What is the management approach for a newborn with a patent foramen ovale (PFO)?

Management of Patent Foramen Ovale in Newborns

Patent foramen ovale (PFO) in newborns requires no specific intervention as it is a normal finding that typically resolves spontaneously over time.

Understanding Patent Foramen Ovale in Newborns

Patent foramen ovale is a normal part of fetal circulation that allows oxygenated blood from the placenta to bypass the lungs. This opening between the right and left atria is present in all fetuses and typically closes after birth due to hemodynamic changes associated with lung expansion 1. However:

• PFO is extremely common, persisting in approximately 20-34% of the general adult population 2
• In most newborns, PFO poses no threat to health and requires no intervention
• The prevalence of PFO decreases with age 2

Assessment of PFO in Newborns

When a PFO is detected in a newborn, assessment should include:

• Measurement of PFO size on echocardiogram
• Evaluation for presence of a flap valve
• Assessment of right-to-left shunting
• Monitoring for any symptoms of hemodynamic compromise

Clinical Significance of PFO Size

Research on extremely low birth weight (ELBW) infants has shown that:

• Most small PFOs (<3mm) do not increase significantly in size with weight gain (88%) 1
• Large PFOs (>3mm) tend to nearly double in size with postnatal growth 1
• The presence of a flap valve on echocardiogram correlates with eventual resolution 1

Management Approach

1. For asymptomatic newborns with PFO:

   • No specific intervention is required
   • No anticoagulation or antiplatelet therapy is needed
   • Routine clinical follow-up is sufficient

2. For PFOs detected incidentally on echocardiogram:

   • Document size and presence/absence of flap valve
   • For large PFOs (>3mm), consider echocardiographic re-evaluation prior to discharge 1
   • For small PFOs, no specific follow-up echocardiogram is necessary unless clinically indicated

3. For follow-up of large PFOs:

   • Time to resolution is variable (6 months to 3 years) 1
   • The presence of a flap valve is associated with eventual resolution 1

Special Considerations

Stroke Risk

Unlike in adults, where PFO has been associated with cryptogenic stroke, there is insufficient evidence to support PFO closure in children with ischemic stroke 3. The American College of Chest Physicians guidelines state that:

• The significance of PFO and optimal treatment of paradoxical embolism in children with ischemic stroke is not known 3
• There is insufficient research evidence to support closure of PFO in children with ischemic stroke 3

Monitoring for Complications

While rare in newborns, potential complications to monitor for include:

• Right-to-left shunting (extremely rare in the absence of pulmonary hypertension)
• Paradoxical embolism (virtually unheard of in the newborn period)

When to Consider Referral to Pediatric Cardiology

Consider referral if:

• PFO is large (>3mm) and persists beyond 1 year of age
• There are symptoms of hemodynamic compromise
• There are other associated congenital heart defects
• There is evidence of right-to-left shunting

Conclusion

The vast majority of PFOs in newborns require no specific intervention and will close spontaneously or persist as a benign finding. Management consists primarily of documentation and appropriate follow-up for larger defects.