eMedicine Specialties > Pediatrics: Cardiac Disease and Critical Care Medicine > Cardiology

Atrial Septal Defect, Patent Foramen Ovale: Differential Diagnoses & Workup

Author: Barry A Love, MD, Assistant Professor, Department of Medicine, Division of Cardiology, Assistant Professor, Division Pediatric Cardiology, Pediatrics and Medicine, Division of Pediatric Cardiology, Mount Sinai School of Medicine
Coauthor(s): Michael A Portman, MD, Research Director, Department of Pediatrics, Division of Cardiology, Associate Professor, Childrens' Hospital
Contributor Information and Disclosures

Updated: Mar 18, 2009

Differential Diagnoses

Atrial Septal Defect, Coronary Sinus
Atrial Septal Defect, Ostium Primum
Atrial Septal Defect, Ostium Secundum
Atrial Septal Defect, Sinus Venosus
Partial Anomalous Pulmonary Venous Connection
Total Anomalous Pulmonary Venous Connection

Other Problems to Be Considered

Other causes of cerebral ischemic events
Other causes of right-to-left shunting (eg, left superior vena cava [SVC] to the left atrium, right SVC to left atrium, pulmonary arteriovenous malformation)

Workup

Laboratory Studies

  • No laboratory tests are specific for patent foramen ovale (PFO).
  • In patients with a cryptogenic stroke and a patent foramen ovale, a complete hypercoagulable workup is indicated to rule out a hypercoagulable state. If a hypercoagulable condition is found, specific treatment of this condition with antiplatelet therapy or anticoagulation may be indicated. Consultation with a hematologist should be considered for patients in whom a hypercoagulable state is suspected. Closure of the patent foramen ovale may be indicated in patients with a hypercoagulable state, although one needs to be aware that surgical closure should be considered because the risk of thrombosis on transcatheter occlusion devices may be increased in the presence of a hypercoagulable state.
  • A hypercoagulable workup typically consists of the following tests:
    • CBC count (for platelet count)
    • Prothrombin time (PT), activated partial thromboplastin time (aPTT), international normalized ratio (INR)
    • Factor V Leiden assessment
    • Prothrombin gene mutation
    • Protein C and protein S assessment (Note that proteins C and S are vitamin K–dependent factors and should not be measured while the patient is taking warfarin [Coumadin]).
    • Antithrombin III assessment
    • Homocysteine assessment

Imaging Studies

  • Transthoracic 2-dimensional echocardiography can generally resolve the atrial septum and show the flap of the foramen ovale in infants and small children. Color Doppler flow across the atrial septum proves the presence of the foramen ovale. A foramen ovale may be differentiated from an atrial septal defect by the overlap of septal tissue. In older children and adults, transthoracic echocardiography does not visualize the atrial septum as well.
  • Transesophageal echocardiography (TEE) is preferred in patients where the atrial septum is inadequately visualized by transthoracic echocardiography. Older children and adults fall into this category. In addition to the patent foramen ovale, redundancy of septum primum can also be seen. When the redundancy of the septum moves more than 1 cm, it is called an atrial septal aneurysm. In the presence of a patent foramen ovale in patients who have had a prior stroke, atrial septal aneurysm confers an increased risk for a subsequent neurologic event.14
  • Bubble-contrast echocardiography is mandatory to diagnose a patent foramen ovale and to demonstrate a potential right-to-left shunt.

    Transesophageal echocardiogram showing the atrial...

    Transesophageal echocardiogram showing the atrial septum. The "flap" of the septum primum is seen. The diagnosis of patent foramen ovale (PFO) cannot be made until right-to-left bubble contrast is demonstrated. LA = Left atrium; RA = Right atrium.

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    Transesophageal echocardiogram showing the atrial...

    Transesophageal echocardiogram showing the atrial septum. The "flap" of the septum primum is seen. The diagnosis of patent foramen ovale (PFO) cannot be made until right-to-left bubble contrast is demonstrated. LA = Left atrium; RA = Right atrium.


    • A bubble-contrast study is performed by inserting a peripheral intravenous line and agitating 8 mL of saline with 1 mL of the patient's blood and 1 mL of air. The air is agitated into the solution and the bubble contrast is injected. The atrial septum and left atrium are visualized during the injections. In the presence of a patent foramen ovale, bubbles can be seen crossing the atrial septum and entering the left atrium.
    • The bubble-contrast injection should be performed at rest and with a Valsalva maneuver. The Valsalva maneuver transiently increases right atrial pressure above left atrial pressure, encouraging potential right-to-left shunting.

      Bubble-contrast injection during Valsalva maneuve...

      Bubble-contrast injection during Valsalva maneuver. The "flap" of the foramen ovale is opened and bubbles are seen crossing from the right atrium to the left atrium (arrow).

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      Bubble-contrast injection during Valsalva maneuve...

      Bubble-contrast injection during Valsalva maneuver. The "flap" of the foramen ovale is opened and bubbles are seen crossing from the right atrium to the left atrium (arrow).

    • TEE is usually the best echocardiographic imaging tool to use with a bubble-contrast injection, although it can be performed using transthoracic echocardiography. The sensitivity of transthoracic echocardiography with bubble-contrast injection is poor compared with transesophageal imaging.
  • Transcranial Doppler imaging with bubble-contrast injection is a useful screening tool for right-to-left shunting via a patent foramen ovale. An ultrasound probe is placed on the head, and the ultrasound beam is used to sample the middle cerebral arteries. A bubble-contrast injection is performed at rest and with the Valsalva maneuver. Any right-to-left shunt is revealed by the appearance of bubble artifacts on the transcranial Doppler signal. The number of bubble counts correlates with the potential for right-to-left shunting. Modern transcranial Doppler with bubble-contrast injection is as sensitive as TEE with bubble-contrast injection in identifying a patent foramen ovale.15

More on Atrial Septal Defect, Patent Foramen Ovale

Overview: Atrial Septal Defect, Patent Foramen Ovale
Differential Diagnoses & Workup: Atrial Septal Defect, Patent Foramen Ovale
Treatment & Medication: Atrial Septal Defect, Patent Foramen Ovale
Follow-up: Atrial Septal Defect, Patent Foramen Ovale
Multimedia: Atrial Septal Defect, Patent Foramen Ovale
References
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References

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Further Reading

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Keywords

atrial septal defect, patent foramen ovale, ASD PFO, interatrial communication, congenital heart defect, left-to-right shunting, right-to-left shunting, incompetent valve of the fossa ovalis, right atrial enlargement, left atrial enlargement, paradoxical embolism, mitral valve stenosis, mitral valve regurgitation, patent ductus arteriosus, ventricular septal defect, tricuspid valve stenosis, right ventricular hypoplasia, tricuspid atresia, total anomalous pulmonary venous return, migraine headaches, deep venous thrombosis, hypoplastic left-sided heart syndrome, stroke, transient ischemic attacks

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Contributor Information and Disclosures

Author

Barry A Love, MD, Assistant Professor, Department of Medicine, Division of Cardiology, Assistant Professor, Division Pediatric Cardiology, Pediatrics and Medicine, Division of Pediatric Cardiology, Mount Sinai School of Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Michael A Portman, MD, Research Director, Department of Pediatrics, Division of Cardiology, Associate Professor, Childrens' Hospital
Michael A Portman, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American Heart Association, American Physiological Society, and Society for Pediatric Research
Disclosure: Nothing to disclose.

Medical Editor

Paul M Seib, MD, Associate Professor of Pediatrics, University of Arkansas for Medical Sciences; Medical Director, Cardiac Catheterization Laboratory, Co-Medical Director, Cardiovascular Intensive Care Unit, Arkansas Children's Hospital
Paul M Seib, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American Heart Association, Arkansas Medical Society, International Society for Heart and Lung Transplantation, and Society for Cardiac Angiography and Interventions
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Alvin J Chin, MD, Professor of Pediatrics, Division of Cardiology, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine
Alvin J Chin, MD is a member of the following medical societies: American Association for the Advancement of Science and American Heart Association
Disclosure: Nothing to disclose.

CME Editor

Gilbert Z Herzberg, MD, Assistant Professor, Department of Pediatrics, Section of Pediatric Cardiology, New York Medical College; Consulting Staff, Department of Pediatrics, Sound Shore Medical Center
Gilbert Z Herzberg, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Chief Editor

Stuart Berger, MD, Professor of Pediatrics, Division of Cardiology, Medical College of Wisconsin; Chief of Pediatric Cardiology, Medical Director of Pediatric Heart Transplant Program, Medical Director of The Heart Center, Children's Hospital of Wisconsin
Stuart Berger, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American College of Chest Physicians, American Heart Association, and Society for Cardiac Angiography and Interventions
Disclosure: Nothing to disclose.

 
 
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