She was difficult to wean from the ventilator, prompting initiation of extracorporeal membranous oxygenation (ECMO) ten days post-transplant. She remained on ECMO for eleven days, and due to her continued desaturation when weaning from ECMO, underwent percutaneous PFO closure. Roughly two-weeks post-PFO closure, she was noted to have right-sided weakness and right-sided facial droop when weaned from sedation. MR brain showed infarction in the anterior left medulla. DISCUSSION: The etiology of this patient's complicated post-operative course is multifactorial including pneumonia, underlying HPS and underlying PFO. This case questions the current standard of care for patients pre-transplant with known PFO. While the existing data suggests there is no indication for prophylactic PFO closure, some authors recommend considerations for closure in the presence of HPS. Some liver transplant centers recommend routine closure of PFO prior to liver transplant. Further studies are needed to define the population at high risk for paradoxical embolization and other complications of shunting that would benefit from PFO closure prior to liver transplant.