Journal of the American College of Cardiology Vol. 38, No. 3, 2001 © 2001 by the American College of Cardiology ISSN 0735-1097/01/$20.00 Published by Elsevier Science Inc. PII S0735-1097(01)01427-9 REVIEW ARTICLE Patent Foramen Ovale: A Review of Associated Conditions and the Impact of Physiological Size Edmund K. Kerut, MD, FACC,* William T. Norfleet, MD,† Gary D. Plotnick, MD, FACC,‡ Thomas D. Giles, MD, FACC* New Orleans, Louisiana; Houston, Texas; and Baltimore, Maryland Patent foramen ovale (PFO) is implicated in platypnea-orthodeoxia, stroke and decompres- sion sickness (DCS) in divers and astronauts. However, PFO size in relation to clinical illness is largely unknown since few studies evaluate PFO, either functionally or anatomically. The autopsy incidence of PFO is approximately 27% and 6% for a large defect (0.6 cm to 1.0 cm). A PFO is often associated with atrial septal aneurysm and Chiari network, although these anatomic variations are uncommon. Methodologies for diagnosis and anatomic and func- tional sizing of a PFO include transthoracic echocardiography (TTE), transesophageal echocardiography (TEE) and transcranial Doppler (TCD), with saline contrast. Saline injection via the right femoral vein appears to have a higher diagnostic yield for PFO than via the right antecubital vein. Saline contrast with TTE using native tissue harmonics or transmitral pulsed wave Doppler have quantitated PFO functional size, while TEE is presently the reference standard. The platypnea-orthodeoxia syndrome is associated with a large resting PFO shunt. Transthoracic echocardiography, TEE and TCD have been used in an attempt to quantitate PFO in patients with cryptogenic stroke. The larger PFOs (approximately Ն4 mm size) or those with significant resting shunts appear to be clinically significant. Approximately two-thirds of divers with unexplained DCS have a PFO that may be responsible and may be related to PFO size. Limited data are available on the incidence of PFO in high altitude aviators with DCS, but there appears to be a relationship. A large decompression stress is associated with extra vehicular activity (EVA) from spacecraft. After four cases of serious DCS in EVA simulations, a resting PFO was detected by contrast TTE in three cases. Patent foramen ovales vary in both anatomical and functional size, and the clinical impact of a particular PFO in various situations (platypnea-orthodeoxia, thrombo- embolism, DCS in underwater divers, DCS in high-altitude aviators and astronauts) may be different. (J Am Coll Cardiol 2001;38:613–23) © 2001 by the American College of Cardiology Patent foramen ovale (PFO) has been implicated in several These techniques assess PFO risk based on anatomic and pathologic processes, including paradoxical embolism in functional size. cryptogenic stroke (1–6) and venous-to-arterial gas embo- lism (AGE) in serious forms of decompression sickness (DCS) (an occupational hazard for underwater divers [7–9] EMBRYOLOGY and high altitude aviators and astronauts [10–13]). En- hanced right-to-left shunting of venous blood through a Patent foramen ovale is a remnant of the fetal circulation. PFO in certain pathologic states (14–16), including the Oxygenated placental blood enters the right atrium (RA) via platypnea-orthodeoxia syndrome (17–24), may cause sys- the inferior vena cava (IVC) and crosses the valve of the temic hypoxemia. Only a few studies have attempted to foramen ovale to enter the systemic arterial system (25). The quantitate the size of a PFO, either functionally or anatom- IVC flow preferentially flows toward the interatrial septum ically. (IAS) and foramen ovale. The crista interveniens directs The availability of noninvasive techniques for assessment superior vena cava flow away from the IAS. Coronary sinus of PFO provides the opportunity for clinicians to diagnose flow is also directed away from the IAS (26). At birth, pathologic states that were heretofore difficult to diagnose. pulmonary vascular resistance and right-sided cardiac pres- sures drop with a reversal of the RA-to-left atrium (LA) From the *Cardiovascular Research Laboratory, Division of Cardiology, Louisiana pressure gradient. The flap of the foramen ovale (septum State University Health Sciences Center, New Orleans, Louisiana; †National Aero- primum) closes against the atrial septum (septum secun- nautics and Space Administration, Johnson Space Center, Houston, Texas; ‡Division of Cardiology, University of Maryland Hospitals, Baltimore, Maryland. Supported, in dum), with fusion usually occurring within the first two part, by unrestricted funds from the Cardiovascular Research Laboratory, LSU Health years of life. Fusion is incomplete in about 25% of people, Sciences Center, New Orleans, Louisiana, and Toshiba America Medical Systems, resulting in an oblique slit-like defect. Termed a PFO, it Tustin, California. Manuscript received October 3, 2000; revised manuscript received May 4, 2001, functions as a valve-like structure with the “door-jam” on accepted May 21, 2001. the LA side of the atrial septum (25) (Fig. 1). 614 Kerut et al. JACC Vol. 38, No. 3, 2001 Patent Foramen Ovale: Size and Clinical Significance September 2001:613–23 incidence of PFO declined with age, suggesting that ana- Abbreviations and Acronyms tomic closure may occur even in adulthood (28). AGE ϭ arterial gas embolism ASA ϭ atrial septal aneurysm ASSOCIATED ANATOMICAL STRUCTURES ASD ϭ atrial septal defect DCS ϭ decompression sickness Atrial septal aneurysm (ASA) (29,30) (Fig. 2) and Chiari EMU ϭ extravehicular mobility unit network (31) (Fig. 3) are associated with PFO. Atrial septal ϭ EVA extravehicular activity (spacewalk) aneurysm incidence is 1% by an autopsy study (32) and 1.9% IAS ϭ interatrial septum ϭ by transthoracic echocardiography (TTE) (10,803 subjects) ISS International Space Station Ն IVC ϭ inferior vena cava (33), defining ASA as a septal excursion of 10 mm, with LA ϭ left atrium a base diameter of Ն15 mm. Another TTE study using an MRI ϭ magnetic resonance imaging excursion of Ն15 mm found an ASA incidence of 0.22% ϭ NTH native tissue harmonics (34). PAVS ϭ pulmonary arteriovenous shunt ϭ A monoplane transesophageal echocardiography (TEE) PFO patent foramen ovale Ն PV ϭ pulmonary vein study (30) defined ASA excursion 11 mm and base RA ϭ right atrium diameter of 15 mm to compare patients with embolic stroke TCD ϭ transcranial Doppler (n ϭ 133) with controls (n ϭ 277). An ASA was present in ϭ TEE transesophageal echocardiography 15% of the stroke group and 4% of controls. A PFO was TMD ϭ transmitral Doppler TTE ϭ transthoracic echocardiography diagnosed by saline contrast injection in 70% of stroke patients with an ASA and 75% of controls with an ASA. Of the 32 ASAs in this study, six had an associated Chiari INCIDENCE network. Notably, TTE identified only 12/32 (37.5%) of the ASAs. A biplane TEE study (29) found an ASA in Two autopsy studies determined PFO incidence, with the 28/355 (7.9%) of stroke patients and 8/363 (2.2%) of ϭ first (n 1,100) revealing a “probe” patent PFO (0.2 cm to controls. A PFO was found by saline contrast in 56% of 0.5 cm maximum dimension) in 29% and “pencil” patent ASA patients. No other possible source of embolism was ϭ PFO (0.6 cm to 1.0 cm) in 6% (27). The second study (n found in 24/28 (86%) of the stroke patients with an ASA. In 965) recorded a PFO incidence of 27.3%, with PFOs another study, if a mobile IAS or fossa ovalis measured varying in size from 1 mm to 19 mm (mean 4.9 mm). The Ն14 mm, there appeared to be an increased PFO incidence (35). These data indicate that an ASA occurs commonly in patients with unexplained stroke and is more frequently detected by TEE than by TTE. The Chiari network is a remnant of the septum spurium and the right valve of the sinus venosus resulting from incomplete resorption of these structures (36). Lace-like remnants of the original septum may persist and be evident as coarse or fine fibers in the RA. These fibers originate from either the Eustachian or Thebesian valve and have attachments to the upper wall of the RA or IAS. The Eustachian valve may also be relatively mobile and fenes- trated but does not attach to the upper wall of the right atrium or IAS and, therefore, should not be termed a “Chiari network.” The autopsy incidence of the Chiari network has been reported as 2% to 3% (37). A TEE study found a Chiari network in 29/1,436 (2%), whereas TTE identified only 8. A TEE-determined PFO was found in 24/29 (83%) of these, with more “intense” right-to-left shunting noted. An ASA was found by TEE in 33/1,436 (2.3%), with 7/33 having a coexistent Chiari network (31). DIAGNOSIS OF A PFO Before the advent of echocardiography, diagnosis of a Figure 1. Longitudinal imaging transesophageal echocardiography in the right-to-left shunt was problematic. A PFO without a midupper esophagus. A large patent foramen ovale (PFO) is evident. The arrow illustrates how to measure the PFO width. LA ϭ left atrium; RA ϭ significant resting right-to-left shunt is generally not asso- right atrium. ciated with any abnormality of the patient history, physical JACC Vol. 38, No. 3, 2001 Kerut et al. 615 September 2001:613–23 Patent Foramen Ovale: Size and Clinical Significance Figure 2. M-mode (left) and two-dimensional (right) transesophageal echocardiography longitudinal image in the midupper esophagus. The M-mode demonstrates marked interatrial septum (IAS) mobility, with an excursion Ͼ15 mm. By definition this is an atrial septem aneurysm. LA ϭ left atrium; RA ϭ right atrium; SVC ϭ superior vena cava. examination, electrocardiogram or chest radiograph. Heart eration of a dye dilution curve from a dichromatic earpiece catheterization is generally inadequate for diagnosis of PFO, densitometer was reported in patients with cryptogenic unless a right heart catheter crosses the IAS into the LA.