What general practitioners need to know about patent foramen ovale

A patent foramen ovale (PFO) consists of a hole between the right and left atriums of the heart that did not close the way it should after birth. Twenty five percent of the population have a PFO, but this usually does not cause problems, because the opening is functionally closed by the difference in pressure between the heart and the chest. This study is a literature review about the clinical significance of PFO and its management in three clinical situations: cryptogenic strokes, migraine with aura and scuba divers who sustained a decompression sickness. PFOs had been linked with various medical conditions such as strokes, migraine, and with certain types of decompression sickness (DCS). In general, this association is not very well established. Young patients who sustain a cardiovascular event without a known cause (cryptogenic stroke) have resulted in the tendency to screen these patents becoming the norm and more PFOs are being closed using standard methods and devices. The association of PFOs and migraine attacks is less clear. In the case of scuba divers the risk of suffering from a decompression accident is increased if one has a PFO. The management of these patients remains difficult.peer-reviewe

Percutaneous closure of the patent foramen ovale: A cardiological perspective

A patent foramen is commonly found in the general population.Evidence exists that a patent foramen ovale (PFO) and atrial septal aneurysm are strongly associated with cryptogenic stroke. Associations with migraine have also been described, but the status of cause and effect is less clear. Management of PFO is controversial and no form of therapy has been properly evaluated. PFO closure devices are readily available and can be safely and effectively implanted percutaneously. Complication rates are low and symptoms are improved in most patients. At present, there is a lack of guidelines for the treatment of PFO and results of prospective randomised trials are eagerly awaited

Percutaneous Closure of Patent Foramen Ovale for the Treatment of Refractory Migraine Headaches

Background: Migraine headaches both with and without aura vary in frequency, duration and intensity, affecting the quality of life of up to 10% of the total population. Migraines are treated with both prophylactic and acute medications. Patent foramen ovale (PFO) is one likely cause of migraine headaches and this is present in up to 25% of the total population. Percutaneous PFO closure is a likely option for definitive treatment for migraine. Once proven refractory to medical treatment, do patients with PFO and migraine respond to percutaneous PFO closure to reduce the frequency, duration and intensity of migraine headaches? Methods: An exhaustive search of available medical literature was conducted using Medline/Ovid, CINAHL and Evidence-Based Medicine Reviews Multifile using the keywords: patent foramen ovale, migraine disorders, therapeutics and refractory. Inclusion criteria consisted of participants with a known patent foramen ovale and migraine headaches refractory to medical treatment, as well as studies performing percutaneous PFO closure measuring cessation or reduction in frequency, duration and intensity of migraine headaches. All articles were assessed for quality using GRADE. Results: One randomized controlled trial, three prospective observational studies and one retrospective observational study fit the inclusion criteria. All observational studies demonstrated resolution of migraine with aura along with improved migraine symptomology in MIDAS score, frequency, duration and intensity of migraines. However the only randomized controlled trial (RCT) to date demonstrated no resolution of migraine headaches after six months. No other endpoints were measured such as frequency, duration or intensity. Many complications, both minor and serious, resulted in this RCT. After GRADE assessment, the RCT was determined to be high validity and all observational studies very low validity. Conclusion: Four observational studies show some benefit to percutaneous PFO closure as treatment for refractory migraine headaches. However, one randomized controlled trial shows no benefit, unable to meet its endpoints. At this time, a recommendation cannot be made for percutaneous PFO closure in patients with refractory migraine headaches until further RCTs are performed and improvements are made in future studies

Atrial Septal Defect

Atrial Septal Defects (ASDs) are relatively common both in children and adults. Recent reports of increase in the prevalence of ASD may be related use of color Doppler echocardiography. The etiology of the ASD is largely unknown. While the majority of the book addresses closure of ASDs, one chapter in particular focuses on creating atrial defects in the fetus with hypoplastic left heart syndrome. This book, I hope, will give the needed knowledge to the physician caring for infants, children, adults and elderly with ASD which may help them provide best possible care for their patients

Transcatheter Closure of Patent Foramen Ovale: A Single Center Experience

BACKGROUND: Percutaneous transcatheter closure (PTC) of patent foramen ovale (PFO) is implicated in cryptogenic stroke, transitional ischemic attack (TIA) and treatment of a migraine.AIM: Our goal was to present our experience in the interventional treatment of PFO, as well as to evaluate the short and mid-term results in patients with closed PFO.MATERIAL AND METHODS: Transcatheter closure of PFO was performed in 52 patients (67.3% women, mean age 40.7 ± 11.7 years). Patients were interviewed for subjective grading of the intensity of headaches before and after the PFO closure.RESULTS: During 2 years of follow-up, there was no incidence of new stroke, TIA and/or syncope. Follow-up TCD performed in 35 patients showed complete PFO closure in 20 patients (57.1%). Out of 35 patients, 22 (62.9%) reported having a migraine before the procedure with an intensity of headaches at 8.1 ± 1.9 on a scale from 1 to 10. During 2 years of follow-up, symptoms of a migraine disappeared in 4 (18.2%) and the remaining 18 patients reported the significant decrease in intensity 4.8 ± 2.04 (p = 0.0001). In addition, following PFO closure the incidence of the headaches decreased significantly (p = 0.0001).CONCLUSIONS: Percutaneous transcatheter closure of PFO is a safe and effective procedure showing mid-term relief of neurological symptoms in patients as well as significant reduction of migraine symptoms

Patent Foramen Ovale: Current Pathology, Pathophysiology, and Clinical Status

Patent foramen ovale (PFO) is experiencing increased clinical interest as a congenital cardiac lesion persisting into adulthood. It is implicated in several serious clinical syndromes, including stroke, myocardial infarction, and systemic embolism. The PFO is now amenable to percutaneous interventional therapies, and multiple novel technologies are either available or under development for lesion closure. The PFO should be better understood to take advantage of emerging percutaneous treatment options. This paper reviews PFO anatomy, pathology, pathophysiology, and clinical impact and discusses current therapeutic options

Percutaneous closure of patent foramen ovale: an underutilized prevention?

Stroke is a devastating event for patients and their families. Paradoxical embolism through a patent foramen ovale (PFO) is a recognized cause of stroke. Percutaneous PFO closure is a simple and safe procedure. The debate on PFO closure is far from settled. This is, in part, due to the fact that the three published randomized controlled trials (RCTs) on PFO closure vs. medical therapy were negative regarding their primary endpoint; however, as-treated and per-protocol analyses as well as several meta-analyses report a benefit of PFO closure. In our opinion, PFO closure is underutilized and the results of the three RCTs are not adequately reflected in the current guidelines