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High prevalence of undetected permanent foramen ovale, as an underestimated risk factor for cerebral embolism
Cenk U. Oezpeker, Christoph Krapf, Bastian Schneider, Elfriede Ruttmann, Juliane Kilo, Michael Grimm, Ludwig Mueller.
University of Innsbruck, Innsbruck, Austria.

OBJECTIVE: The overall incidence of patent foramen ovale or atrial septal defect (PFO/ASDII) is reported to be 27.3%. During mitral or tricuspid valve surgery sometimes a PFO is encountered which was not detected by transthoracic and transeophageal echocardiography (TTE/TEE).Untreated PFO, however, may be of clinical relevance in occult cerebral embolism. The aim of this investigation was to analyze the prevalence of undetected PFO in patients undergoing minimally invasive mitral/tricuspid valve surgery.
METHODS: : From 2001 until 2015, 657 patients underwent mitral - and/ or tricuspid valve surgery via mini lateral thoracotomy. In 93 patients a PFO/ASD was closed during the procedure. In 80 patients a mitral valve repair, with concomitant tricuspid valve repair (TVRep) in 16 of these patients, was performed. In seven patients a mitral valve replacement with additionall TVRep in three patients was the surgical intervention. In six patients isolated TVRep was performed. In all patients the existence of PFO had been examined pre- and intraoperatively by TTE and TEE.
RESULTS: The incidence of surgically proven and closed PFO in the total cohort of 657 patients was 93 (14.2 %). However, in 65 (69.9 %) of these patients no echocardio-graphic signs for PFO/ASD had been diagnosed preoperatively.
CONCLUSIONS: These data indicate that 70% of PFOs may be not diagnosed by TTE and TEE. Consequently a high prevalence of PFOs in the population remains untreated and may be a potential risk factor for cerebral embolization. This should be taken into account if embolic stroke occurs and source of embolization remains unclear.

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