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J Am Coll Cardiol, 2001; 38:613-623
© 2001 by the American College of Cardiology Foundation
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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{dagger}, Gary D. Plotnick, MD, FACC{ddagger} and Thomas D. Giles, MD, FACC*

* Cardiovascular Research Laboratory, Division of Cardiology, Louisiana State University Health Sciences Center, New Orleans, Louisiana, USA
{dagger} National Aeronautics and Space Administration, Johnson Space Center, Houston, Texas, USA
{ddagger} Division of Cardiology, University of Maryland Hospitals, Baltimore, Maryland, USA

Manuscript received October 3, 2000; revised manuscript received May 4, 2001, accepted May 21, 2001.

Reprint requests and correspondence: Dr. Thomas D. Giles, Louisiana State University Health Sciences Center, 1542 Tulane Avenue, Room 331E, New Orleans, Louisiana 70112-2822
tgiles{at}lsumc.edu

Patent foramen ovale (PFO) is implicated in platypnea-orthodeoxia, stroke and decompression 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 functional 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 ≥4 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, thromboembolism, DCS in underwater divers, DCS in high-altitude aviators and astronauts) may be different.

Abbreviations and Acronyms
  AGE = arterial gas embolism
  ASA = atrial septal aneurysm
  ASD = atrial septal defect
  DCS = decompression sickness
  EMU = extravehicular mobility unit
  EVA = extravehicular activity (spacewalk)
  IAS = interatrial septum
  ISS = International Space Station
  IVC = inferior vena cava
  LA = left atrium
  MRI = magnetic resonance imaging
  NTH = native tissue harmonics
  PAVS = pulmonary arteriovenous shunt
  PFO = patent foramen ovale
  PV = pulmonary vein
  RA = right atrium
  TCD = transcranial Doppler
  TEE = transesophageal echocardiography
  TMD = transmitral Doppler
  TTE = transthoracic echocardiography




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