Isolated prenatal foramen ovale closure or restriction presenting after birth: a distinct, under-recognized clinical condition

Background The foramen ovale (FO) plays a central role in fetal circulation. Prenatal FO closure or restriction is well-characterized in fetuses and in neonates with congenital heart defects, but is rarely described as an isolated finding after birth. This study aimed to characterize the clinical presentation, echocardiographic features, management, and outcomes of neonates with isolated prenatal FO closure or restriction. Methods We retrospectively analyzed 10 consecutive neonates admitted to our tertiary neonatal intensive care unit between September 2018 and August 2025 with FO closure or restriction diagnosed after birth. Results The median gestational age was 39 + 1 weeks (range 36 + 4–41 + 1), and the median birth weight was 3,345 g (range 2,600–4,000 g). All the neonates presented within 9 h after birth, nine of them with central or differential cyanosis, seven with associated respiratory distress, and one with apnea. Echocardiography uniformly revealed persistent pulmonary hypertension of the newborn (PPHN) and significantly impaired left ventricular (LV) function with preserved right ventricular (RV) contractility. The interatrial septum was closed in six neonates and was restrictive in four. A prostaglandin infusion was administered to nine neonates. All the patients received inotropic support and pulmonary arterial hypertension (PAH) therapy. In survivors, normalization of LV function occurred in 1–4 days, followed by transition to a predominant left-to-right ductus arteriosus (DA) shunt in 1–8 days. One neonate died from refractory LV failure and pulmonary hemorrhage; one developed global developmental delay. Conclusions Isolated prenatal FO closure or restriction represents a distinct and likely under-recognized condition, causing severe neonatal PPHN associated with significant LV failure. These echocardiographic findings, together with preserved RV function, should prompt careful evaluation of the interatrial septum. Early recognition and hemodynamic support can lead to full recovery in the majority of cases.