Hole in the heart - patching or not patching?

My own stroke was blamed on a hole in my heart - a patent foramen ovale, or an opening between the two upper chambers of the heart. The opening was closed in 2007. To read more about that, you can follow this link.

Researchers have been back and forth on whether closing the hole is a good idea or not. The most recent discussion made more sense - to this layman - and how for some, the closure makes sense. For others, not as much.

For example, relatively young people with a combination of the hole and an atrial septal aneurysm - that's when the wall between the two upper chambers of the heart is bulging - might benefit more. That was my case.

So follow this link to read more about the results of PFO closure in the long term:

While patent foramen ovale (PFO) closure still doesn't pan out for overall outcomes in long-term follow-up, the procedure does what it is supposed to in terms of reducing recurrent cryptogenic strokes, particularly for younger adults, the RESPECT trial showed.

A follow-up about holes in the heart

Almost five years ago - how time does fly - the hole between my two upper chambers were closed by a catheterization procedure.

Doctors had guessed since 1998 that my stroke at that time was caused by a series of actions:

• A hole in the heart we're all born with - patent foramen ovale - never closed.
• The wall between the two chambers was not a nice straight, smooth surface, but was more wavy with a divot, also called an atrial septal aneurysm.
• Normally, blood pumps into the vein side of the heart, then out the lungs to get oxygen and get filtered for clots and debris, the back into the arterial side and eventually out to the brain and body,
• However, clots and debris could collect in the divot and with a little extra chest pressure - even a sneeze - could push that from vein side to arterial side, bypassing the filtering process.
• The clot or debris is pumped out to the brain.
• Stroke happens.

So, after a transient ischemic attack, or a TIA mini-stroke, in 2007, I decided to take an offer to close that hole. (See video below.) It went great. A little over a year later, I finished a marathon.

Now, however, a new study stirred questions about whether the procedure works any better than medication. I was on a blood-thinner called warfarin, or Coumadin.

I think, though, one important takeaway from this research came from an ABC News quote:

Dr. Anthony Furlan, the study's lead author and chairman of neurology at University Hospitals Case Medical Center in Cleveland, said the evidence just isn't there to support a PFO closure procedure over simply giving patients medication.

"We're not saying there are no patients who should have the hole closed, but we are saying the selection criteria have to be radically refined," he said. Ideally, a patient would be under age 45, have a very large hole in their heart and a heart defect called an atrial septal aneurysm.

When my stroke occurred, I was a "young" 39. Plus, the atrial septal aneurysm was - now much more solid thanks to the device implanted - present.

Did I really want to be on a sometimes-dangerous blood thinner for the rest of my life? No. For me, I think the closure was the best choice. Is it  for everyone? The real answer, like many medical answers, is not so clear. Each individual's circumstances should be considered.

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.

One stroke is enough

Sometimes, a picture says it all.

This is from the Stroke Update Web site, a United Kingdom-based Web site chocked with stroke-related links, articles, news, studies, books and events.

At this writing, its lead articles were about younger adults returning to work after strokes and the June 2008 Welsh Stroke Conference. Another article explores the connection of a stroke with the combination of patent foramen ovale and atrial septal aneurysm.

Often, one stroke, or even a transient ischemic attack - also known as a mini-stroke - increases the risk for another. That's one reason why research is so vital - finding ways to prevent that second event that can be deadly.

Anniversary of hole repaired

Close to the end of the day today, June 25, 2008, remembered that this is the first anniversary of the procedure that plugged a hole in my heart.

My 1998 stroke was likely caused by a small hole between the two atrial chambers, called a patent foramen ovale. Everyone is born with the hole and most of the time, it seals up shortly after birth. And add another defect: The wall between the two chambers, called the atrial septum, should be smooth and flat. If so, even a patent foramen ovale is unlikely to cause a problem. In some instances, though, the atrial septum is misshaped, called an atrial septal aneurysm. The hole and the aneurysm combination increases the chances of a problem.

Normally, the right atrium receives blood from the vein side of the circulatory system, then passes it along to the lungs. In addition to processing oxygen for the blood supply, the lungs also use a filtering mechanism to remove debris, such as clots. From the lungs, the blood is moved back to the other side of the heart and pumped out to the arterial system, supplying oxygen-rich filtered blood to the body. However, if the atrial septum has a divot, if you will, then debris can collect. When pressure builds up in the chest -- say, from coughing or sneezing -- then blood and debris can move through the patent foramen ovale from the right atrium to the left atrium, circumventing the lung's filtering system. Unfiltered blood is pumped out into the body, including the brain.

Because of this, 10 years ago I experienced a cryptogenic stroke -- that is, a stroke with no obvious cause. In April 2007, a much more minor episode occurred, which triggered a round of tests. As long as the conditions remained, my risk of stroke was several percentage points higher than the rest of the population, despite the fact that I don't smoke, have low cholesterol levels, excellent blood pressure readings and, being a distance runner going on 20 years, am generally quite fit.

Thus, a year ago, I went through a procedure, in which a doctor snaked a couple of tubes through some arteries and deployed a device that plugged the hole. Within six weeks, I was back to normal. After six months, I received a final OK that the hole was completely sealed. No more restrictions, no more prescription blood-thinner, no higher stroke risk than the rest of the population.

Found a video about the procedure, including the very same doctor who did the work at Barnes-Jewish Hospital in St. Louis. If nothing else, I hope this gives someone reassurance that even a hole in the heart can be defeated.

There's a hole in my heart

A word to the around-40-year-old set: It can happen to you, too. Strokes are not always confined to the elderly.

I post this not to encourage pity, but rather to issue a warning: Be aware of stroke symptoms, even if you're young and in the best of health. A lurking birth defect can cause trouble, and it's important to act promptly when you even suspect stroke symptoms.

The above video is an experiment, so please forgive my amateur presentation. But considering the information below, it might save the life of someone you love -- or your own.

For nine years, I've had the nagging information that there is a small hole in my heart (more information to follow) that, in all likelihood, contributed to my stroke in 1998. A minor transient ischemic attack in April 2007, though, put that hole back on my radar. And with it, a hope to drastically reduce my stroke risk. Permanently.

Thus the video. It's from a transesophageal echocardiogram, big words to describe a camera that goes down your gullet to capture images of your moving heart. It was conducted at the Missouri Heart Center in Columbia, Mo. This is one snippet and it's my best guess of the location of the hole. At one point of the video, you see no color, then a burst of blue then red, appearing to pass through a small hole. If it's wrong, I'll correct the video. Again, it's my amateur's best guess.

The hole is between the two top chambers of my heart. This is a common birth defect. There are a few complicating physical factors -- based on the characteristics of the wall between the two chambers -- that places me at relatively high risk of stroke. So a doctor in St. Louis will snake a tube through some arteries to the heart and apply a patch device, comprised of two quarter-size pieces of nickel-titanium mesh. This is the same procedure done on Tedy Bruschi, a current New England Patriots linebacker.

The heart procedure is set for Monday, June 25. Dr. John LaSala will conduct this procedure at Barnes-Jewish Hospital.

Warning: This is written by a non-doctor. So please, don't take this as actual medical expertise. It's the best I can do, and it's probably 'way too simplified. If you think you're having or have had stroke or TIA symptoms, see a doctor. Now.

I offer these details to illustrate how it can happen to a relatively young, relatively fit person.

The small hole between the two atrial chambers is called a patent foramen ovale. Everyone is born with the hole and, depending on who you ask, somewhere between 75 and 80 percent of the time, it seals up shortly after birth. That means about 1 out of 4 or 5 people actually have a foramen ovale, which is not a huge problem. For most.

There are exceptions to that statement, though; my particular problem centers on the muscular wall between the two chambers, called the atrial septum. It should be smooth and flat. If so, the vast majority of people with a foramen ovale never know and no problems ever develop. In some instances, though, the atrial septum is misshaped, called an atrial septal aneurysm. That's where the problem arises.

Normally, the right atrium receives blood from the vein side of the circulatory system, then passes it along to the lungs. In addition to processing oxygen for the blood supply, the lungs also use a filtering mechanism to remove debris, such as clots. From the lungs, the blood is moved back to the other side of the heart and pumped out to the arterial system, supplying oxygen-rich filtered blood to the body. However, if the atrial septum has a divot, if you will, then debris can collect. When pressure builds up in the chest -- say, from coughing or sneezing -- then blood and debris can move through the foramen ovale from the right atrium to the left atrium, circumventing the lung's filtering system. Unfiltered blood is pumped out into the body, including the brain.

Because of this, nine years ago I experienced a cryptogenic stroke -- that is, a stroke with no obvious cause. Last April, a much more minor episode occurred, which triggered a round of tests recently completed. As long as the current conditions remain, my risk of stroke is several percentage points higher than the rest of the population, despite the fact that I don't smoke, have low cholesterol levels, excellent blood pressure readings and, being a distance runner going on 20 years, am generally quite fit.

Dr. LaSala will use an arterial catheter to insert a metal-mesh object that, once in place, will expand into shapes that look like two small umbrellas and cover the hole, one on one side and one on the other. Over time, scar tissue should cover the patch and permanently seal it against the atrial septum.

The final result: My stroke risk will fall dramatically and should actually be lower than the general population. I anticipate a complete recovery and, in fact, to be in better health than ever.

That, at least, is the plan. What will happen? It's not up to me. But I trust the one who is in charge.