Chest
Volume 107, Issue 6, June 1995, Pages 1504-1509
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Clinical Investigations: Cardiology and Cardiac Surgery
The Incidence of Patent Foramen Ovale in 1,000 Consecutive Patients: A Contrast Transesophageal Echocardiography Study

https://doi.org/10.1378/chest.107.6.1504Get rights and content

Study objective

Patent foramen ovale (PFO) is present in 10 to 35% of people and has been reported to be an important risk factor for cardioembolic cerebrovascular accidents (CVAs) and transient ischemic attacks (TIAs), especially in younger patients. While contrast transthoracic echocardiography has been used to detect PFO, contrast transesophageal echocardiography (TEE) has a greater sensitivity. Prior studies reported the incidence of PFO in patients presenting with a CVA or TIA.

Design

To determine the incidence of PFO in a more general population, we reviewed 1,000 consecutive TEEs performed with contrast and color Doppler for the presence of PFO and other cardioembolic risk factors, including atrial septal aneurysm (ASA), aortic plaque, atrial fibrillation (AFib), and atrial thrombi. While imaging with monoplane or biplane TEE, multiple injections of agitated saline solution were injected during cough or Valsalva maneuver to detect flow through a PFO.

Patients

There were 482 male and 518 female patients with mean age of 60 ± 17 years (range 11 to 93 years).

Results

Patent foramen ovale was found in 9.2% of all patients and, though seen in all age groups divided by decade, the incidence in patients aged 40 to 49 years was greater than those aged 70 to 79 years (12.96% vs 6.15%, p=0.03). Contrast TEE had a much higher detection rate than color Doppler alone. Importantly, there was no greater incidence of PFO in patients with CVA vs those without CVA, or in male vs female patients. Also, there was a very strong correlation between the presence of ASA and PFO (p<.001).

Conclusion

Thus, PFO detected by TEE, frequently seen with ASA, is seen in all age groups and does not in itself present a risk factor for CVA. The association of PFO with peripheral thrombosis and CVA needs further study.

Section snippets

Study Population

We reviewed 1,000 consecutive nonsurgical TEEs that included 518 female subjects and 482 male subjects, with a mean age of 60 ± 17 years (range, 11 to 93 years). Patients were referred to the echocardiography laboratory from both hospital and outpatient settings. The most common clinical indications for the procedures included evaluation to rule out possible cardioembolic sources of stroke (including patients with TIA, stroke, peripheral emboli, atrial fibrillation, or other arrhythmias prior

Results

Patent foramen ovale was detected in 9.2% of all subjects (Table 2), with equal incidence in male and female subjects (9.54 vs 8.88%, respectively; p=not significant [NS]) The mean age of patients with PFO was 58.3 years compared with 60.6 years without PFO (p=NS). When the patients were separated by their age by decades, PFO was seen in all groups (Table 3). Because our patients were referred primarily by adult cardiologists, only 53 of our patients were younger than 30 years, in whom only

Discussion

Previous studies have implicated PFO as a possible cardioembolic source for cerebrovascular events.1, 2, 3,5, 8 To our knowledge, the current retrospective report is the largest study to examine each subject for the presence of PFO by both color Doppler and contrast TEE. Additionally, we evaluated 1,000 consecutive patients referred for TEE, not just those with suspected cardioembolic events. The incidence of PFO in this study was 9.2%, comparable with findings of other studies of normal

Conclusions

Our 9.2% incidence of PFO detected in all subjects was similar to findings in normal subjects in other studies,3, 9 but significantly lower than 27.3% incidence found in an autopsy study.4 Hausman et al18 demonstrated better detection of PFO with color and contrast TEE, and an increased prevalence of PFO in young patients with otherwise unexplained ischemic stroke. However, to our knowledge, our study of 1,000 patients represents the largest single report of the use of contrast TEE on a general

Recommendations

Transesophageal echocardiography with contrast may detect the cause from a cardioembolic source in patients with neurologic events. While PFO has been correlated with paradoxic emboli, one cannot assume the presence of PFO to be the culprit of all cryptogenic strokes. Currently, aspirin may be appropriate therapy for large-vessel atherosclerotic disease and for nonvalvular atrial fibrillation in patients younger than 75 years.19 However, anticoagulation with warfarin may be the preferred

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