Patent foramen ovale: Difference between revisions

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==Background==
==Background==
Patent foramen ovale (PFO) is a flap-like opening between the atrial septa primum and secundum at the location of the fossa ovalis that persists after 1 year of age. This inter-atrial communication gives potential for right-to-left shunting in the cardiovascular system. Although most patients with an isolated PFO are asymptomatic, there is increasing evidence being found that PFO is the culprit in paradoxical embolic events and therefore, the relative importance of the anomaly is being re-evaluated.
*Flap-like opening between the atrial septa primum and secundum
*Occurs at fossa ovalis
*Persists beyond 1 year of age
*Inter-atrial communication allows right-to-left cardiac shunting
*Most patients with isolated PFO are asymptomatic
**But there is increasing evidence that PFO is the culprit in [[Missile embolism|paradoxical embolic events]]


==Clinical Features==
==Clinical Features==
*History of stroke or TIA of undefined etiology
*[[Stroke]] or [[TIA]] of undefined etiology
*Migraine or migraine-like symptoms
**Consider in young, healthy patients without risk factors for stroke
*Neurologic decompression sickness (seen in scuba divers)
*[[Migraine]] or migraine-like symptoms
*Acute myocardial infarction
*Neurologic [[decompression sickness]] (seen in scuba divers)
*Systemic embolism, such as renal infarction
*[[Acute myocardial infarction]]
*Systemic [[thromboembolism|embolism]], such as renal infarction
*Fat embolism
*Fat embolism
*Paradoxical embolism caused by right atrial tumors that increase right atrial pressure
*Paradoxical embolism caused by right atrial tumors that increase right atrial pressure
*Left-sided valve disease in carcinoid syndrome
*Left-sided valve disease in [[carcinoid syndrome]]


==Diagnosis==
==Differential Diagnosis==
*Color flow Doppler imaging: small "flame" of color signal may be seen in middle region of atrial septum
{{Missile embolism types}}
*Contrast echocardiography (Bubble Study): After obtaining optimal visualization of atrial septum on TTE or TEE, a bolus of agitated saline is injected to an antecubital vein. Subsequently, microbubbles appear in the right atrium. The study is positive for PFO if microbubbles appear in left atrium within 3 cardiac cycles of their appearance in the right atrium. Valsalva increases right atrial pressure and facilitates right-to-left shunting if present.
 
*2D TEE with contrast provides superior visualization and is therefore preferred for detecting PFO. When clinically indicated, 2D TEE with contrast is strongly recommended if transthoracic echo is negative.
==Evaluation==
*[[Echocardiography]]: color flow Doppler imaging
**Small "flame" of color signal may be seen in middle region of atrial septum
*[[Contrast echocardiography]] (Bubble Study)
**Bolus of agitated saline injected to antecubital vein
**Microbubbles appear in right atrium
***Study positive for PFO if microbubbles appear in left atrium within 3 cardiac cycles of their appearance in right atrium  
**Valsalva increases right atrial pressure and facilitates right-to-left shunting if present
*2D TEE with contrast provides superior visualization and is preferred
**Obtain 2E TEE with constrast if suspicion is high and TTE is negative


==Management==
==Management==
*Most patients with incidental or isolated PFO receive no treatment
*Treatment more common when PFO associated with unexplained neurologic event, but no consensus for treatment exists


==Disposition==
===Medical Therapy===
*[[Aspirin]] therapy alone in low risk patients
*[[Warfarin]] with ASA (INR 2-3) in high-risk individuals
 
===Surgical Closure===
*Indications:
**PFO more than 25 mm in size
**Inadequate rim of tissue around defect
**Percutaneous device failure
*Advantages of surgical closure
**Permanent closure of defect
**Prevents future paradoxical emboli
**No need for long-term anticoagulation
*Percutaneous closure
**Emergency therapeutic option


==See Also==
==See Also==
*[[Congenital Heart Disease]]
*[[Missile embolism]]


==External Links==
==External Links==
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==References==
==References==
<references/>
<references/>
emedicine.Medscape.com
[[Category:Cardiology]]

Latest revision as of 16:07, 25 September 2019

Background

  • Flap-like opening between the atrial septa primum and secundum
  • Occurs at fossa ovalis
  • Persists beyond 1 year of age
  • Inter-atrial communication allows right-to-left cardiac shunting
  • Most patients with isolated PFO are asymptomatic

Clinical Features

Differential Diagnosis

Missile embolism types

  • Intrapericardial foreign body
  • Systemic venous embolism
  • Right heart and pulmonary artery embolism
  • Pulmonary vein embolism
  • Left heart embolism
  • Coronary artery embolism
  • Paradoxical embolus (due to patent foramen ovale)

Evaluation

  • Echocardiography: color flow Doppler imaging
    • Small "flame" of color signal may be seen in middle region of atrial septum
  • Contrast echocardiography (Bubble Study)
    • Bolus of agitated saline injected to antecubital vein
    • Microbubbles appear in right atrium
      • Study positive for PFO if microbubbles appear in left atrium within 3 cardiac cycles of their appearance in right atrium
    • Valsalva increases right atrial pressure and facilitates right-to-left shunting if present
  • 2D TEE with contrast provides superior visualization and is preferred
    • Obtain 2E TEE with constrast if suspicion is high and TTE is negative

Management

  • Most patients with incidental or isolated PFO receive no treatment
  • Treatment more common when PFO associated with unexplained neurologic event, but no consensus for treatment exists

Medical Therapy

  • Aspirin therapy alone in low risk patients
  • Warfarin with ASA (INR 2-3) in high-risk individuals

Surgical Closure

  • Indications:
    • PFO more than 25 mm in size
    • Inadequate rim of tissue around defect
    • Percutaneous device failure
  • Advantages of surgical closure
    • Permanent closure of defect
    • Prevents future paradoxical emboli
    • No need for long-term anticoagulation
  • Percutaneous closure
    • Emergency therapeutic option

See Also

External Links

References

emedicine.Medscape.com