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What is a PFO?

Assessment for the presence of a PFO is useful for:

- patients who have suffered a TIA/stroke or heart attack from a blood clot that cannot be explained

- sufferers of severe migraine with or without aura (with life disabling symptoms)

- commercial, military or advanced recreational divers

Patent Foramen Ovale (PFO) is a flap-like opening between the two upper chambers of the heart known as the left and right atria.

A PFO is present in approximately 25% of the population. PFO is not a heart defect; it is a remnant of the foetal blood circulation. In

the womb, all babies have this opening to allow the circulation to bypass the lungs. After birth this flap normally closes to form a

solid wall (called a septum) between the chambers. If the PFO does not close, the opening can permit venous blood, normally

filtered by the lungs, to pass unfiltered into the left atrium and out to

the body, including the brain.

PFO is associated with a number of medical conditions including Migraine, Decompression Illness, Stroke and other Thromboemboli (clots travelling to organs such as legs, kidneys, gut …). The     same conditions can occur from an atrial septal defect (ASD) which PFO is a sometimes labelled as. Sharpe Cardiology has a keen interest in these conditions, and their relationship to patent foramen ovale. We are involved in research and the clinical application of the latest knowledge in this area. Stroke or transient ischaemic accident (TIA) can occur for a variety of reasons. The one cause often overlooked by patients and doctors is stroke from a blood clot (embolus) passing through the PFO/ASD and up into the arteries supplying the brain. This is the leading cause of an unexplained (cryptogenic) stroke in the young (ages <60). Migraine can be an extremely disabling condition that can destroy lives. It also has a huge social and economic cost burden to the community. Migraineurs that also have an ‘aura’ (visual or other sensory/neurological changes),  have a much higher incidence of a PFO than the general population. These patients also have a much higher cure rate after closure of the PFO. The incidence of stroke in a patient with severe migraine with aura is much higher than the general population. Not all migraineures have a hole in their heart and not all hole in the hearts need to be closed. We are very experienced at assessing which patients will respond to PFO closure. View our blog to read about our research published at Euro PCR 2014, Europe’s largest interventional cardiology conference.

Cryptogenic Stroke and PFO Evidence Update 

There have been 3 landmark studies published in the New England Journal of Medicine, 14th September 2017 which strongly support closure of the PFO in cryptogenic stroke over medical therapy. There was some evidence 5 years ago when the RESPECT study short-term follow up showed in the Per Protocol and Actual Treatment analysis significant p-values suggesting PFO closure was benifical. SOME OF THE DATA:

RESPECT: the 10-year Intention-to-Treat data has shown a risk reduction of secondary CVA of 62% (p=0.007) in the

Amplatzer (Abbott) device arm. No serious adverse event in device arm.

REDUCE: showed patients randomised to medical therapy had a 400% (p= 0.001) higher annualised risk of recurrent

stroke versus the closure Cardioform (GORE) arm.

CLOSE: had no strokes in the device arm compared to 14 strokes in the medical therapy arm. This study allowed

physician discretion in choosing the closure device.


Do not wait for the second stroke! “

SCUBA Divers that suffer from migraine (particularly with aura) are at increased risk due to likelihood of an undiagnosed PFO/ASD. Decompression illness (DCI) or the ‘Bends’  are due the nitrogen gas accumulation in the blood stream, tissues and joints whilst diving at depth. Recreational SCUBA diving has a very good safety record because there is a strict adherence to dive tables and more recently advanced dive computers. However, there is a strong relationship between decompression illness (DCI) and the presence of a large patent foramen ovale (PFO). During and after resurfacing nitrogen off-gassing occurs mostly in the tissues and joints and venous circulation. In the presence of a PFO/ASD there is a direct communication to the arterial circulation. The more serious DCI such as cerebral arterial gas embolism (CAGE) or neurological/spinal DCI are more likely to be directly related to divers with a PFO. The European and Northern American military screen their divers for PFO/ASD using transcranial Doppler with contrast. We recommend that all Commercial divers performing saturation dives as well as advanced and technical recreational divers that they be screened also. Anyone wishing to take up diving with a history of migraine with aura, unexplained stroke or heart attack should also be assessed and screened for a PFO. (as per section A4.8(c) of the South Pacific Underwater Medical Society (SPUMS) guidelines for recreational divers). There are a few important considerations for divers: 1. Not suffering from migraine does not exclude you from having a PFO 2. Not all people or divers for that matter with a PFO need it to closed. There are different sizes and grades of PFO/shunt. 3. Even experienced divers with no DCI events to date can have an undiagnosed PFO.  4. After a successful PFO closure divers can resume normal activities within approximately 3 months.   For a brochure about Diving and PFO -  St Jude Medical - Divers Information Guide - Decompression Illness and Patent Foramen Ovale.