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  • Review Article
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Patent foramen ovale: anatomy, outcomes, and closure

Nature Reviews Cardiology volume 8, pages 148–160 (2011)Cite this article

Subjects

Abstract

Patent foramen ovale (PFO) is a normal fetal communication between the right and left atria that persists after birth. PFO is a common finding that occurs in 20–34% of the population, although its prevalence decreases with age. In most cases, a PFO poses no threat to health. However, some PFOs have the ability to open widely under certain hemodynamic conditions, which enables any bloodborne material, such as thrombi, air, or vasoactive substances, to pass from the venous to the arterial circulation, with the potential to cause a cerebrovascular event. PFO has been linked to several conditions, including cryptogenic stroke, migraine with aura, decompression illness, and systemic arterial embolism. However, the data that support PFO closure in these conditions are mostly from nonrandomized cohort series, and are often contradictory. In this Review, we discuss the existing data on PFO closure, including results of the first randomized, controlled trial comparing device closure of PFO with medical therapy for cryptogenic stroke, and we examine controversies in the literature as well as ongoing studies. We also focus on the anatomy of a PFO and how it impacts on the procedure of PFO closure with a percutaneous device.

Key Points

  • Patent foramen ovale (PFO) is a normal fetal communication between the right and left atria that persists postpartum

  • PFOs are present in 20–34% of the population, but they pose no threat to health in the majority of cases

  • Under certain hemodynamic circumstances, PFOs can open and act as a conduit for thrombi to pass from the systemic venous circulation to the systemic arterial circulation, which can potentially cause a stroke

  • PFOs have been associated with cryptogenic stroke, decompression illness, systemic arterial embolism, and migraine with aura

  • Percutaneous device closure of a PFO is a low-risk procedure, although data from randomized, controlled trials that support its efficacy are lacking

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Figure 1: Development of the atrial septum in utero.
Figure 2: Schematic representation of the atrial septal anatomy from an en-face view of the right atrium.
Figure 3: Anatomical variants of PFOs seen on two-dimensional TEE.
Figure 4: Three-dimensional TEE images of the atrial septum of a patient with a PFO but no atrial septal defect.
Figure 5: Impending paradoxical embolus.
Figure 6: Bubble contrast echocardiography.
Figure 7: Procedural imaging of a PFO.

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Authors and Affiliations

  1. Cardiology Department, Papworth Hospital NHS Foundation Trust, Papworth Everard, CB23 3RE, Cambridge, UK

    Patrick A. Calvert, Bushra S. Rana, Anna C. Kydd & Leonard M. Shapiro

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P. A. Calvert researched data to include in the manuscript and wrote the article. All the authors contributed to discussion of content, reviewed and edited the manuscript before submission, and revised the manuscript in response to the peer-reviewers' comments.

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Calvert, P., Rana, B., Kydd, A. et al. Patent foramen ovale: anatomy, outcomes, and closure. Nat Rev Cardiol 8, 148–160 (2011). https://doi.org/10.1038/nrcardio.2010.224

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