Practice Essentials

Patent foramen ovale (PFO) is a flaplike opening between the atrial septa primum and secundum at the location of the fossa ovalis (see the image below) that persists after age 1 year. With increasing evidence being found that PFO is the culprit in paradoxical embolic events, the relative importance of the anomaly is being reevaluated.

This 2-dimensional echocardiogram in an infant (subcostal long-axis view) shows a patent foramen ovale. Right atrium (RA) and left atrium (LA

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Signs and symptoms

Most patients with isolated PFO are asymptomatic. Possible of the signs and symptoms can include:

History of stroke or transient ischemic event of undefined etiology
Migraine or migraine-like symptoms - Whether symptoms are due to transient ischemic attacks or paradoxical embolism is not clear
Neurologic decompression sickness - Seen with PFO in a small percent of scuba divers

Other, less common clinical manifestations of PFO include the following:

Acute myocardial infarction
Systemic embolism, such as renal infarction
Fat embolism
Paradoxical embolism caused by right atrial tumors that increase right atrial pressure
Left-sided valve disease in carcinoid syndrome

See Presentation for more detail.

Diagnosis

The following types of echocardiography can be used in the detection of PFO:

Color flow Doppler imaging: A small "flame" of color signal may be seen in the middle region of the atrial septum
Contrast echocardiography: Usually required to detect a small PFO

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[Guideline] Lopez L, Saurers DL, Barker PCA, et al. Guidelines for performing a comprehensive pediatric transthoracic echocardiogram: recommendations from the American Society of Echocardiography. J Am Soc Echocardiogr. 2024 Feb. 37 (2):119-70. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Diener HC, Akagi T, Durongpisitkul K,et al. Closure of the patent foramen ovale in patients with embolic stroke of undetermined source: A clinical expert opinion and consensus statement for the Asian-Pacific region. Int J Stroke. 2020 Dec. 15 (9):937-44. [QxMD MEDLINE Link].
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Lanzone AM, Castelluccio EV, Della Pina P, Boldi E, Lussardi G, Frati G, et al. Comparative diagnostic accuracy of transcranial Doppler and contrast-enhanced transthoracic echocardiography for the diagnosis of patent foramen ovale and atrial septal defect. Panminerva Med. 2024 Jun. 66 (2):124-30. [QxMD MEDLINE Link].
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Media Gallery

This 2-dimensional echocardiogram in an infant (subcostal long-axis view) shows a patent foramen ovale. Right atrium (RA) and left atrium (LA
Color Doppler of the patent foramen ovale (PFO) seen in the previous image. A small amount of left-to-right flow is present. This left-to-right flow pattern is typical for PFO seen in newborn infants
Color Doppler of the patent foramen ovale (PFO) seen in the previous image. A small amount of left-to-right flow is present. This left-to-right flow pattern is typical for PFO seen in newborn infants

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