Pediatric Patent Foramen Ovale Atrial Septal Defects Clinical Presentation

Updated: Sep 16, 2019
  • Author: Barry A Love, MD; Chief Editor: Syamasundar Rao Patnana, MD  more...
  • Print


The trivial amount of left-to-right shunting through a patent foramen ovale (PFO) generally produces no symptoms.

Patients with right-to-left shunting can experience transient or persistent periods of cyanosis. This can be exacerbated by acute increases in pulmonary vascular resistance, such as those that occur during breath holding, crying, or the Valsalva maneuver. Persistent cyanosis due to right-to-left shunting may also occur during the neonatal period until pulmonary vascular resistance falls.

Premature closure of the foramen ovale in-utero may lead to underdevelopment of the left-sided structure of the heart and hypoplastic left-sided heart syndrome. About 10% of patients with hypoplastic left-sided heart syndrome have an intact or nearly intact atrial septum in-utero.

Paradoxical emboli through a patent foramen ovale can cause a constellation of neurologic symptoms, such as stroke or transient ischemic attacks. Paradoxical embolization more often produces symptoms when the embolization occurs in the posterior cerebral circulation.

Migraine headaches are associated with a patent foramen ovale. [6, 7] The exact mechanism is not yet clear.

Rarely, the clinical constellation of orthodeoxia-platypnea may be seen as a result of a patent foramen ovale. [8] Orthodeoxia is desaturation with upright posture, whereas platypnea is dyspnea with upright posture. This occurs even in the absence of pulmonary hypertension and with relatively low or normal right and left atrial pressures and is sometimes seen following pneumonectomy. Transcatheter patent foramen ovale closure eliminates the right-to-left shunt and restores normal arterial oxygen saturation. [9]


Physical Examination

No physical findings clearly indicate a patent foramen ovale without an associated congenital heart defect; however, the presence of a patent foramen ovale with right-to-left shunting should be considered in an infant with generalized cyanosis.

Right-to-left atrial level shunting results in symmetric central cyanosis rather than differential cyanosis.