Pediatric Patent Foramen Ovale Atrial Septal Defects Workup
- Author: Barry A Love, MD; Chief Editor: P Syamasundar Rao, MD more...
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
Transthoracic 2-dimensional echocardiography
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.
Bubble-contrast echocardiography is mandatory to diagnose a patent foramen ovale and to demonstrate a potential right-to-left shunt.
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.
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
Transcranial Doppler imaging with bubble-contrast injection is a useful screening tool for right-to-left shunting via a patent foramen ovale (see image and video below). 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.
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