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Vol. 74. Issue 8.
Pages 725-726 (August 2021)
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Vol. 74. Issue 8.
Pages 725-726 (August 2021)
Letter to the Editor
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Relationship between patent foramen ovale and COVID-19 in patients admitted to an intensive care unit
Foramen oval permeable en pacientes ingresados por COVID-19 en cuidados intensivos
Saber Eskandaria, Pooya Jalalib,
Corresponding author

Corresponding author:
a Department of Nursing, School of Nursing & Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
b Department of Medicine, Islamic Azad University Tabriz Branch, Tabriz, Iran
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To the Editor,

In December 2019, an outbreak of coronavirus disease 2019 (COVID-19), which was caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), broke out in Wuhan, China.1,2 COVID-19 was of clustering onset and mainly affected the respiratory system with some patients rapidly progressing to acute respiratory distress syndrome (ARDS).3,4 Evidence shows that, while patients with COVID–19-associated respiratory distress syndrome meet the Berlin criteria for ARDS, they generally present with an atypical form of this syndrome.5

Patent foramen ovale (PFO) is an integral part of the normal fetal circulation. The anatomical closure of the foramen ovale occurs around the second year of life in the majority of the population.6 Autopsy and detailed contrast echocardiography studies demonstrate that anatomic closure is incomplete in approximately 1 in every 4 adults, with the frequency being similar in both sexes.7

PFO may have significant clinical implications. It may lead to several pathological conditions, notably right-to-left shunt, paradoxical embolism, hypoxemia, and cerebral fat embolism.8–11 Older patients with cryptogenic embolism and PFO exhibited a higher burden of cardiovascular risk factors.12

Mechanical ventilation, especially in patients with ARDS, may stretch the pulmonary vasculature and right ventricle, thus reversing the interatrial pressure gradient, leading to the foramen ovale opening and a right-to-left shunt.13,14 The prevalence of PFO is reported to be between 16% and 19% even in ARDS patients mechanically ventilated with protective ventilation strategies.15–17 A PFO shunt is associated with decreased effectiveness of positive end-expiratory pressure titration in improving oxygenation, greater use of adjunctive interventions, and longer times on mechanical ventilation and in the intensive care unit.17

For this reason, we decided to evaluate patients with COVID-19 under mechanical ventilation to identify PFO and the pathophysiological effects of this structural heart disorder on the treatment process of patients with COVID-19 and also to obtain an appropriate strategy for managing mechanical ventilation in these patients and evaluating its effectiveness in their recovery.


The authors received no financial support for the research, authorship, and/or publication of this article.


S. Eskandari conceived of the presented idea and P. Jalali developed the theory. P. Jalali wrote the article in consultation with S. Eskandari.


The authors declare that they have no conflict of interest.

C. Huang, Y. Wang, X. Li, et al.
Clinical features of patients with 2019 novel coronavirus in Wuhan, China.
Lancet., 395 (2020), pp. 497-506
N. Zhu, D. Zhang, W. Wang, et al.
A novel coronavirus from patients with pneumonia in China, 2019.
N Engl J Med., 382 (2020), pp. 727-733
J.F.-W. Chan, S. Yuan, K.-H. Kok, et al.
A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster.
Lancet., 395 (2020), pp. 514-523
L.T. Phan, T.V. Nguyen, Q.C. Luong, et al.
Importation and human-to-human transmission of a novel coronavirus in Vietnam.
N Engl J Med., 382 (2020), pp. 872-874
D.N. Nader, M. Ata.
COVID-Associated Respiratory Distress Syndrome [CARDS] in Pregnancy; What Makes it so Different?.
IJWHR., 8 (2020), pp. 336-337
S. Kutty, P.P. Sengupta, B.K. Khandheria.
Patent foramen ovale: the known and the to be known.
J Am Coll Cardiol., 59 (2012), pp. 1665-1671
P.T. Hagen, D.G. Scholz, W.D. Edwards.
Incidence and size of patent foramen ovale during the first 10 decades of life: an autopsy study of 965 normal hearts.
Mayo Clin Proc., 59 (1984), pp. 17-20
J.B. Seward, D.L. Hayes, H.C. Smith, et al.
Platypnea-orthodeoxia: clinical profile, diagnostic workup, management, and report of seven cases.
Mayo Clin Proc., 59 (1984), pp. 221-231
D. Ranoux, A. Cohen, L. Cabanes, P. Amarenco, M.G. Bousser, J.L. Mas.
Patent foramen ovale: is stroke due to paradoxical embolism?.
Stroke., 24 (1993), pp. 31-34
S.F. Rimoldi, S. Ott, E. Rexhaj, et al.
Patent Foramen Ovale Closure in Obstructive Sleep Apnea Improves Blood Pressure and Cardiovascular Function.
Hypertension., 66 (2015), pp. 1050-1057
A.C. Pell, D. Hughes, J. Keating, J. Christie, A. Busuttil, G.R. Sutherland.
Brief report: fulminating fat embolism syndrome caused by paradoxical embolism through a patent foramen ovale.
N Engl J Med., 329 (1993), pp. 926-929
Wintzer-Wehekind, A. Alperi, C. Houde, et al.
Transcatheter closure of patent foramen ovale in patients older than 60 years of age with cryptogenic embolism.
Rev Esp Cardiol., 73 (2020), pp. 219-224
K.N. Asrress, M. Marciniak, A. Marciniak, R. Rajani, B. Clapp.
Patent foramen ovale: the current state of play.
Heart., 101 (2015), pp. 1916-1925
B. Cujec, P. Polasek, I. Mayers, D. Johnson.
Positive end-expiratory pressure increases the right-to-left shunt in mechanically ventilated patients with patent foramen ovale.
Ann Intern Med., 119 (1993), pp. 887-894
G. Lhéritier, A. Legras, A. Caille, et al.
Prevalence and prognostic value of acute cor pulmonale and patent foramen ovale in ventilated patients with early acute respiratory distress syndrome: a multicenter study.
Intensive Care Med., 39 (2013), pp. 1734-1742
F. Boissier, S. Katsahian, K. Razazi, et al.
Prevalence and prognosis of cor pulmonale during protective ventilation for acute respiratory distress syndrome.
Intensive Care Med., 39 (2013), pp. 1725-1733
A.M. Dessap, F. Boissier, R. Leon, et al.
Prevalence and prognosis of shunting across patent foramen ovale during acute respiratory distress syndrome.
Crit Care Med., 38 (2010), pp. 1786-1792
Copyright © 2021. Sociedad Española de Cardiología
Revista Española de Cardiología (English Edition)

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