Identification of patent foramen ovale permitting paradoxic embolism

Objectives. We sought to analyze the morphologic and functional characteristics of the patent foramen ovale in patients with different clinical likelihoods for paradoxic embolism. Background. The incidence of patent foramen ovale is increased in patients with otherwise unexplained arterial ischemic events. Because signs of venous thrombosis are absent in most patients, the diagnosis of paradoxic embolism is often questioned, even when patent foramen ovale is the only potential explanation for the ischemic event. Methods. Seventy-eight patients with patent foramen ovale detected by contrast transesophageal echocardiography were studied: 21 patients with an otherwise unexplained arterial ischemic event and clinical evidence implying paradoxic embolism (group I), 30 patients with an unexplained ischemic event but no clinical evidence for paradoxic embolism (group II) and 27 patients without an ischemic event (group III). Results. During transesophageal contrast echocardiography, patients in group I had more severe right to left shunting (mean ± SD 52 ± 16% of the left atrial are filled with contrast medium) and wider opening of the patent foramen ovale (7.1 ± 3.6-mm separation between the septum primum and the septum secundum) than did patients in group II (35 ± 15% and 4.4 ± 3.2 mm, respectively, p < 0.001) or group III (23 ± 12% and 3.0 ± 2.0 mm, respectively, p < 0.001). The incidence of atrial septal aneurysm was similar in the three groups. Severe contrast shunting (≥50% of the left atrial are filled with contrast medium) and wide opening of the patent foramen ovale (≥5-mm separation) revealed high sensitivity (71% and 86%, respectively) and high specificity (86% and 96%, respectively) for identification of group I patients. Conclusions. Right to left contrast shunting is more severe and opening of the patent foramen ovale is larger in patients with ischemic arterial events considered to be due to paradoxic embolism. In patients with patent foramen ovale as the only potential cause for ischemic events and no signs of venous thrombosis, morphologic and functional variables assessed by transesophageal echocardiography may be helpful in estimating the likelihood of paradoxic embolism.