Patent foramen ovale and intestinal ischemia leading to short gut: Is there a correlation?

Anil Vaidya¹, Oliver Ormerod¹, Srikanth Reddy¹, Peter Friend¹

¹Vaidya, Oxford University hospitals, Oxford, United Kingdom

Introduction: Intestinal ischemia in adults is an important cause of ultra-short gut requiring intestinal transplantation. Acute occlusion of the superior mesenteric artery (SMA) is associated with embolic events secondary to atrial fibrillation (AF), valvular defects, cardiac failure and thrombophilia. Patent Foramen Ovale (PFO) is often only detected after acute embolic events, usually stroke or migraine. Association of PFO with acute SMA occlusion in this cohort of patients has not been previously reported.

Methods: Patient records of all referrals for intestinal assessment were reviewed. Patients with ultra-short gut due to an ischemic event went through a thrombophilia screen and bubble contrast echo in addition to a myocardial perfusion scan as part of their cardiac work-up. 

Results: From June 2008 to March 2013, 25 patients were assessed for intestinal transplant at our centre. Ten patients (40%) had an acute SMA occlusion leading to ultra-short gut. Within the SMA occlusion cohort, 8 (80%) patients demonstrated a PFO. One patient (10%) had thrombophilia (Anti-thrombin III deficiency) and 1 patient (10%) had extensive atherosclerosis of the abdominal aorta with no evidence of a PFO. There was no evidence of any valvular pathology or incidence of AF in this cohort. There was no difference in inducible ischemia or left ventricular ejection fraction between the SMA occlusion group and patients with other causes of short gut.

Conclusion: There is a strong correlation between PFO and acute SMA occlusion in this cohort of patients. 80% of those with acute SMA occlusion had a non-physiologic PFO, compared to an incidence of 15-35% reported in the general population. Although numbers in this cohort are small, the findings are important because they identify a treatable pthology that would help avoid further episodes of thrombosis (clinical or subclinical) after transplantation. We recommend ruling out a PFO in all patients referred for an intestinal transplant due to acute SMA thrombosis. Conducting bubble contrast echocardiograms in a similar group of patients who are established on HPN, but not yet referred for transplantation may contribute to strengthen this association.