eMedicine Specialties > Cardiology > Congenital Heart Disease in the Adult

Patent Foramen Ovale: Treatment & Medication

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

Treatment

Medical Care

Most patients with a patent foramen ovale (PFO) as an isolated finding receive no special treatment. No consensus exists on treatment of PFO in patients with transient ischemic attack or stroke.

  • When PFO is associated with an otherwise unexplained neurologic event, traditional treatment has been antiplatelet (ie, aspirin) therapy alone in low-risk patients or combined with warfarin in high-risk individuals to prevent cryptogenic stroke. With administration of warfarin, the international normalized ratio (INR) is maintained at 2-3. Consultation with a neurologist is mandatory to direct this treatment.
  • The recurrence rate of stroke or transient ischemic attack has been reported to be as high as 3.4-3.9% per year.
  • In patients with atrial septal aneurysm and PFO, the risk of first recurrent stroke within 2 years has been reported to be as high as 9%, while the rate of subsequent stroke or transient ischemic attack recurrence within 2 years increases to 22%.

Surgical Care

Surgical closure of PFO with double continuous suture has resulted in elimination of residual shunt across the PFO.

  • Indication
    • PFO more than 25 mm in size
    • Inadequate rim of tissue around the defect
    • Percutaneous device failure
  • Advantages
    • Permanent closure of the defect.
    • Prevents future paradoxical emboli.
    • No long-term anticoagulation and its risks.
  • Disadvantages
    • General anesthesia
    • Open-heart surgery
    • Hospital stay for a few days
    • The usual risks of cardiac surgery

Percutaneous care

Percutaneous closure of PFO during cardiac catheterization is an emerging therapeutic option.

  • Indications
    • Recurrent cryptogenic stroke due to presumed paradoxical embolism through PFO failure of conventional drug therapy
    • Contraindications to anticoagulant treatment
    • Alternative to medical therapy or surgical closure - Cryptogenic TIA due to presumed paradoxical embolism through a PFO
    • Presumed paradoxical peripheral or coronary embolism through PFO
    • Cryptogenic stroke, TIA, or peripheral or coronary embolism due to presumed paradoxical embolism through a PFO that is associated with hypercoagulability state
      • Divers with a PFO who are at risk of clinical events that are related to paradoxical embolism through a PFO during decompression
      • Systemic deoxygenation due to right-to-left shunting through a PFO in the absence of severe pulmonary hypertension (eg, platypnea orthodeoxia, right ventricular infarction)
      • Migraine headache accompanied by aura
      • Posttraumatic fat embolism syndrome with cerebral embolism by way of PFO
  • The Federal Drug Administration (FDA) has approved 2 percutaneous devices for PFO closure.
    • CardioSEAL Septal Occlusion System (NMT Medical Inc, Boston, MA) is a double umbrella-shaped permanent implant. It is made up of metal framework to which polyester fabric is attached. The CardioSEAL implant is available in sizes 17 mm, 23 mm, 28 mm, and 33 mm.
    • Amplatzer PFO Occluder (AGA Medical Corp, Golden Valley, Minn) is a self-expanding wire mesh with double discs. It contains inner polyester fabric patches that, along with the wire mesh, cause the formation and accumulation of a blood clot, which seals the opening. After the device is in place, tissue will grow over it, and the device then becomes a part of the atrial septum. 
  • The procedure requires a hospital stay of 24-48 hours and prophylactic aspirin or warfarin for 6 months following the procedure. After more than 5 years of follow-up observation, the results are promising.

Medication

Most patients with a patent foramen ovale as an isolated finding receive no particular treatment.

Anticoagulants

Antiplatelet therapy and anticoagulation with warfarin can be indicated to prevent recurrent systemic thromboembolism.


Warfarin (Coumadin)

Interferes with hepatic synthesis of vitamin K-dependent coagulation factors. Used for prophylaxis and treatment of venous thrombosis, pulmonary embolism, and thromboembolic disorders.

Tailor dose to maintain an INR in the range of 2 to 3.

Adult

5-15 mg/d PO qd for 2-5 d; adjust dose according to desired INR

Pediatric

Administer weight-based dose of 0.05-0.34 mg/kg/d PO; adjust dose according to desired INR

Drugs that may decrease anticoagulant effects include griseofulvin, carbamazepine, glutethimide, estrogens, nafcillin, phenytoin, rifampin, barbiturates, cholestyramine, colestipol, vitamin K, spironolactone, oral contraceptives, and sucralfate

Medications that may increase anticoagulant effects of warfarin include oral antibiotics, capecitabine, phenylbutazone, salicylates, sulfonamides, chloral hydrate, clofibrate, diazoxide, anabolic steroids, ketoconazole, ethacrynic acid, miconazole, nalidixic acid, sulfonylureas, allopurinol, chloramphenicol, cimetidine, disulfiram, metronidazole, phenylbutazone, phenytoin, propoxyphene, sulfonamides, gemfibrozil, acetaminophen and sulindac

Documented hypersensitivity; severe liver or kidney disease; open wounds or GI ulcers

Pregnancy

X - Contraindicated; benefit does not outweigh risk

Precautions

Do not switch brands after achieving therapeutic response; caution in active tuberculosis or diabetes; patients with protein C or S deficiency are at risk of developing skin necrosis

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

  1. Hagen PT, Scholz DG, Edwards WD. Incidence and size of patent foramen ovale during the first 10 decades of life: an autopsy study of 965 normal hearts. Mayo Clin Proc. Jan 1984;59(1):17-20. [Medline].

  2. Adams HP. Patent foramen ovale: paradoxical embolism and paradoxical data. Mayo Clin Proc. Jan 2004;79(1):15-20. [Medline].

  3. Aslam F, Shirani J, Haque AA. Patent foramen ovale: assessment, clinical significance and therapeutic options. South Med J. Dec 2006;99(12):1367-72. [Medline].

  4. Bogousslavsky J, Garazi S, Jeanrenaud X, et al. Stroke recurrence in patients with patent foramen ovale: the Lausanne Study. Lausanne Stroke with Paradoxal Embolism Study Group. Neurology. May 1996;46(5):1301-5. [Medline].

  5. Bridges ND, Hellenbrand W, Latson L, et al. Transcatheter closure of patent foramen ovale after presumed paradoxical embolism. Circulation. Dec 1992;86(6):1902-8. [Medline].

  6. Cheng TO. Transcatheter closure of patent foramen ovale: a definitive treatment for platypnea-orthodeoxia. Catheter Cardiovasc Interv. Sep 2000;51(1):120. [Medline].

  7. Cujec B, Mainra R, Johnson DH. Prevention of recurrent cerebral ischemic events in patients with patent foramen ovale and cryptogenic strokes or transient ischemic attacks. Can J Cardiol. Jan 1999;15(1):57-64. [Medline].

  8. Danzi GB, Sesana M, Capuano C, Baglini R. Percutaneous closure of patent foramen ovale: pathophysiology, indications, and technique. Neurol Sci. May 2003;24 Suppl 1:S17-9. [Medline].

  9. Devuyst G, Bogousslavsky J, Ruchat P, et al. Prognosis after stroke followed by surgical closure of patent foramen ovale: a prospective follow-up study with brain MRI and simultaneous transesophageal and transcranial Doppler ultrasound. Neurology. Nov 1996;47(5):1162-6. [Medline].

  10. Donnan GA, Davis SM. Patent foramen ovale and stroke: closure by further randomized trial is required!. Stroke. Mar 2004;35(3):806. [Medline].

  11. Dubourg O, Bourdarias JP, Farcot JC, et al. Contrast echocardiographic visualization of cough-induced right to left shunt through a patent foramen ovale. J Am Coll Cardiol. Sep 1984;4(3):587-94. [Medline].

  12. Fransson SG. The Botallo mystery. Clin Cardiol. Jun 1999;22(6):434-6. [Medline].

  13. Furlan AJ. Patent foramen ovale and recurrent stroke: closure is the best option: yes. Stroke. Mar 2004;35(3):803-4. [Medline].

  14. Guffi M, Bogousslavsky J, Jeanrenaud X, et al. Surgical prophylaxis of recurrent stroke in patients with patent foramen ovale: a pilot study. J Thorac Cardiovasc Surg. Aug 1996;112(2):260-3. [Medline].

  15. Hara H, Virmani R, Ladich E, Mackey-Bojack S, Titus J, Reisman M. Patent foramen ovale: current pathology, pathophysiology, and clinical status. J Am Coll Cardiol. Nov 1 2005;46(9):1768-76. [Medline].

  16. Hausmann D, Mugge A, Daniel WG. Identification of patent foramen ovale permitting paradoxic embolism. J Am Coll Cardiol. Oct 1995;26(4):1030-8. [Medline].

  17. Homma S, Sacco RL, Di Tullio MR, et al. Effect of medical treatment in stroke patients with patent foramen ovale: patent foramen ovale in Cryptogenic Stroke Study. Circulation. Jun 4 2002;105(22):2625-31. [Medline].

  18. Kerut EK, Norfleet WT, Plotnick GD, Giles TD. Patent foramen ovale: a review of associated conditions and the impact of physiological size. J Am Coll Cardiol. Sep 2001;38(3):613-23. [Medline].

  19. Khairy P, O'Donnell CP, Landzberg MJ. Transcatheter closure versus medical therapy of patent foramen ovale and presumed paradoxical thromboemboli: a systematic review. Ann Intern Med. Nov 4 2003;139(9):753-60. [Medline].

  20. Kizer JR, Devereux RB. Clinical practice. Patent foramen ovale in young adults with unexplained stroke. N Engl J Med. Dec 1 2005;353(22):2361-72. [Medline].

  21. Landzberg MJ, Khairy P. Indications for the closure of patent foramen ovale. Heart. Feb 2004;90(2):219-24. [Medline].

  22. Lechat P, Mas JL, Lascault G, et al. Prevalence of patent foramen ovale in patients with stroke. N Engl J Med. May 5 1988;318(18):1148-52. [Medline].

  23. Lock JE. Patent foramen ovale is indicted, but the case hasn't gone to trial. Circulation. Feb 29 2000;101(8):838. [Medline].

  24. Marie Valente A, Rhodes JF. Current indications and contraindications for transcatheter atrial septal defect and patent foramen ovale device closure. Am Heart J. Apr 2007;153(4 Suppl):81-4. [Medline].

  25. 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. French Study Group on Patent Foramen Ovale and Atrial Septal Aneurysm. Am Heart J. Nov 1995;130(5):1083-8. [Medline].

  26. Meier B, Lock JE. Contemporary management of patent foramen ovale. Circulation. Jan 7 2003;107(1):5-9. [Medline].

  27. Mohrs OK, Petersen SE, Erkapic D, et al. Diagnosis of patent foramen ovale using contrast-enhanced dynamic MRI: a pilot study. AJR Am J Roentgenol. Jan 2005;184(1):234-40. [Medline].

  28. Ranoux D, Cohen A, Cabanes L, et al. Patent foramen ovale: is stroke due to paradoxical embolism?. Stroke. Jan 1993;24(1):31-4. [Medline].

  29. Ruchat P, Bogousslavsky J, Hurni M, et al. Systematic surgical closure of patent foramen ovale in selected patients with cerebrovascular events due to paradoxical embolism. Early results of a preliminary study. Eur J Cardiothorac Surg. May 1997;11(5):824-7. [Medline].

  30. Sievert H, Babic UU, Hausdorf G, et al. Transcatheter closure of atrial septal defect and patent foramen ovale with ASDOS device (a multi-institutional European trial). Am J Cardiol. Dec 1 1998;82(11):1405-13. [Medline].

  31. Sievert H, Taaffe M. Patent foramen ovale: the jury is still out. Eur Heart J. Mar 2004;25(5):361-2. [Medline].

  32. Siostrzonek P, Zangeneh M, Gossinger H, et al. Comparison of transesophageal and transthoracic contrast echocardiography for detection of a patent foramen ovale. Am J Cardiol. Nov 1 1991;68(11):1247-9. [Medline].

  33. Slavin L, Tobis JM, Rangarajan K, Dao C, Krivokapich J, Liebeskind DS. Five-year experience with percutaneous closure of patent foramen ovale. Am J Cardiol. May 1 2007;99(9):1316-20. [Medline].

  34. Somberg J. Patent foramen ovale closure devices: thoughts from the circulatory device advisory panel. Am J Cardiol. Sep 1 2007;100(5):905-6. [Medline].

  35. 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. Jan 1996;131(1):158-61. [Medline].

  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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