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

Atrial Septal Defect, Patent Foramen Ovale: Follow-up

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

Follow-up

Further Inpatient Care

  • Inpatient observation in the neonate with cyanosis due to atrial right-to-left shunting may be required until the underlying cause is defined.

Further Outpatient Care

  • Outpatient follow-up is indicated for patients with cyanosis due to right-to-left shunting at the patent foramen ovale (PFO) to check for evidence of resolution of shunting as changes in pulmonary vascular resistance occur. Follow-up echocardiography is recommended after surgical closure or placement of a transcatheter device to confirm persistent closure.

Transfer

  • Transfer of patients with patent foramen ovale is likely to be indicated only for surgical closure or transcatheter device closure of the patent foramen ovale in patients with problematic right-to-left shunting.

Complications

  • Symptomatic desaturation due to right-to-left shunting at the patent foramen ovale or paradoxical embolus with stroke or other systemic embolization may occur as described above.

Prognosis

  • In general, the prognosis is excellent but may depend on underlying problems or associated defects. For instance, the neonate with right-to-left patent foramen ovale shunting resulting in cyanosis may have complete resolution of right-to-left shunting as pulmonary vascular resistance falls. Alternatively, associated congenital heart defects (eg, Ebstein malformation of the tricuspid valve) may continue to exhibit right-to-left shunting, especially with exercise, as these patients grow. Also, some patients with stroke thought to be caused by paradoxical embolus may continue to have cryptogenic stroke even after surgical or transcatheter device closure of a patent foramen ovale.
  • Healthy patients who have a patent foramen ovale discovered incidentally do not require any special treatment or follow-up. Patients with a patent foramen ovale who have not had prior stroke or transient ischemic attack are not at measurably increased risk for these events.

Miscellaneous

Medicolegal Pitfalls

  • Failure to recognize a patent foramen ovale as a source of paradoxical embolism
  • Failure to evaluate a patient for patent foramen ovale prior to a sitting neurosurgical procedure

Special Concerns

  • Pregnancy: Patients with a patent foramen ovale who have not had a prior stroke or transient ischemic attack do not appear to be at any elevated risk during pregnancy. Normal pregnancy and delivery can be safely advised.
 


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
[ CLOSE WINDOW ]

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. Agnetti A, Carano N, Sani E, et al. Cryptogenic stroke in children: possible role of patent foramen ovale. Neuropediatrics. Feb 2006;37(1):53-6. [Medline].

  3. Bartz PJ, Cetta F, Cabalka AK, et al. Paradoxical emboli in children and young adults: role of atrial septal defect and patent foramen ovale device closure. Mayo Clin Proc. May 2006;81(5):615-8. [Medline].

  4. Filippi L, Palermo L, Pezzati M, et al. Paradoxical embolism in a preterm infant. Dev Med Child Neurol. Oct 2004;46(10):713-6. [Medline].

  5. Petty GW, Khandheria BK, Meissner I, et al. Population-based study of the relationship between patent foramen ovale and cerebrovascular ischemic events. Mayo Clin Proc. May 2006;81(5):602-8. [Medline].

  6. Reisman M, Christofferson RD, Jesurum J, et al. Migraine headache relief after transcatheter closure of patent foramen ovale. J Am Coll Cardiol. Feb 15 2005;45(4):493-5. [Medline].

  7. Kruit MC, van Buchem MA, Hofman PA, Bakkers JT, Terwindt GM, Ferrari MD. Migraine as a risk factor for subclinical brain lesions. JAMA. Jan 28 2004;291(4):427-34. [Medline].

  8. Post MC, Budts W. The relationship between migraine and right-to-left shunt: Fact or fiction?. Chest. Sep 2006;130(3):896-901. [Medline].

  9. Kizer JR, Silvestry FE, Kimmel SE, Kasner SE, Wiegers SE, Erwin MB. Racial differences in the prevalence of cardiac sources of embolism in subjects with unexplained stroke or transient ischemic attack evaluated by transesophageal echocardiography. Am J Cardiol. Aug 15 2002;90(4):395-400. [Medline].

  10. Gupta V, Yesilbursa D, Huang WY, Aggarwal K, Gupta V, Gomez C. Patent foramen ovale in a large population of ischemic stroke patients: diagnosis, age distribution, gender, and race. Echocardiography. Feb 2008;25(2):217-27. [Medline].

  11. Fisher DC, Fisher EA, Budd JH, et al. The incidence of patent foramen ovale in 1,000 consecutive patients. A contrast transesophageal echocardiography study. Chest. Jun 1995;107(6):1504-9. [Medline].

  12. Schwedt TJ, Demaerschalk BM, Dodick DW. Patent foramen ovale and migraine: a quantitative systematic review. Cephalalgia. May 2008;28(5):531-40. [Medline].

  13. Toffart AC, Bouvaist H, Feral V, Blin D, Pison C. Hypoxemia-orthodeoxia related to patent foramen ovale without pulmonary hypertension. Heart Lung. Sep-Oct 2008;37(5):385-9. [Medline].

  14. Mas JL, Arquizan C, Lamy C, Zuber M, Cabanes L, Derumeaux G. Recurrent cerebrovascular events associated with patent foramen ovale, atrial septal aneurysm, or both. N Engl J Med. Dec 13 2001;345(24):1740-6. [Medline].

  15. Telman G, Yalonetsky S, Kouperberg E, Sprecher E, Lorber A, Yarnitsky D. Size of PFO and amount of microembolic signals in patients with ischaemic stroke or TIA. Eur J Neurol. Sep 2008;15(9):969-72. [Medline].

  16. Homma S, Sacco RL, Di Tullio MR, Sciacca RR, Mohr JP. 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].

  17. Mammoto T, Hayashi Y, Ohnishi Y, Kuro M. Incidence of venous and paradoxical air embolism in neurosurgical patients in the sitting position: detection by transesophageal echocardiography. Acta Anaesthesiol Scand. Jul 1998;42(6):643-7. [Medline].

  18. Torti SR, Billinger M, Schwerzmann M, et al. Risk of decompression illness among 230 divers in relation to the presence and size of patent foramen ovale. Eur Heart J. Jun 2004;25(12):1014-20. [Medline]. [Full Text].

  19. von Bardeleben RS, Richter C, Otto J, Himmrich L, et al. Long term follow up after percutaneous closure of PFO in 357 patients with paradoxical embolism: Difference in occlusion systems and influence of atrial septum aneurysm. Int J Cardiol. Aug 18 2008;[Medline].

  20. Majunke N, Baranowski A, Zimmermann W, et al. A suture not always the ideal solution: Problems encountered in developing a suture-based PFO closure technique. Catheter Cardiovasc Interv. Oct 27 2008;73(3):376-382. [Medline].

  21. Sievert H, Ruygrok P, Salkeld M, et al. Transcatheter closure of patent foramen ovale with radiofrequency: Acute and intermediate term results in 144 patients. Catheter Cardiovasc Interv. Oct 27 2008;73(3):368-373. [Medline].

  22. Messe SR, Silverman IE, Kizer JR, Homma S, Zahn C, Gronseth G. Practice parameter: recurrent stroke with patent foramen ovale and atrial septal aneurysm: report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. Apr 13 2004;62(7):1042-50. [Medline].

  23. Arquizan C, Coste J, Touboul PJ, Mas JL. Is patent foramen ovale a family trait? A transcranial Doppler sonographic study. Stroke. Jul 2001;32(7):1563-6. [Medline]. [Full Text].

  24. Berger F, Ewert P, Bjornstad PG, et al. Transcatheter closure as standard treatment for interatrial defects: experience in 200 patients treated with the Amplatzer Septal Occluder. Cardiol Young. 1999;9:468-473. [Medline].

  25. Chatterjee T, Petzsch M, Ince H, et al. Interventional closure with Amplatzer PFO occluder of patent foramen ovale in patients with paradoxical cerebral embolism. J Interv Cardiol. Jun 2005;18(3):173-9. [Medline].

  26. Dearani JA, Ugurlu BS, Danielson GK, et al. Surgical patent foramen ovale closure for prevention of paradoxical embolism-related cerebrovascular ischemic events. Circulation. Nov 9 1999;100(19 Suppl):II171-5. [Medline].

  27. Duke DA, Lynch JJ, Harner SG, et al. Venous air embolism in sitting and supine patients undergoing vestibular schwannoma resection. Neurosurgery. Jun 1998;42(6):1282-6; discussion 1286-7. [Medline].

  28. Fuchs G, Schwarz G, Stein J, et al. Doppler color-flow imaging: screening of a patent foramen ovale in children scheduled for neurosurgery in the sitting position. J Neurosurg Anesthesiol. Jan 1998;10(1):5-9. [Medline].

  29. Guntheroth WG, Schwaegler R, Trent E. Comparative roles of the atrial septal aneurysm versus patent foramen ovale in systemic embolization with inferences from neonatal studies. Am J Cardiol. Nov 15 2004;94(10):1341-3. [Medline].

  30. Hansen LK, Oxhoj H. High prevalence of interatrial communications during the first three months of life. Pediatr Cardiol. Mar-Apr 1997;18(2):83-5. [Medline].

  31. Hanzel GS. Complications of patent foramen ovale and atrial septal defect closure devices. J Interv Cardiol. Apr 2006;19(2):160-2. [Medline].

  32. Kizer JR, Silvestry FE, Kimmel SE, et al. Racial differences in the prevalence of cardiac sources of embolism in subjects with unexplained stroke or transient ischemic attack evaluated by transesophageal echocardiography. Am J Cardiol. Aug 15 2002;90(4):395-400. [Medline].

  33. Maisel WH, Laskey WK. Patent foramen ovale closure devices: moving beyond equipoise. JAMA. Jul 20 2005;294(3):366-9. [Medline].

  34. Meissner I, Khandheria BK, Heit JA, et al. Patent foramen ovale: innocent or guilty? Evidence from a prospective population-based study. J Am Coll Cardiol. Jan 17 2006;47(2):440-5. [Medline].

  35. Rao PS. Transcatheter management of platypnea-orthodeoxia syndrome. J Invasive Cardiol. Oct 2004;16(10):583-4. [Medline].

  36. Schuchlenz HW, Weihs W, Berghold A, et al. Secondary prevention after cryptogenic cerebrovascular events in patients with patent foramen ovale. Int J Cardiol. May 11 2005;101(1):77-82. [Medline].

  37. Wilmshurst PT, Pearson MJ, Nightingale S, et al. Inheritance of persistent foramen ovale and atrial septal defects and the relation to familial migraine with aura. Heart. Nov 2004;90(11):1315-20. [Medline]. [Full Text].

  38. Wyland J, Krulak D. U.S. navy diver/aviator/skydiver with AGE from a previously unknown PFO. Undersea Hyperb Med. Mar-Apr 2005;32(2):129-33. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

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

[ CLOSE WINDOW ]

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.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.