PFO/ASA and Closure

[zalue]

35 y/o male, good health with hypothyroidism as my major complaint (I take 75 mcg Synthroid, TSH = 2.25). I don't recall any strokes in past.  

Diagnosed with MVP as a teen, and had echoes every 3-5 years since. In 2005 one revealed a potential ASA. Cardio ordered an echo with a bubble study to check for PFO.

TTE revealed an ASA and a PFO, with shunting of microbubbles from right to left. Cardio said take an aspirin and don't snorkel. He ordered some clotting tests. Unfortunately, I am positive for the heterozygous prothrombin mutation.

Hematologist said mutation only slightly increased my clot chances and aspirin was useless for this, because DVTs are the genesis for PFO stroke, and aspirin does nothing for venous clots. Said heparin dangerous at my relatively young age.

TEE done a few weeks ago. Confirmed the PFO, but much smaller than thought (4 mm) and the shunting of bubbles was less than the TTE. I don't remember any coughing or Valsalva type things during either TTE or TEE, so I was essentially at rest. Also confirmed the MVP and ASA, although the latter just met the minimum "movement" requirements.

I'm scheduled to see a cardiac interventionist later this week to discuss my options, including closure. Based upon the info I've given:

1. Would you recommend closure, anticoagulation, or nothing at this time?
2. If closure, what type of surgery and device?
3. Is closure more/less risky than living with PFO/ASA (I've had no strokes, yet)
4. I'm still on the baby aspirin a day. Is this advisable?

Thanks!

[Forum-M.D.-MM]

Hi Zalue,

That is a very good question.  

1. Would you recommend closure, anticoagulation, or nothing at this time?

Unfortuately, I don't think there strick data driven guidelines that deal with that specific question.  You are probably aware that even within the subspecialty of cardiology, there are sub-sub specialties like intervention, imaging, electrophysiology and adult congenital, among others.  If I saw a patient like your self in clinic, I would refer them to a sub sub specialist to help with that decision.

2. If closure, what type of surgery and device?

Again, I would send you to a interventional cardiologist that closes PFOs to make sure it is feasible -- it probably is.  I favor less invasive means when possible.

3. Is closure more/less risky than living with PFO/ASA (I've had no strokes, yet)

Closing a PFO is a relatively safe, low risk procedure.  I think in the end, your doctor will be able to inform you of the risks/benefits, but you will likely have to make up your mind based on your comfort with the procedure versus your long term risk of stroke.

4. I'm still on the baby aspirin a day. Is this advisable?

If you were at the Cleveland Clinic, I would refer you to adult congenital and vasucular medicine to discuss your long term risk of a blood clot.

I hope this answers some of your questions.  Good luck and thanks for posting.

[EchoTech]

I would go with the aspirin therapy.  I don't really know about the clotting disorder that you have.  As far as having the procedure, I would try to take in account family history and other factors in consideration for PFO closure device implantation.  The center that I work in that does these PFO closure devices is that they cardiologists are fairly shy about putting them into someone that hasn't had a mini stroke or some other symptom. There are risks associated with the catherization and deployment process, but there is also a peace of mind that you've got your PFO closed.  There are roughly 65 million people in America with the PFO.  It is a hard decision, but I am sure you will come to one that makes you feel comfortable.

Good night and good luck.

[zalue]

I stated this thread...

Anyway, I met with the cardiac interventionist on March 9th, and he does not want to close my PFO at this time. He said the risk of the procedure is roughly the same as the risk of stroke via PFO, so why chance it? Also, I have not had a stroke in my life. He increased my aspirin to 162 mg a day and said no scuba diving.

One thing I forgot to ask: are there any other "lifestyle" limitation with a PFO? Namely, what about light weight training or aerobic activity?

Thanks!

[EchoTech]

Other than the scuba diving, I think that would be the only limitation.  With the weight lifting, I don't know if that would really have a detrimental effect or not.  You could call his office and tell the receptionist about your question and to give him a message about it.  Most likely, they'll give you a call back with the right answer.

[claudaugh]

Hello Everyone,

I am a 44 year old female that had a stress test performed on April 2 at CCF main campus in cleveland and they found I had a PVC with Patent Foramen Ovale and Interatrial Septal Aneurysm with right to left flow through the interatrial septum. Heart problems are not an occurance in my family and I am really nervous about inventional catherization and/or surgery.

I have an appointment with a cardiologist on May 1st and my heart and chest always is painful and tight. I also have asmtha which flairs up with stress therefore making my chest hurt.

Has anyone had a catherization or surgury on this that they can share there experience with me? I also have a trivial mitral regurgitation, trivial tricuspid regurgitation, trivial pulmonic regurgitation.

Thank you for anyone that can give me advice
Lauren

[T_bone]

Lauren,

Did you see the doctor today?  If so, what was their recommendation?  I have a PFO and ASA also and have the same concerns you do.  Knowing that our stroke risk is higher is definitely making some sleepless nights for me.  

T.

[kyleauz]

Hi,
I am a 36 year old female
Last year i had a stroke and the nuerologist put it down as migraine was the cause.
Being me i hate not having something written on paper what the definate cause was so I took a look into my hospital transcripts and sure enough there was a few things that came up but the nuerologist did not tell me about this.
So anyways I took it on myself to visit a cardiologist and ask about it.
I gave him my symptons at the time of the stroke and after. He said i bet you have a PFO.
Had TEE and it came back with a large PFO with atrial septal aneurysm and a very long tunnel.And the flap was very flimsy and was always open flapping like it was facing the wind.And a positive bubble study showing right to left as well as right to left shunting demonstrated at the Atrial Level.
I was told there is a risk with the procedure, if i was to leave it I could have another stroke and perhaps not be as lucky as last time.
And because of the long tunnel the surgeon has to do a left transeptal puncture which was an additional risk on top. but i went ahead with it.
I'm glad I did, I no longer have migraines. I felt nothing and i was awake through it. If i hadn't looked into my records and left it as migaine was the cause who knows what would have happened.

[kyleauz]

Hi,
I would ask around who performs this procedure, because not alot of them do it. there is only three in florida.
The procedure usually takes 45 minutes to an hour.
Mine took 4 hours due to the bonus left transeptal puncture ( that is when they go in from the other side of the heart instead of going through the PFOcause the tunnel is too long, and they have to make a new hole). it was pain free through out it.
Only pain was in the recovery room when they take the catherder sheath out.
Oh boy and make sure that the nurse realizes that she does not have to grip with so much pressure on the vein cause it is not an arterie.LOL That happened to me. A male nurse did just that which had me in total agony which made the blood keep pouring and the head nurse kept saying breathe slowly you have to calm down. I screamed back "I can't" and then she realized what the male nurse was doing.
other than that there is nothing to worry about. I was scared at first especially working on the heart.

[T_bone]

How hard was it to get them to close your PFO/ASA?  Seems like the FDA has withdrawn their "humanitarian exemption" of devices and they aren't allowed for PFO closures.  

How are you feeling now?  Notice any difference?

[ASA help!]

[ASA help!]

My 18 yr old son was having a stabbing type of chest pain in his left pectoral area. He had a chest xray, EKG both were clear. However, after Echocardiogram he was diagnosed with ASA and a myxoma in the left atrial along with mild pulmonic valve regurgitation.  It was also noted that his aneurysm covered 2/3 of his right atrial.  After having a CCTA & TEE, the myxoma was ruled out but the TEE showed a small hole with mild shunting from right to left.  No mention of a PFO...is that medical term for hole in the aneurysm?   He does get migraines and they have been more frequent the last year and a half.  I have read that migraines increase the risk of stroke...Is aspirin therapy the best choice? What about surgical repair while he is young & healthy rather than risk a stroke?  I can find plenty of info on an ASA but not the risks or recommended treatment especially for young adult.  Would like viewpoints from different types of treatment.  

[MaryMaryO]

I need help!   Aspirin or heart surgery.. sounds like a silly quesion, doesn't it. They're both such opposite extremes. Here's my situatin: I am a very healthy, active 45-year-old woman with no major health problems. I happen to have a congenital eye defect that leaves me blind in my left eye (no big deal). This past May, I suddenly lost partial vision in my right eye (big deal) that lasted for less than a week and gradually got better. Upon further investigation, my ophthalmologist found a cottonwool spot in my eye.. which they say is evidence of a vascular infarction. So I had a little stroke. Ouch. More investigation found and ASD and an ASA.  So.. the docs are thinking they are related and could be the cause of the infarction; although there is no proof.. all evidence points that way. So here's my dilemma: At first I was told that my choices were 1. Aspirin therapy (325) for life 2. Amplatzer occluder via cath.  3. Open heart surgery. 4. Rototics surgery.  Initially, all the doctors were in agreement that it should be closed.  Of course the cardiologists who perform the cath device say that's the way to go and the surgeons say surgery is the way to go (with a push towards robotics).  After further investigation, it was determined that the FDA now has a criteria for the occluder device trial.  You have to have two paradoxical strokes in order to be considered (how crazy is that?!?) and even then, 50% of patients get put into control group with Coumadin for 5 years.  So now I'm scratching that option off my list.  How odd is it that the doctors who told me that my ASD needs to be closed now say I will be ok on aspirin since I do not meet the criteria for their device.  I think I'm somewhat grateful as I was a bit concerned about a foreign body in my heart for the rest of my life.  Plus, I've heard that some of these devices are being redesigned. The docs who would have done the device are saying surgery is too drastic.  The surgeons say that the robotics surgery has come a long way and an excellent way to diminish my chance of stroke again.. which could cause permanent damage the next time.  I only have one eye and am terrified of loosing it .. or worse.  Surgery sounds so drastic and my current choice of aspirin or heart surgery seems crazy!  What should I do??

[35m_fla]

A related discussion, PFO exercise limitations was started.