C-80 | A New Clinical Syndrome of PFO, Vasospastic Angina and Migraine

Patent foramen ovale (PFO) is the most common congenital cardiac abnormality and results in a potential communication between the left and right sides of the heart. While it is typically considered a benign finding, we hypothesize PFO may facilitate vasospastic angina and migraine by shunting venous blood directly to the arterial circulation and bypassing the pulmonary vasculature. Percutaneous closure of the PFO results in reduced burden of symptoms, as demonstrated by the cases described at our institution. Objective: To highlight a potentially novel syndrome including PFO, migraine and vasospastic angina and review the existing literature. We reviewed our institutional database to identify patients with PFO who had concomitant angina with or without migraine. Appropriate patients had documentation of vasospastic angina by angiography or acetylcholine provocation. The clinical response to PFO closure, if applicable, was noted. Of 1175 patients who were seen with PFO-related conditions between 2001 -2023, 9 patients had prominent angina, of whom 8 also had migraine. Vasospastic angina was documented in all 9 patients by coronary angiography or by intracoronary administration of acetylcholine. Of these 9 patients, 7 underwent PFO closure, with all 7 experiencing improvement in chest pain. Notably, all 6 patients with migraine that underwent PFO closure also reported improvement in migraine symptoms. This observational case series supports a novel mechanistic link between PFO and vasospastic angina. It also identifies PFO closure as a potential therapeutic intervention for individuals with PFO who suffer from vasospastic angina. Taken together, patients with vasospastic angina should be evaluated for the presence of a right to left shunt.