patent foramen ovale (PFO)
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Etiology
- occurs if the septum primum fails to fuse with the foramen ovale after birth
- occurs frequently in association with an atrial septal aneurysm
Epidemiology
- occurs in 25-30% of population[1]
Pathology
- PFO associated with an increased risk of embolic stroke[3][4]
- PFO found in 40-63% of cryptogenic ischemic strokes in patients < 55-60 years of age & 39% in patients > 55
- PFOis likely responsible for ~5% of all ischemic strokes & 10% of those occurring in young & middle-aged adults[17]
- atrial septal aneurysm increases likelihood of embolism through PFO
- possible mechanisms of embolic stroke
- paradoxical embolism from the venous circulation
- thrombosis with atrial septal aneurysm
- atrial arrhythmias
Clinical manifestations
- most patients are asymptomatic
Diagnostic procedures
- often discovered incidentally on transthoracic echocardiography
- transthoracic echocardiography bubble study (diagnostic)
- agitated saline is injected into a peripheral intravenous catheter to demonstrate right-to-left intracardiac shunt often enhanced by the Valsalva maneuver
- electrocardiogram
Radiology
- chest X-ray
- normal with small PDA
- with large PDA:
- cardiomegaly
- increased pulmonary vascular markings
- calcification of PDA (occasional)
- with pulmonary hypertension
- prominent central pulmonary arteries
- reduced peripheral pulmomary vascularity
Complications
- embolic stroke (see pathology)
- recurrent strokes are uncommon & usually unrelated to the patent foramen ovale[5]
- preoperatively diagnosed patent foramen ovale increases risk for perioperative stroke (3.2% vs 0.5% noncardiac surgery)[16]
- evidence in support of causal link with migraines is insufficient
- platypnea-orthodeoxia
- may be associated with pneumonectomy[1]
- endocarditis
- heart failure (with large PDA)
Management
- no treatment or follow-up needed for asymptomatic patients[1]
- surgical closure
- indications:
- ACP (MKSAP19) endorses patent foramen ovale device closure after 1st cryptogenic stroke (reversal of prior recommendations)[1]
- PFO occlusion device FDA approved 10/16
- formerly recurrent cryptogenic stroke despite medical therapy
- may be of benefit, but the number needed to treat is ~50[8]; 56[12]
- clinical trials do not support surgical closure to reduce risk of recurrent stroke or migraine[1]
- PFO closure associated with lower rate of recurrent ischemic strokes than medical therapy[14]
- younger patients < 60 years with larger shunts most likely to benefit[18]
- PFO associated atrial septal aneurysm or large interatrial shunt may benefit from closure[14]
- endovascular device closure of patent foramen ovale reduces stroke risk for patients with prior cryptogenic stroke (RR=0.03 in CLOSE trial - 0.23 in REDUCE trial)[13]
- PFO closure associated with increased risk of atrial fibrillation (4% vs 1%) & device complications[14]
- cryptogenic stroke (3.6% vs 6.3%)[15]
- platypnea-orthodeoxia[1]
- ACP (MKSAP19) endorses patent foramen ovale device closure after 1st cryptogenic stroke (reversal of prior recommendations)[1]
- contraindications:
- asymptomatic patients without history of stroke[1]
- indications:
- anti-platelet therapy recommended for cryptogenic stroke[1]
- not recommended in the absence of cryptogenic stroke[1]
- anticoagulation rcommended for recurrent stroke or initial stroke in a patient with a hypercoagulable state[1][18]
- no benbefit of surgical closure if hypercoagulable state[18]
Notes
- Reference[2] reports risk of recurrent stroke associated with both atrial septal aneurysm & patent foramen ovale, but not with either alone. Reference[3] found no such association.
More general terms
Additional terms
- atrial septal aneurysm
- foramen ovale
- patent foramen ovale (PFO) occlusion device (Amplatzer)
- septum primum
References
- ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 Medical Knowledge Self Assessment Program (MKSAP) 11, 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2009, 2012, 2015, 2018, 2022
- ↑ 2.0 2.1 Journal Watch 22(2):11, 2002 Mas JL et al Recurrent cerebrovascular events associated with patent foramen ovale, atrial septal aneurysm, or both. N Engl J Med 345:1740, 2001 PMID: https://www.ncbi.nlm.nih.gov/pubmed/11742048
- ↑ 3.0 3.1 3.2 Journal Watch 22(16):126-27, 2002 Homma S et al, Effect of medical treatment in stroke patients with patent foramen ovale: patent foramen ovale in Cryptogenic Stroke study Circulation 105:2565, 2002 PMID: https://www.ncbi.nlm.nih.gov/pubmed/12045168
Halperin JL & Fuster V, Patent foramen ovale and recurrent stroke: another paradoxical twist. Circulation 105:2580, 2002 PMID: https://www.ncbi.nlm.nih.gov/pubmed/12045158 - ↑ 4.0 4.1 Handke M et al, Patient foramen ovale and cryptogenic stroke in older patients. N Engl J Med 2007, 357:2262 PMID: https://www.ncbi.nlm.nih.gov/pubmed/18046029
- ↑ 5.0 5.1 Journal Watch, Massachusetts Medical Society, March 16, 2012 Furlan AJ et al. Closure or medical therapy for cryptogenic stroke with patent foramen ovale. N Engl J Med 2012 Mar 15; 366:991. PMID: https://www.ncbi.nlm.nih.gov/pubmed/22417252
- ↑ A.D.A.M. Medical Encyclopedia Patent foramen ovale http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002102/
- ↑ Shan SN eMedicine (Medscape): Patent foramen ovale http://emedicine.medscape.com/article/156863-overview
- ↑ 8.0 8.1 Meier B et al. for the PC Trial investigators. Percutaneous closure of patent foramen ovale in cryptogenic embolism. N Engl J Med 2013 Mar 21; 368:1083 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/23514285 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMoa1211716
Carroll JD et al. for the RESPECT investigators. Closure of patent foramen ovale versus medical therapy after cryptogenic stroke. N Engl J Med 2013 Mar 21; 368:1092 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/23514286 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMoa1301440 - ↑ Meier B, Lock JE. Contemporary management of patent foramen ovale. Circulation. 2003 Jan 7;107(1):5-9. PMID: https://www.ncbi.nlm.nih.gov/pubmed/12515733
- ↑ Chen L, Luo S, Yan L, Zhao W A systematic review of closure versus medical therapy for preventing recurrent stroke in patients with patent foramen ovale and cryptogenic stroke or transient ischemic attack. J Neurol Sci. 2014 Feb 15;337(1-2):3-7 PMID: https://www.ncbi.nlm.nih.gov/pubmed/24300230
- ↑ DeSimone CV, Friedman PA, Noheria A et al Stroke or transient ischemic attack in patients with transvenous pacemaker or defibrillator and echocardiographically detected patent foramen ovale. Circulation. 2013 Sep 24;128(13):1433-41. PMID: https://www.ncbi.nlm.nih.gov/pubmed/23946264
- ↑ 12.0 12.1 Messe SR et al. Practice advisory: Recurrent stroke with patent foramen ovale (update of practice parameter). Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology 2016 Jul 27 PMID: https://www.ncbi.nlm.nih.gov/pubmed/27466464
- ↑ 13.0 13.1 Phend C PFO Closure for Cryptogenic Stroke Prevents Recurrences - First overall stroke reduction with closure reported in two trials. MedPage Today. May 16, 2017 https://www.medpagetoday.com/Cardiology/Strokes/65348
- ↑ 14.0 14.1 14.2 14.3 Mas JL et al Patent Foramen Ovale Closure or Anticoagulation vs. Antiplatelets after Stroke. N Engl J Med 2017; 377:1011-1021. September 14, 2017 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28902593 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMoa1705915
Saver JL et al Long-Term Outcomes of Patent Foramen Ovale Closure or Medical Therapy after Stroke. N Engl J Med 2017; 377:1022-1032. September 14, 2017 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28902590 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMoa1610057
Sondergaard L et al Patent Foramen Ovale Closure or Antiplatelet Therapy for Cryptogenic Stroke. N Engl J Med 2017; 377:1033-1042. September 14, 2017 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28902580 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMoa1707404
Farb A et al Patent Foramen Ovale after Cryptogenic Stroke - Assessing the Evidence for Closure. N Engl J Med 2017; 377:1006-1009. September 14, 2017 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28902595 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMp1700218
Ropper AH. Tipping point for patent foramen ovale closure. N Engl J Med 2017 Sep 14; 377:1093 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28902592 <Internet> http://www.nejm.org/doi/10.1056/NEJMe1709637 - ↑ 15.0 15.1 De Rosa S, Sievert H, Sabatino J et al Percutaneous Closure Versus Medical Treatment in Stroke Patients With Patent Foramen Ovale: A Systematic Review and Meta-analysis. Ann Intern Med. 2018. Jan 9. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/29310133 <Internet> http://annals.org/aim/article-abstract/2668217/percutaneous-closure-versus-medical-treatment-stroke-patients-patent-foramen-ovale
Shah R, Nayyar M, Jovin IS Device Closure Versus Medical Therapy Alone for Patent Foramen Ovale in Patients With Cryptogenic Stroke: A Systematic Review and Meta-analysis. Ann Intern Med. 2018. Jan 9. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/29310136 <Internet> http://annals.org/aim/article-abstract/2668216/device-closure-versus-medical-therapy-alone-patent-foramen-ovale-patients - ↑ 16.0 16.1 Ng PY, Ng AKy, MSubramaniam B et al Association of Preoperatively Diagnosed Patent Foramen Ovale With Perioperative Ischemic Stroke. JAMA. 2018;319(5):452-462 PMID: https://www.ncbi.nlm.nih.gov/pubmed/29411032 https://jamanetwork.com/journals/jama/fullarticle/2671466
Kasner SE, Messe SR Is Patent Foramen Ovale a Risk Factor for Perioperative Stroke? JAMA. 2018;319(5):446-447. PMID: https://www.ncbi.nlm.nih.gov/pubmed/29411017 https://jamanetwork.com/journals/jama/article-abstract/2671449 - ↑ 17.0 17.1 Elgendy AV, Saver JL, Amin Z et al Proposal for Updated Nomenclature and Classification of Potential Causative Mechanism in Patent Foramen Ovale-Associated Stroke. JAMA Neurol. Published online April 13, 2020 PMID: https://www.ncbi.nlm.nih.gov/pubmed/32282016 https://jamanetwork.com/journals/jamaneurology/fullarticle/2763602
- ↑ 18.0 18.1 18.2 18.3 Messe SR et al. Practice advisory update summary: Patent foramen ovale and secondary stroke prevention: Report of the Guideline Subcommittee of the American Academy of Neurology. Neurology 2020 May 19; 94:876. PMID: https://www.ncbi.nlm.nih.gov/pubmed/32350058 https://n.neurology.org/content/94/20/876