Patent foramen ovale: anatomy, outcomes, and closure

Calvert, Patrick A.; Rana, Bushra S.; Kydd, Anna; Shapiro, Leonard M.

doi:10.1038/nrcardio.2010.224

Cited by 157 publications

(127 citation statements)

References 115 publications

Supporting

Mentioning

114

Contrasting

Unclassified

Order By: Relevance

“…The septum secundum does not close fully and an oval-shaped opening remains, which becomes the foramen ovale. 17 Prior to birth, the fetus is dependent on the maternal circulation for oxygenation, as the immature fetal lungs do not yet participate in oxygen exchange. As such, the foramen ovale (as well as the ductus arteriosus), enables shunting of blood away from the pulmonary circulation.…”

mentioning

confidence: 99%

Patent Foramen Ovale and Stroke

Sun

Homma

2016

Circ J

View full text Add to dashboard Cite

Circulation Journal Official Journal of the Japanese Circulation Society http://www. j-circ.or.jp coalesce into a single orifice that becomes the foramen secundum. The septum secundum then forms via involution of the ventrocranial wall and overlaps with the foramen secundum. The septum secundum does not close fully and an oval-shaped opening remains, which becomes the foramen ovale. 17 Prior to birth, the fetus is dependent on the maternal circulation for oxygenation, as the immature fetal lungs do not yet participate in oxygen exchange. As such, the foramen ovale (as well as the ductus arteriosus), enables shunting of blood away from the pulmonary circulation. At birth, when the neonate's lungs begin to participate in oxygen exchange, there is a precipitous drop in the pulmonary vascular resistance and there is reversal of flow through both the foramen ovale and ductus arteriosus. 18 In approximately 75% of individuals, the foramen ovale closes within a few years while in the remaining others, it stays open permanently as a PFO. EpidemiologyThe prevalence of PFO in the healthy adult population ranges from 15% to 25% on echocardiography and 15-35% on autopsy studies. 1,2,19,20 Observational and autopsy studies have showed that the prevalence of detected PFOs is lower in older patients and that detected PFOs in older individuals tend to be larger. 1,19,20 Those studies, however, may be confounded by selection and detection bias because none of the longitudinal studies have demonstrated that individual PFOs change in size. The prevalence of PFOs is equal among men and women, though there may be race-ethnic differences. 1,19,21 he foramen ovale is an important fetal structure that closes after birth in most individuals and remains open as a patent foramen ovale (PFO) in approximately 25% of the healthy population. 1-3 In these individuals, bypass of the pulmonary circulation via shunting from the right-sided venous circulation to the left-sided arterial circulation is possible. Although most patients with PFOs are completely asymptomatic, reports from the late 1800 s by Cohnheim and Litten described cases of patients who were found to have the triad of deep venous thrombosis (DVT), PFO and systemic embolization. They hypothesized that the PFO enabled bypass of a venous thrombosis to the systemic arterial circulation, a process now termed paradoxical embolization. 4,5 Since those initial observations, additional studies have demonstrated a strong association between the presence of PFO and cryptogenic stroke in young patients. 6-11 In addition to its association with stroke, PFO has also been implicated in platypneaorthodeoxia, 12 decompression illness, 13 myocardial infarction, 14 obstructive sleep apnea, 15 and migraine headaches. 16 This review will focus on the relationship between PFO and stroke, discussing the embryology, epidemiology, association, mechanisms, diagnostic methods, associated anatomic factors and management strategies. EmbryologyThe right and left atria begin as a single chamber and separation b...

show abstract

mentioning

confidence: 99%

Patent Foramen Ovale and Stroke

Sun

Homma

2016

Circ J

View full text Add to dashboard Cite

show abstract

“…With the use of ventilation perfusion scanning, 1 study showed asymptomatic pulmonary emboli inUp to 25% of the population may have a PFO detectable on autopsy, with persistence after the birth of a connection between the right and left atria. 10,11 In patients with elevated right-sided pressures, flow through a PFO provides a mechanism of blood flow from the right heart to the left-sided circulation. In patients with a PFO, endovascular leads may pose a unique hazard, because the thrombi that develop on leads may shunt across the PFO to the systemic circulation, resulting in ischemic cerebrovascular events or other systemic thromboembolisms.…”

mentioning

confidence: 99%

Stroke or Transient Ischemic Attack in Patients With Transvenous Pacemaker or Defibrillator and Echocardiographically Detected Patent Foramen Ovale

et al. 2013

View full text Add to dashboard Cite

15% of patients within 2 weeks of device implantation without heparin prophylaxis, 8 and, at autopsy, pulmonary emboli were present in 21% of patients with CIEDs. 6 A study using intracardiac echocardiography at the time of a planned electrophysiological procedure found mobile thrombi attached to leads in 30% of patients. 9 These thrombi were rarely seen with the use of transthoracic echocardiography (TTE), reflecting their small size. Moreover, the presence of lead-related thrombi was associated with increased pulmonary artery systolic pressure, suggesting subclinical pulmonary embolic events.9 Elevated pulmonary artery pressures may in turn increase the likelihood of right-to-left shunting across a patent foramen ovale (PFO). Clinical Perspective on p 1441Background-A patent foramen ovale (PFO) may permit arterial embolization of thrombi that accumulate on the leads of cardiac implantable electronic devices in the right-sided cardiac chambers. We sought to determine whether a PFO increases the risk of stroke/transient ischemic attack (TIA) in patients with endocardial leads. Methods and Results-We retrospectively evaluated all patients who had endocardial leads implanted between January 1, 2000, and October 25, 2010, at Mayo Clinic Rochester. Echocardiography was used to establish definite PFO and non-PFO cohorts. The primary end point of stroke/TIA consistent with a cardioembolic etiology and the secondary end point of mortality during postimplantation follow-up were compared in PFO versus non-PFO patients with the use of Cox proportional hazards models. We analyzed 6075 patients (364 with PFO) followed for a mean 4.7±3.1 years. The primary end point of stroke/TIA was met in 30/364 (8.2%) PFO versus 117/5711 (2.0%) non-PFO patients (hazard ratio, 3.49; 95% confidence interval, 2.33-5.25; P<0.0001). The association of PFO with stroke/TIA remained significant after multivariable adjustment for age, sex, history of stroke/TIA, atrial fibrillation, and baseline aspirin/warfarin use (hazard ratio, 3.30; 95% confidence interval, 2.19-4.96; P<0.0001). There was no significant difference in all-cause mortality between PFO and non-PFO patients (hazard ratio, 0.91; 95% confidence interval, 0.77-1.07; P=0.25). Conclusions-In patients with endocardial leads, the presence of a PFO on routine echocardiography is associated with a substantially increased risk of embolic stroke/TIA. This finding suggests a role of screening for Up to 25% of the population may have a PFO detectable on autopsy, with persistence after the birth of a connection between the right and left atria. 10,11 In patients with elevated right-sided pressures, flow through a PFO provides a mechanism of blood flow from the right heart to the left-sided circulation. In patients with a PFO, endovascular leads may pose a unique hazard, because the thrombi that develop on leads may shunt across the PFO to the systemic circulation, resulting in ischemic cerebrovascular events or other systemic thromboembolisms. We have previously published 2 case series on device...

show abstract

“…It was also underlined an increased incidence of atrial fibrillation in the group of patients treated with closure device compared to the group in medical therapy (5.7% vs 0.7%, respectively, P <0.001). This aspect, according to some authors may have contributed, in the percutaneous treatment group, to the finding of a stroke rate higher than expected [25]. Therefore, the presentation of the results of CLOSURE I indicates that PFO closure with Starflex ® device does not significantly reduces the rate of recurrent events compared to medical therapy, at a 2 years follow-up.…”

Section: Discussionmentioning

confidence: 92%

“…Therefore, the presentation of the results of CLOSURE I indicates that PFO closure with Starflex ® device does not significantly reduces the rate of recurrent events compared to medical therapy, at a 2 years follow-up. However, several criticisms have been raised [25]. Several methodological reasons, in fact, may explain why the end points were not reached: a follow-up too short to demonstrate the benefits of PFO closure and to overcome the procedural complications; the imprecision of the inclusion criteria, stroke or cryptogenic TIA.…”

Section: Discussionmentioning

confidence: 99%