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Manifestations of open foramen ovale in adults

Manifestations of open foramen ovale in adults



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I read that foramen ovale opens in 30% of adults. I do not know how much of these openings can then close again. Probably, none. It is not pathogenic if no symptoms.

It allows blood to enter from right atrium to left atrium (fetal), but from left atrium to right atrium in adults. Assume that 50% of blood is doing so in adults. This means that 50% of blood is not oxygenated. Heart has to pump stronger to get some level of oxygenated blood as before.

Some thoughts about manifestations of open foramen ovale

  • hypertension
  • ischemic hypoxia
  • Clubbing
  • possible organ failures
  • higher risk for infections, SIRS and sepsis

Therefore, I think open foramen ovale can be a risk factor for myocardial infarction.

What are the manifestations of an open foramen ovale in adults?


A fully patent foramen ovale (pfo) is rare however a partial or small pfo is present in about 30% of the population.

Now the manifestations you described are partially correct. A pfo causes a left to right shunt in the adult whilst a right to left shunt in the fetus. In the fetus this is normal. In the adult, it is left to right because the left atrium is at higher pressure than the right. Due to this some of your manifestations are the wrong way round but still correct.

For example you mentioned hypertension, but presumably you meant systemic hypertension. It is more common at least in the early stages to get pulmonary hypertension. The pressures in the left atrium cause the pressures in the right atrium to increase when there is shunting. This is frequently seen when pressures in the left are increased due to factors like systemic hypertension. Coronary artery disease can also worsen the shunt and increase pressures in the right atrium and pulmonary pressures because the left ventricle can be stiffer.

Despite all this the more common presentation of a clinically significant pfo is right heart failure. Volume overloaded,the right heart dilates and fails. This will cause the usual presentation of right heart failure i.e. peripheral oedema, ascites and hepatomegaly.

Of course increased pulmonary pressures also causes strain to the right heart and can also cause right heart failure.

They then may go on to develop congestive cardiac failure and the exertional dyspnoea that comes with it. The inadequacy of the right heart can lead to excess strain to the left heart through a number of mechanisms that leads to it also failing. Dilation of the right heart can also lead to atrial fibrillation which in turn leads to stroke all being other possible presentations.

Cyanosis usually doesn't occur at least early in the disease as there isn't a shift from right to left (unoxygenated to oxygenated) but the other way round.

The severity of the pfo will lead to the severity of the clinical manifestation and how early it is picked up. Most people have routine checks of their heart (the murmur is usually pretty loud) so it is frequently corrected before any clinical disease manifests. In patients with small pfos they may never notice unless they become hypertensive or put strain on their heart during pregnancy. Yes they have a slight disadvantage as they lose some oxygenated blood but not anything noticeable.

If anything is unclear or you have more questions, please ask.


Foramen ovale (heart)

In the fetal heart, the foramen ovale ( / f ə ˈ r eɪ m ən oʊ ˈ v æ l i , - m ɛ n -, - ˈ v ɑː -, - ˈ v eɪ -/ [1] [2] [3] ), also foramen Botalli, or the ostium secundum of Born, allows blood to enter the left atrium from the right atrium. It is one of two fetal cardiac shunts, the other being the ductus arteriosus (which allows blood that still escapes to the right ventricle to bypass the pulmonary circulation). Another similar adaptation in the fetus is the ductus venosus. In most individuals, the foramen ovale closes at birth. It later forms the fossa ovalis.


Patent Foramen Ovale Closure: State of the Art

Patent foramen ovale (PFO) is a common abnormality affecting between 20% and 34% of the adult population. For most people, it is a benign finding however, in some people, the PFO can open widely to enable paradoxical embolus to transit from the venous to arterial circulation, which is associated with stroke and systemic embolisation. Percutaneous closure of the PFO in patients with cryptogenic stroke has been undertaken for a number of years, and a number of purpose-specific septal occluders have been marketed. Recent randomised control trials have demonstrated that closure of PFO in patients with cryptogenic stroke is associated with reduced rates of recurrent stroke. After a brief overview of the anatomy of a PFO, this article considers the evidence for PFO closure in cryptogenic stroke. The article also addresses other potential indications for closure, including systemic arterial embolisation, decompression sickness, platypnoea-orthodeoxia syndrome and migraine with aura. The article lays out the pre-procedural investigations and preparation for the procedure. Finally, the article gives an overview of the procedure itself, including discussion of closure devices.

Keywords: Stroke cryptogenic stroke decompression illness migraine patent foramen ovale patent foramen ovale closure platypnoea–orthodeoxia syndrome.


Manifestations of open foramen ovale in adults - Biology

Des études épidémiologiques récentes suggèrent un lien bidirectionnel entre foramen ovale perméable (FOP) et migraine avec aura (MA) avec un risque relatif de 2 d’avoir un FOP en cas de MA et d’avoir une MA en cas de FOP. Il n’y a pas de preuve d’un lien entre FOP et migraine sans aura (MSA). Le lien entre FOP et MA n’est pas systématique et ne concerne qu’une minorité de FOP, essentiellement les plus larges, et une minorité de migraines avec aura. Bien qu’une co-morbidité ne soit pas exclue, il se peut que ce lien soit en partie causal et que des FOP à large shunt puissent favoriser, chez des sujets génétiquement prédisposés, la survenue de crises de MA en permettant à des substances vaso-actives, des embols plaquettaires ou des embolies paradoxales de court-circuiter le filtre pulmonaire et de déclencher la dépression corticale propagée qui sous-tend l’aura migraineuse.

La première étude contrôlée conduite en double aveugle de fermeture de FOP dans la MA « réfractaire », « MIST », n’a cependant pas montré de bénéfice sur le critère principal d’efficacité : la disparition des crises pendant la période d’analyse comprise entre le 3 e et le 6 e mois après fermeture. Il n’y a donc actuellement aucune raison scientifique pour rechercher un FOP, ou a fortiori fermer un FOP, chez les migraineux.

Recent epidemiological data suggest a bidirectional link between patent foramen ovale (PFO) and migraine with aura (MA) with a relative risk of 2 for PFO in subjects with MA and for MA in subjects with PFO. There is no evidence for a link between PFO and migraine without aura. This link is not systematic and applies only to subsets of PFO, mostly large ones, and to subsets of patients with MA. Although comorbidity cannot be ruled out, it may be that this link is partly causal and that some large PFOs may favor MA attacks in genetically predisposed subjects, by allowing vasoactive substances, platelet emboli or paradoxical emboli to bypass the lung filter and trigger the cortical spreading depression of the aura.

The first double blind randomised trial of PFO closure in refractory MA, “MIST”, has failed to show a benefit on the primary efficacy end point: cessation of attacks during the analysis period included between 3 and 6 months after the procedure.

There is thus at present no scientific reason to look for PFO or to close PFO in migraine patients.


Authors' reply

We thank Dr Demetriades for his comments on our study. While the average person with a patent foramen ovale (PFO) may not be at increased risk for neurological events, there seem to be subgroups of patients at increased risk. PFOs with large diameters, right to left shunting at rest, or high membrane mobility and PFOs associated with atrial septal aneurysms have been identified as “dangerous PFOs” by several investigators. 1– 3 In addition, coagulation abnormalities may promote paradoxical emboli in patients with PFO. 4 To this list, Dr Demetriades adds special occupations or sports that may be dangerous in people with PFOs, specifically divers. Playing wind instruments has also been mentioned previously. 5

However, many problems related to PFO remain unresolved. Even in groups that are believed to be at high risk for neurological events, deciding whether and how to treat a PFO cannot be derived from evidence based medicine. Deciding how to proceed depends on the opinion of the attending physician and is not based on data from randomised studies.

The PICSS (PFO in cryptogenic stroke study) showed that secondary prevention of cryptogenic stroke in patients with PFO by using warfarin or aspirin does not result in any difference. 6 The PC-trial is an ongoing randomised trial we initiated to compare endovascular PFO closure versus medical treatment alone. We hope that it will provide useful information on secondary stroke prevention in patients with presumed paradoxical embolism. It is also conceivable that divers who have ever had “the bends” would benefit from PFO closure.

Recently reported data suggest links between decompression illness, migraine with aura, and right to left shunts. 8 These observations not only extend the clinical manifestations of PFO but also bring into discussion new pathophysiological aspects of migraine. If the association between complicated migraine and PFO can be corroborated, a randomised trial on PFO in such patients may be worth while.


PFO diagnosis

A doctor trained in heart conditions (cardiologist) may order one or more of the following tests to diagnose a patent foramen ovale:

Echocardiogram

An echocardiogram shows the anatomy, structure and function of your heart.

A common type of echocardiogram is called a transthoracic echocardiogram. In this test, sound waves directed at your heart from a wandlike device (transducer) held on your chest produce video images of your heart in motion. Doctors may use this test to diagnose a patent foramen ovale and detect other heart problems.

Variations of this procedure may be used to identify patent foramen ovale, including:

  • Color flow Doppler. When sound waves bounce off blood cells moving through your heart, they change pitch. These characteristic changes (Doppler signals) and computerized colorization of these signals can help your doctor examine the speed and direction of blood flow in your heart. If you have a patent foramen ovale, a color flow Doppler echocardiogram could detect the flow of blood between the right atrium and left atrium.
  • Saline contrast study (bubble study). With this approach, a sterile salt solution is shaken until tiny bubbles form and then is injected into a vein. The bubbles travel to the right side of your heart and appear on the echocardiogram. If there’s no hole between the left atrium and right atrium, the bubbles will simply be filtered out in the lungs. If you have a PFO (patent foramen ovale), some bubbles will appear on the left side of the heart. The presence of a PFO may be difficult to confirm by a transthoracic echocardiogram.

Transesophageal echocardiogram

Doctors may conduct another type of echocardiogram called a transesophageal echocardiogram to get a closer look at the heart and blood flow through the heart. In this test, a small transducer attached to the end of a tube is inserted down the tube leading from your mouth to your stomach (esophagus).

This is generally the most accurate available test for doctors to see a PFO (patent foramen ovale) by using the ultrasound in combination with color flow Doppler or a saline contrast study.

Other tests

Your doctor may recommend additional tests if you’re diagnosed with a PFO (patent foramen ovale) and you have had a stroke. Your doctor may also refer you to a doctor trained in brain and nervous system conditions (neurologist).


Symptoms and Causes

What are the Risks and Symptoms of Patent Foramen Ovale?

Most patients with a PFO do not have any symptoms. However, the condition may play a role in migraine headaches and it increases the risk of stroke, transient ischemic attack and heart attack.

Migraine headaches

Patients with a PFO may have migraine headaches with aura. Although the migraines stop for some patients who have the PFO closed, more studies are needed to determine if closure provides relief.

Stroke, transient ischemic attack and heart attack

Patent Foramen Ovale increases the risk of transient ischemic attack (TIA), stroke and heart attack. This is because when pressure increases in the chambers on the right side of the heart, it is possible for a blood clot or solid particles in the blood to move from the right side of the heart to the left through the open PFO, and travel to the brain (which causes a TIA or stroke) or a coronary artery (which causes a heart attack). A TIA is caused by a temporary lack of blood flow to the brain. The symptoms are the same as a stroke, but last less than 24 hours.

Many times, a TIA or stroke is the first sign of a PFO. Patients younger than Age 55 who have a stroke without a known cause (cryptogenic stroke) are more likely to have a PFO. These patients are also more likely to have a deep vein thrombosis (DVT).

Patients with a PFO may also have an atrial septal aneurysm. This condition means the top portion of the septum is bulging into one or both of the atria (top chambers of the heart).

Symptoms of a Stroke and Transient Ischemic Attack (TIA)

  • Sudden weakness or numbness in the face, arm or leg on one side of the body
  • Sudden blurred vision or trouble seeing out of one or both eyes
  • Can’t speak or trouble talking or understanding what others are saying
  • Dizziness, loss of balance, unstable walking
  • Passing out for a short time
  • Suddenly can’t move part of the body (paralysis)

How is a patent foramen ovale treated?

Most PFOs need no treatment. People who have no risk factors for stroke or any history of traveling blood clots often don't get treatment. Your healthcare provider may want to treat your PFO if you have had problems from these traveling blood clots, such as a stroke.

  • Antiplatelet medicines such as aspirin, to help prevent blood clots
  • Anticoagulant medicines such as warfarin, to help prevent blood clots
  • Closure of the PFO with a catheter-based procedure. A catheter is a long, thin tube inserted through a vessel.
  • Closure of the PFO during heart surgery

Ask your provider what treatment plan is best for you.


Is Patent Foramen Ovale A Disability?

Currently, there is a lot of research and studies about this congenital heart condition. Since this is a very common condition and never produces complications, undergoing the surgery to prevent the risk of stroke and migraine isn’t worth the risk. But the literature remains very controversial due to inconclusive evidence on the long-term outcomes. 3

Most congenital heart conditions come with serious limitations however some disorders like patent foramen ovaleare being barely noticed. However, if your type of patent foramen ovale is very severe such as a stroke that makes you unable to work then you will be eligible for disability benefits.

Congenital heart condition is classified into two types cyanotic(marked by or causing a bluish or purplish discoloration) when the heart is unable to provide enough oxygen to the body and acyanotic (cardiac malformations that affect the blood shunt from the left side of the heart to the right). Cyanosis is one of the rare symptoms of PFO, you will meet the general disability eligibility requirements. If you are seeking disability benefits first check with the Social Security Administration for eligibility. 4

A patent foramen ovale is a small flap-like opening between the right and left atria of the heart. This is perhaps a part of fetal circulation allowing the blood to bypass the lungs by transporting oxygen to the brain and other parts of the body when the fetus is in the mother’s womb.

In general, patent foramen ovale closes on its own after birth but in some cases, it remains open either fully or partially with no symptoms. Most people with patent foramen ovale do not face any disruption in the heart function so the condition is not diagnosed until you undergo a test for other heart conditions.


Atrial Septal Defect and Patent Foramen Ovale

What are Atrial Septal Defect and Patent Foramen Ovale?

An atrial septal defect and a patent foramen ovale (PFO) are 2 types of holes in the wall (septum) of the heart. The septum is the wall that separates the two upper chambers (parts) of the heart. These chambers are called the right atrium and left atrium.

An atrial septal defect happens when the septum wall doesn&rsquot grow completely before a baby is born. The larger the hole, the more likely it is to become a problem.

A foramen ovale is hole that&rsquos supposed to be there before a baby is born and then close after birth. In as many as 1 out of every 4 people, the hole doesn&rsquot close and becomes a patent (open) foramen ovale. As many as 1 out of every 4 people have a PFO.

A PFO hole is usually smaller than a hole from an atrial septal defect. The larger the hole, the more likely it is to cause the following problems:

  • The body not getting enough oxygen. Normally, blood in the right side of the heart doesn&rsquot have much oxygen. The heart pumps the blood from the right side of the heart to the lungs to get oxygen. Oxygen-rich blood comes back to the heart on the left side, where it is pumped out to the rest of the body. A hole in the septum lets oxygen-filled blood (from the left atrium) leak back into the right side of the heart instead of getting pumped out to the body. In effect, the oxygen in that blood is wasted. The heart and lungs have to work harder to get oxygen to the body.
  • Blood clots that can travel to the heart and brain, potentially causing a stroke.

Symptoms

Some people with an atrial septal defect never have symptoms. It depends on how big the hole is and where it is. Sometimes a person with a small hole won’t have symptoms until middle age or later.

Patent foramen ovale is common, but most people never have symptoms.

When symptoms of either type are present, they may include:

  • Trouble breathing or getting enough breath, especially during exercise or activity
  • Getting tired quickly during exercise or activity
  • A lot of respiratory infections (colds and coughs) in children
  • Heart palpitations (hard, fast, or irregular heartbeats)
  • Migraine headaches (more common with patent foramen ovale)
  • Fainting
  • High blood pressure in adults who have not been treated

In serious cases, these symptoms may happen:

When to See a Doctor

Call 911 immediately if a person is having signs of a stroke or heart attack.

The abbreviation BE FAST can help you remember the signs of stroke:

  • B alance: sudden loss of balance or coordination
  • E yes: sudden change in vision
  • F ace: sudden weakness of the face
  • A rms: sudden weakness of an arm or leg
  • S peech: sudden difficulty speaking
  • T ime: time the symptoms started

Signs of a heart attack include:

  • Lightheaded feeling, dizziness, nausea, or cold sweats
  • Pressure, fullness, or squeezing in the chest that lasts more than a few minutes or keeps coming back
  • Pain or discomfort in other parts of the upper body, like the neck, shoulders, or arms

Make an appointment to see the doctor if you have any of these symptoms:

  • Frequent severe migraines
  • Fainting spells
  • Tendency to get tired quickly during activity
  • Heart palpitations — hard, fast, or irregular heartbeats

Causes

Diagnosis and Tests

Tests to diagnose atrial septal defect or patent foramen ovale (PFO) are usually done only if a person has symptoms. If the hole from an atrial septal defect is large enough, the doctor will sometimes be able to hear a heart murmur when listening to your heart during a routine exam.

To diagnose a PFO, the doctor will use an echocardiogram (Echo). This test uses ultrasound to make a picture of the heart. Sometimes the foramen ovale is still hard to see, so the doctor will do a "bubble test." The doctor will inject salt water into the body and watch to see if there are little air bubbles moving from the left to the right of the heart. This means there is likely a hole.

These tests can help the doctor diagnose an atrial septal defect:

  • Echo. Uses ultrasound to make a picture of the heart.
  • Doppler echo. Uses sound waves to look at how the blood is flowing in the heart.
  • Coronary angiography. Uses x-ray and a special dye to show how the blood is flowing in the heart.
  • Electrocardiogram (ECG or EKG). Checks the rhythm of the heart by looking at its electrical activity.
  • Magnetic Resonance Imaging (MRI) of the heart, which generates a detailed image of the heart structure.

Treatments

Patent foramen ovales (PFO) typically don’t cause problems and don’t need to be treated. If a PFO is causing symptoms, treatment could include:

  • Medicine. The first type of treatment the doctor will try is blood-thinning medicine (such as aspirin or warfarin) to prevent blood clots from forming. This does not close the hole but does prevent the problems.
  • Surgery. In some cases, a procedure may be recommended to close the hole with a device. This device is put in place with a catheter (a thin, flexible tube) that is moved through a vein from the groin to the heart. Some people may need open-heart surgery to close the hole, but this is rare.

Small atrial septal defects that are not causing problems don’t need to be treated. However, if the hole is large and a lot of blood is leaking, surgery may be needed to close the hole. The hole can be closed with a closure device that the doctor puts in with a catheter (tube) that goes from the groin through a vein to the heart.

Sometimes open-heart surgery is needed to close the hole. This is especially true when the person has other heart problems in addition to the hole.


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