This case report presents a female with a paradoxical embolism due to a patent foramen ovale (PFO). The patient initially presented with a fractured left foot. Despite thrombosis prophylaxis, she developed a pulmonary embolism. This caused the pressure in the right ventricle and atrium to rise, the PFO to open and a venous thrombus to pass on to the arterial circulation. Because the risk of recurrence of venous thromboembolism was considered high, lifelong rivaroxaban was prescribed. Although recent studies find the percutaneous closure of the PFO to be beneficial over antiplatelet therapy alone, the studies lack convincing evidence that suggests it is superior to the use of anticoagulants as well. Furthermore, percutaneous PFO closure is associated with new-onset atrial fibrillation and other problems related to the closure device. Therefore, when anticoagulants are prescribed, the additional risk reduction achieved by closing the PFO is limited and might not justify the risks associated with percutaneous closure. © 2021, Netherlands Society of Intensive Care. All rights reserved.