Patent Foramen Ovale Symptoms & Causes

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In-Depth

It’s natural for you to be concerned right now about your child’s health—a diagnosis of patent foramen ovale (PFO) can be distressing. But you can rest assured that at Children’s Hospital Boston, your child is in expert hands.

With more than 80 cardiac experts on our staff, Children’s operates the largest pediatric heart program in the nation. Every year, we treat thousands of children, adolescents and adults who are living with a broad spectrum of cardiac problems—ranging from congenital heart defects to blood vessel disorders, heart and lung disease and congestive heart failure.

What is the foramen ovale? What is a patent foramen ovale?

  • A foramen ovale is a flap-like hole between the wall (atrial septum) that separates the heart’s right and left upper chambers (atria).
  • Before a baby is born, this hole is a naturally occurring opening allows blood to bypass the fetus’ lungs, which will not receive oxygen until the baby’s first cry at birth.
  • Because the fetus’s lungs do not yet function, it’s the mom’s umbilical cord that sends oxygen-rich blood across the foramen ovale and out to the fetus.
  • After birth, oxygen-enriched blood returns directly from the baby’s own lungs, and the foramen ovale seals in 75 percent of the population. In the other 25 percent, the opening fails to seal and remains open (patent)—this persistently open hole is a patent foramen ovale. It is similar in location to atrial septal defects (ASD) but it rarely results in disease on its own.

Are there additional defects associated with a PFO?

A PFO can be associated with more serious heart defects, such as hypoplastic left heart syndrome, Ebstein’s anomaly or pulmonary atresia. When repairing these defects, the surgeon will often close the PFO.

What are the symptoms of a PFO? Why is it a concern?

Unlike many other heart defects, a PFO in isolation (occurring by itself without other defects) usually causes no signs or symptoms and doesn’t need treatment. A PFO will usually become evident only if a child has another associated cardiac problem.

Rarely, a baby with a PFO will develop a bluish skin tone (cyanosis) when he strains (as in a bowel movement) or cries. If a PFO causes a baby’s oxygen levels to be low because of right-to-left blood flow across it, the doctor may close the hole surgically.

Untreated PFOs have been considered to have association with some other conditions in adults, including stroke, migraines and “the bends” and sleep apnea, but the PFO’s relationship to these conditions is not conclusive and is still being studied at Children’s and other research centers.

How do you diagnose a PFO?

Most babies, children and adults with a PFO show no symptoms, so if it’s discovered, it’s usually “accidentally” during an exam for another cardiac issue or symptom.

Diagnostic testing for a PFO may include EKG (electrocardiogram) or one of several types of echocardiogram.

One type of echocardiogram that gives particularly detailed views of a PFO is a transesophageal echo (TEE), which uses a small ultrasound probe placed into a child’s esophagus to closely evaluate the heart and blood vessels within his chest. This technique obtains a clearer image because sound waves don’t have to pass through skin, muscle or bone tissue.

How do you treat a PFO?

Most of the time, a baby or child with a PFO doesn’t need treatment at all. If a child needs surgery to treat an associated heart defect, the PFO may be closed at the time of the surgery.

Closing a PFO surgically—usually by insertion of a device that “plugs” the PFO and is gradually enveloped by the body’s tissue—is useful under uncommon select circumstances that your physician may guide you about. For more, see Treatment & Care.

Will my child be OK after surgery for a patent foramen ovale?

The outlook varies from child to child, but heart surgeries at Children’s have success rates approaching 98 percent—among the highest in the nation among large pediatric cardiac centers. Between 2007 and 2010 atrial septal defect repairs such as those performed for patent foramen ovale had 100 percent success at Children’s.

What causes a patent foramen ovale?

The exact reason that a foramen ovale will remain open instead of closing naturally is unknown, but it’s thought that heredity and genetics may play a role.

It’s important for parents to understand that you’ve done nothing to cause your baby’s PFO or any accompanying defects. Nothing you’ve ingested or have been exposed to environmentally has been definitively linked to having a baby with PFO.

How common is a PFO?

It’s fairly common. After birth, the foramen ovale closes in 75 percent of the population. In the other 25 percent, the opening fails to close and remains open (patent).

Will my baby be OK in the future?

Most people who have had congenital heart disease will have an ongoing relationship with their Children’s cardiologist. Your cardiologist may recommend that your child take aspirin or another blood-thinner because of PFO’s potential for association with stroke.

The doctor will follow your child during maturation into childhood, the teen years and even adulthood. It’s uncommon for any restrictions to be placed on future activities for your child. We’ll watch for specific complications of PFO or related disease, and will advise on daily-life issues, such as exercise and activity levels, nutrition and precautions related to pregnancy, if such exist.

If my child needs care and support for a PFO when he grows up, where can he find it?

  • The Boston Adult Congenital Heart and Pulmonary Hypertension Service (BACH) provides long-term inpatient and outpatient care and advanced therapeutic options for patients with congenital heart disease and pulmonary hypertension as they reach and progress through adulthood.
  • BACH is an international center for excellence, with physicians and services from Children’s, Brigham and Women’s Hospital and Beth Israel Deaconess Medical Center. The center promotes and supports clinical and scientific research for the advancement of care of these patients, and is a leader in the education of providers caring for this unique population.
  • The Adult Congenital Heart Association (ACHA) is a national not-for-profit organization dedicated to improving the quality of life—and extending the life—of adults with congenital heart defects. The organization serves and supports many of the adults with congenital heart defects (thought to number as many as one million), their families and the medical community, as well as conducting research and providing advocacy, outreach and education.


Frequently Asked Questions (FAQ) about Patent Foramen Ovale 

Q: Are there different types of patent foramen ovale?
A:
There aren’t different types of PFO, but there are different conditions under which it can occur:

  • in isolation (uncomplicated): If the PFO occurs by itself without other heart defects present, it will very likely not need to be treated.
  •  in association with other heart defects: A PFO can be present along with other more serious heart defects that need surgery, such as hypoplastic left heart syndrome, Ebstein’s anomaly or pulmonary atresia. The PFO is often closed at the same time that surgery takes place for these other defects.

Q: If my child needs surgery for his PFO, will he be OK?
A:
The outlook varies from child to child, but heart surgeries at Children’s have

  • success rates approaching 98 percent—among the highest in the nation among large pediatric cardiac centers. Between 2007 and 2010 atrial septal defect repairs similar to those performed for patent foramen ovale had 100 percent success at Children’s.

Q: If my child has a PFO, what should I ask my doctor?
A:
Some questions you may want to ask include:

  • Does my child’s heart have other defects associated with his PFO?
  • What tests will you perform to further diagnose my child?
  • Will my child need surgery?
  • Are there alternative therapies?
  • Will my child be OK if he has a PFO?
  • What are the long-term health risks?
  • Will there be restrictions on my child’s activities?
  • Is there associated risk for stroke or migraines?
  • Is there need to take blood-thinners?
  • Will there be long-term effects?
  • What can we do at home?

Q: When is a PFO usually diagnosed, and how?
A:
Most babies, children and adults with a PFO show no symptoms, so if it’s discovered, it’s usually “accidentally” during an exam for another cardiac issue or symptom.

Diagnostic testing for a PFO may include an EKG (electrocardiogram) or one of several types of echocardiogram.

Q: What is Children’s’ experience treating congenital heart defects?
A:
Children’s surgeons treat some of the most complex pediatric heart conditions in the world, with overall success rates approaching 98 percent—among the highest in the nation among large pediatric cardiac centers. Each year, we treat hundreds of children, adolescents and even adults with a wide variety of heart defects and disorders.

Our experts have pioneered some of medical science’s most advanced heart treatments, now in use around the globe. Children’s is among the only major pediatric heart centers in the world performing fetal heart interventions for certain congenital defects.

Q: What heart research and innovations are coming from Children’s?
A:
A significant amount of Children’s groundbreaking cardiac research aims to refine and advance the open heart surgery and catheterization procedures that treat congenital heart defects in newborns and young children—including pulmonary atresia. Children’s Cardiac Surgery Research Laboratory is studying the mechanisms of heart disease and new treatments for children with congenital heart defects.

Children’s Hospital has been part of the leadership and organization of randomized clinical trials assessing the role of PFO in disease, as well as the possible risks and benefits of treatment of PFO in diseases felt to be associated with PFO.

Learn more about Children’s cardiac research initiatives and Children’s current projects in cardiology research.

Causes of Patent Foramen Ovale 

The exact reason that a foramen ovale will remain open instead of closing naturally is unknown, but it’s thought that heredity and genetics may play a role.

It’s important for parents to understand that you’ve done nothing to cause your baby’s PFO or any accompanying defects. Nothing you’ve ingested or have been exposed to environmentally has been definitively be linked to having a baby with PFO.

When to seek medical advice

Call your health care provider immediately if your baby or child is having difficulty breathing or is breathing rapidly, has a bluish color or seems to tire too easily.

Questions to ask your doctor

After your child is diagnosed with PFO, you may feel overwhelmed with information. It can be easy to lose track of the questions that occur to you. Lots of parents find it helpful to jot down questions as they arise—that way, when you talk to your child’s doctors, you can be sure that all of your concerns are addressed.

  • Some questions you may want to ask include:
  • Does my child’s heart have other defects associated with his PFO?
  • What tests will you perform to further diagnose my child?
  • Will my child need surgery?
  • Are there alternative therapies?
  • Will my child be OK if he has a PFO?
  • What are the long-term health risks?
  • Will there be restrictions on my child’s activities?
  • Is there associated risk for stroke or migraines?
  • Is there need to take blood-thinners?
  • Will there be long-term effects?
  • What can we do at home?

Who’s at risk

Congenital heart defects usually occur sporadically (by chance), with no clear reason for their development. So, it’s difficult to predict who’s at risk. Familial cases have been reported, but no genetic link has been confirmed.

A PFO is often present in association with more complex heart defects, such as hypoplastic left heart syndrome, Ebstein’s anomaly or pulmonary atresia.

Precautions and complications

Be sure to tell your child’s doctors about the presence of PFO if your child ever needs IV fluids for another condition, since it’s possible that the PFO could become problematic if air or dirt were to contaminate the IV line and enter the veins. The fact that a PFO is present might change some aspects of what a surgeon does in preparation for, or during an operation.
 

Untreated PFOs have potential for association with some other conditions in adults, including stroke, migraines, “the bends” and sleep apnea, but the PFO’s relationship to these conditions is not conclusive and is still being studied at Children’s and other research centers. As your child grows, it’s important to sustain a relationship with your cardiologist.

Long-term outlook

The outlook varies from child to child, but heart surgeries at Children’s have success rates approaching 98+ percent—among the highest in the nation among large pediatric cardiac centers. Between 2007 and 2010 atrial septal defect repairs similar to those performed for patent foramen ovale had 100 percent success at Children’s.

Nevertheless, your child will need monitoring and possibly medication, since he may be at some risk for stroke.

For teens

If you’re a teen with a congenital heart defect, you have a lot to cope with. Besides the typical issues any teenager faces—from social acceptance to body changes and more—you’ll also have to deal with medical appointments, some delay of your natural wish for independence, feeling a little different and assuming a lot of personal responsibility for maintaining your own good health.

It may help to remember that most teens with PFO do the same stuff as other teens, like going to school, doing chores and hanging out with friends. Most kids with a PFO don’t have restrictions on their activities, either.

If your doctor has cleared you to do so, you can play sports and participate in even rigorous or high altitude activities without any problems. Plus, you’ll have a lot of backup: Doctors, counselors, physical therapists and other members of your treatment team are all there to support you.

Even so, if you feel depressed or anxious through this important time in your transition to adulthood, speak to your doctor, counselor or parent—they’re all on your team, and they want to help.

For adults

Aging in general tends to bring out any underlying pathology in the heart or other major organs. So, if, as a person with a PFO, you start experiencing physical problems because of age-related changes, the doctor may take a closer look at the PFO just to rule it out as a contributing factor.

If you were diagnosed with, or treated for, a PFO as a child, you’re probably being followed by your cardiologist, since complications can arise in adulthood. You may need monitoring and medication by your cardiologist, since you could be at some risk for stroke.

Fortunately, Children’s can help adults with congenital heart defects. Many adults who were patients at Children’s as babies or children continue to be monitored by the clinicians who’ve followed them since childhood.

In addition, our Boston Adult Congenital Heart and Pulmonary Hypertension Service (BACH) provides long-term inpatient and outpatient care and advanced therapeutic options for patients with congenital heart disease and pulmonary hypertension as they reach and progress through adulthood.

BACH is an international center for excellence, with physicians and services from Children’s, Brigham and Women’s Hospital and Beth Israel Deaconess Medical Center. The center promotes and supports clinical and scientific research for the advancement of care of these patients, and is a leader in the education of providers caring for this unique population.

Prevention

The exact reason that a foramen ovale remains open instead of closing naturally is unknown, but it’s thought that heredity and genetics may play a role.

It’s important for parents to understand that you’ve done nothing to cause your baby’s PFO or any accompanying defects. Nothing you’ve ingested or have been exposed to environmentally has been definitively be linked to having a baby with PFO.

PFO glossary

  • aorta: one of the heart’s two great arteries. In a normal heart, the aorta arises from the left ventricle and carries oxygen-rich blood out to the body.
  • atrial septal defect (ASD): a congenital (present at birth) heart defect in which there is an opening in the tissue wall (septum) that divides the two upper chambers of the heart (right and left atria). A patent foramen ovale (PFO) is a type of ASD.
  • cardiac/cardio-: pertaining to the heart
  • cardiac magnetic resonance imaging (MRI): a non-invasive diagnostic tool
  • cardiac surgery: a surgical procedure performed on the heart or one of the blood vessels connected to the heart
  • cardiac surgeon: a doctor who performs surgery on the heart. A pediatric cardiac surgeon performs surgery on the hearts of infants and children.
  • cardiologist: a doctor who diagnoses and treats heart problems non-surgically. A pediatric cardiologist treats infants, children and some adults with heart problems.
  • cyanosis (cyanotic): blue color of skin, lips and nailbeds caused by a reduction in the amount of oxygen-rich (red) blood circulating in baby’s bloodstream
  • congenital heart defect: heart defect present at birth. The heart usually starts to form in the first eight weeks of fetal development. It’s thought that most congenital heart defects develop during this period.
  • diagnosis: medical determination of illness or disease based on history, physical examinations and advanced technology diagnostic testing tools
  • echocardiogram (echo, cardiac ultrasound): a diagnostic tool that evaluates the structure and function of the heart using sound waves that produce a moving picture of your child’s heart and heart valves. The ultrasound can be used to understand flow in the different chambers and to estimate pressures.
  • electrocardiogram (ECG, EKG): a diagnostic tool that evaluates the electrical activity of your child’s heart. An EKG is usually the initial test for detecting a PFO.
  • in isolation: occurring by itself; used to mean a defect occurring without other associated defects
  • IV: intravenous, into the vein; one method of delivering medication
  • PFO (patent foramen ovale): a defect in the wall (septum) between the upper two heart chambers (the left and right atria)
  • signs and symptoms: the physical reasons why a child needs medical attention. Characteristics such as onset, quality, triggers and severity help diagnosticians to determine a disease, or to decide which testing is needed to determine the disease.

For a more complete list of cardiovascular terms, visit our Cardiovascular Glossary.

For in-depth visual information on several of the conditions, diagnostic tools and procedures described above, visit our cardiovascular Multimedia Library.

Children's Heart Center

The Heart Center at Children’s is the largest pediatric heart program in the United States. Our staff of more than 80 pediatric cardiac specialists cares for thousands of children and adults with congenital and acquired heart defects each year, from simple to complex cases. We have experience treating rare heart problems—with results that are among the best in the world.

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