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Patent Foramen Ovale (PFO)

Patent Foramen Ovale

Patent Foramen Ovale (PFO) is a remnant of fetal circulation, presenting as a persistent connection between the left and right atria. Affecting approximately 25–30% of the population, it often has no symptoms but may be associated with certain clinical conditions.

Associated Defects:

  • Atrial Septal Aneurysms (ASA)
  • Chiari Network
  • Eustachian valve
  • Atrial Septal Defect
  • Ebstein Anomaly

Clinical Manifestations:

  • Cryptogenic Stroke: Stroke without a clear source, not aligning with small vessel disease patterns (20-40% of cryptogenic strokes may involve PFO).
  • Migraine/Vascular Headache: Mixed evidence regarding its association with PFO, with no significant benefit noted from PFO closure in trials.
  • Decompression Sickness: Formation of gas bubbles in blood, primarily in divers, potentially leading to systemic embolization with PFO.
  • Platypnea-Orthodeoxia Syndrome: Dyspnea and desaturation in the upright position, which improves when supine, often linked to PFO.

Diagnosis:

  • Transthoracic Echocardiography (TTE): Basic screening tool with 63–100% sensitivity using a bubble study.
  • Transesophageal Echocardiography (TEE): More definitive, providing direct visualization with higher sensitivity, particularly effective with bubble studies for shunt localization.

Management: Based on clinical findings, incidental PFOs may not require closure. For specific conditions:

  • Platypnea-Orthodeoxia Syndrome: Consider closure.
  • Cryptogenic Stroke: Evaluate PFO-associated stroke risk using tools like the RoPE score, which assesses likelihood of PFO-related stroke and classifies closure recommendations using the PASCAL score.

Risk of Paradoxical Embolism (RoPE Score): Factors such as no history of hypertension, diabetes, stroke, smoking, and age contribute points toward estimating stroke risk likelihood and whether to consider PFO closure.

Produced by: Dr. Rawan Amir
Edited and Reviewed by: Dr. Richard A. Ferraro, Dr. Ahmed H. Ghoneem, Dr. Teodora Donisan, Dr. Amit Goyal

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