Patent foramen ovale (PFO)

Diagnosis

A patent foramen ovale (PFO) is often detected incidentally while testing for other health issues. In case your healthcare provider suspects the presence of PFO, they may recommend imaging tests to examine the heart. If you have suffered a stroke and have been diagnosed with PFO, your healthcare provider may refer you to a neurologist who specializes in treating brain and nervous system disorders.

• Imaging tests:
  • Echocardiogram: An echocardiogram is a test that provides a visual representation of the heart’s action, allowing the doctor to assess its pumping function. During this test, high-frequency sound waves from a hand-held wand placed on the chest are used to take photos of the valves and chambers. An echocardiogram is commonly used to diagnose a patent foramen ovale.
  • Transthoracic echocardiogram: Is a test that uses ultrasound to create images of the heart. It helps determine how well the heart is functioning and identify the underlying cause of symptoms. During the procedure, a transducer, an ultrasonic instrument, is placed on the skin around the heart area and used to record the echoes of the heart’s sound waves. TTE is either noninvasive or minimally invasive, and patients can quickly resume their normal daily activities.
• Transthoracic echocardiography (TTE) offers several imaging techniques that can be employed to visualize the heart, including:
  • Color-Doppler. Detects changes in pitch of sound waves that bounce off blood cells in motion within the heart, known as Doppler signals. These signals are displayed in different colors on the echocardiogram, enabling visualization of the speed and direction of blood flow in the heart. In individuals with a patent foramen ovale, this imaging technique typically reveals the movement of blood between the upper chambers of the heart.
  • Bubble study. In a regular echocardiogram, a sterile salt solution comprising small bubbles is intravenously administered. These bubbles travel to the right side of the heart and are visible on the echocardiogram. In the absence of any opening between the upper chambers of the heart, the lungs filter out the bubbles. However, if an individual has a patent foramen ovale, some of these bubbles may appear on the left side of the heart during imaging.
• Transesophageal echocardiogram: If a standard echocardiogram fails to confirm a patent foramen ovale, your healthcare provider may suggest a transesophageal echocardiogram as it is the most accurate way to diagnose this condition. The test involves inserting a flexible probe with an ultrasound device down the throat and into the esophagus to capture images of the heart from inside the body.

Treatment

Most cases of patent foramen ovale do not require treatment. If a PFO is incidentally discovered during echocardiography that was performed for another reason, typically surgery to close the hole is avoided. However, patients who have a history of stroke or are at a high risk of blood clots may need treatment. Recent studies indicate that closing a PFO in patients who have had an unexplained stroke can help prevent future strokes. The treatment options for PFO may comprise medication, device closure, or surgical closure.

• Medications:  For individuals who have had a stroke and are diagnosed with patent foramen ovale, blood thinners may be a useful treatment option. Medications such as aspirin or warfarin can be prescribed to prevent blood clots.
• Surgery or other procedures: The decision to close a patent foramen ovale to prevent recurrent stroke is made based on expert recommendations and the individual patient’s situation. Patients with PFO and low blood oxygen levels or unexplained stroke may require a procedure to seal the hole. Generally, closure of a patent foramen ovale is not recommended as a first-line therapy.

Treatment options include:

• Catheterization: Catheterization has been shown in studies to be more effective than surgery in treating PFO in people under the age of 60. Tear in the heart or blood vessels, device movement, or irregular heartbeats, although rare, are possible device closure complications.

This procedure requires the use of a long, thin tube (catheter) to seal the flap. The catheter is inserted into a big vein in the groin and advanced through the blood vessel to the heart. The catheter tip contains a mechanism for plugging the PFO.

• Heart surgery: An open-heart surgery or minimally invasive robotically assisted patent foramen ovale repair may be recommended if catheterization fails. If heart surgery is done for another reason, the doctor may advise having it treated at the same time. During the procedure, the doctor will create an incision in the middle of the chest and stitch the flap closed.