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{{Patent foramen ovale}}
{{Patent foramen ovale}}


{{CMG}}; '''Associate Editors-In-Chief:''' [[Priyamvada Singh|Priyamvada Singh, M.B.B.S.]] [mailto:psingh13579@gmail.com]; '''Assistant Editor-In-Chief:''' [[Kristin Feeney|Kristin Feeney, B.S.]] [mailto:kfeeney@elon.edu]
{{CMG}}; {{AE}} {{IO}}, [[Priyamvada Singh|Priyamvada Singh, M.B.B.S.]] [mailto:psingh13579@gmail.com], [[Kristin Feeney|Kristin Feeney, B.S.]] [mailto:kfeeney@elon.edu]


==Overview==
==Overview==
A [[patent foramen ovale]] is a flap-like structure in inter-atrial septum that is formed by failure of postnatal fusion of [[septum primum]] and septum secundum. It periodically opens and allows [[blood]] to [[shunt]] between the two [[atria]]. Thus, it is also sometimes called as a probe patent (PFO). This flap-like structure functions like a one-way valve mechanism that only opens to allow blood to flow from the [[right atrium]] to the [[left atrium]] during times where there is an increase flow or pressure in the right atrium.  Elevation of pressure in the pulmonary circulatory system (i.e.: [[pulmonary hypertension]], [[cough]] or [[valsalva maneuver]]) can cause the foramen ovale to open.
During the 4th week of [[gestation]], formation of the [[Interatrial septum|atrial septum]] begins. Formation of the [[septum primum]] and septum secundum leads to the development of a [[foramen ovale]] which allows [[blood]] to flow from the [[right atrium]] to the [[left atrium]] in the [[fetus]]. Fusion of both septa's occurs after birth with increased [[Left atrium|left atrial]] pressure. The [[foramen ovale]] remains patent in some people due to failure of fusion of the [[septum primum]] and septum secundum. This permits [[blood]] flow from the [[right atrium]] to the [[left atrium]] during periods of increased [[Right atrium|right atrial]] pressure. Some conditions associated with [[patent foramen ovale]] include [[cryptogenic stroke]], [[migraine with aura]], and [[decompression sickness]] in divers.


==Pathophysiology==
==Pathophysiology==
===Embryology===
*[[Atrium (heart)|Atrial]] septation begins at about the 4th week of [[gestation]]. A crescent-shaped [[septum primum]] grows from the primordial [[Atrium (heart)|atrial]] roof towards the [[Endocardial cushions|endocardial cushion]] and partially divides the common [[Atrium (heart)|atrium]] into right and left halves.<ref name="pmid27541719">{{cite journal| author=Kloesel B, DiNardo JA, Body SC| title=Cardiac Embryology and Molecular Mechanisms of Congenital Heart Disease: A Primer for Anesthesiologists. | journal=Anesth Analg | year= 2016 | volume= 123 | issue= 3 | pages= 551-69 | pmid=27541719 | doi=10.1213/ANE.0000000000001451 | pmc=4996372 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27541719  }} </ref><ref name="HaraVirmani2005">{{cite journal|last1=Hara|first1=Hidehiko|last2=Virmani|first2=Renu|last3=Ladich|first3=Elena|last4=Mackey-Bojack|first4=Shannon|last5=Titus|first5=Jack|last6=Reisman|first6=Mark|last7=Gray|first7=William|last8=Nakamura|first8=Masato|last9=Mooney|first9=Michael|last10=Poulose|first10=Anil|last11=Schwartz|first11=Robert S.|title=Patent Foramen Ovale: Current Pathology, Pathophysiology, and Clinical Status|journal=Journal of the American College of Cardiology|volume=46|issue=9|year=2005|pages=1768–1776|issn=07351097|doi=10.1016/j.jacc.2005.08.038}}</ref>
*Formation of the [[endocardial cushions]] occurs on the ventral and dorsal walls of the [[atrioventricular canal]]. Before the [[septum primum]] reaches the [[endocardial cushion]], [[programmed cell death]] occurs in the more cranial part giving rise to perforations that become a large window called the [[ostium secundum]]/foramen secundum.
*Around day 33, a crescent-shaped septum secundum forms on the right side of the [[septum primum]]. It grows gradually and overlaps part of the [[ostium secundum]]/foramen secundum forming an oval-shaped, incomplete septal partition that becomes the [[foramen ovale]]. The [[foramen ovale]] permits [[blood]] to pass from the [[right atrium]] to the [[left atrium]].
*A flap-like [[valve]] is formed by the remaining [[septum primum]] over the [[foramen ovale]]. Fusion of both septa's occur after birth.
===Physiology===
*In [[Fetus|fetal]] circulation, [[oxygenated blood]] from the [[placenta]] flows through the [[umbilical vein]] to the [[inferior vena cava]] and makes its way into the [[right atrium]]. Due to greater [[Right atrium|right atrial]] pressure compared to [[Left atrium|left atrial]] pressure [[in utero]], [[blood]] flows from the [[right atrium]] to the left through the [[foramen ovale]]. [[Blood]] from the [[left atrium]] flows into the [[left ventricle]], into the [[aorta]] and to the systemic circulation. The deoxygenated [[blood]] from the systemic circulation travels back to the [[placenta]] through the [[Umbilical artery|umbilical arteries]] for [[oxygenation]] by the mother.<ref name="HaraVirmani2005">{{cite journal|last1=Hara|first1=Hidehiko|last2=Virmani|first2=Renu|last3=Ladich|first3=Elena|last4=Mackey-Bojack|first4=Shannon|last5=Titus|first5=Jack|last6=Reisman|first6=Mark|last7=Gray|first7=William|last8=Nakamura|first8=Masato|last9=Mooney|first9=Michael|last10=Poulose|first10=Anil|last11=Schwartz|first11=Robert S.|title=Patent Foramen Ovale: Current Pathology, Pathophysiology, and Clinical Status|journal=Journal of the American College of Cardiology|volume=46|issue=9|year=2005|pages=1768–1776|issn=07351097|doi=10.1016/j.jacc.2005.08.038}}</ref>
*At birth, [[oxygen]] fills the [[alveolus]] resulting in a drop in right heart pressure and [[pulmonary vascular resistance]]. The amount of [[blood]] entering the [[left atrium]] from the [[Lung|lungs]] increases leading to increased [[Left atrium|left atrial]] pressure. These mechanisms cause closure of the [[foramen ovale]]. In most individuals, the [[foramen ovale]] closes by age two.
===Pathogenesis===
*Soon after birth, as an [[infant]] takes its first breath, the negative intrathoracic pressure closes the [[foramen ovale]]. It may remain open in a number of people due to failure of fusion of the [[septum primum]] and septum secundum making the closure incomplete. This [[patent foramen ovale]] permits interatrial flow of [[blood]] from the [[right atrium]] to the [[left atrium]] during periods when the [[Right atrium|right atrial]] pressure exceeds that of the [[left atrium]], for example, [[Cough|coughing]], [[Sneeze|sneezing]] or straining<ref name="pmid30858890">{{cite journal| author=Giblett JP, Abdul-Samad O, Shapiro LM, Rana BS, Calvert PA| title=Patent Foramen Ovale Closure in 2019. | journal=Interv Cardiol | year= 2019 | volume= 14 | issue= 1 | pages= 34-41 | pmid=30858890 | doi=10.15420/icr.2018.33.2 | pmc=6406129 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30858890  }} </ref><ref name="pmid11733736">{{cite journal| author=Wahl A, Windecker S, Meier B| title=Patent foramen ovale: pathophysiology and therapeutic options in symptomatic patients. | journal=Minerva Cardioangiol | year= 2001 | volume= 49 | issue= 6 | pages= 403-11 | pmid=11733736 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11733736  }} </ref>
*It is undetected in a majority of people and may be seen during cardiac investigation.<ref name="pmid30858890">{{cite journal| author=Giblett JP, Abdul-Samad O, Shapiro LM, Rana BS, Calvert PA| title=Patent Foramen Ovale Closure in 2019. | journal=Interv Cardiol | year= 2019 | volume= 14 | issue= 1 | pages= 34-41 | pmid=30858890 | doi=10.15420/icr.2018.33.2 | pmc=6406129 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30858890  }} </ref>


A patent foramen ovale is a flap-like structure that periodically opens and allows shunting of blood from right-to-left atria. As a result, it is also sometimes called as a probe patent patent foramen ovale. The shunting could occur with a transient elevation of pressure in the [[pulmonary artery|pulmonary circulation]] that occurs during [[pulmonary hypertension]], [[valsalva maneuver]] or [[cough]].  The size and the degree of right-to-left shunt appear to be important in determining the pathological significance of [[patent foramen ovale]]<ref name="pmid8128511">{{cite journal| author=Homma S, Di Tullio MR, Sacco RL, Mihalatos D, Li Mandri G, Mohr JP| title=Characteristics of patent foramen ovale associated with cryptogenic stroke. A biplane transesophageal echocardiographic study. | journal=Stroke | year= 1994 | volume= 25 | issue= 3 | pages= 582-6 | pmid=8128511 | doi= | pmc= | url= }} </ref><ref name="pmid7560596">{{cite journal| author=Hausmann D, Mügge A, Daniel WG| title=Identification of patent foramen ovale permitting paradoxic embolism. | journal=J Am Coll Cardiol | year= 1995 | volume= 26 | issue= 4 | pages= 1030-8 | pmid=7560596 | doi=10.1016/0735-1097(95)00288-9 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7560596 }} </ref><ref name="pmid9596240">{{cite journal| author=Steiner MM, Di Tullio MR, Rundek T, Gan R, Chen X, Liguori C et al.| title=Patent foramen ovale size and embolic brain imaging findings among patients with ischemic stroke. | journal=Stroke | year= 1998 | volume= 29 | issue= 5 | pages= 944-8 | pmid=9596240 | doi= | pmc= | url= }} </ref>. In a multi-center randomized trial, larger [[patent foramen ovale]] were found to be more associated with [[Paradoxical embolism|cryptogenic stroke]] than smaller patent foramen ovale<ref name="pmid12045168">{{cite journal| author=Homma S, Sacco RL, Di Tullio MR, Sciacca RR, Mohr JP, PFO in Cryptographic Stroke Study (PICSS) Investigators| title=Effect of medical treatment in stroke patients with patent foramen ovale: patent foramen ovale in Cryptogenic Stroke Study. | journal=Circulation | year= 2002 | volume= 105 | issue= 22 | pages= 2625-31 | pmid=12045168 | doi= | pmc= | url= }} </ref>.
==Genetics==
*F2 ([[prothrombin]]) and [[Apolipoprotein]]-C3 [[genes]] may be associated with [[patent foramen ovale]].<ref name="pmid22784820">{{cite journal| author=Lantz M, Sjöstrand C, Kostulas K| title=Ischemic stroke and patent foramen ovale: risk factors and genetic profile. | journal=J Stroke Cerebrovasc Dis | year= 2013 | volume= 22 | issue= 6 | pages= 841-5 | pmid=22784820 | doi=10.1016/j.jstrokecerebrovasdis.2012.06.002 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22784820 }} </ref>


===Embryology===
==Associated Conditions==
During [[fetal]] development, the presence of a [[patent foramen ovale]] is necessary for life as it allows for right-to-left shunting so that [[oxygenated blood]] can flow to the left side of the [[heart]]. At the time of [[birth]], [[blood]] begins to flow through the pulmonary circulation and this results in a rise in left atrial pressure. This rise in left atrial pressure functionally closes the flap-like structure. This functional closure is usually followed by the mechanical or anatomic closure of the structure by the age of one. A patent foramen ovale or [[PFO]] forms by failure of postnatal fusion of the two components that form the inter-atrial septum i.e. [[septum primum]] and [[septum secundum]].
Conditions associated with [[patent foramen ovale]] include:<ref name="YakhkindCastaldo2017">{{cite journal|last1=Yakhkind|first1=A.|last2=Castaldo|first2=J.|last3=Leary|first3=M.C.|title=Stroke and Migraine|year=2017|pages=570–573|doi=10.1016/B978-0-12-803058-5.00111-9}}</ref><ref name="pmid11527606">{{cite journal| author=Kerut EK, Norfleet WT, Plotnick GD, Giles TD| title=Patent foramen ovale: a review of associated conditions and the impact of physiological size. | journal=J Am Coll Cardiol | year= 2001 | volume= 38 | issue= 3 | pages= 613-23 | pmid=11527606 | doi=10.1016/s0735-1097(01)01427-9 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11527606  }} </ref><ref name="GafoorSharma2017">{{cite journal|last1=Gafoor|first1=Sameer|last2=Sharma|first2=Rahul|last3=Zhang|first3=Ming|last4=Casterella|first4=Peter|last5=Atianzar|first5=Kimberly|title=Update on the Management of Patent Foramen Ovale in 2017: Indication for Closure and Literature Review|journal=US Cardiology Review|volume=11|issue=2|year=2017|pages=75|issn=1758-3896|doi=10.15420/usc.2017:18:1}}</ref>
*[[Cryptogenic stroke]]
*[[Migraine|Migraine headache]]
*Atrial septal aneurysm
*[[Chiari network]]
*[[Obstructive sleep apnea]]
*[[Decompression sickness]]


==References==
==References==
{{Reflist|2}}
{{reflist|2}}


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[[Category:Up-To-Date]]




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Latest revision as of 15:56, 13 February 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ifeoma Odukwe, M.D. [2], Priyamvada Singh, M.B.B.S. [3], Kristin Feeney, B.S. [4]

Overview

During the 4th week of gestation, formation of the atrial septum begins. Formation of the septum primum and septum secundum leads to the development of a foramen ovale which allows blood to flow from the right atrium to the left atrium in the fetus. Fusion of both septa's occurs after birth with increased left atrial pressure. The foramen ovale remains patent in some people due to failure of fusion of the septum primum and septum secundum. This permits blood flow from the right atrium to the left atrium during periods of increased right atrial pressure. Some conditions associated with patent foramen ovale include cryptogenic stroke, migraine with aura, and decompression sickness in divers.

Pathophysiology

Embryology

Physiology

Pathogenesis

Genetics

Associated Conditions

Conditions associated with patent foramen ovale include:[6][7][8]

References

  1. ↑ Kloesel B, DiNardo JA, Body SC (2016). "Cardiac Embryology and Molecular Mechanisms of Congenital Heart Disease: A Primer for Anesthesiologists". Anesth Analg. 123 (3): 551–69. doi:10.1213/ANE.0000000000001451. PMC 4996372. PMID 27541719.
  2. ↑ 2.0 2.1 Hara, Hidehiko; Virmani, Renu; Ladich, Elena; Mackey-Bojack, Shannon; Titus, Jack; Reisman, Mark; Gray, William; Nakamura, Masato; Mooney, Michael; Poulose, Anil; Schwartz, Robert S. (2005). "Patent Foramen Ovale: Current Pathology, Pathophysiology, and Clinical Status". Journal of the American College of Cardiology. 46 (9): 1768–1776. doi:10.1016/j.jacc.2005.08.038. ISSN 0735-1097.
  3. ↑ 3.0 3.1 Giblett JP, Abdul-Samad O, Shapiro LM, Rana BS, Calvert PA (2019). "Patent Foramen Ovale Closure in 2019". Interv Cardiol. 14 (1): 34–41. doi:10.15420/icr.2018.33.2. PMC 6406129. PMID 30858890.
  4. ↑ Wahl A, Windecker S, Meier B (2001). "Patent foramen ovale: pathophysiology and therapeutic options in symptomatic patients". Minerva Cardioangiol. 49 (6): 403–11. PMID 11733736.
  5. ↑ Lantz M, Sjöstrand C, Kostulas K (2013). "Ischemic stroke and patent foramen ovale: risk factors and genetic profile". J Stroke Cerebrovasc Dis. 22 (6): 841–5. doi:10.1016/j.jstrokecerebrovasdis.2012.06.002. PMID 22784820.
  6. ↑ Yakhkind, A.; Castaldo, J.; Leary, M.C. (2017). "Stroke and Migraine": 570–573. doi:10.1016/B978-0-12-803058-5.00111-9.
  7. ↑ Kerut EK, Norfleet WT, Plotnick GD, Giles TD (2001). "Patent foramen ovale: a review of associated conditions and the impact of physiological size". J Am Coll Cardiol. 38 (3): 613–23. doi:10.1016/s0735-1097(01)01427-9. PMID 11527606.
  8. ↑ Gafoor, Sameer; Sharma, Rahul; Zhang, Ming; Casterella, Peter; Atianzar, Kimberly (2017). "Update on the Management of Patent Foramen Ovale in 2017: Indication for Closure and Literature Review". US Cardiology Review. 11 (2): 75. doi:10.15420/usc.2017:18:1. ISSN 1758-3896.


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