What is Patent Foramen Ovale (PFO)?
- The septum is the muscular wall separating the heart into the left and right sides.
- The atrial septum is the wall separating the atria (the two upper chambers).
- The ventricular septum is the wall separating the ventricles (the two lower chambers).
The foramen ovale is a small hole located in the atrial septum that is used during fetal circulation to speed up the travel of blood through the heart. 
When in the womb,a baby does not use it's own lungs for oxygen-rich blood, it relies on the mother to provide oxygen rich blood from the placenta through the umbilical cord to the fetus. Therefore, blood can travel from the veins to the right side of the baby's heart and cross to the left side of the heart through the foramen ovale and skip the trip to the baby's lungs.
Normally the foramen ovale closes at birth when increased blood pressure on the left side of the heart forces the opening to close.
If the atrial septum does not close properly, it is called a patent foramen ovale. This type of defect generally works like a flap valve, only opening during certain conditions when there is more pressure inside the chest. This increased pressure occurs when people strain while having a bowel movement, cough, or sneeze.
If the pressure is great enough, blood may travel from the right atrium to the left atrium. If there is a clot or particles in the blood traveling in the right side of the heart, it can cross the PFO, enter the left atrium, and travel out of the heart and to the brain (causing a stroke) or into a coronary artery (causing a heart attack).
How Common is Patent Foramen Ovale?
The prevalence of PFO is about 25 percent in the general population. In patients who have stroke of unknown cause (cryptogenic stroke), the prevalence of PFO increases to about 40 percent. This is especially true in patients who have had a stroke at age less than 55 years. See the American Heart Association and American Stroke Association's guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack.
A PFO can be associated with atrial septal aneurysm, which is characterized by excessive mobility of the atrial septum.
Symptoms of PFO
Most patients do not have any symptoms with PFO.
Stroke and PFO:
About 40 percent of patients who have an ischemic stroke have no known cause (called cryptogenic stroke). PFO is present and associated with an increase in stroke in about 40 percent of cases. The most common symptoms of stroke are:
- weakness or numbness of the face, arm or leg on one side of the body
- loss of vision or dimming (like a curtain falling) in one or both eyes
- loss of speech, difficulty talking or understanding what others are saying
- sudden, severe headache with no known cause
- loss of balance, unstable walking, usually combined with another symptom
Migraine headache and PFO:
Migraine headaches are more common in patients with PFO. While it seems as though closure of PFO results in improvement of migraine symptoms, larger studies are needed to confirm this finding.
Diagnosis of PFO
Patent Foramen Ovale can be detected by echocardiogram. In some cases the patient is asked to cough or perform the Valsalva maneuver to increase pressure in the right atrium. This can increase the flow of blood from the right to left atrium. Transesophageal echo, can provide a closer and more detailed view of the PFO.
Treatment for Patent Foramen Ovale (PFO)
Medical management
People with PFO do not need any treatment if there are no associated problems, such as a stroke. Patients who have had a stroke or transient ischemic attack (TIA) may be placed on some type of blood thinner medication, such as aspirin, plavix (clopidogrel), or coumadin (warfarin) to prevent recurrent stroke.
Non-surgical treatment: Cardiac implant
In some patients a cardiologist and a neurologist may recommend closure of PFO. Most frequently, percutaneous rather than surgical closure is preferred. As part of the procedure, you will first undergo a cardiac catheterization. During this test, catheters (hollow, flexible, tube) will be inserted into the veins in your groins and advanced to your heart. A balloon may be placed across the opening to determine the size and location of the hole in your heart. Measurements are taken of the pressure inside your heart chambers. A tiny catheter with an echo transducer is placed in the heart for imaging.
If the cardiac catheterization shows your PFO is an appropriate size and in an appropriate location for closure with this device, the cardiologist will position the device to close the hole.
PFO Repair
It is not clear what the best treatment is for PFOs discovered during routine clinical imaging. Research is still being done. No scientific studies have shown the benefit of taking primary preventive measures to prevent stroke in patients with PFO.
A person with PFO who already has had a stroke may have a higher risk of future strokes, depending on factors such as the degree of shunting and the presence of another defect known as an atrial septal aneurysm (a "floppy" atrial septum). Therapy recommendations for these patients continue to be investigated and may include anticoagulant therapy (blood thinners) such as aspirin, clopidogrel or warfarin; surgery to close the defect; or a percutaneous closure device. The risks and long-term benefits of using percutaneous occlusion devices to treat patients with PFO are not yet determined. This type of treatment generally is recommended only for patients taking medication to reduce their risk of blood clots who have a second stroke or transient ischemic attack (TIA, or "mini stroke") thought to be caused by PFO.
Percutaneous Closure Devices for PFO Repair
AMPLATZER® device used for PFO repair. Photo used with permission from AGA Medical Corporation*
The closure devices commonly used for percutaneous PFO repair include the Amplatzer® PFO Occluder, the GORE HELEX® Occluder and the STARflex® Septal Repair Implant.
AMPLATZER® PFO Occluder
The AMPLATZER® PFO Occluder is a transcatheter closure device used to treat PFO. It is made of two wire mesh discs filled with polyester fabric. It is folded into a special delivery catheter, similar to the catheter used to cross the heart defect during a catheterization. The catheter is inserted into a vein in the leg, advanced into the heart and through the defect.
When the catheter is in the proper position, the device slowly is pushed out of the catheter until the discs of the device sit on each side of the defect, like a sandwich. The two discs are linked together by a short connecting waist.
Over time, heart tissue grows over the implant, and it becomes part of the heart.
GORE HELEX® Septal Occluder
The GORE HELEX® Septal Occluder is a transcatheter closure device used to treat PFO. It is a disc-like device that consists of ePTFE patch material supported by a single Nitinol wire frame.
The device is folded into a special catheter and inserted into a vein in the leg. Using a guide wire, the device is advanced through the atrial septum.
When the catheter is in the correct position, the device slowly is pushed out of the catheter until it covers and bridges the defect. Over time, heart tissue grows over the implant, and it becomes part of the heart, correcting the defect.
STARflex® Septal Repair Implant
The STARFlex® Septal Repair Implant, manufactured by NMT Medical, Inc., is a transcatheter closure device used to treat PFO. It includes two umbrella-shaped discs, one for each side of the septum.
The device is folded into a special delivery catheter, similar to the catheter used to cross the heart defect during a catheterization. The catheter is inserted into a vein in the leg, advanced into the heart and through the defect.
When the device is in the proper position, it slowly is released from the catheter. Each "umbrella" opens up and conforms to the defect by covering each side, like a sandwich. Over time, heart tissue grows over the implant, permanently closing the defect.
Living with PFO
Patients with a patent foramen ovale are not at an increased risk of endocarditis and antibiotic prophylaxis is not indicated. For those who have had their PFO closed with a transcatheter device, endocarditis prevention is recommended for at least 6 months following the device implant. According to the American Heart Association, after 6 months, there is insufficient data to make recommendations for prophylactic therapy. If your PFO has been repaired, ask your physician if you require continued bacterial endocarditis prevention. (Prevention of Endocarditis, AHA Recommendations, Circulation. 1997;96:358-366)
Your doctor will tell you how often to make appointments for follow-up.
How to find a doctor if you have patent foramen ovale
Doctors vary in quality due to differences in training and experience; hospitals differ in the number of services available. The more complex your medical problem, the greater these differences in quality become and the more they matter.
Clearly, the doctor and hospital that you choose for complex, specialized medical care will have a direct impact on how well you do. To help you make this choice, read more about our Miller Family Heart & Vascular Institute outcomes.
How to find a doctor if you have adult congenital heart disease
Doctors vary in quality due to differences in training and experience; hospitals differ in the number of services available. The more complex your medical problem, the greater these differences in quality become and the more they matter.
Clearly, the doctor and hospital that you choose for complex, specialized medical care will have a direct impact on how well you do. To help you make this choice, read more about our Sydell and Arnold Miller Family Heart & Vascular Institute outcomes. See about us to learn more about the Miller Family Heart & Vascular Institute at Cleveland Clinic.
The Center for Adult Congenital Heart Disease in the Sydell and Arnold Miller Family Heart & Vascular Institute is a specialized center involving a multi-disciplinary group of specialists, including cardiologists, cardiac surgeons and nurses from Cardiovascular Medicine, Pediatric Cardiology, Pediatric and Congenital Heart Surgery, Cardiothoracic Surgery, Diagnostic Radiology, Pulmonary, Allergy and Critical Care Medicine, and Transplantation Center, who provide a comprehensive approach to diagnosing and treating adult congenital heart disease.
Cardiologists Richard Krasuski, MD, Director of Adult Congenital Heart Disease Services, Murat Tuzcu, MD and Samir Kapadia, MD are Interventional Cardiologists, specializing in catheter-based treatment of adult congential heart defects
To make an appointment, please call 800.659.7822.
For More Information