Strokes and holes in the heart - a solid explanation

A good explanation of what likely happened to me almost 20 years ago - a hole in the heart causing a stroke. A trusty Google alert found this good, simple explanation how after a stroke with no clear cause, a heart repair may be in order:

A still from the video of my PFO closure.
Click here to watch the video.

Most strokes occur when a clot blocks blood flow to part of the brain. Often, doctors can tell what caused the clot to form. But about a quarter of the time — especially in people younger than 60 — there is no obvious reason. These types of strokes are known as cryptogenic (meaning "of hidden origin").

One possible cause underlying a cryptogenic stroke is an opening in the wall that separates the heart's right and left upper chambers (atria). Known as a patent foramen ovale, or PFO, this flaplike opening is quite common. About one-quarter of all adults have a PFO (see "What is a patent foramen ovale?").

"But about 45% of people who have cryptogenic strokes have a PFO, which suggests the two conditions are related," says Dr. John Jarcho, a cardiologist at Harvard-affiliated Brigham and Women's Hospital. Yet for years, the question of whether closing a PFO could prevent additional strokes has been hard to answer.

Click on the link above for the entire article. And you can click here to read more about my own experience, including a heart repair in 2007.

Closure of hole in the heart reduces stroke recurrence

A still from the video of my PFO being closed.
Click here to view the video.

If you've read this blog before, you might know that my hole-in-the-heart was closed 10 years ago. Click here to read details.

The hole is called a patent foramen ovale, or PFO. It's an opening between the upper chambers of the heart. We're all born with one, but it's normally closed shortly after birth. For some, though, it remains. For some people, blood clots can pass from one side to the other, getting pumped out to the arteries and eventually in the brain, causing a stroke.

Another hole-in-the-heart story about an unexpected stroke

A story similar to mine - a stroke that came out of nowhere. One woman's story about the undiscovered hole in the heart can lead to a stroke:

A still shot of the repair of my hole in the heart.
Click here to read more about it.

“I had four strokes,” Dean said. “A clot ran up from my leg, broke off a piece into my lung and the other half went into a hole in my heart that I didn't know I had and it went into my head and sprayed into four strokes.”

It’s called patent foramen ovale (PFO), Latin for “open oval window.” It is a small hole located in the upper chamber of the heart, which makes it possible for a baby in utero to get blood from the placenta through the umbilical cord to the heart, but it typically closes a few months after birth.

Story of a clinical trial provides serious food for thought

A still from the video of my PFO closure.
Click here to watch the video.

Something to think about: Clinical trials are necessary but can be thought-provoking.

The Houston Chronicle recently published a look at a clinical trial to find answers about closing a heart defect called a patent foramen ovale, or a PFO. It's potentially a stroke-causing defect. It was the probable cause of my stroke in 1998. It got patched up in 2007. You can click here to read about it.

But even though mine was fixed almost 10 years ago, it didn't end the controversy over whether the procedure - done in a cardiac catheterization lab - was really better than treating the defect with medication. One of my personal choices involved not taking blood-thinning warfarin - click here to read about it - for the rest of my life.

Another chapter of: To close or not to close

A still from the video of my PFO closure.
Click here to watch a video.

The arguments continue: To close or not to close.

Back in 2007, after a mini-stroke that spring, I had a heart procedure designed to close a hole in my heart called a patent foramen ovale (PFO). It's a hole between the upper two chambers of the heart and was blamed for my 1998 stroke and the 2007 mini-stroke. I was taking a blood-thinner at the time.

You can read the story about the procedure, including video, by following this link.

Now, the American Academy of Neurology says we should not routinely close the hole. Others disagree. Click on the link after reading this snippet on how AAN nixes routine PFO closure:

Patent foramen ovale (PFO) closure is not recommended as a routine therapy for patients with cryptogenic ischemic stroke, according to the American Academy of Neurology (AAN).

Latest study leans toward an answer to a stroke risk factor

A still from the video of my PFO being closed
click here to view the video

We've seen a lot of information bounced back and forth about the efficacy of closing a patent foramen ovale, or a hole between the two upper heart chambers.

Now, read about a study showing that the closure may prevent further patent foramen ovale-related strokes:

"PFO-related cryptogenic strokes tend to be larger and more superficial, and PFO-unrelated cryptogenic strokes tend to be deeper and smaller, so in the medical management group we saw more larger and superficial strokes than in the device group, suggesting there were still PFO strokes in the medical management group," Thaler told MedPage Today. "So it all makes sense even though the overall trial was negative."

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.

The story of the unknown unknowns

The famous quote about the "unknown unknowns" is back. Check out the video for some background, then read on.

My stroke was an "unknown" - unexplained at the time. It was later explained as a hole between the two upper chambers of my heart, also known as a patent foramen ovale. Click here to read more about PFO, strokes and heart repair.

Recently, experts had an interesting discussion about finding out the causes of unexplained - or cryptogenic - strokes.

Dr. Groucho got it right

Groucho Marx might have said it best: "I intend to live forever, or die trying."

I can connect with Groucho after a hole in my heart was closed back in 2007. Click on this link for info about my patent foramen ovale (PFO) closure and why.

The short story version is that the hole between the upper two chambers in my heart apparently allowed a blood clot to circumvent the clot-filtering mechanism in the lung, leading to a stroke in 1998 and a mini-stroke in 2007.

Since then, I've seen lots of studies indicating that this procedure might or might not be the best way to treat stroke survivors, looking at procedure vs. blood-thinning medication. My concern about warfarin (also known as Coumadin) was that as a fairly active person, taking pills that make you bleed easier might not be a good idea. Plus, pills and the related monthly blood tests cost money. I ditched the pills six months after the procedure.

That's more of a long-term concern instead of the relatively short-term outcomes in most studies. However, a recent study suggests that PFO closure may be cost-effective over long term:

PFO closure reached the incremental cost-effectiveness threshold of  < $50,000 per quality-adjusted life-year (QALY) gained in 2.6 years. Moreover, the treatment met the threshold of < $50,000 per life-year gained in 4.9 years. The per-patient mean cost of medical therapy surpassed that of PFO closure after 30.2 years of follow-up.

Now, I was in my 40s when my PFO closure occurred, so I plan to live 30.2 years (and more, I hope!) afterward.

PFO closure still an open question

The question of plugging a hole in the heart - a patent foramen ovale, a possible stroke risk - made medical news a few days ago.

MedPage's article PFO closure still an open question came with the following bullet points:

• Two new randomized studies found that there was no significant benefit associated with closure of a patent foramen ovale in adults who had had a cryptogenic ischemic stroke.
• Point out that in one of the studies, there was a significant between-group difference in the rate of recurrent stroke that favored treatment among those in the pre-specified per-protocol and as-treated analyses, but that the low overall rate of events in both studies raises statistical questions about this result.

I have a vested interest in PFO closure because mine was closed in the summer of 2007. As a result, I no longer take the medication warfarin, which has its own risks.

Now, the research is indicating that PFO closure outcome is, statistically speaking, about the same in terms of preventing future strokes. There's a lot of language in the stories I read about making case-by-case decisions as to whether the procedure is a good idea.

From my vantage point, I am still glad I had this done. Fewer medications. Fewer side effects. Warfarin was giving me headaches and, especially for someone relatively young who tries to be active, can cause excessive bleeding.

Is that a good choice for everyone? Certainly not. Each individual's circumstances should be considered.

(Video of the implanting of my PFO occluder)

Debating PFO closure for stroke risk

An article a bit thick to get through, but very informative about the debate about patent foramen ovale closure for stroke risk. That being said, if you're interested in the topic, heart.org did a nice job in getting different expert opinions. Read the entire article, but here's a snippet:

Depending on one's point of view, the studies fail to support the continued treatment of patent foramen ovale (PFO) with the Amplatzer occluder (St Jude Medical, St Paul, MN) for the prevention of stroke recurrence or provide yet more evidence that closing PFOs is the right thing to do.

The conflict arises from the fact that both randomized, controlled clinical trials missed their primary end point. As reported by heartwire, the studies were negative, with RESPECT suggesting a benefit when evaluating the "as-treated" patients only, and this has left researchers, clinicians, and other experts trying to understand what went wrong and the potential reasons the trials don't line up with published observational reports.

Plugging holes in the heart good for you? Maybe. Maybe not.

So ... for stroke prevention, do plugging holes in the heart serve better than taking blood thinner medications? The resounding answer: Maybe not. But maybe so.

A recent paper outlined the results of research of the effects of plugging a patent foramen ovale (click here for details about that term) in terms of preventing strokes. My 1998 cryptogenic stroke - that is, a stroke with no clear reason - was finally attributed to a hole between two heart chambers. (Click here for my own story about what happened.)

For this post, let's go through two articles and one press release (which you should read in their entirety) with a few snippets included. First, here's one headlined that Plugging PFOs no help for stroke -- maybe:

He said physicians should consider the following:

• First, we're talking about a stroke risk reduction that, if it plays out over time in a 46-year-old, is important.

• Second, for patients who are in the midst of their lives regarding career or family, they are looking for the best strategy to reduce the risk of having another stroke with all those consequences. So, what may be a small difference [in absolute risk reduction to an observer], is a huge difference to these patients

• And third, when we review pharmacologic studies that look at the risk reduction of secondary stroke prevention, we are not dealing with the same magnitude. These magnitudes of risk reduction [in RESPECT] are really substantial. That's what you must keep in mind when dealing with this patient population.

So, the story is that decisions need to be made on a patient-by-patient basis. I agree with that idea. The next item is a little more positive on the closure side.

PFO closure may be superior to medical therapy in preventing stroke:

"In contrast to a previously reported randomized trial for the treatment of cryptogenic stroke, the RESPECT trial enrolled only patients with documented cryptogenic embolic strokes and excluded patients with other potential causes of stroke and/or TIA. The period of follow-up approached nine years and was not restricted to only events within the initial two years of follow-up," said Richard Smalling, M.D., Ph.D., James D. Wood Distinguished Chair in Cardiovascular Medicine at The University of Texas Health Science Center at Houston (UTHealth), who served on the steering committee and as a principal investigator of the trial.

"As a result, the trial enrolled patients at high-risk for recurrent events and followed them for a long period of time, enabling the detection of relatively infrequent recurrent stroke," said Smalling, who is director of interventional cardiovascular medicine at the Memorial Hermann Heart and Vascular Institute. "The totality of evidence in the RESPECT trial clearly demonstrates the superiority of device closure using the Amplatzer PFO Occluder in patients with the above entry criteria compared to standard medical therapy."

Finally a story with a decided negative bent is headlined how St. Jude device to close heart holes fails to stop stroke:

The results won’t change medical practice very much, with some high-risk patients still likely to get treated even without formal FDA approval, Ajay Kirtane, director of the interventional cardiology fellowship program at Columbia University Medical Center/New York-Presbyterian Hospital in New York, said at the meeting.

“I would like as a physician to have the option to discuss it with the patient and be able to use it if the patient elects to do so,” he said. “That would be the ideal scenario. To use it in everybody, I don’t think you can do that on the basis of this data.” ...

“These are healthy people, and the results are something a 46-year-old stroke patient wants to know,” said lead researcher John Carroll, director of interventional cardiology at the University of Colorado. “It works. What we are debating is how superior it is to medical therapy. Any benefit that could potentially cut the risks down the road has a big impact.”

So my own bottom line hasn't changed on this: It's very much a decision that needs to be informed and made carefully between doctor(s) and patient. A single answer won't fit everybody, in this case.

I am convinced mine has prevented further strokes or mini-strokes. That being said, I was an active relatively young man when mine happened. Everyone has his or her own circumstances, and those have to be taken into account in any serious medical decision.

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.

Apparently successful hole-in-the-heart story

Given my own interest in the possible link between a hole in the heart - also known as a patent foramen ovale or PFO - and stroke, saw some news today about entertainer Bret Michaels leaving an Arizona hospital after his own hole in the heart was repaired:

Valley-based rocker and reality-TV star Bret Michaels has been released from St. Joseph's Hospital and Medical Center in Phoenix after successful heart surgery.

Michaels, 47, was released after undergoing a successful heart procedure on Monday, Jan. 24, to repair a patent foramen ovale (PFO), a hole in the heart.

"Bret's procedure had excellent results," said Dr. Mansour Assar, interventional cardiologist at St. Joseph's, in a statement. "Because of the successful outcome and Bret's determination, I believe he will be able to return to normal activity within weeks."

Like many people with PFOs who have strokes, Michaels was somewhat young for the stereotypical stroke victim. Although as readers of this blog know, just being young or young-ish doesn't mean you're stroke-proof.

Michaels' procedure  was apparently very similar to mine (link includes a video of my procedure back in 2007) and if his outcome is similar, he'll be back to full speed in several weeks. I had one in in June 2007, started running again that August and finished a marathon less than a year later.

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.

Myth: Only the obviously unhealthy have strokes

 Now, it's trendy to be stroke aware - it happened when Bret Michaels had a warning stroke and later diagnosed with a patent foramen ovale - a hole between the upper chambers of his heart:

So what exactly is a patent foramen ovale, and how common is it? We spoke with Dr. Jonathan Tobis, clinical professor of cardiology and director of interventional cardiology at the Ronald Reagan UCLA Medical Center, who explained that this is a congenital condition. Fetuses normally have a hole, or flap, between the left and right atria of the heart that allows blood to flow in between, bypassing the lungs. Once the baby is born and taking in oxygen to the lungs, that flap seals up -- or it's supposed to. In about 20% to 25% of people it stays open, leaving a small to large hole that still allows some blood to flow between the atria.

Most people never know they have this condition. But it may cause strokes, although rarely, Tobis said: "A blood clot can form and travel a pathway from the right to the left atrium and up to the brain, causing a stroke." It’s typically corrected these days with a catheter-based method that "is sort of like closing a button hole," he said. "It's a relatively simple procedure done as an outpatient."

Tobis said people shouldn't go running to their doctors demanding an echocardiogram to see whether they have this condition, because most remain asymptomatic throughout their lives.

Michaels, 47, has had a few struggles in his life but on appearance, seems healthy enough. His story, though, can serve as a cautionary tale. He's not old. Not puny or weak-looking. Active. So was I. So have countless others.

So even if someone seems healthy, know and pay attention to the signs and symptoms of a stroke.

Yes, strokes can happen to the below-45 crowd

Strokes are increasing among young:

A total of 7.3% of stroke victims were younger than age 45 in 2005, up from 4.5% in 1993, says Brett M. Kissela, M.D., of the University of Cincinnati Neuroscience Institute.

The most likely culprits: rising rates of obesity, high blood pressure, and diabetes -- the major risk factors for stroke -- among younger people, Kissela tells WebMD.

The average age of stroke patients dropped from 71 in 1993 to 68 in 2005, he says.

 Mine happened at age 39, and I'm not alone. More and more people of that age bracket are suffering strokes. Mine was apparently caused by a small hole between my upper heart chambers, allowing a small clot to pass from one side to another and to my brain.

Most of the factors blamed are preventable - so pay attention to stroke prevention.

A hole in an Osmond heart

Another story of a young - relatively - stroke survivor with a hole in the heart.

Entertainer Jimmy Osmond had a hole in the heart for 40 years before he found it the hard way:

Jimmy was given a bubble echocardiogram - a procedure in which an ultrasound scan of the heart is followed by an injection of a bubble of saline (purified water) into the arm to make the heart functions more visible.

It revealed a Patent Foramen Ovale (PFO) - a hole the size of a pound coin in the septal wall that separates the right and upper left chambers of the heart. It was a birth defect that had gone undetected.

Jimmy had been through many insurance medicals but had never been given an echocardiogram as there had not appeared to be any need for one. No abnormal heart sounds had been detected, and his blood pressure and cholesterol were normal.

"My doctor explained that over time, tiny blood clots that he described as 'particles' had travelled from my heart to my brain, forming a large clot. and this is what had caused the stroke," says Jimmy.

The Daily Mail article included the great graphic (above) that explains the procedure quite well.

To plug or not to plug...

Interesting article in The New York Times about lack of solid evidence of whether a patent foramen ovale is a stroke-causing condition.

The patent foramen ovale was one of two heart defects corrected in a procedure I underwent in June 2007. A PFO is a hole in the heart, between the two upper chambers. Everyone is born with the hole and most of the time, it seals up shortly after birth.

Another complication, described from a previous posting:

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.

To combat the problem, in June 2007, a doctor snaked a tube into my heart through a catheterization procedure, and deployed a device to plug the hole. My mother went through a similar procedure - not a PFO, but another type of hole - late 2008.

Now, as stated in the article, this connection between a PFO and a stroke isn't absolutely proven and that the Federal Drug Administration hasn't approved the specific use for the device. Won't prevent the use - just doesn't officially approve that specific use, according to The New York Times article.

Will plugging a PFO guarantee no more strokes, ever? No. The world doesn't work that way. That being said, no other explanation was ever found for my stroke. I had none of the classic indicators - cholesterol good, blood pressure good, nonsmoker, longtime distance runner, not overweight. I feel good about my decision.

More research needed? Yes, yes, yes. Even those convinced that the PFO and connection exist agree. How will the research be conducted? Who's willing to take the risks of fatal consequences? Questions seeking answers.

A special no-more-hole-in-the-heart story

Like mother, like son?

More than a year ago, this blog featured a posting about how a certain type of hole in the heart could raise the risk of stroke among elderly people. The study hit home the other day.

My mother, who is 81, has had a series of mini-strokes in recent years, including slurred speech and other symptoms. It turned out that, like her son, she had a couple of holes between her upper heart chambers. "Had" is an important term.

Like mine, this condition can cause unfiltered blood shunt from the right side of the heart to the left, then pumped out, perhaps with a clot, to cause a stroke or transient ischemic attack. The holes were not exactly the same variety of mine, but the danger was similar.

So on Dec. 29, 2008,my mother went throught the same catheterization procedure I went through, by the same doctor at the same hospital!

She's just over two weeks out and recovering well. An implanted device called an Amplatzer sealed the holes, which should mean reduced chances of stroke.

As I've said before, this blog is not really about me. Today, it's about my mother. As you read this, say a little prayer for her.