Journal of Rare Cardiovascular Diseases

Patent foramen ovale (PFO) is a residue of the foramen ovale, an integral part of the normal fetal circulation. It closes in most of newborns, however 25–30% of adults may have it patent. Conditions such as crytpogenic stroke, migraine and vascular headaches or decompression sickness are strongly related to the presence of PFO. Less frequently acute myocardial infarction, renal infarction or acute mesenteric ischemia may also occur. We present a case of a 67-year-old man after cerebral ischemic episode, acute myocardial infarction treated with primary coronary intervention and pulmonary embolism, who was eventually diagnosed with PFO and factor V Leiden mutation. Life-long anticoagulation was initiated in this patient as a standard-of-care. He additionally underwent successful percutaneous PFO closure. As a result no subsequent thromboembolic complication occurred in this patient at the follow-up period. JRCD 2015; 2 (2): 18–21

V Leiden mutation; anticoagulation; device closure

Hara H, Virmani R, Ladich E, et al. Patent foramen ovale: current pathology, pathophysiology, and clinical status. J Am Coll Cardiol. 2005; 46: 1768–1776.

Podolec P, Suchoń E, Kabłak-Ziembicka A. Przetrwały otwór owalny – diagnostyka i wskazania do przezskórnego zamykania PFO. Echokardiografia Praktyczna, Vol. III, Chapter 14, Medycyna Praktyczna 2005: 183–191.

Hagen PT, Scholz DG, Edwards WD. Incidence and size of patent foramen ovale during the first 10 decades of life: an autopsy study of 965 normal hearts. Mayo Clin Proc.1984; 59: 17–20.

Clark EB. Pathogenetic mechanisms of congenital cardiovascular malformations revisited. Semin Perinatol 1996; 20: 465–472.

Kerut EK, Norfleet WT, Plotnick GD, et al. Patent foramen ovale: a review of associated conditions and the impact of physiological size. J Am Coll Cardiol. 2001; 38: 613–623.

Larrue V, Berhoune N, Massabuau P et al. Etiologic investigation of ischemic stroke in young adults. Neurology 2011; 76: 1983–1988.

Anzola GP, Magoni M, Guindani M, et al. Potential source of cerebral embolism in migraine with aura: a transcranial Doppler study. Neurology 1999; 52: 1622–1625.

Agostoni P, Gasparini G, Destro G. Acute myocardial infarction probably caused by paradoxical embolus in a pregnant woman. Heart. 2004; 90: e12.

Carey HB, Boltax R, Dickey KW, et al. Bilateral renal infarction secondary to paradoxical embolism. Am J Kidney Dis. 1999; 34: 752–755.

Mas JL, Arquizan C, Lamy C, et al. Recurrent cerebrovascular events associated with patent foramen ovale, atrial septal aneurysm, or both. N Engl J Med. 2001; 345: 1740 –1746.

Alsheikh-Ali AA, Thaler DE, Kent DM. Patent foramen ovale in cryptogenic stroke: incidental or pathogenic? Stroke. 2009; 40: 2349–2355.

Pinto FJ. When and how to diagnose patent foramen ovale. Heart. 2005; 91: 438–440.

Lee RJ, Bartzokis T, Yeoh TK, et al. Enhanced detection of intracardiac sources of cerebral emboli by transesophageal echocardiography. Stroke1991; 22: 734–739.

Pearson AC, Labovitz AJ, Tatineni S, et al. Superiority of transesophageal echocardiography in detecting cardiac source of embolism in patients with cerebral ischemia of uncertain etiology. J Am Coll Cardiol 1991; 17: 66–72.

Kerr AJ, Buck T, Chia K, et al. Transmitral Doppler: a new transthoracic contrast method for patent foramen ovale detection and quantification. J Am Coll Cardiol. 2000; 36: 1959–1966.

Blersch WK, Draganski BM, Holmer SR, et al. Transcranial duplex sonography in the detection of patent foramen ovale. Radiology 2002; 225: 693–699.

Ringleb PA, Bousser MG, Ford G, et al. Guidelines for Management of Ischaemic Stroke and Transient Ischaemic Attack 2008. Cerebrovasc Dis. 2008; 25: 457–507.

Homma S, Sacco RL, Di Tullio MR, et al. Effect of medical treatment in stroke patients with patent foramen ovale: patent foramen ovale in Cryptogenic Stroke Study. Circulation 2002; 105: 2625–2631.

Lansberg MG, O’Donnell MJ, Khatri P, et al. Antithrombotic and thrombolytic therapy for ischemic stroke: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141(2 Suppl): e601S.

Furie KL, Kasner SE, Adams RJ, et al. Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack: a guideline for healthcare professionals from the american heart association/american stroke association. Stroke 2011; 42: 227–276.

Homma S, Di Tullio MR, Sacco RL, et al. Surgical closure of patent foramen ovale in cryptogenic stroke patients. Stroke 1997; 28: 2376–2381.

Dearani JA, Ugurlu BS, Danielson GK, et al. Surgical patent foramen ovale closure for prevention of paradoxical embolism-related cerebrovascular ischemic events. Circulation 1999; 100 (19 Suppl): II171-175.

Devuyst G, Bogousslavsky J, Ruchat P, et al. Prognosis after stroke followed by surgical closure of patent foramen ovale: a prospective follow-up study with brain MRI and simultaneous transesophageal and transcranial Doppler ultrasound. Neurology 1996; 47: 1162–1166.

O’Gara PT, Messe SR, Tuzcu EM, et al. Percutaneous device closure of patent foramen ovale for secondary stroke prevention: a call for completion of randomized clinical trials. A science advisory from the American Heart Association/American Stroke Association and the American College of Cardiology Foundation. J Am Coll Cardiol. 2009; 53: 2014–2018.

Bruch L, Parsi A, Grad MO, et al. Transcatheter closure of interatrial communications for secondary prevention of paradoxical embolism: single-center experience. Circulation 2002; 105: 2845–2848.

Windecker S, Wahl A, Nedeltchev K, et al. Comparison of medical treatment with percutaneous closure of patent foramen ovale in patients with cryptogenic stroke. J Am Coll Cardiol. 2004; 44: 750–758.

Agarwal S, Bajaj NS, Kumbhani DJ, et al. Meta-analysis of transcatheter closure versus medical therapy for patent foramen ovale in prevention of recurrent neurological events after presumed paradoxical embolism. JACC Cardiovasc Interv. 2012; 5: 777–789.

Furlan AJ, Reisman M, Massaro J, et al. Closure or medical therapy for cryptogenic stroke with patent foramen ovale. N Engl J Med. 2012; 366: 991–999.

Meier B, Kalesan B, Mattle HP, et al. Percutaneous closure of patent foramen ovale in cryptogenic embolism. N Engl J Med. 2013; 368: 1083–1091.

Carroll JD, Saver JL, Thaler DE, et al. Closure of patent foramen ovale versus medical therapy after cryptogenic stroke. N Engl J Med. 2013; 368: 1092–100