eMedicine Specialties > Cardiology > Congenital Heart Disease in the Adult

Patent Foramen Ovale

Author: Sandy N Shah, DO, MBA, Private Practice, Houston, Texas
Coauthor(s): Dawn M Calderon, DO, Co-Director of Center for Adults With Congenital Heart Disease, Clinical Associate Professor, Departments of Cardiology and Internal Medicine, Deborah Heart and Lung Center, Robert Wood Johnson School of Medicine
Contributor Information and Disclosures

Updated: May 1, 2008

Introduction

Background

Patent foramen ovale (PFO) is an anatomical interatrial communication with potential for right-to-left shunt. Foramen ovale has been known since the time of Galen. In 1564, Leonardi Botali, an Italian surgeon, was the first to describe the presence of foramen ovale at birth. However, the function of foramen ovale in utero was not known at that time. In 1877, Cohnheim described paradoxical embolism in relation to PFO.

Pathophysiology

PFO is a flaplike opening between the atrial septa primum and secundum at the location of the fossa ovalis that persists after age 1 year. In utero, the foramen ovale serves as a physiologic conduit for right-to-left shunting. Once the pulmonary circulation is established after birth, left atrial pressure increases, allowing functional closure of the foramen ovale. This is followed by anatomical closure of the septum primum and septum secundum by the age of 1 year.

The Mayo Clinic autopsy study revealed that the size of a PFO increases from a mean of 3.4 mm in the first decade to 5.8 mm in the 10th decade of life, as the valve of fossa ovalis stretches with age.1

With increasing evidence that PFO is the culprit in paradoxical embolic events, the relative importance of the anomaly is being reevaluated. James Lock, MD has postulated that PFO anatomy results in a cul-de-sac between the septa primum and secundum, predisposing individuals to hemostasis and clot formation. Any conditions that increase right atrial pressure more than left atrial pressure can induce paradoxical flow and may result in an embolic event.

This reasoning has greatly altered the previous conception of PFO and is changing current management of the condition.

Frequency

United States

PFO is detected in 10-15% of the population by contrast transthoracic echocardiography. Autopsy studies show a 27% prevalence of probe-patent foramen ovale.1 This difference is probably due to the ability to directly visualize PFO on autopsy study, while contrast echocardiography relies on detection of secondary physiologic phenomena.

Clinical

History

  • Most patients with isolated patent foramen ovale (PFO) are asymptomatic.
  • Patients may have a history of stroke or transient ischemic event of undefined etiology.
  • Some present with migraine or migrainelike symptoms. Whether symptoms are due to transient ischemic attacks or paradoxical embolism is not clear.
  • Neurologic decompression sickness is seen with PFO in a small percent of scuba divers. Risk of nitrogen gas embolism across PFO increases in scuba divers. In unexperienced divers, PFO can worsen hypoxemia at great depth leading to death. 

Physical

No abnormal cardiac clinical findings are associated with isolated PFO.

More on Patent Foramen Ovale

Overview: Patent Foramen Ovale
Differential Diagnoses & Workup: Patent Foramen Ovale
Treatment & Medication: Patent Foramen Ovale
Follow-up: Patent Foramen Ovale
References
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References

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  36. Windecker S, Wahl A, Chatterjee T, et al. Percutaneous closure of patent foramen ovale in patients with paradoxical embolism: long-term risk of recurrent thromboembolic events. Circulation. Feb 29 2000;101(8):893-8. [Medline].

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Further Reading

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Keywords

patent foramen ovale, PFO, paradoxical embolism, atrial septum primum, atrial septum secundum, fossa ovalis, atrial septal aneurysm, right-to-left shunt, stroke, transient ischemic event, Valsalva maneuver, atrial septal aneurysm, cryptogenic stroke, paradoxical embolization

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Contributor Information and Disclosures

Author

Sandy N Shah, DO, MBA, Private Practice, Houston, Texas
Sandy N Shah, DO, MBA is a member of the following medical societies: American College of Cardiology, American Heart Association, and American Osteopathic Association
Disclosure: Nothing to disclose.

Coauthor(s)

Dawn M Calderon, DO, Co-Director of Center for Adults With Congenital Heart Disease, Clinical Associate Professor, Departments of Cardiology and Internal Medicine, Deborah Heart and Lung Center, Robert Wood Johnson School of Medicine
Dawn M Calderon, DO is a member of the following medical societies: American College of Cardiology and American Osteopathic Association
Disclosure: Nothing to disclose.

Medical Editor

Park W Willis IV, MD, Sarah Graham Distinguished Professor of Medicine and Pediatrics, University of North Carolina at Chapel Hill School of Medicine
Park W Willis IV, MD is a member of the following medical societies: American Society of Echocardiography
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Marschall S Runge, MD, PhD, Charles and Anne Sanders Distinguished Professor of Medicine, Chairman of Medicine, Vice Dean for Clinical Affairs, Chairman, Department of Medicine, University of North Carolina at Chapel Hill School of Medicine
Marschall S Runge, MD, PhD is a member of the following medical societies: American Association for the Advancement of Science, American College of Cardiology, American College of Physicians-American Society of Internal Medicine, American Federation for Clinical Research, American Federation for Medical Research, American Heart Association, American Physiological Society, American Society for Clinical Investigation, American Society for Investigative Pathology, Association of American Physicians, Association of Professors of Cardiology, Association of Professors of Medicine, Southern Society for Clinical Investigation, and Texas Medical Association
Disclosure: Pfizer Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; Orthoclinica Diagnostica Consulting fee Consulting

CME Editor

Amer Suleman, MD, Consultant in Electrophysiology and Cardiovascular Medicine, Department of Internal Medicine, Division of Cardiology, Medical City Dallas Hospital
Amer Suleman, MD is a member of the following medical societies: American College of Physicians, American Heart Association, American Institute of Stress, American Society of Hypertension, Federation of American Societies for Experimental Biology, Royal Society of Medicine, and Society of Cardiac Angiography and Interventions
Disclosure: Nothing to disclose.

Chief Editor

Park W Willis IV, MD, Sarah Graham Distinguished Professor of Medicine and Pediatrics, University of North Carolina at Chapel Hill School of Medicine
Park W Willis IV, MD is a member of the following medical societies: American Society of Echocardiography
Disclosure: Nothing to disclose.

 
 
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