A Patent Foramen Ovale (PFO) is a common anatomical variation found in the hearts of many healthy people. This opening is a remnant of a structure active during fetal development, and its persistence often goes unnoticed. When a PFO is discovered after experiencing a symptom like chest pain, it naturally raises questions about its role in health. This discussion clarifies the relationship between this common cardiac finding and chest pain, which is frequently a source of patient anxiety.
Understanding Patent Foramen Ovale
The PFO is a flap-like opening in the interatrial septum, the wall separating the heart’s two upper chambers (the right and left atria). Before birth, this opening, called the foramen ovale, is necessary for fetal circulation, allowing blood to bypass the non-functional lungs. When a newborn takes its first breath, pressure in the left atrium rises, pushing the flap closed against the septum.
In 20% to 34% of adults, this flap does not permanently seal, leaving the potential passage known as a Patent Foramen Ovale. For the vast majority of people who have this opening, it remains a silent, harmless finding and is considered a normal anatomical variation rather than a structural defect.
PFO, Chest Pain, and Associated Symptoms
PFO is overwhelmingly asymptomatic and is rarely considered a direct cause of typical cardiac chest pain, such as angina. If a person with a PFO experiences chest discomfort, the cause is highly likely due to other common reasons. Cardiac specialists usually investigate more common causes like coronary artery disease or muscular issues before considering the PFO as a factor.
The primary medical concern related to a PFO is its potential role in allowing material to pass from the right side of the heart to the left, known as a right-to-left shunt. This shunt can permit small blood clots originating in the venous system to bypass the lungs’ filtration system and enter the systemic circulation. This phenomenon, called a paradoxical embolism, can travel to the brain, leading to an ischemic stroke of unknown cause (cryptogenic stroke). PFOs have also been linked to other specific neurological issues, most notably migraine headaches with aura.
Diagnostic Procedures for PFO
The detection of a Patent Foramen Ovale typically begins with a transthoracic echocardiogram (TTE), which uses sound waves to create images of the heart. To confirm a right-to-left shunt, this test is coupled with a saline contrast study, commonly called a “bubble study.” During this procedure, sterile saline is shaken to create tiny microbubbles and injected into a vein.
If a PFO is present, the bubbles travel to the right side of the heart and are visualized crossing the atrial septum into the left atrium. A more definitive follow-up test is the transesophageal echocardiogram (TEE), where a probe is guided down the esophagus to offer a clearer view of the PFO structure. Diagnosis is often incidental, meaning the PFO is found while investigating an unrelated condition, usually prompted by a history of a neurological event rather than isolated chest pain.
Treatment Approaches for Symptomatic PFO
Most individuals with an incidentally discovered, asymptomatic PFO require no specific treatment and are simply monitored. Intervention is reserved for patients who have experienced a clear complication, such as a cryptogenic stroke or transient ischemic attack, where the PFO is presumed to be the pathway for the clot. Management involves either medical therapy or procedural closure.
Medical management includes antithrombotic medications, such as antiplatelet agents or anticoagulant therapy (blood thinners). These drugs reduce the risk of clot formation, lowering the chance of a paradoxical embolism. For patients who have had a PFO-associated stroke, a minimally invasive procedure called device closure may be recommended. This closure uses a catheter threaded through a vein to deploy a small, umbrella-like device that seals the opening, permanently eliminating the right-to-left shunt.