Patent foreman ovale (PFO)

Signs and symptoms: Most patients with PFO do not have any symptoms. The condition may play a role in migraine headaches and increases the risk of stroke, transient ischemic attack and heart attack. Migraine headaches occurs wuth aura and relived with the closure of PFO. Risk of the stroke ischemic attach and heart attack increases because of the increase chances of the clot to move from right to left side thus blocking cranial or coronary artery. Patient younger than 55ys of age, having stroke without a known cause are more likely to have a PFO. • Sudden weakness or numbness in the face, arm or leg on one side of the body. • Sudden blurred vision or trouble seeing out of one or both eyes. • Can’t speak or trouble talking or understanding what others are saying. • Dizziness, loss of balance, unstable walking. • Passing out for a short time. • Suddenly can’t move part of the body (paralysis). • Obstructive sleep apnea . Cardaic anomalies: PDO is associated with other cardiac anomalies like; • Atrial septal aneurysm: Bulging of the top portion of the septum into one or both atria. • Eustachian valve: Eustachian valve is located at junction of inferior vena cava and right atrium. • Chiari network: A fenestrated mobile structure consists of a network of threads and fibers in the right atrium that originate from the region of the Eustachian and thebesian valve at the orifice of inferior vena cava with attachments to upper wall of right atrium or atrial septum. • In a study by Schneider, 1436 consecutive patients were referred for TEE. A Chiari network was found in 29 subjects (2%), 24 (83%) had PFO, and 7 (24%) had an atrial septal aneurysm. [1] • Atrial septal defect: In a study of 103 patients by Khositseth who were referred for transcatheter closure for a paradoxical embolism, PFO was present in 81 subjects , ASD in 12 subjects, and both PFO and ASD in 10 subjects. [2] • Ebstein anomaly: In a study by Attenhofer of 106 patients, 79% had either persistent or previously closed PFO or atrial septal defect. [3] PDO is associated with other cardiac anomalies like Diagnosis: Special tests are required to diagnose a case of patent foramen ovale. • Color flow Doppler imaging. using sound waves to detect abnormal flow between right and left atrium • Echocardiogram (echo) – An ultrasound of the heart to check blood flow across the heart valves and chambers. • Tran esophageal echo (TEE) – A probe with a tiny camera is placed in the esophagus (swallowing/ food tube). This type of echo shows a clearer picture of the defect than a standard echo does. two type either 2-D or 3-D TEE • Bubble study – This is done during an echo or TEE. An IV filled with agitated saline is placed in your arm. The saline makes bubbles that the doctor watches to see if they move from one side of the heart to the other. Other tests are required to check for the complication that may arise as a result of PFO mentioned above. Treatment: Medical treatment: Patient with PFO as an isolated finding require no treatment. However if PFO is associated with unexplained neurological event medical treatment option includes • Antiplatelets (aspirin,clopidogeral) • Warfarin in combination with aspirin in high risk patient Maintain international normalization ratio (INR) between 2-3. Both require to prevent cryptogenic(unexplained) stroke.[4,5] The recurrence rate of stroke or TIA has been reported to be as high as 3.4-3.9% per year. Surgical treatment: Double continuous suture is being use for the surgical closure of the patent foramen ovale. Indication includes • PFO more than 25 mm in size • Inadequate rim of tissue around the defect • Percutaneous device failure Advantages include: • Permanent closure of the defect • Prevents future paradoxical emboli • No long-term anticoagulation and its risks Disadvantages include: • General anesthesia • Open-heart surgery • Hospital stay for a few days • The usual risks of cardiac surgery Percutaneous care Percutaneous closure of PFO during cardiac catheterization is an emerging therapeutic option. Indications • Recurrent stroke • Contraindication of anticoagulant therapy • Paradoxical peripheral or coronary embolism • Patient with hypercoagubility state. The Federal Drug Administration (FDA) has approved 2 percutaneous devices for PFO closure. • The Cardio SEAL Septal Occlusion System is a double umbrella-shaped permanent implant. • The Amplatzer PFO Occluder is a self-expanding wire mesh with double discs Procedure require 24-48 hours hospital stay and prophylactic 6 months aspirin and warfarin therapy. Complication: Complications of catheter-based closure of patent foramen ovale (PFO) includes: • Embolism of device. • Device entrapment within the Chiari network. • Frame fracture. • Vessel damage, or perforation of atrial wall, may require further surgery • Air embolism during device delivery. • Thrombus formation around the device. • Infective endocarditis.