When may a PFO or ASD Need to be closed?
This article may be of particular interest to those individuals diagnosed with PFO or ASD.
Diagnosis of a stroke or a transient ischemic attack is made by a physician. Determining the cause of an unexplained stroke or transient ischemic attack becomes more difficult if there is a PFO (patent foramen ovale) or ASD (atrial septal defect) through which a clot may have passed to the brain. A blood-thinner called coumadin may be recommended while doctors try to determine the cause and then develop a strategy designed to best protect from further such events.
In order to plan the best treatment approach, a neurologist needs to exclude other causes of stroke or TIA.
- No disease or abnormalities in the arteries to the brain (often done by magnetic resonance angiography, although other methods can be used).
- No other sources of travelling material that could cause a stroke, such as from:
- An artificial cardiac valve
- Cholesterol deposits in the aorta (the main artery coming out of the heart and delivering oxygen to all parts of the body except the lungs)
- A heart infection
- Seriously damaged or weakened heart muscle that might have allowed a clot to form and then break off
- A heart tumor (usually "benign")
Next, any clotting abnormality that could have caused the stroke or TIA needs to be checked for.
- Special blood tests to look for such a condition need to be done. While any physician may be able to do the blood tests, we recommend a specialist in blood clotting disorders. He/ she may even check for genes that may have caused such clotting abnormalities.
If neither the neurologist nor the specialist in blood clotting can explain why a stroke or TIA has occurred, and there is a PFO or ASD, it may be time to consider closing the defect or hole in that heart.
Options to treat an unexplained stroke or TIA
The good news is that there are at least three treatment choices available. The bad news is that we have no scientific or factual basis as yet for recommending any of them over the others. The best we can do is give you some information and ideas about the options and the issues.
There are 3 ways to protect oneself that we think one should consider:
- Long-term coumadin treatment
- Device closure of the PFO or ASD
- Surgical closure of the PFO or ASD.
Here are some advantages and disadvantages of each.
Long-term Coumadin Treatment
- No procedure needs to be done
- This option can be used as a permanent strategy, or as a temporizing method (e.g. if someone wanted to wait until reconsidering one of the methods of closure)
- Regular blood tests (usually every 2-6 weeks) required as long as one is on coumadin
- Risk of important bleeding is about 1% annually. This consists of bleeds requiring a patient to be treated or transfused. The bleeding is most commonly in the digestive tract (e.g. stomach or bowel), or inside the head.
Device Closure of PFO or ASD
This technique is relatively new (significant numbers of device insertions for about ten years). In that time, many device models have been designed and tested. The ones currently in use in our centres are the Amplatzer and CardioSeal devices. As the number of patients requiring a device closure is small, only a few centres in Canada do this procedure. This is to ensure expertise in device closures is concentrated in those few centres.
- Relatively convenient and easy for the patient. Requires a 1-day admission. No chest scar. No heart surgery. Little discomfort. Almost immediate recovery.
- The procedure is very safe, although there is a low risk of complications as in any heart catheterization procedure, such as bleeding or bruising in the groin area.
- No solid information available on how effective these will be at preventing further strokes or TIAs, as for the other options.
- No solid information on the risks of complications as time passes.
- They don`t always close the PFO completely, although the chance of complete closure is very good.
Surgical closure of PFO or ASD
This operation has been performed for over 40 years. In recent years, surgeons have been willing to use a small incision involving the lower 2-3" of the breastbone. This is less painful than a full-length breastbone incision, enables quicker healing, and gives a better cosmetic result (more women than men have ASDs).
- The time honoured method. Extensively studied in the scientific literature, although most of these studies have been for larger ASDs.
- The PFO or ASD is almost always completely closed.
- The procedure is very safe, although as with any procedure there is always a risk of complications.
- All the drawbacks of most operations - significant pain for weeks; recovery period needed; left with a scar.
- So-called cardiopulmonary bypass or "the heart-lung machine" is used, as in most cardiac operations. This can have effects on brain function in some patients.
What might I do now?
You might do any of a number of things:
- Speak with your doctor(s) to get more information.
- Speak with the nurse coordinator at your congenital heart clinic.
- Do some more research, often on the Internet. If you do this, you might try the following sites:
- www.cachnet.org (look up the consensus conference recommendations about ASDs, read or post messages in the Message Centre, or connect to other sites of interest)
- www.tchin.org (a site mainly for children and young people, but worth visiting for information and links)
- www.agamedical.com (the company AGA that makes the Amplatzer device that we often use)
- Nitinol Medical Technologies Inc. - www.nitinolmed.com (the company that makes the CardioSeal device that we often use)
- Ask to meet with an interventional cardiologist at one of the centres which do this procedure to get more information on the device option.
- Ask to meet with a heart surgeon to get more information on surgery.
- Make a decision as to how you wish to proceed, and tell any member of our team, who will see that your decision is communicated to the others who have seen you to:
- Plan surgical closure
- Plan device closure
- Plan to take coumadin until you decide differently