Wednesday, November 24, 2010

Is closing the hole in the heart really best idea?

A recent study brings into question whether stroke survivors with a hole between the two upper chambers of the heart - called a patent foramen ovale - should have the hole patched:
Full final results from the first randomized controlled trial of patent foramen ovale (PFO) closure for stroke/transient ischemic attack (TIA) to reach completion have found no differences in the primary end point of stroke or TIA at two years, all-cause mortality at 30 days, and neurological mortality between 31 days and two years.

[Dr Anthony] Furlan [University Hospitals Case Medical Center, Cleveland] said it's "too soon to say" what impact the results will have on PFO-closure procedures: several trials are still ongoing, and while the devices are investigational in the U.S., they are market-approved in Europe and elsewhere.

"Ultimately I think CLOSURE I, if the other ongoing trials show similar results, will obviously ratchet down the number of endovascular PFO closures [performed]," he said.

"The challenge now, in my view, for the endovascular community is to refine the selection criteria and not so liberally be closing these holes in cryptogenic-stroke patients."
I have an interest in this because I had my PFO closed in 2007 and no longer take blood-thinners. Before that, I had been on both warfarin and Plavix, plus aspirin.

My understanding of my own case is that the PFO was just one of two factors; the other was an atrial septal aneurysm. That's when the wall between the two upper chambers of the heart - which normally should be fairly straight and smooth - is bulging. Basically, I was told, it had a divot, where blood clots could gather. Then, when chest pressure increases by something as simple as a sneeze, a clot could go from one side of the heart to another, through the hole, to the brain, causing a stroke.

This research points out the need to have intelligent conversations with your doctor(s) about any medical procedure, including discussion of possible outcomes, factors in your particular case, risks and alternative treatements.

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