Skip to main content

Patent Foramen Ovale

Neurological Considerations

  • Chapter
Interventional Cardiology

Part of the book series: Contemporary Cardiology ((CONCARD))

  • 958 Accesses

Abstract

Patent foramen ovale (PFO) and atrial-septal aneurysm (ASA) are congenital cardiac abnormalities that are highly prevalent in the general population. Observational studies have found an association between these anomalies and several neurologic diseases, including stroke, decompression sickness from SCUBA diving, migraine, and others. In this chapter, we will discuss the diagnosis of PFO and ASA, review the data that implicate them as causes of neurologic disorders—particularly cryptogenic stroke in the young—and assess the available treatment options.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 169.00
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
Hardcover Book
USD 219.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. Hagen PT, Scholz DG, Edwards WD. Incidence and size of patent foramen ovale during the first 10 decades of life: an autopsy study of 965 normal hearts. Mayo Clin Proc 1984;59:17–20.

    PubMed  CAS  Google Scholar 

  2. Seib G. Incidence of the patent foramen ovale cordis in adult american whites and american negroes. Am J Anat 1934;55:511–525.

    Article  Google Scholar 

  3. Thompson T, Evans W. Paradoxical embolism. Q J Med 1930;23:135–152.

    Google Scholar 

  4. de Belder MA, Tourikis L, Leech G, Camm AJ. Risk of patent foramen ovale for thromboembolic events in all age groups. Am J Cardiol 1992;69:1316–1320.

    Article  PubMed  Google Scholar 

  5. Lechat P, Mas JL, Lascault G, et al. Prevalence of patent foramen ovale in patients with stroke. N Engl J Med 1988;318:1148–1152.

    Article  PubMed  CAS  Google Scholar 

  6. Hanna JP, Sun JP, Furlan AJ, et al. Patent foramen ovale and brain infarct. Echocardiographic predictors, recurrence, and prevention. Stroke 1994;25:782–786.

    PubMed  CAS  Google Scholar 

  7. Di Tullio MR, Sacco RL, Sciacca RR, et al. Patent foramen ovale and risk of ischemic stroke in a community—the northern manhattan study. Stroke 2003;34 (abstract).

    Google Scholar 

  8. Meissner I, Whisnant JP, Khandheria BK, et al. Prevalence of potential risk factors for stroke assessed by transesophageal echocardiography and carotid ultrasonography: the SPARC study. Stroke prevention: assessment of risk in a community. Mayo Clin Proc 1999;74:862–869.

    PubMed  CAS  Google Scholar 

  9. Cabanes L, Mas JL, Cohen A, et al. Atrial septal aneurysm and patent foramen ovale as risk factors for cryptogenic stroke in patients less than 55 years of age. Astudy using transesophageal echocardiography. Stroke 1993;24:1865–1873.

    PubMed  CAS  Google Scholar 

  10. Schneider B, Harath P, Vogel P, Meinertz T. Improved morphologic characterization of atrial septal aneurysm by tranesophageal echocardiography: relation to cerebrovascular events. J Am Coll Cardiol 1990;16: 1000–1009.

    PubMed  CAS  Google Scholar 

  11. Pearson AC, Nagelhout D, Castello R, et al. Atrial septal aneurysm and stroke: a transesophageal echocardiographic study. J Am Coll Cardiol 1991;18:1223–1229.

    PubMed  CAS  Google Scholar 

  12. Silver MD, Dorsey JS. Aneurysms of the septum primum in adults. Arch Pathol Lab Med 1978;102: 62–65.

    PubMed  CAS  Google Scholar 

  13. Agmon Y, Khandheria BK, Meissner I, et al. Frequency of atrial septal aneurysms in patients with cerebral ischemic events. Circulation 1999;99:1942–1944.

    PubMed  CAS  Google Scholar 

  14. Kerut EK, Norfleet WT, Plotnick GD, Giles TD. Patent foramen ovale: a review of associated conditions and the impact of physiological size. J Am Coll Cardiol 2001;38:613–623.

    Article  PubMed  CAS  Google Scholar 

  15. Meier B, Lock JE. Contemporary management of patent foramen ovale. Circulation 2003;107:5–9.

    Article  PubMed  Google Scholar 

  16. Schuchlenz HW, Weihs W, Beitzke A, et al. Transesophageal echocardiography for quantifying size of patent foramen ovale in patients with cryptogenic cerebrovascular events. Stroke 2002;33:293–296.

    Article  PubMed  Google Scholar 

  17. Pfleger S, Konstantin Haase K, et al. Haemodynamic quantification of different provocation manoeuvres by simultaneous measurement of right and left atrial pressure: implications for the echocardiographic detection of persistent foramen ovale. Eur J Echocardiogr 2001;2:88–93.

    Article  PubMed  CAS  Google Scholar 

  18. Lamy C, Giannesini C, Zuber M, et al. Clinical and imaging findings in cryptogenic stroke patients with and without patent foramen ovale: The PFO-ASA study. Stroke. 2002;33:706–711.

    Article  PubMed  CAS  Google Scholar 

  19. Cabanes L, Coste J, Derumeaux G, et al. Interobserver and intraobserver variability in detection of patent foramen ovale and atrial septal aneurysm with transesophageal echocardiography. J Am Soc Echocardiogr 2002; 15:441–446.

    Article  PubMed  Google Scholar 

  20. Serena J, Segura T, Perez-Ayuso MJ, et al. The need to quantify right-to-left shunt in acute ischemic stroke: a case-control study. Stroke 1998;29:1322–1328.

    PubMed  CAS  Google Scholar 

  21. Blersch WK, Draganski BM, Holmer SR, et al. Transcranial duplex sonography in the detection of patent foramen ovale. Radiology 2002;225:693–699.

    Article  PubMed  Google Scholar 

  22. Cohnheim J. Thrombose und embolie: vorlesung uber allgemeine pathologie. Berlin, 1877:134.

    Google Scholar 

  23. Rice MJ, McDonald RW, Reller MD. Fetal atrial septal aneurysm: a cause of fetal atrial arrhythmias. J Am Coll Cardiol 1988;12:1292–1297.

    Article  PubMed  CAS  Google Scholar 

  24. Cabanes L, Mas JL, Cohen A, et al. Atrial septal aneurysm and patent foramen ovale as risk factors for cryptogenic stroke in patients less than 55 years of age. A study using transesophageal echocardiography. Stroke 1993;24:1865–1873.

    PubMed  CAS  Google Scholar 

  25. Mugge A, Daniel WG, Angermann C, et al. Atrial septal aneurysm in adult patients. Circulation 1995; 91:2785–2792.

    PubMed  CAS  Google Scholar 

  26. Berthet K, Lavergne T, Cohen A, et al. Significant association of atrial vulnerability with atrial septal abnormalities in young patients with ischemic stroke of unknown cause. Stroke 2000;31:398.

    PubMed  CAS  Google Scholar 

  27. Somody E, Albucher JF, Casteignau G, et al. Anomalies of the interatrial septum and latent atrial vulnerability in unexplained ischemic stroke in young adults. Arch Mal Coeur Vaisseaux 2000;93:1495–1500.

    CAS  Google Scholar 

  28. Lechat P, Mas JL, Lascault G, et al. Prevalence of patent foramen ovale in patients with stroke. N Engl J Med 1988;318:1148–1152.

    Article  PubMed  CAS  Google Scholar 

  29. Sacco RL, Ellenberg JH, Mohr JP, et al. Infarcts of undetermined cause: the NINCDS stroke data bank. Ann Neurol 1989;25:382–390.

    Article  PubMed  CAS  Google Scholar 

  30. Kittner SJ, Stern BJ, Wozniak M, et al. Cerebral infarction in young adults: the Baltimore-Washington cooperative young stroke study. Neurology 1998;50:890–894.

    PubMed  CAS  Google Scholar 

  31. Adams HP Jr, Kappelle LJ, Biller J, et al. Ischemic stroke in young adults. Experience in 329 patients enrolled in the Iowa Registry of stroke in young adults. Arch Neurol 1995;52:491–495.

    PubMed  Google Scholar 

  32. Webster MW, Chancellor AM, Smith HJ, et al. Patent foramen ovale in young stroke patients. Lancet 1988;2:11–12.

    Article  PubMed  CAS  Google Scholar 

  33. Di Tullio MR, Sacco RL, Gopal A, et al. Patent foramen ovale as a risk factor for cryptogenic stroke. Ann Intern Med 1992;117:461–465.

    PubMed  Google Scholar 

  34. Jones EF, Calafiore P, Donnan GA, Tonkin AM. Evidence that patent foramen ovale is not a risk factor for cerebral ischemia in the elderly. Am J Cardiol 1994;74:596–599.

    Article  PubMed  CAS  Google Scholar 

  35. Petty GW, Khandheria BK, Chu CP, et al. Patent foramen ovale in patients with cerebral infarction. A transesophageal echocardiographic study. Arch Neurol 1997;54:819–822.

    PubMed  CAS  Google Scholar 

  36. Steiner MM, Di Tullio MR, Rundek T, et al. Patent foramen ovale size and embolic brain imaging findings among patients with ischemic stroke. Stroke 1998;29:944–948.

    PubMed  CAS  Google Scholar 

  37. Cujec B, Mainra R, Johnson DH. Prevention of recurrent cerebral ischemic events in patients with patent foramen ovale and cryptogenic strokes or transient ischemic attacks. Can J Cardiol 1999;15:57–64.

    PubMed  CAS  Google Scholar 

  38. Homma S, Di Tullio MR, Sacco RL, et al. Characteristics of patent foramen ovale associated with cryptogenic stroke. A biplane transesophageal echocardiographic study. Stroke 1994;25:582–586.

    PubMed  CAS  Google Scholar 

  39. Overell JR, Bone I, Lees KR. Interatrial septal abnormalities and stroke: a meta-analysis of case-control studies. Neurology 2000;55:1172–1179.

    PubMed  CAS  Google Scholar 

  40. Van Camp G, Schulze D, Cosyns B, Vandenbossche JL. Relation between patent foramen ovale and unexplained stroke. Am J Cardiol 1993;71:596–598.

    Article  PubMed  Google Scholar 

  41. Hausmann D, Mugge A, Daniel WG. Identification of patent foramen ovale pemitting paradoxic embolism. J Am Coll Cardiol 1995;26:1030–1038.

    Article  PubMed  CAS  Google Scholar 

  42. Stone DA, Godard J, Corretti MC, et al. Patent foramen ovale: association between the degree of shunt by contrast transesophageal echocardiography and the risk of future ischemic neurologic events. Am Heart J 1996; 131:158–161.

    Article  PubMed  CAS  Google Scholar 

  43. De Castro S, Cartoni D, Fiorelli M, et al. Morphological and functional characteristics of patent foramen ovale and their embolic implications. Stroke 2000;31:2407–2413.

    PubMed  Google Scholar 

  44. Mattioli AV, Aquilina M, Oldani A, et al. Atrial septal aneurysm as a cardioembolic source in adult patients with stroke and normal carotid arteries. A multicentre study. Eur Heart J 2001;22:261–268.

    Article  PubMed  CAS  Google Scholar 

  45. Lucas C, Goullard L, Marchau M Jr, et al. Higher prevalence of atrial septal aneurysms in patients with ischemic stroke of unknown cause. Acta Neurol Scand 1994;89:210–213.

    Article  PubMed  CAS  Google Scholar 

  46. Mas JL, Arquizan C, Lamy C, et al. Recurrent cerebrovascular events associated with patent foramen ovale, atrial septal aneurysm, or both. N Engl J Med 2001;345:1740–1746.

    Article  PubMed  CAS  Google Scholar 

  47. Homma S, Sacco RL, Di Tullio MR, et al. Effect of medical treatment in stroke patients with patent foramen ovale: patent foramen ovale in cryptogenic stroke study. Circulation 2002;105:2625–2631.

    Article  PubMed  Google Scholar 

  48. Homma S, Sacco RL, Di Tullio MR, Sciacca RR, PICSS Investigators. Relationship of atrial septal anuerysm with patent foramen ovale: insights from pfo in cryptogenic stroke study (PICSS). Circulation 2001; 104(Suppl):II-670 (abstract).

    Google Scholar 

  49. Homma S, Sacco RL, Di Tullio MR, et al. Atrial anatomy in non-cardioembolic stroke patients: effect of medical therapy. J Am Coll Cardiol 2003;42:1066–1072.

    Article  PubMed  Google Scholar 

  50. Hanna JP, Sun JP, Furlan AJ, et al. Patent foramen ovale and brain infarct. Echocardiographic predictors, recurrence, and prevention. Stroke 1994;25:782–786.

    PubMed  CAS  Google Scholar 

  51. Mas JL, Zuber M. Recurrent cerebrovascular events in patients with patent foramen ovale, atrial septal aneurysm, or both and cryptogenic stroke or transient ischemic attack. French study group on patent foramen ovale and atrial septal aneurysm. Am Heart J 1995;130:1083–1088.

    Article  PubMed  CAS  Google Scholar 

  52. Bogousslavsky J, Garazi S, Jeanrenaud X, et al. Stroke recurrence in patients with patent foramen ovale: the Lausanne study. Lausanne stroke with paradoxal embolism study group. Neurology 1996;46:1301–1305.

    PubMed  CAS  Google Scholar 

  53. De Castro S, Cartoni D, Fiorelli M, et al. Patent foramen ovale and its embolic implications. Am J Cardiol 2000;86:51G–52G.

    Article  PubMed  Google Scholar 

  54. Dearani JA, Baran US, Danielson GK, et al. Surgical patent foramen ovale closure for prevention of paradoxical embolism-related cerebrovascular ischemic events. Circulation 1999;100(Suppl II):II171–II175.

    PubMed  CAS  Google Scholar 

  55. Homma S, Di Tullio MR, Sacco RL, et al. Surgical closure of patent foramen ovale in cryptogenic stroke patients. Stroke 1997;28:2376–2381.

    PubMed  CAS  Google Scholar 

  56. Windecker S, Wahl A, Chatterjee T. Percutaneous closure of patent formaen ovale in patients with paradoxical embolism: long-term risk of recurrent thromboembolic events. Circulation 2000;101:893–898.

    PubMed  CAS  Google Scholar 

  57. Hung J, Landzberg MJ, Jenkins KJ, et al. Closure of patent foramen ovale for paradoxical emboli: intermediate-term risk of recurrent neurological events following transcatheter device placement. J Am Coll Cardiol 2000;35:1311–1316.

    Article  PubMed  CAS  Google Scholar 

  58. Martin F, Sanchez PL, Doherty E, et al. Percutaneous transcatheter closure of patent foramen ovale in patients with paradoxical embolism. Circulation 2002;106:1121–1126.

    Article  PubMed  Google Scholar 

  59. Orgera MA, O’Malley PG, Taylor AJ. Secondary prevention of cerebral ischemia in patent foramen ovale: systematic review and meta-analysis. South Med J 2001;94:699–703.

    PubMed  CAS  Google Scholar 

  60. Hyers TM, Agnelli G, Hull RD, et al. Antithrombotic therapy for venous thromboembolic disease. Chest 1998;114:561S–578S.

    PubMed  CAS  Google Scholar 

  61. Bogousslavsky J, Garazi S, Jeanrenaud X, Aebischer N, Van Melle G. Stroke recurrence in patients with patent foramen ovale: the Lausanne study. Neurology 1996;46:1301–1305.

    PubMed  CAS  Google Scholar 

  62. Lethen H, Flachskampf FA, Schneider R, et al. Frequency of deep vein thrombosis in patients with patent foramen ovale and ischemic stroke or transient ischemic attack. Am J Cardiol 1997;80:1066–1069.

    Article  PubMed  CAS  Google Scholar 

  63. Stollberger C, Slany J, Schuster I, et al. The prevalence of deep venous thrombosis in patients with suspected paradoxical embolism. Ann Intern Med 1993;119:461–465.

    PubMed  CAS  Google Scholar 

  64. Devuyst G, Bogousslavsky J, Ruchat P, et al. Prognosis after stroke followed by surgical closure of patent foramen ovale: a prospective follow-up study with brain MRI and simultaneous transesophageal and transcranial Doppler ultrasound. Neurology 1996;47:1162–1166.

    PubMed  CAS  Google Scholar 

  65. Bridges ND, Hellenbrand W, Latson L, et al. Transcatheter closure of patent foramen ovale after presumed paradoxical embolism. Circulation 1992;86:1902–1908.

    PubMed  CAS  Google Scholar 

  66. Ende DJ, Chopra PS, Rao PS. Transcatheter closure of atrial septal defect or patent foramen ovale with the buttoned device for prevention of recurrence of paradoxic embolism. Am J Cardiol 1996;78:233–236.

    PubMed  CAS  Google Scholar 

  67. Sievert H, Babic UU, Hausdorf G, et al. Transcatheter closure of atrial septal defect and patent foramen ovale with ASDOS device (a multi-institutional European trial). Am J Cardiol 1998;82:1405–1413.

    Article  PubMed  CAS  Google Scholar 

  68. Wahl A, Meier B, Haxel B, et al. Prognosis after percutaneous closure of patent foramen ovale for paradoxical embolism. Neurology 2001;57:1330–1332.

    PubMed  CAS  Google Scholar 

  69. Braun MU, Fassbender D, Schoen SP, et al. Transcatheter closure of patent foramen ovale in patients with cerebral ischemia. J Am Coll Cardiol 2002;39:2019–2025.

    Article  PubMed  Google Scholar 

  70. Onorato E, Melzi G, Casilli F, et al. Patent foramen ovale with paradoxical embolism: mid-term results of transcatheter closure in 256 patients. J Intervent Cardiol 2003;16:43–50.

    Article  PubMed  Google Scholar 

  71. Berdat PA, Chatterjee T, Pfammatter J-P, et al. Surgical management of complications after transcatheter closure of an atrial septal defect or patent foramen ovale. J Thorac Cardiovasc Surg 2000;120:1034–1039.

    Article  PubMed  CAS  Google Scholar 

  72. USA Food and Drug Administration. HDE #H990011. Washington, DC: FDA, 2000.

    Google Scholar 

  73. Albers GW, Caplan LR, Easton JD, et al. Transient ischemic attack—proposal for a new definition. N Engl J Med 2002;347:1713–1716.

    Article  PubMed  Google Scholar 

  74. Pritz MB. Timing of carotid endarterectomy after stroke. Stroke 1997;28:2563–2567.

    PubMed  CAS  Google Scholar 

  75. Del Sette M, Angeli S, Leandri M, et al. Migraine with aura and right-to-left shunt on transcranial Doppler: a case-control study. Cerebrovasc Dis 1998;8:327–330.

    Article  PubMed  Google Scholar 

  76. Anzola GP, Magoni M, Guindani M, et al. Potential source of cerebral embolism in migraine with aura: a transcranial Doppler study. Neurology 1999;52:1622–1625.

    PubMed  CAS  Google Scholar 

  77. Sztajzel R, Genoud D, Roth S, et al. Patent foramen ovale, a possible cause of symptomatic migraine: a study of 74 patients with acute ischemic stroke. Cerebrovasc Dis 2003;13:102–106.

    Article  Google Scholar 

  78. Milhaud D, Bogousslavsky J, van Melle G, Liot P. Ischemic stroke and active migraine. Neurology 2001;57:1805–1811.

    PubMed  CAS  Google Scholar 

  79. Morandi E, Anzola GP, Angeli S, et al. Transcatheter closure of patent foramen ovale: a new migraine treatment? J Intervent Cardiol 2003;16:39–42.

    Article  PubMed  Google Scholar 

  80. Wilmshurst PT, Nightingale S, Walsh KP, Morrison WL. Effect on migraine of closure of cardiac right-to-left shunts to prevent recurrence of decompression illness or stroke or for haemodynamic reasons. Lancet 2000; 356: 1648–1651.

    Article  PubMed  CAS  Google Scholar 

  81. Moon RE, Camporesi EM, Kisslo JA. Patent foramen ovale and decompression sickness in divers. Lancet 1989;1:513–514.

    Article  PubMed  CAS  Google Scholar 

  82. Wilmshurst PT, Byrne JC, Webb-Peploe MM. Relation between interatrial shunts and decompression sickness in divers. Lancet 1989;2:1302–1306.

    Article  PubMed  CAS  Google Scholar 

  83. Knauth M, Ries S, Pohimann S, et al. Cohort study of multiple brain lesions in sport divers: role of a patent foramen ovale. Br Med J 1997;314:701.

    CAS  Google Scholar 

  84. Schwerzmann M, Seiler C, Lipp E, et al. Relation between directly detected patent foramen ovale and ischemic brain lesions in sport divers. Ann Intern Med 2001;134:21–24.

    PubMed  CAS  Google Scholar 

  85. Cartoni D, DeCastro S, Valente G, et al. Identification of scuba divers with patent foramen ovale at risk for decompression sickness. J Am Coll Cardiol 1998;31:515.

    Article  Google Scholar 

  86. Cantais E, Louge P, Suppini A, et al. Right-to-left shunt and risk of decompression illness with cochleovestibular and cerebral symptoms in divers: case control study in 101 consecutive dive accidents. Crit Care Med 2003;31:84–88.

    Article  PubMed  Google Scholar 

  87. Bendrick GA, Ainscough MJ, Pilmanis AA, Bisson RU. Prevalence of decompression sickness among U-2 pilots. Aviat Space Environ Med 1996;67:199–206.

    PubMed  CAS  Google Scholar 

  88. Gallagher DL, Hopkins EW, Clark JB, Hawley TA. US Navy experience with type II decompression sickness and the association with patent foramen ovale. Aviat Space Environ Med 1996;67:712.

    Google Scholar 

  89. Klotzsch C, Sliwka U, Berlit P, Noth J. An increased frequency of patent foramen ovale in patients with transient global amnesia. Analysis of 53 consecutive patients. Arch Neurol 1996;53:504–508.

    PubMed  CAS  Google Scholar 

  90. Akkawi NM, Agosti C, Anzola GP, et al. Transient global amnesia: a clinical and sonographic study. Eur Neurol 2003;49:67–71.

    Article  CAS  Google Scholar 

  91. Aebi C, Kaufmann F, Schaad UB. Brain abscess in childhood—long-term experiences. Eur J Pediatr 1991;150:282–286.

    Article  PubMed  CAS  Google Scholar 

  92. Kawamata T, Takeshita M, Ishizuka N, Hori T. Patent foramen ovale as a possible risk factor for cryptogenic brain abscess: report of two cases. Neurosurgery 2001;49:204–206; discussion 206–207.

    Article  PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Editor information

Editors and Affiliations

Rights and permissions

Reprints and permissions

Copyright information

© 2005 Humana Press Inc., Totowa, NJ

About this chapter

Cite this chapter

Messé, S.R., Kasner, S.E., Furlan, A. (2005). Patent Foramen Ovale. In: Herrmann, H.C. (eds) Interventional Cardiology. Contemporary Cardiology. Humana Press. https://doi.org/10.1385/1-59259-898-6:115

Download citation

  • DOI: https://doi.org/10.1385/1-59259-898-6:115

  • Publisher Name: Humana Press

  • Print ISBN: 978-1-58829-367-1

  • Online ISBN: 978-1-59259-898-4

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics