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How will you quickly differentiate PFO from small ASD ?

Posted Jul 13 2010 10:41am

Patent foramen ovale is probably  the commonest  congenital heart defect.  (Bicuspid aortic valve will run close to it ! )

Note : PFOs  cannot be  called as a  true disease , since it is a  benign anatomical defect with little or no hemodynamic impact.

Consider  this scenario . . .

The incidence  of PFO could be as high as 20% of adult population. It means nearly 100 crore people of this planet  will suffer from this entity !

When does it become significant ?

Paradoxical embolism : In young persons with cerbro vascular accident , PFO s are more commonly observed , implicating some form form of venous to arterial embolus .

In some persons it is believed , it can shunt few CC of blood from right atrium to left atrium at times of right atrial hemodynamic stress. Like severe physical  straining  (valsalva like )

In seriously ill ventilated patients  PFOs can worsen the  hypoxia especially with  PAPP  mode .

When does it become a life saving savior ?

  • In patients with DTGV and intact IAS  even a a small PFO can sustain a life  till , emergency surgery or intervention is done .
  • In patients  with severe  pulmonary hypertension the PFO may act like a safety valve, opening at a critical moment and decompress the  right atrium and which  indirectly relieves  the RV wall stress as well .

Fancy relationships

Now , it is  considered PFO  is related to migraine by some means ! ( What means !)  The belief has strong evidence base that has lead  the aggressive  interventional cardiologists to  find a new hole to close  . This indication ,  if  approved will have a perennial supply of patients  as there are 100 crores of them .

How will you differentiate a PFO from a small ASD ?

Size alone can be a useful pointer in differentiating a ASD from PFO.

A PFO can  measure  between  2 to 10mm  ( most measuring between 4-6mm diameter)

Size matters !  The upper limit of PFO is the lower limit of ASD .

Practical experience suggest any defect  above 7mm should alert  us about the possibility of true ASD.

Other useful clues

  • PFO are always restrictive  (Use pulse doppler probe right across the PFO /ASD in subcostal view .If you pick up a gradient > 4mmhg (velocity 1 m /sec) PFO is confirmed.
  • Most ASDs do not show any significant  gradient
  • Right ventricle and right atrium should be normal in PFO  (Unless due to some other cause )
  • Doppler flow across  pulmonary valve can be very useful . If it exceeds 1.5m/sec , left to right  shunting is likely to be significant and PFO is unlikely.

Is there an entity called restrictive ostium secundum ASD ?

If so ,  how will you  differentiate it from PFO ?

Yes , we have ,especially in  cyanotic heart disease

Like TGA , Ebstien etc .

Isolated restrictive secundum ASD is extremely rare .

* There is no way to differentiate a restrictive ASD from a similar sized PFO .

What is the role of TEE in diagnosing PFO

It has a major  role in delineating the IAS anatomy .

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