Patent foramen ovale and obstructive sleep apnoea: From pathophysiology to diagnosis of a potentially dangerous association

Archives of Cardiovascular Diseases

Volumn 104, Issue 4, 2011, Pages 242-251

  Pellaton, Cyril ^a   Heinzer, Raphaël ^a   Michel, Patrik ^a   Eeckhout, Eric ^a  

^a LAUSANNE UNIVERSITY HOSPITAL   (Switzerland)

Author keywords

Foramen ovale; Obstructive; Patent; Sleep apnoea; Stroke

Indexed keywords

ANTICOAGULANT AGENT; ANTITHROMBOCYTIC AGENT;

CONSERVATIVE TREATMENT; DIAGNOSTIC PROCEDURE; DISEASE ASSOCIATION; DOPPLER ECHOGRAPHY; ELECTROCARDIOGRAM; ELECTROENCEPHALOGRAM; ELECTROMYOGRAM; ELECTROOCULOGRAM; EPIDEMIOLOGICAL DATA; HEART RIGHT LEFT SHUNT; HUMAN; HYPOXEMIA; MEDICAL RECORD REVIEW; PATENT FORAMEN OVALE; PATHOPHYSIOLOGY; PERCUTANEOUS CLOSURE; POLYSOMNOGRAPHY; POSITIVE END EXPIRATORY PRESSURE; PULSE OXIMETER; REVIEW; RISK; SLEEP APNEA SYNDROME; STROKE; SURGICAL TECHNIQUE; TRANSESOPHAGEAL ECHOCARDIOGRAPHY; TRANSIENT ISCHEMIC ATTACK; TRANSTHORACIC ECHOCARDIOGRAPHY;

COMORBIDITY; FORAMEN OVALE, PATENT; HUMANS; PREVALENCE; RISK ASSESSMENT; RISK FACTORS; SLEEP APNEA, OBSTRUCTIVE; STROKE;

EID: 79957969447     PISSN: 18752136     EISSN: 18752128     Source Type: Journal    
DOI: 10.1016/j.acvd.2010.12.008     Document Type: Review

References (111)

1. Fisher DC, Fisher EA, Budd JH, Rosen SE, Goldman ME. The incidence of patent foramen ovale in 1,000 consecutive patients. A contrast transesophageal echocardiography study. Chest 1995;107:1504-9.
2. Meissner I, Khandheria BK, Heit JA, et al. Patent foramen ovale: innocent or guilty? Evidence from a prospective population-based study. J Am Coll Cardiol 2006;47:440-5. (Pubitemid 43063268)
3. Petty GW, Khandheria BK, Meissner I, et al. Population-based study of the relationship between patent foramen ovale and cerebrovascular ischemic events. Mayo Clin Proc 2006;81:602-8.
4. Lechat P, Mas JL, Lascault G, et al. Prevalence of patent foramen ovale in patients with stroke. N Engl J Med 1988;318:1148-52.
5. Lynch JJ, Schuchard GH, Gross CM, Wann LS. Prevalence of right-to-left atrial shunting in a healthy population: detection by Valsalva maneuver contrast echocardiography. Am J Cardiol 1984;53:1478-80. (Pubitemid 14104798)
6. Hagen PT, Scholz DG, Edwards WD. Incidence and size of patent foramen ovale during the first 10 decades of life: an autopsy study of 965 normal hearts. Mayo Clin Proc 1984;59:17-20.
7. Penther P. Patent foramen ovale: an anatomical study. Apropos of 500 consecutive autopsies. Arch Mal Coeur Vaiss 1994;87:15-21.
8. Overell JR, Bone I, Lees KR. Interatrial septal abnormalities and stroke: a meta-analysis of case-control studies. Neurology 2000;55:1172-9.
9. Handke M, Harloff A, Olschewski M, Hetzel A, Geibel A. Patent foramen ovale and cryptogenic stroke in older patients. N Engl J Med 2007;357:2262-8.
10. Di Tullio MR, Sacco RL, Sciacca RR, Jin Z, Homma S. Patent foramen ovale and the risk of ischemic stroke in a multiethnic population. J Am Coll Cardiol 2007;49:797-802.
11. Di Tullio MR, Homma S. Patent foramen ovale and stroke: what should be done? Curr Opin Hematol 2009;16:391-6.
12. Thaler DE, Kent DM. Rethinking trial strategies for stroke and patent foramen ovale. Curr Opin Neurol 2010;23:73-8.
13. Mas JL, Arquizan C, Lamy C, et al. Recurrent cerebrovascular events associated with patent foramen ovale, atrial septal aneurysm, or both. N Engl J Med 2001;345:1740-6.
14. Bogousslavsky J, Garazi S, Jeanrenaud X, Aebischer N, Van Melle G. Lausanne Stroke with Paradoxal Embolism Study Group. Stroke recurrence in patients with patent foramen ovale: the Lausanne Study. Neurology 1996;46:1301-5. (Pubitemid 26159291)
15. Serena J, Marti-Fàbregas J, Santamarina E, et al. Recurrent stroke and massive right-to-left shunt: results from the prospective Spanish multicenter (CODICIA) study. Stroke 2008;39:3131-6.
16. Nedeltchev K, Arnold M, Wahl A, et al. Outcome of patients with cryptogenic stroke and patent foramen ovale. J Neurol Neurosurg Psychiatry 2002;72:347-50.
17. Botto N, Spadoni I, Giusti S, Ait-Ali L, Sicari R, Andreassi MG. Prothrombotic mutations as risk factors for cryptogenic ischemic cerebrovascular events in young subjects with patent foramen ovale. Stroke 2007;38:2070-3.
18. Homma S, Sacco RL, Di Tullio MR, Sciacca RR, Mohr JP; PFO in Cryptogenic Stroke Study (PICSS) Investigators. Effect of medical treatment in stroke patients with patent foramen ovale: patent foramen ovale in Cryptogenic Stroke Study. Circulation 2002;105:2625-31. (Pubitemid 34596039)
19. Sztajzel R, Genoud D, Roth S, Mermillod B, Le Floch-Rohr J. Patent foramen ovale, a possible cause of symptomatic migraine: a study of 74 patients with acute ischemic stroke. Cerebrovasc Dis 2002;13:102-6. (Pubitemid 34195679)
20. Dowson A, Mullen MJ, Peatfield R, et al. Migraine Intervention With STARFlex Technology (MIST) trial: a prospective, multicenter, double-blind, sham-controlled trial to evaluate the effectiveness of patent foramen ovale closure with STARFlex septal repair implant to resolve refractory migraine headache. Circulation 2008;117:1397-404.
21. Anzola GP, Morandi E, Casilli F, Onorato E. Different degrees of right-to-left shunting predict migraine and stroke: data from 420 patients. Neurology 2006;66:765-7. (Pubitemid 43739842)
22. Diener HC, Kurth T, Dodick D. Patent foramen ovale, stroke, and cardiovascular disease in migraine. Curr Opin Neurol 2007;20:310-9.
23. Schwerzmann M, Nedeltchev K, Lagger F, et al. Prevalence and size of directly detected patent foramen ovale in migraine with aura. Neurology 2005;65:1415-8.
24. Del Sette M, Angeli S, Leandri M, et al. Migraine with aura and right-to-left shunt on transcranial Doppler: a case-control study. Cerebrovasc Dis 1998;8:327-30.
25. Anzola GP, Magoni M, Guindani M, Rozzini L, Dalla Volta G. Potential source of cerebral embolism in migraine with aura: a transcranial Doppler study. Neurology 1999;52:1622-5. (Pubitemid 29220637)
26. Wilmshurst PT, Nightingale S,Walsh KP, Morrison WL. Effect on migraine of closure of cardiac right-to-left shunts to prevent recurrence of decompression illness or stroke or for haemodynamic reasons. Lancet 2000;356:1648-51.
27. Schwerzmann M, Seiler C. Recreational scuba diving, patent foramen ovale and their associated risks. Swiss Med Wkly 2001;131:365-74.
28. Torti SR, Billinger M, Schwerzmann M, et al. Risk of decompression illness among 230 divers in relation to the presence and size of patent foramen ovale. Eur Heart J 2004;25:1014-20.
29. Cartoni D, De Castro S, Valente G, et al. Identification of professional scuba divers with patent foramen ovale at risk for decompression illness. Am J Cardiol 2004;94:270-3.
30. Ryan CM, Bradley TD. Pathogenesis of obstructive sleep apnea. J Appl Physiol 2005;99:2440-50. (Pubitemid 41691668)
31. White DP. Pathogenesis of obstructive and central sleep apnea. Am J Respir Crit Care Med 2005;172:1363-70. (Pubitemid 43069808)
32. The AASM manual for the scoring of sleep and associated events: rules, terminology and technical specifications, 1st ed. Westchester; 2007.
33. The Report of an American Academy of Sleep Medicine Task Force. Sleep-related breathing disorders in adults: recommendations for syndrome definition and measurement techniques in clinical research. Sleep 1999;22:667-89.
34. Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med 1993;328:1230-5. (Pubitemid 23115702)
35. Terán-Santos J, Jiménez-Gómez A, Cordero-Guevara J. Cooperative Group Burgos-Santander. The association between sleep apnea and the risk of traffic accidents. N Engl J Med 1999;340:847-51. (Pubitemid 29142628)
36. Peppard PE, Young T, Palta M, Skatrud J. Prospective study of the association between sleep-disordered breathing and hypertension. N Engl J Med 2000;342:1378-84. (Pubitemid 30262394)
37. Marin JM, Carrizo SJ, Vicente E, Agusti AG. Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: an observational study. Lancet 2005;365:1046-53. (Pubitemid 40386782)
38. Peker Y, Hedner J, Norum J, Kraiczi H, Carlson J. Increased incidence of cardiovascular disease in middle-aged men with obstructive sleep apnea: a 7-year follow-up. Am J Respir Crit Care Med 2002;166:159-65. (Pubitemid 34765451)
39. Shahar E, Whitney CW, Redline S, et al. Sleep-disordered breathing and cardiovascular disease: cross-sectional results of the Sleep Heart Health Study. Am J Respir Crit Care Med 2001;163:19-25. (Pubitemid 32095247)
40. Wolk R, Kara T, Somers VK. Sleep-disordered breathing and cardiovascular disease. Circulation 2003;108:9-12. (Pubitemid 36859012)
41. Yaggi HK, Concato J, Kernan WN, Lichtman JH, Brass LM, Mohsenin V. Obstructive sleep apnea as a risk factor for stroke and death. N Engl J Med 2005;353:2034-41. (Pubitemid 41609096)
42. Hu FB, Willett WC, Manson JE, et al. Snoring and risk of cardiovascular disease in women. J Am Coll Cardiol 2000;35:308-13. (Pubitemid 30125518)
43. Smirne S, Palazzi S, Zucconi M, Chierchia S, Ferini-Strambi L. Habitual snoring as a risk factor for acute vascular disease. Eur Respir J 1993;6:1357-61. (Pubitemid 23329555)
44. Koskenvuo M, Kaprio J, Telakivi T, Partinen M, Heikkilä K, Sarna S. Snoring as a risk factor for ischaemic heart disease and stroke in men. Br Med J (Clin Res Ed) 1987;294:16-9. (Pubitemid 17224631)
45. Dyken ME, Somers VK, Yamada T, Ren ZY, Zimmerman MB. Investigating the relationship between stroke and obstructive sleep apnea. Stroke 1996;27:401-7. (Pubitemid 26081432)
46. Arzt M, Young T, Finn L, Skatrud JB, Bradley TD. Association of sleep-disordered breathing and the occurrence of stroke. Am J Respir Crit Care Med 2005;172:1447-51. (Pubitemid 43069819)
47. Newman AB, Nieto FJ, Guidry U, et al. Relation of sleepdis-ordered breathing to cardiovascular disease risk factors: the Sleep Heart Health Study. Am J Epidemiol 2001;154:50-9. (Pubitemid 32565686)
48. Yaggi H, Mohsenin V. Obstructive sleep apnoea and stroke. Lancet Neurol 2004;3:333-42. (Pubitemid 38648854)
49. Franklin KA. Cerebral haemodynamics in obstructive sleep apnoea and Cheyne-Stokes respiration. Sleep Med Rev 2002;6:429-41. (Pubitemid 35477407)
50. Mohsenin V. Sleep-related breathing disorders and risk of stroke. Stroke 2001;32:1271-8.
51. Wedzicha JA, Syndercombe-Court D, Tan KC. Increased platelet aggregate formation in patients with chronic airflow obstruction and hypoxaemia. Thorax 1991;46:504-7.
52. Sanner BM, Konermann M, Tepel M, Groetz J, Mummenhoff C, Zidek W. Platelet function in patients with obstructive sleep apnoea syndrome. Eur Respir J 2000;16:648-52.
53. Nobili L, Schiavi G, Bozano E, De Carli F, Ferrillo F, Nobili F. Morning increase of whole blood viscosity in obstructive sleep apnea syndrome. Clin Hemorheol Microcirc 2000;22:21-7. (Pubitemid 30139722)
54. Chin K, Ohi M, Kita H, et al. Effects of NCPAP therapy on fibrinogen levels in obstructive sleep apnea syndrome. Am J Respir Crit Care Med 1996;153:1972-6. (Pubitemid 26187928)
55. Javaheri S, Parker TJ, Liming JD, et al. Sleep apnea in 81 ambulatory male patients with stable heart failure. Types and their prevalences, consequences, and presentations. Circulation 1998;97:2154-9.
56. Kanagala R, Murali NS, Friedman PA, et al. Obstructive sleep apnea and the recurrence of atrial fibrillation. Circulation 2003;107:2589-94. (Pubitemid 36628941)
57. Holmes DR Jr, Cohen H, Katz WE, Reeder GS. Patent foramen ovale, systemic embolization and closure. Curr Probl Cardiol 2004;29:56-94.
58. Stoddard MF, Keedy DL, Dawkins PR. The cough test is superior to the Valsalva maneuver in the delineation of right-to-left shunting through a patent foramen ovale during contrast transesophageal echocardiography. Am Heart J 1993;125:185-9.
59. Luotolahti M, Saraste M, Hartiala J. Saline contrast and colour Doppler transoesophageal echocardiography in detecting a patent foramen ovale and right-to-left shunts in stroke patients. Clin Physiol 1995;15:265-73.
60. Seiler C. How should we assess patent foramen ovale? Heart 2004;90:1245-7.
61. Johansson MC, Helgason H, Dellborg M, Eriksson P. Sensitivity for detection of patent foramen ovale increased with increasing number of contrast injections: a descriptive study with contrast transesophageal echocardiography. J Am Soc Echocardiogr 2008;21:419-24.
62. Gin KG, Huckell VF, Pollick C. Femoral vein delivery of contrast medium enhances transthoracic echocardiographic detection of patent foramen ovale. J Am Coll Cardiol 1993;22:1994-2000. (Pubitemid 23359663)
63. Sloan MA, Alexandrov AV, Tegeler CH, et al. Assessment: transcranial Doppler ultrasonography: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 2004;62:1468-81. (Pubitemid 38608182)
64. Klotzsch C, Janssen G, Berlit P. Transesophageal echocardiography and contrast-TCD in the detection of a patent foramen ovale: experiences with 111 patients. Neurology 1994;44:1603-6.
65. Jauss M, Zanette E. Detection of right-to-left shunt with ultrasound contrast agent and transcranial Doppler sonography. Cerebrovasc Dis 2000;10:490-6.
66. Droste DW, Jürgens R,Weber S, Tietje R, Ringelstein EB. Benefit of echocontrast-enhanced transcranial color-coded duplex ultrasound in the assessment of intracranial collateral pathways. Stroke 2000;31:920-3. (Pubitemid 30198439)
67. Anzola GP. Clinical impact of patent foramen ovale diagnosis with transcranial Doppler. Eur J Ultrasound 2002;16:11-20.
68. Devuyst G, Piechowski-Józwiak B, Karapanayiotides T, et al. Controlled contrast transcranial Doppler and arterial blood gas analysis to quantify shunt through patent foramen ovale. Stroke 2004;35:859-63.
69. Shanoudy H, Soliman A, Raggi P, Liu JW, Russell DC, Jarmukli NF. Prevalence of patent foramen ovale and its contribution to hypoxemia in patients with obstructive sleep apnea. Chest 1998;113:91-6.
70. Gossage JR. Prevalence of patent foramen ovale and its contribution to hypoxemia in patients with obstructive sleep apnea. Chest 1998;114:1790.
71. Beelke M, Angeli S, Del Sette M, et al. Prevalence of patent foramen ovale in subjects with obstructive sleep apnea: a transcranial Doppler ultrasound study. Sleep Med 2003;4:219-23.
72. Shiomi T, Guilleminault C, Stoohs R, Schnittger I. Leftward shift of the interventricular septum and pulsus paradoxus in obstructive sleep apnea syndrome. Chest 1991;100:894-902.
73. Shiomi T, Stoohs R, Guilleminault C. Aging, respiratory efforts during sleep, and pulsus paradoxus. Lung 1993;171:203-11. (Pubitemid 23181364)
74. Shepard Jr JW. Cardiopulmonary consequences of obstructive sleep apnea. Mayo Clin Proc 1990;65:1250-9. (Pubitemid 20332188)
75. Guilleminault C, Motta J, Mihm F, Melvin K. Obstructive sleep apnea and cardiac index. Chest 1986;89:331-4. (Pubitemid 16126293)
76. Parish JM, Shepard Jr JW. Cardiovascular effects of sleep disorders. Chest 1990;97:1220-6. (Pubitemid 20166818)
77. Douglas NJ. The sleep apnoea/hypopnoea syndrome. Eur J Clin Invest 1995;25:285-90.
78. Okabe S, Hida W, Kikuchi Y, et al. Role of hypoxia on increased blood pressure in patients with obstructive sleep apnoea. Thorax 1995;50:28-34.
79. Somers VK, Dyken ME, Clary MP, Abbpid FM. Sympathetic neural mechanisms in obstructive sleep apnea. J Clin Invest 1995;96:1897-904.
80. Chaouat A, Weitzenblum E, Krieger J, Oswald M, Kessler R. Pulmonary hemodynamics in the obstructive sleep apnea syndrome. Results in 220 consecutive patients. Chest 1996;109:380-6.
81. Beelke M, Angeli S, Del Sette M, et al. Obstructive sleep apnea can be provocative for right-to-left shunting through a patent foramen ovale. Sleep 2002;25:856-62.
82. Soliman A, Shanoudy H, Liu J, Russell DC, Jarmukli NF. Increased prevalence of patent foramen ovale in patients with severe chronic obstructive pulmonary disease. J Am Soc Echocardiogr 1999;12:99-105.
83. Konstantinides S, Geibel A, Kasper W, Olschewski M, Blümel L, Just H. Patent foramen ovale is an important predictor of adverse outcome in patients with major pulmonary embolism. Circulation 1998;97:1946-51.
84. Kasper W, Geibel A, Tiede N, Just H. Patent foramen ovale in patients with haemodynamically significant pulmonary embolism. Lancet 1992;340:561-4.
85. Sommer RJ. Patent foramen ovale: where are we in 2009? Am J Ther 2009;16:562-72.
86. Bradley TD, Martinez D, Rutherford R, et al. Physiological determinants of nocturnal arterial oxygenation in patients with obstructive sleep apnea. J Appl Physiol 1985;59:1364-8. (Pubitemid 16197395)
87. Xie A, Skatrud JB, Dempsey JA. Effect of hypoxia on the hypopnoeic and apnoeic threshold for CO2 in sleeping humans. J Physiol 2001;535:269-78. (Pubitemid 32782743)
88. Lévy P, Pépin JL, Arnaud C, et al. Intermittent hypoxia and sleep-disordered breathing: current concepts and perspectives. Eur Respir J 2008;32:1082-95.
89. Nieto FJ, Herrington DM, Redline S, Benjamin EJ, Robbins JA. Sleep apnea and markers of vascular endothelial function in a large community sample of older adults. Am J Respir Crit Care Med 2004;169:354-60. (Pubitemid 38134814)
90. Johansson MC, Eriksson P, Peker Y, Hedner J, Råstam L, Lindblad U. The influence of patent foramen ovale on oxygen desaturation in obstructive sleep apnoea. Eur Respir J 2007;29:149-55.
91. Ozdemir O, Beletsky V, Hachinski V, Spence JD. Cerebrovascular events on awakening, patent foramen ovale and obstructive sleep apnea syndrome. J Neurol Sci 2008;268:193-4.
92. Pressman MR, Schetman WR, Figueroa WG, Van Uitert B, Caplan HJ, Peterson DD. Transient ischemic attacks and minor stroke during sleep. Relationship to obstructive sleep apnea syndrome. Stroke 1995;26:2361-5.
93. Ozdemir AO, Tamayo A, Munoz C, Dias B, Spence JD. Cryptogenic stroke and patent foramen ovale: clinical clues to paradoxical embolism. J Neurol Sci 2008;275:121-7.
94. King TD, Thompson SL, Steiner C, Mills NL. Secundum atrial septal defect. Nonoperative closure during cardiac catheterization. JAMA 1976;235:2506-9.
95. Bridges ND, Hellenbrand W, Latson L, Filiano J, Newburger JW, Lock JE. Transcatheter closure of patent foramen ovale after presumed paradoxical embolism. Circulation 1992;86:1902-8.
96. Ruchat P, Bogousslavsky J, Hurni M, Fischer AP, Jeanrenaud X, von Segesser LK. Systematic surgical closure of patent foramen ovale in selected patients with cerebrovascular events due to paradoxical embolism. Early results of a preliminary study. Eur J Cardiothorac Surg 1997;11:824-7.
97. Dearani JA, Ugurlu BS, Danielson GK, et al. Surgical patent foramen ovale closure for prevention of paradoxical embolism-related cerebrovascular ischemic events. Circulation 1999;Suppl. 100:II171-5.
98. Braun M, Gliech V, Boscheri A, et al. Transcatheter closure of patent foramen ovale (PFO) in patients with paradoxical embolism. Periprocedural safety and mid-term follow-up results of three different device occluder systems. Eur Heart J 2004;25:424-30.
99. Meier B. Paradoxical embolism through the patent foramen ovale-the elderly is where the money is. Catheter Cardiovasc Interv 2008;72:971-2.
100. Wahl A, Krumsdorf U, Meier B, et al. Transcatheter treatment of atrial septal aneurysm associated with patent foramen ovale for prevention of recurrent paradoxical embolism in high-risk patients. J Am Coll Cardiol 2005;45:377-80.
101. Sacco RL, Adams R, Albers G, et al. Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack: a statement for healthcare professionals from the American Heart Association/American Stroke Association Council on Stroke: co-sponsored by the Council on Cardiovascular Radiology and Intervention: the American Academy of Neurology affirms the value of this guideline. Circulation 2006;113:e409-49.
102. European Stroke Organisation (ESO) Executive Committee; ESO Writing Committee. Guidelines for management of ischaemic stroke and transient ischaemic attack 2008. Cerebrovasc Dis 2008;25:457-507.
103. Slottow TL, Steinberg DH, Waksman R. Overview of the 2007 Food and Drug Administration Circulatory System Devices Panel meeting on patent foramen ovale closure devices. Circulation 2007;116:677-82.
104. Young T, Peppard PE, Gottlieb DJ. Epidemiology of obstructive sleep apnea: a population health perspective. Am J Respir Crit Care Med 2002;165:1217-39. (Pubitemid 34461732)
105. Marti S, Sampol G, Muñoz X, et al. Mortality in severe sleep apnoea/hypopnoea syndrome patients: impact of treatment. Eur Respir J 2002;20:1511-8. (Pubitemid 35476811)
106. Becker HF, Jerrentrup A, Ploch T, et al. Effect of nasal continuous positive airway pressure treatment on blood pressure in patients with obstructive sleep apnea. Circulation 2003;107:68-73. (Pubitemid 36070935)
107. Martínez-García MA, Soler-Cataluña JJ, Ejarque-Martínez L, et al. Continuous positive airway pressure treatment reduces mortality in patients with ischemic stroke and obstructive sleep apnea: a 5-year follow-up study. Am J Respir Crit Care Med 2009;180:36-41.
108. Silver B, Greenbaum A, McCarthy S. Improvement in sleep apnea associated with closure of a patent foramen ovale. J Clin Sleep Med 2007;3:295-6. (Pubitemid 46762068)
109. Agnoletti G, Iserin L, Lafont A, Sidi D, Desnos M. Obstructive sleep apnoea and patent foramen ovale: successful treatment of symptoms by percutaneous foramen ovale closure. J Interv Cardiol 2005;18:393-5.
110. Pinet C, Orehek J. CPAP suppression of awake right-to-left shunting through patent foramen ovale in a patient with obstructive sleep apnoea. Thorax 2005;60:880-1.
111. Lau EM, Yee BJ, Grunstein RR, Celermajer DS. Patent foramen ovale and obstructive sleep apnea: a new association? Sleep Med Rev 2010;14:391-5.