Patent foramen ovale - Symptoms, Causes, Images, and Treatment Options

Diseases

Highlights & Basics

Key Highlights

Patent foramen ovale (PFO) is a common finding, reported in approximately 10% of people undergoing contrast echo.
Usually asymptomatic but may be associated with cryptogenic stroke.
Atrial septal aneurysm is a risk factor for PFO, and when present in combination is associated with an increased risk of cerebrovascular accident (CVA).
Asymptomatic patients are generally observed without medical intervention.
In patients younger than 60 years with PFO and cryptogenic stroke, percutaneous PFO closure with antiplatelet therapy is recommended.

Transesophageal echo with color flow Doppler showing presence of PFO

From the collection of Kul Aggarwal, MD

Quick Reference

History & Exam
- Key Factors
- Other Factors
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Diagnostics Tests
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Treatment Options
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Definition

Epidemiology

Etiology

Pathophysiology

Images

Transesophageal echo showing a 2D image of the interatrial septum with location of the PFO
Intracardiac echo showing a catheter placed across the PFO into the left atrium
Transesophageal echo with intravenous injection of agitated saline showing contrast crossing through PFO into left atrium
Transesophageal echo with color flow Doppler showing presence of PFO

Citations

Key Articles

Silvestry FE, Cohen MS, Armsby LB, et al. Guidelines for the echocardiographic assessment of atrial septal defect and patent foramen ovale: from the American Society of Echocardiography and Society for Cardiac Angiography and Interventions. J Am Soc Echocardiogr. 2015 Aug;28(8):910-58.[Abstract][Full Text]
Meier B, Kalesan B, Mattle HP, et al. Percutaneous closure of patent foramen ovale in cryptogenic embolism. N Engl J Med. 2013 Mar 21;368(12):1083-91.[Abstract]

Other Online Resources

Warfarin dosing

Referenced Articles

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9. Rodriguez CJ, Homma S, Sacco RL, et al. Race-ethnic differences in patent foramen ovale, atrial septal aneurysm, and right atrial anatomy among ischemic stroke patients. Stroke. 2003 Sep;34(9):2097-102.[Abstract][Full Text]
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12. Mas JL, Zuber M. Recurrent cerebrovascular events in patients with patent foramen ovale, atrial septal aneurysm, or both and cryptogenic stroke or transient ischemic attack. Am Heart J. 1995 Nov;130(5):1083-8.[Abstract]
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16. Silvestry FE, Cohen MS, Armsby LB, et al. Guidelines for the echocardiographic assessment of atrial septal defect and patent foramen ovale: from the American Society of Echocardiography and Society for Cardiac Angiography and Interventions. J Am Soc Echocardiogr. 2015 Aug;28(8):910-58.[Abstract][Full Text]
17. Rana BS, Thomas MR, Calvert PA, et al. Echocardiographic evaluation of patent foramen ovale prior to device closure. JACC Cardiovasc Imaging. 2010 Jul;3(7):749-60.[Abstract]
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20. Schuchlenz HW, Weihs W, Beitzke A, et al. Transesophageal echocardiography for quantifying size of patent foramen ovale in patients with cryptogenic cerebrovascular events. Stroke. 2002 Jan;33(1):293-6.[Abstract][Full Text]
21. Earing MG, Cabalka AK, Seward JB, et al. Intracardiac echocardiographic guidance during transcatheter device closure of atrial septal defect and patent foramen ovale. Mayo Clin Proc. 2004 Jan;79(1):24-34.[Abstract]
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25. Kuijpers T, Spencer FA, Siemieniuk RAC, et al. Patent foramen ovale closure, antiplatelet therapy or anticoagulation therapy alone for management of cryptogenic stroke? A clinical practice guideline. BMJ. 2018 Jul 25;362:k2515.[Abstract][Full Text]
26. Handke M, Harloff A, Olschewski M, et al. Patent foramen ovale and cryptogenic stroke in older patients. N Engl J Med. 2007 Nov 29;357(22):2262-8.[Abstract][Full Text]
27. Overell JR, Bone I, Lees KR. Interatrial septal abnormalities and stroke: a meta-analysis of case-control studies. Neurology. 2000 Oct 24;55(8):1172-9.[Abstract]
28. Messé SR, Gronseth GS, Kent DM, et al. Practice advisory update summary: patent foramen ovale and secondary stroke prevention: report of the Guideline Subcommittee of the American Academy of Neurology. Neurology. 2020 May 19;94(20):876-85.[Abstract][Full Text]
29. Pristipino C, Germonpré P, Toni D, et al. European position paper on the management of patients with patent foramen ovale. Part II - Decompression sickness, migraine, arterial deoxygenation syndromes and select high-risk clinical conditions. Eur Heart J. 2021 Apr 21;42(16):1545-53.[Abstract][Full Text]
30. National Institute for Health and Care Excellence (UK). Percutaneous closure of patent foramen ovale for the secondary prevention of recurrent paradoxical embolism in divers. Dec 2010 [internet publication].[Full Text]
31. O'Gara PT, Messe SR, Tuzcu EM, et al. Percutaneous device closure of patent foramen ovale for secondary stroke prevention: a call for completion of randomized clinical trials: a science advisory from the American Heart Association/American Stroke Association and the American College of Cardiology Foundation. Circulation. 2009 May 26;119(20):2743-7.[Abstract][Full Text]
32. Kitsios GD, Dahabreh IJ, Abu Dabrh AM, et al. Patent foramen ovale closure and medical treatments for secondary stroke prevention: a systematic review of observational and randomized evidence. Stroke. 2012 Feb;43(2):422-31.[Abstract]
33. Furlan AJ, Reisman M, Massaro J, et al; CLOSURE I Investigators. Closure or medical therapy for cryptogenic stroke with patent foramen ovale. N Engl J Med. 2012 Mar 15;366(11):991-9.[Abstract]
34. Meier B, Kalesan B, Mattle HP, et al. Percutaneous closure of patent foramen ovale in cryptogenic embolism. N Engl J Med. 2013 Mar 21;368(12):1083-91.[Abstract]
35. Baumgartner H, De Backer J, Babu-Narayan SV, et al. 2020 ESC guidelines for the management of adult congenital heart disease. Eur Heart J. 2021 Feb 11;42(6):563-645.[Abstract][Full Text]
36. Bogousslavsky J, Garazi S, Jeanrenaud X, et al. Stroke recurrence in patients with patent foramen ovale: the Lausanne study. Neurology. 1996 May;46(5):1301-5.[Abstract]
37. Stone DA, Godard J, Corretti MC, et al. Patent foramen ovale: association between the degree of shunt by contrast transesophageal echocardiography and the risk of future ischemic neurologic events. Am Heart J. 1996 Jan;131(1):158-61.[Abstract]
38. Hung J, Landzberg MJ, Jenkins KJ, et al. Closure of patent foramen ovale for paradoxical emboli: intermediate-term risk of recurrent neurological events following transcatheter device placement. J Am Coll Cardiol. 2000 Apr;35(5):1311-6.[Abstract]
39. Homma S, Di Tullio MR, Sacco RL, et al. Surgical closure of patent foramen ovale in cryptogenic stroke patients. Stroke. 1997 Dec;28(12):2376-81.[Abstract][Full Text]
40. Pezzini A, Grassi M, Zotto ED, et al. Do common prothrombotic mutations influence the risk of cerebral ischaemia in patients with patent foramen ovale? Systematic review and meta-analysis. Thromb Haemost. 2009 May;101(5):813-7.[Abstract]
41. Dowson A, Mullen MJ, Peatfield R, et al. Migraine Intervention with STARFlex Technology (MIST) trial: a prospective, multicenter, double-blind, sham-controlled trial to evaluate the effectiveness of patent foramen ovale closure with STARFlex septal repair implant to resolve refractory migraine headache. Circulation. 2008 Mar 18;117(11):1397-404.[Abstract]
42. Kamineni R, Heuser R. Treatment of residual shunt after percutaneous closure of patent foramen ovale with a second Cardioseal device. Vasc Disease Manage. 2005 Jan-Feb;2(1):8-9.
43. Krumsdorf U, Ostermayer S, Billinger K, et al. Incidence and clinical course of thrombus formation on atrial septal defect and patent foramen ovale closure devices in 1,000 consecutive patients. J Am Coll Cardiol. 2004 Jan 21;43(2):302-9.[Abstract]
44. Delaney JW, Li JS, Rhodes JF. Major complications associated with transcatheter atrial septal occluder implantation: a review of the medical literature and the manufacturer and user facility device experience (MAUDE) database. Congenit Heart Dis. 2007 Jul-Aug;2(4):256-64.[Abstract]