PFO Nedir? Belirtileri ve Kapatma Tedavisi

What is a PFO?

In the womb, there is normally an opening (hole) in the septum between the right and left atria of the baby’s (fetus) heart. This is a normal part of fetal blood circulation. Since this hole is no longer needed after birth, it closes spontaneously in most people. However, in some individuals, it remains open. In medical terminology, this hole is called patent foramen ovale (PFO); which means “open oval hole.” Since the word “hole” is frequently used for PFO in colloquial language, for ease of understanding throughout the rest of the text, the word “hole” will be used instead of “opening.”

What is the difference between a PFO and an ASD?

Both of these are types of holes located in the septum between the atria. However, in ASD, there is a pathological failure of the tissue forming the septum to partially develop. Thus, the baby is born with a hole in the heart. PFO, on the other hand, is not a developmental defect; that is, there is no missing tissue involved. The presence of a PFO alone is not considered a disease. For it to pose a problem, a clot formed elsewhere in the body must additionally reach the heart. PFO can be medically significant because it allows a clot arriving at the heart to pass from the right side to the left side, which may result in a stroke if the clot travels to the brain with the blood flow. However, this probability is extremely low. In other words, unless a stroke or a few specific clinical conditions are present, the incidental detection of a PFO in an individual has no significance on its own.

How common is a PFO?

PFO is quite common; it is present in 1 out of every 4 people. This means that, ultimately, 2 billion people out of the world’s 8 billion population have a PFO.

What causes a PFO?

It is not clearly known what causes a PFO.

What are the symptoms of a PFO?

Most people do not experience any symptoms or signs directly caused by a PFO. A PFO is usually discovered incidentally during tests performed for other reasons.

How is a PFO diagnosed?

ECHO (Echocardiography; heart ultrasound): This is the fundamental test for diagnosing PFO. It is a device that works using sound waves. It captures a motion picture of the heart. The hole and the blood leaking through it can be seen directly. However, in most cases, it cannot actually be seen directly. In this situation, a “contrast ECHO” is performed. In a contrast ECHO, water containing microbubbles is administered through a vein in the arm; these bubbles reach the heart, and if a PFO is present, these bubbles are observed passing from the right side to the left side of the heart.
TEE (Transesophageal ECHO): Performing an ECHO from inside the esophagus, which is adjacent to the heart, can provide clearer images. For this, a flexible cable the diameter of a pencil is inserted into the esophagus. At the end of this cable is a special mechanism that allows image acquisition. In this way, the size and shape of the opening are determined in detail. TEE is used to confirm the diagnosis when a PFO is suspected in a contrast ECHO and to guide doctors during the non-surgical closure of the PFO.
Transcranial Doppler: Like a contrast ECHO, this device works using sound waves and water bubbles. However, the ultrasound is performed on the skull rather than the heart. The aim is to detect water bubbles that pass through the PFO and reach the skull (and thus the brain) via the bloodstream. If no water bubbles are seen here, it is understood that there is no PFO. However, if water bubbles are detected, TEE must still be performed to confirm the presence of the PFO.

What can a PFO cause?

The most significant complication of PFO is stroke; in other words, an embolism to the brain. A stroke can be permanent or temporary. The temporary type is called a TIA (transient ischemic attack). However, the probability of a PFO causing a stroke is extremely low (Remember; if everyone with a PFO had a stroke, 1 out of every 4 people in the world would have had to have a stroke). The most common causes of stroke are actually vascular problems such as clots or bleeding. Vascular problems are also generally seen in elderly patients. Therefore, if a stroke is seen in a young person, the probability of PFO being the cause is higher compared to the elderly. Besides stroke, PFO can very rarely cause other complications:

Clot in a heart vessel (heart attack)
Embolism to organs other than the brain
Migraine-type headache
Air embolism during diving

What should people with a PFO be aware of?

Diving carries a specific risk in PFO. However, when the rules of diving are strictly followed, PFO is not an obstacle to diving. Nevertheless, if the rules are not observed, air bubbles forming within the vessels can pass through the PFO and lead to various problems.
There is no harm in exercising. However, if the PFO has been closed, competitive or heavy sports should be avoided for the first month.
After the PFO is closed, it may take up to 6 months for the umbrella-like device to be covered with tissue. During this process, microorganisms entering the bloodstream can directly infect the device via the blood, leading to a serious infection called infective endocarditis. For this reason, for the first 6 months, antibiotics must be taken before procedures involving bleeding, such as tooth extraction or surgery on another organ. Such precautions are not needed after 6 months. However, rarely, a permanent blood leak may continue at the edge of the device; in this case, taking antibiotics before procedures involving bleeding is always recommended.
It is often assumed that the metallic structures of the umbrella-like devices, which are made of nickel-titanium alloy, will be affected by the magnetic field of an MRI. However, these devices have weak susceptibility to magnetic fields; therefore, it is safe to undergo an MRI, including 3 Tesla.

Is treatment necessary for a PFO?

For most people with PFO, treatment is not necessary. This is because PFO itself is not considered a disease. For treatment to be required, the complications mentioned above should have developed. At this point, most people have a question in mind: “In other words, can’t we take precautions before having a stroke? Do we have to wait for a stroke to occur?“. However, it should not be forgotten that treatment decisions in medicine are always based on a risk-benefit analysis. The option that is always better is preferred. For example, if the treatment in question is the closure of the PFO, the treatment is either using blood-thinning medication or, in addition to medication, closing the PFO using non-surgical methods with umbrella-like devices. However, medications carry a risk of serious bleeding (brain hemorrhage, stomach bleeding, etc.). In the closure procedure, complications such as heart perforation may develop. Therefore, starting these treatments for every patient with a detected PFO actually means unnecessarily exposing someone, whose probability of having a stroke during their lifetime is extremely low, to a higher probability of the possible complications of these treatments.

What is PFO closure?

HTML etiketlerini, stil tanımlamalarını ve bağlantıları koruyarak hazırladığım İngilizce çeviri aşağıdadır: “PFO closure” refers to the non-surgical closure of the PFO. This procedure is technically very similar to the ASD closure procedure. It is performed by interventional cardiologists. A thin, flexible, and long tube (catheter) is sent to the heart through the groin vein. The PFO is closed with an umbrella-like closure device that is compressed inside the catheter. It is called a non-surgical method because the heart is not stopped and the rib cage is not cut. Performing heart surgery to close a PFO is not a preferred method, as the non-surgical method is much safer.

Prof. Dr. Şükrü Akyüz is an interventional cardiologist. His area of expertise is the treatment of heart diseases using non-surgical methods. He is a proctor (instructor) and consultant for structural heart disease procedures, including PFO closure.

PFO occluder

When is a PFO closed?

In a person who has had a stroke (whether temporary or permanent, mild or severe), other causes of stroke such as carotid artery stenosis and heart rhythm disorders (atrial fibrillation) are investigated. If none of these causes are present but a hole called PFO exists in the heart, it is assumed that the cause of the stroke is likely clots escaping through this hole and traveling to the brain, and the PFO is closed. In this case, additionally, blood-thinning medications (Aspirin, clopidogrel, LMWH, or NOACs…) are started to prevent re-clotting.

What is the success rate of PFO closure?

The success rate is generally over 95%.

What are the risks of PFO closure?

As with any invasive procedure, there are certain risks associated with PFO closure. Serious complications, such as device dislodgement or clot formation on the device, occur in 1 out of every 100 people; death occurs in 1 out of every 1,000 people. You may be justified in feeling concerned about these risks; however, please remember: these complications are rare. What matters most is whether the procedure is truly necessary. If the decision has been made in accordance with current scientific data and guidelines, avoiding this procedure actually means exposing yourself to far greater risks—particularly stroke.

How long does a PFO closure procedure take?

Generally, 1 hour. However, depending on the anatomical characteristics of the PFO, this duration may be shorter or longer.

Is the procedure performed by stopping the heart, as is done in heart surgery?

No. There is no need to stop the heart.

Is the PFO closure procedure painful?

No. The procedure is performed either under sedation or under general anesthesia. The difference is this: Under general anesthesia, a tube is inserted into the patient’s airway, and the patient receives air from a ventilator; under sedation, no breathing tube is inserted, the patient is not connected to a ventilator, and the patient is simply put to sleep while breathing on their own. In both techniques, medications are administered to prevent the patient from feeling pain during the procedure. Performing the procedure under general anesthesia (with intubation) is more comfortable for the patient.

When will I be discharged after the procedure?

Most patients are discharged the next day.

Does the PFO closure device shift out of place over time?

Although cases in which the implant has reportedly shifted from its original position have been reported in the literature, this is a very rare occurrence. Once the implant has been covered by tissue within a few months, it is no longer possible for it to move.

Can you feel the device in your body?

No.

Will the device remain in the body for life?

Yes. There is no question of removing the device.

Will I need to take blood thinners after the PFO closure procedure?

Yes. Generally, two blood-thinning medications are used together for the first few months; in most cases, one of these is low-dose aspirin, and the other is a different medication containing the active ingredient clopidogrel. After a few months, one of these is discontinued. Then, depending on the neurologist’s recommendation, the same or a different blood-thinning medication is continued for life.

Examples of our PFO closure cases

Instagram Reels A post shared by Prof. Dr. Şükrü Akyüz (@prof.dr.sukruakyuz)

What is a PFO? Should PFO be Closed?