Patent foramen ovale-management challenges: a case series

    Authors

    Abstract

    **Background**: Patent foramen ovale (PFO) is an anatomical interatrial communication with potential for right-to-left shunt. It is detected in 10-15% of the population by transthoracic echocardiography (TTE) and up to 27% by autopsy. Most patients with isolated PFO are asymptomatic. Patients may have a history of stroke or transient ischemic event of undefined etiology. (1, 2) The recurrence rate of stroke or TIA has been reported to be as high as 3.4-3.9% per year. In patients with atrial septal aneurysm and PFO, the risk of first recurrent stroke within 2 years has been reported to be as high as 9%, whereas the rate of subsequent stroke or TIA recurrence within 2 years increases to 22%. No consensus exists on treatment of PFO in patients with transient ischemic attack (TIA) or stroke. Traditional treatment has been antiplatelet therapy alone in low-risk patients or combined with warfarin in high-risk individuals to prevent cryptogenic stroke. (3, 4) **Case report**: We represent three cases of PFO diagnosed in our hospital within past 14 months. Case 1: 34-year-old man hospitalized at the Neurology Department due to transient loss of consciousness. Echocardiography showed interatrial septal aneurysm, and two septal defects – subaortal, 11mm in diameter with left-to-right shunt and second one, 3mm in diameter. There was also visible smaller thrombotic mass in left auricle. Patient underwent surgical closure. Case 2: 39-year-old woman presented at the routine echocardiographic examination after she was discharged from Neurology department where she was treated for stroke. Her brain MRI showed multiple ischemic infarctions with no focal deficit on neurological examination. TTE showed small PFO, 3mm in diameter with right-to-left shunt (**Figure 1****,****Figure 2**). Patient received percutaneous surgical closure. Case 3: 63-year-old man presented to the internist after loss of consciousness. ECG showed atrial fibrillation and TTE was subsequently performed. It showed atrial septal aneurysm, a septal defect, 14mm in diameter with left-to-right shunt (**Figure 3**, **Figure 4**). The patient is on the waiting list for surgical treatment. FIGURE 1. Patent foramen ovale. FIGURE 2. Patent foramen ovale with right-to-left shunt. FIGURE 3. Atrial septal aneurysm. FIGURE 4. Atrial septal defect with left-to-right shunt. **Conclusion**: Surgical closure PFO has resulted in elimination of residual shunt across the PFO. Advantages include the following: permanent closure of the defect, prevents future paradoxical emboli, no long-term anticoagulation and its risks.

    Keywords

    patent foramen ovale, management

    DOI

    https://doi.org/10.15836/ccar2019.92

    Literature

    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 Jan;59(1):17–20. https://doi.org/10.1016/S0025-6196(12)60336-X
    2. Bonati LH, Wetzel SG, Kessel-Schaefer A, Buser P, Lyrer PA, Engelter ST. Diffusion-weighted imaging findings differ between stroke attributable to spontaneous cervical artery dissection and patent foramen ovale. Eur J Neurol. 2010 Feb;17(2):307–13. https://doi.org/10.1111/j.1468-1331.2009.02805.x
    3. Steenblik MH, Mineau GP, Pimentel R, Michaels AD. Population-based assessment of familial inheritance and neurologic comorbidities among patients with an isolated atrial septal defect. Congenit Heart Dis. 2009 Nov-Dec;4(6):459–63. https://doi.org/10.1111/j.1747-0803.2009.00340.x
    4. Dalen JE, Alpert JS. Cryptogenic strokes and patent foramen ovales: what’s the right treatment? Am J Med. 2016 Nov;129(11):1159–62. https://doi.org/10.1016/j.amjmed.2016.08.006
    Cardiologia Croatica
    Back to search

    Patent foramen ovale-management challenges: a case series

    Extended Abstract
    Issue3-4
    Published
    Pages92-93
    PDF via DOIhttps://doi.org/10.15836/ccar2019.92
    patent foramen ovale
    management

    Authors

    Alma Sijamija*ORCIDTravnik General Hospital, Travnik, Bosnia and Herzegovina
    Nermir GranovORCIDClinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
    Alma AgačevićORCIDTravnik General Hospital, Travnik, Bosnia and Herzegovina
    Omer PervaORCIDClinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
    Nedžad HadžićORCIDTravnik General Hospital, Travnik, Bosnia and Herzegovina

    *Correspondence email: alma.sijamija@hotmail.com

    Abstract

    **Background**: Patent foramen ovale (PFO) is an anatomical interatrial communication with potential for right-to-left shunt. It is detected in 10-15% of the population by transthoracic echocardiography (TTE) and up to 27% by autopsy. Most patients with isolated PFO are asymptomatic. Patients may have a history of stroke or transient ischemic event of undefined etiology. (1, 2) The recurrence rate of stroke or TIA has been reported to be as high as 3.4-3.9% per year. In patients with atrial septal aneurysm and PFO, the risk of first recurrent stroke within 2 years has been reported to be as high as 9%, whereas the rate of subsequent stroke or TIA recurrence within 2 years increases to 22%. No consensus exists on treatment of PFO in patients with transient ischemic attack (TIA) or stroke. Traditional treatment has been antiplatelet therapy alone in low-risk patients or combined with warfarin in high-risk individuals to prevent cryptogenic stroke. (3, 4) **Case report**: We represent three cases of PFO diagnosed in our hospital within past 14 months. Case 1: 34-year-old man hospitalized at the Neurology Department due to transient loss of consciousness. Echocardiography showed interatrial septal aneurysm, and two septal defects – subaortal, 11mm in diameter with left-to-right shunt and second one, 3mm in diameter. There was also visible smaller thrombotic mass in left auricle. Patient underwent surgical closure. Case 2: 39-year-old woman presented at the routine echocardiographic examination after she was discharged from Neurology department where she was treated for stroke. Her brain MRI showed multiple ischemic infarctions with no focal deficit on neurological examination. TTE showed small PFO, 3mm in diameter with right-to-left shunt (**Figure 1****,****Figure 2**). Patient received percutaneous surgical closure. Case 3: 63-year-old man presented to the internist after loss of consciousness. ECG showed atrial fibrillation and TTE was subsequently performed. It showed atrial septal aneurysm, a septal defect, 14mm in diameter with left-to-right shunt (**Figure 3**, **Figure 4**). The patient is on the waiting list for surgical treatment. FIGURE 1. Patent foramen ovale. FIGURE 2. Patent foramen ovale with right-to-left shunt. FIGURE 3. Atrial septal aneurysm. FIGURE 4. Atrial septal defect with left-to-right shunt. **Conclusion**: Surgical closure PFO has resulted in elimination of residual shunt across the PFO. Advantages include the following: permanent closure of the defect, prevents future paradoxical emboli, no long-term anticoagulation and its risks.

    Literature

    1. 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 Jan;59(1):17–20.DOI
    2. 2.
      Bonati LH, Wetzel SG, Kessel-Schaefer A, Buser P, Lyrer PA, Engelter ST. Diffusion-weighted imaging findings differ between stroke attributable to spontaneous cervical artery dissection and patent foramen ovale. Eur J Neurol. 2010 Feb;17(2):307–13.DOI
    3. 3.
      Steenblik MH, Mineau GP, Pimentel R, Michaels AD. Population-based assessment of familial inheritance and neurologic comorbidities among patients with an isolated atrial septal defect. Congenit Heart Dis. 2009 Nov-Dec;4(6):459–63.DOI
    4. 4.
      Dalen JE, Alpert JS. Cryptogenic strokes and patent foramen ovales: what’s the right treatment? Am J Med. 2016 Nov;129(11):1159–62.DOI