Oh No! PFO!



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Internal Medicine

Training Level

Resident PGY 2


Henry Ford Hospital


Introduction: Patent foramen ovale is a congenital cardiac lesion with a prevalence of 25% in the adult population. PFO allows passage of oxygenated blood from right to the left atrium during fetal development. It usually closes by age of two. Majority of individuals with PFO are asymptomatic. Some manifestations include cryptogenic stroke, platypnea, migraine and decompression sickness in scuba divers.

Case Presentation: We present an 80 year old female with history of cryptogenic stroke who presented with shortness of breath and lightheadedness for one week. She had a back surgery two weeks prior to presentation for spine compression fracture. On presentation, the patient was hypoxic and hypotensive. Computed tomography pulmonary angiogram was positive for bilateral pulmonary emboli (PE) with right ventricular strain. The patient underwent emergent thrombectomy, despite that she remained hypoxic. She was found to have right to left atrial shunt. Transesophageal echocardiogram with bubble study showed a large PFO with tunnel diameter of 0.54cm. Lower extremity Doppler ultrasound was positive for deep venous thrombosis. Patient then had successful closure of PFO with an Amplatzer PFO Occluder and was discharged in stable condition.

Discussion: Up to 40% of patient with cryptogenic stroke have a PFO. PFO closure should be done to prevent strokes in the future. Patients who present with acute massive PE and persistent hypoxia despite thrombectomy should have further investigation to rule out shunting. PFO should be closed in patient with history of stroke or those at risk from stroke form propagation of lower limb DVT.

Presentation Date


Oh No! PFO!